Skin Integrity & Wound Care.pdf

CHAPTER 32: SKIN INTEGRITY & WOUND CARE ● Skin is the body’s first line of defense (largest organ of the body) ○ A break or disruption in integrity → life threatening ● Layers of the skin ○ Epidermis – outer layer ■ Stratified epithelial cells ■ Waterproof layer of keratin ■ Regenerates easily and q...

CHAPTER 32: SKIN INTEGRITY & WOUND CARE ● Skin is the body’s first line of defense (largest organ of the body) ○ A break or disruption in integrity → life threatening ● Layers of the skin ○ Epidermis – outer layer ■ Stratified epithelial cells ■ Waterproof layer of keratin ■ Regenerates easily and quickly ○ Dermis – middle layer ■ Elastic connective tissue with collagen ■ Nerves, hair follicles, glands, immune cells, and blood vessels ○ Subcutaneous tissue = innermost layer ■ Anchors the skin to tissues ■ Made up of adipose tissue ■ Stores fat for energy, heat insulator, cushioning effect for protection ● Functions of the skin ○ Protection ○ Temperature regulation ○ Psychosocial → self esteem ○ Sensation → sense of touch, pain, pressure, and temperature ○ Vitamin D production → activated by UV rays from sun ○ Absorption → medications for local and systemic effects ○ Elimination → water, electrolytes, and nitrogenous wastes in sweat ● Adequate circulation, proper nutrition, and good overall health are necessary to maintain cell life ● Developmental considerations ○ Children ■ <2 years – skin is thinner and weaker ■ Skin and mucous membranes are injured easily ■ Becomes increasingly resistant to injury and infection ○ Older adults ■ Structure changes as a person gets older ■ Easily damaged skin ■ Circulation and collagen are impaired → increased risk for tissue damage ■ Healing time is delayed ● Wound = break or disruption in the integrity of the skin and tissues ○ Phases of wound healing (HIP Man) ■ Hemostasis → blood vessels constrict & blood clotting to control bleeding Bryanna Kanning Concepts Peer Tutor 2023 ● Occurs immediately after injury ● Exudate (fluid) is formed ■ Inflammatory → leukocytes and macrophages move to the wound and clean to allow healing ● Lasts 2-3 days ● Characterized by pain, heat, redness, and swelling ● Patient may have elevated temperature, leukocytosis, and discomfort ■ Proliferation → new tissue fills wound space through the action of fibroblasts “new life = new tissue” ● Lasts for several weeks ● Capillaries bring oxygen and nutrients ● Blood flow is reinstituted ● Granulation tissue is formed ■ Maturation → final stage of healing ● After 3 weeks of healing ● Scar tissue begins to heal and is less elastic ○ Wound classification ■ Intentional (surgery) or unintentional (injury: increased infection & bleeding) ● Intentional wound has less risk of infection ■ Acute or chronic ● Acute → heals fast ● Chronic → delayed wound healing 30+ days ○ Factors affecting wound healing ■ Local factors ● Pressure (disrupts blood flow) ● Desiccation (dehydration, cells become dry) ● Maceration (softening of skin due to moisture) ● Trauma ● Edema ● Infection ● Excessive bleeding ● Necrosis ● Biofilm (decreases effectiveness of antibiotics and normal immune response; delays healing) ○ Thick, slimy, protective barrier ■ Systemic factors ● Age (very young and old patients have sensitive skin) ● Circulation and oxygenation Bryanna Kanning Concepts Peer Tutor 2023 ● Nutrition ○ Malnourished or NPO patients are at risk for wound complications ○ High in protein, vitamin A & C = GOOD ● Wound cause ● Medications ○ Corticosteroids decrease inflammatory response ○ Radiation depresses bone marrow function ● Immunosuppression ○ Wound complications ■ Infection ● S&S: increased drainage, pain, redness, swelling, increased body