Skin Integrity and Wound Care PDF

Chapter 33 – Skin Integrity and Wound Care Cross section of normal skin Epidermis - First layer - No blood vessels - Regenerates easily Dermis - Second layer - Connective tissue - Nerves, blood vessels, hair follicles Subcutaneous...

Chapter 33 – Skin Integrity and Wound Care Cross section of normal skin Epidermis - First layer - No blood vessels - Regenerates easily Dermis - Second layer - Connective tissue - Nerves, blood vessels, hair follicles Subcutaneous - Third layer - Anchors skin to underlying tissue - Stores fat for energy - Heat insulator - Cushioning for protection Functions of the skin Protection Body temperature regulation Psychosocial Sensation Vitamin D production Immunologic Absorption Elimination Factors A:ecting the Skin Unbroken and healthy skin and mucous membranes defend against harmful agents Resistance to injury is aLected by age, amount of underlying tissue, and illness Adequately nourished and hydrated body cells are resistant to injury Adequate circulation is necessary to maintain cell life Very thin and very obese people are more susceptible to skin injury  Fluid loss during illness causes dehydration Excessive perspiration during illness predisposes skin to breakdown Jaundice causes yellowish, itchy skin Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care Types of Open wounds Incision – cutting or sharp instrument; wound edges well approximated and aligned; least likely to become infected Laceration – tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps contaminated with dirt – likely to become infected Abrasions – Friction; rubbing or scraping epidermal layer of skin; top layer of skin scraped away; dirt and germs often embedded will become infected. Puncture – blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental; consider penetrating object when considering infection probability. Penetrating – foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues Avulsion (tearing away) -tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures. Chemical – toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis Thermal – high or low temperatures; cellular necrosis as a possible result Pressure ulcers – compromised circulation secondary to pressure or pressured combined with friction- stages 1-4, unstageable, deep tissue injury Venous ulcers – injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction - Have significant drainage. - compression essential Arterial ulcers – injury and underlying ischemia, resulting from a lack of blood flow to the lower extremities secondary to condition s such as atherosclerosis or thrombosis - Many have black eschar - Increasing blood flow is essential for treatment diabetic ulcers – (MOST COMMON)injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure; located below the ankle Types of closed wounds Contusion – blunt instrument, overlaying skin remains intact, with injury to underlying soft tissue; possible bruising or hematoma ( blood bruising) Irradiation (can be visible) – ultraviolet light or radiation exposure; can cause wet or dry desquamation Pressure ulcers – stage 1 Phases of wound healing Hemostasis - Happens immediately after injury - Blood vessels constrict to stop blood loss - Clotting begins with platelet aggregation (activation and clustering) - Blood vessels dilate to increase blood flow with plasma components Inflammatory - Last 2-3 days - Leukocytes come in, to clean wound - Macrophages come to clean and promote growth of new epithelial cells - Fibroblast move in, to help fill in the wound - Exudate forms made up of plasma and blood Proliferation - Last several weeks - Fibroblasts secrete collagen and growth factors for blood vessels and endothelial regeneration - Granulation tissue forms - Collagen deposit continues for weeks to years - New tissue is built to fill the wound space by fibroblasts Maturation (remodeling) - Begins around week 3 and can last years - Collage remodeling and additional deposits - Scar finalizes - Scar becomes flat Local Factors A:ecting Wound Healing Pressure – disrupts the blood supply to the wound area. Interferes with blood flow. Desiccation (dehydration) – drying up. Cells dehydrate and die in a dry environment. Cause crust on the wound Maceration (overhydration) – tissue erosion, results from prolonged exposure to moisture. Moisture-associated skin damage (MASD), boggy (a lot of fluid), mushy skin Trauma – repeated trauma to a wound area results in delayed healing or the inability to heal Edema – interferes with blood supply to the area, resulting in inadequate supply oxygen and nutrients to the tissue. Infection – bacteria in the wound increase stress on the body, inquiring increased energy to deal with invaders Excessive bleeding – results in