temperature, increased WBCs, odor ● Can lead to chronic wounds, bone infection, and sepsis ■ Hemorrhage (highest risk after surgery) ● Check dressing frequently; including UNDER the patient ● If uncontrolled bleeding occurs → APPLY PRESSURE ● Can lead to a hematoma = internal blood clots ■ Dehiscence & Evisceration ● Most serious wound complications !! ● Dehiscence → muscle intact; due to increased abdominal pressure ● Evisceration → bowels protruding from wound; due to increased drainage; requires immediate surgery “something giving away” ○ (1) Position patient in low Fowler’s ○ (2) Cover area with saline moistened sterile gauze ○ (3) NPO for surgery ● Prevention = hold a pillow over abdominal wound during coughing and deep breathing exercises to reduce abdominal pressure ● Bryanna Kanning Concepts Peer Tutor 2023 ■ Fistula ● Abnormal passage from an internal organ or vessel ● Can be purposeful or accidental ● Often results from an abscess (infected fluid that has not drained) ● Can lead to increased infection and skin breakdown ● ● Pressure injury: localized damage to the skin and underlying tissue that usually occurs over a bony prominence ○ Acute or chronic ○ Occur in older adults due to aging skin, chronic illness, immobility, malnutrition ○ Factors in development ■ External pressure compressing blood vessels; occur mainly over the tailbone, heels, and hip bones ● Leads to ischemia (deficiency of blood in an area), hypoxia (inadequate oxygen to cells), edema, inflammation ■ Friction and forces that tear and injure blood vessels; the skin over elbows and heels are affected ○ RISK FACTORS ■ Immobility ■ Nutrition and hydration ■ Moisture (incontinence, drainage) ■ Mental status ■ Age ○ RISK ASSESSMENT → Braden Scale (0-24) ■ MANSS ● Moisture ● Activity ● Nutrition ● Sensory perception ● Shear & friction ■ Score less than 12 = increased risk ○ Prevention ■ Turn every 2 hours. IMPORTANT!! ■ Adequate hydration and nutrition Bryanna Kanning Concepts Peer Tutor 2023 ● Protein, fatty acids, vitamins and minerals ■ Keep skin DRY ■ Specialty beds and offloading devices ○ Stages of Pressure Ulcers ■ Stage 1: Erythema of skin = red skin, changes in sensation, temperature, or firmness ■ Stage 2: Partial-thickness = partial loss of skin with exposed dermis; looks almost like a blister ■ Stage 3: Full-thickness = loss of skin, adipose tissue is visible ■ Stage 4: Full-thickness and tissue loss = exposed fascia, muscle, tendon, ligament, or bone in the ulcer ■ Obscured/Unstageable= tissue damage is obscured by eschar (necrosis) ● Remove necrotic tissue before staging ■ Deep tissue injury = purple, maroon area indicating tissue injury ■ ● Wound assessment ○ Assess old dressings – look for drainage, measure the size, determine location ○ BYR scale for color ■ Black (necrotic) = debris ■ Yellow (sloughy) = cleaning ■ Red (granulating) = protect GOOD ○ Assess the color ○ Palpate for firmness, temperature, and swelling ○ Assess for pain ○ Assess for signs of infection ● Types of wound drainages ○ Serous → clear and watery ○ Sanguineous → fresh bleeding, or darker old bleeding Bryanna Kanning Concepts Peer Tutor 2023 ○ Serosanguineous → serum and red blood cells; light pink to red ○ Purulent → thick, foul odor, may be yellow or green ○ ● Heat and cold therapy ○ Heat therapy ■ Dilates blood vessels, increases tissue metabolism, reduces blood viscosity, reduces muscle tension, helps relieve pain ■ Hot water bags, electric heating pads, hot packs ■ Warm soaks, moist compress ○ Cold therapy ■ Constricts blood vessels, reduces muscle spasms, promotes comfort ■ Reduces inflammation and edema ■ Ice bags, cooling blankets, cold compress Bryanna Kanning Concepts Peer Tutor 2023