large clots. Necrosis (death of tissue) – dead tissue in the would delays healing. Appears slough-moist, yellow, stringy tissue and eschar appears as dry, black, leathery tissue Presence of biofilm (thick grouping of microorganisms) – cause wound bacteria growing Wound Types: Chronology Acute Wounds Heal withing days to weeks Edges approximated Risk of infection lessened First or second intention Chronic Wounds – DIABETIC/ HEART DISEASE Often remain in the inflammatory phase for more than 3 months Wound edges not approximated Increased risk of infection Healing delayed Examples – venous insuLiciency, arterial, pressure ulcers (MOST COMMON) Systemic & External Factors A:ecting Wound Healing Age- age and healthy adults heal more rapidly Circulation and oxygenation – adequate blood flow is essential Nutritional status – healing requires adequate nutrition Wound etiology – specific condition of the wound eLects healing Health status - corticosteroid drugs and postoperative radiation therapy delay healing Immunosuppression Medication use Adherence to treatment plan Nutrition For Healing Protein and amino acids – Most important - Builds muscle, ligaments, skin. - Transports lipids, vitamins, minerals and oxygen - Involved with repair and synthesis of enzymes for wound healing - Meat, eggs, milk, cheese, yogurt, legumes, nuts, seeds Energy (calories) – Most important - Supplies energy - Prevents unintended weight loss - Needed for anabolism, nitrogen synthesis, collagen formation - Protein, carbohydrates, fat - Nutrient- dense energy sources preferred Fluid - Serves as solvent for other nutrients. Helps maintain body temp. transports nutrients and waste - Water, milk, juice, coLee, tea, soda, etc. Vitamin A - Needed for protein synthesis, immune functions, and maintenance of epithelial tissues - Deep green and yellow fruit and vegetables, beef liver, fortified milk Vitamin C - Needed for collagen formation and absorption of iron - Citrus juices and fruits, tomatoes, strawberries, broccoli  Zinc - Serves as co-factor for collagen formation and many aspects of cell metabolism. - Nuts, dried fruit, dried beans, whole-grain cereal, organ meats Copper - Preserves strength of skin, blood vessels, connective tissue - Plays a role in enzymatic reactions in the body - Liver, fish, nuts, seeds Iron - Helps form red blood cells - Transports oxygen and collagen formation - Supports healthy immune system - Liver, meat, fish, poultry, fortified breads, and cereals COMPLICATIONS OF WOUND HEALING Infection Hemorrhage Dehiscence - most complicated Evisceration – Most serious complication of dehiscence - If dehiscence occurs what do you do? o Cover the wound with sterile towels moistened with sterile 0.9% sodium chloride solution Fistula formation – happen when you have abdominal surgeries Who is most at risk? - Young/adult at most risk for chronic diseases Warning signs? - Red, warm to touch, drainage, open wound Interventions? - Antibiotic, culture drainage MOST SERIOUS WOUND COMPLICATION Evisceration - Most serious complication of dehiscence - Protrusion of viscera through the incision - Immediately cover with saline dampened sterile towels and call MD - Keep patient in low Fowlers  - High risk patients o Obese o Malnourished o Smoker o Excessive coughing, vomiting, straining o “Something popped” o The part of the intestine can die if not treated - Intervention o Apply sterile towels/dressing soaked in sterile normal saline and call the MD stat COST ASSOCIATED WITH CHRONIC WOUNDS Most chronic wounds are ulcers associated with ischemia, diabetes, venous statis, or pressure For Medicare patients, surgical site infections and diabetic ulcers were highest Most aLected are 65+ Estimates are 3-6 million people with chronic wound in US alone Costs 20 – 30 billion annually in US. PRINCIPLES OF WOUND HEALING Intact skin is the first line of defense against microorganisms. Careful hand hygiene is used in caring for a wound The body responds systematically to trauma of any of its parts An adequate blood supply is essential for normal body response to injury Normal healing is promoted when the wound is free of foreign material The extent of damage and the person’s state of health aLect wound healing Response to wound is more eLective if proper nutrition is maintained TYPES OF WOUND HEALING Primary intention -surgery Secondary intention – pressure ulcer Tertiary intention – surgeon leaves wound open and let it start healing and then close it up What is used to close wounds? - Sutures - Strips - Glue – common now - Staple TYPES OF DAINAGE SYSTEMS Open systems - Penrose drain Closed systems - Jackson-Pratt drain - Hemovac drain ARTERIAL VS. VENOUS ARTERIAL Cause – insuLicient blood supply to area, causing ischemia (tissue death) Risk factors - Vascular insuLiciency - Uncontrolled blood sugars in people with diabetes mellitus - Limited joint mobility or mobility problems - Improper footwear Characteristics - Punched out appearance - Smooth wound edges - Pain at night and relieved by elevating leg - Usually occurs on the lateral foot but can occur anywhere on the lower legs - Lower extremities are cool to touch - Pale, shiny, think skin - Minimal to no hair growth - Minimal drainage from wound Not a lot of drainage Well defined Losing oxygen in blood Lose hair Venous – Most common Cause – pooling of blood causing increased pressure in veins Risk Factors - Varicose veins - Deep vein thrombosis - Incompetent valves - Muscle weakness in legs - Immobility - Pregnancy Characteristics - Shallow and superficial - Irregular shape - Painful from edema - Phlebitis - Infection - Usually in the lower legs or ankles Not well defined Pressure on vein Hurts because of the swelling/edema PRESSURE ULCERS Definition – wound with localized area of tissue necrosis - Acute or chronic - Develops over bony prominence o Occipital bone, scapula, vertebra, sacrum, coccyx, calcaneus o Frontal bone, mandible, humerus, sternum, tuberosity of pelvis, patella, tibia o Scapula, ribs, iliac crest, greater trochanter, lateral knee, lateral malleolus, medial malleolus o Most common locations – coccyx and calcaneus (heels) - Due to pressure and shear or friction  At risk population for pressure ulcers - Aging skin, chronic illness, malnutrition - Fecal and urinary incontinence - Altered level of consciousness - Spinal cord injuries - Neuromuscular disease Mechanism of Injury - Pressure - Friction - Shear – one layer of tissue slides over another layer. Shear separates the skin from underlying tissue. o Patients who are pulled rather than lifted o Patients sliding down in bed STUDY THE BRADEN SCALE Predict pressure sore risk Nursing Process: Assessment Full, head-to-toe assessment necessary - Acute care - Long-term care - Home health Wound Assessment - Size of wound – measure - Depth of wound - General appearance – location, drainage (color, amount, odor, consistency) - Presence of undermining, tunneling, or sinus tract - Surrounding skin  Blanching - InsuLicient circulation deprives tissue of oxygen and nutrients leading to ischemia (deficiency of blood circulation to a particular area) - Hypoxia, edema, inflammation and ultimately, necrosis and ulcer formation - May form in as little as 1-2 hours - Blanchable – turn white -lighter in color - Non-Blanchable – does NOT turn white – tissue damage already occurred o Something under the skin has been damage PRESSURE ULCER STAGING Stage 1 - Intact skin with a localized are of indicate deep tissue pressure - Non-blanchable erythema - Something under the skin is damage - Dark color Stage 2 - Partial – thickness - Break in the skin - Skin loss involving epidermis and dermis - Superficial ulcer - Presents clinically as an abrasion, blister, shallow crater Stage 3 - Full thickness - Skin loss involving damage or necrosis of subcutaneous tissue that may stand down to, but now through, underlying fascia - Deep crater with or without undermining of adjacent tissue Stage 4 - Full thickness skin loss with extensive destruction - Tissue necrosis - Damaged muscle, bone, or supporting structures (tendon, joint capsule) - Sinus tracts may also be associated with stage IV ulcer - Can involve bone damage Unstageable - Covered with eschar or slough - Requires debridement – surgery to take the black out NURSING PROCESS: DIAGNOSIS Impaired Skin Integrity – diagnosis Actual - Impaired skin integrity - Impaired tissue integrity - Disturbed body image - Knowledge deficit Potential - Risk of impaired skin/tissue integrity - Risk of infection Nursing Process: Planning Outcome Identification Patient will have no evidence of skin breakdown Patient will have no signs and symptoms of infection Patient will verbalize understanding of need to turn every 2 hours Nursing Process: Implementation Prevention is best -implementation - Assess skin - Cleanse the skin routinely and whenever any soiling occurs - Use skin moisturizers for dry skin - Avoid massage over bony prominences - Protect skin from moisture associated with episodes of incontinence or exposure to wound drainage - Minimize skin injury from friction and shearing forcer. Padding, protective devices - Investigate reasons for inadequate dietary intake of protein and calories. - Administer nutritional supplements or more aggressive nutritional intervention as needed - Improve mobility and activity. Turning every 2 hours  - Document measures used to prevent pressure ulcers and the results of these interventions Wound Care – implementation - The goal of wound care is to promote tissue repair and regeneration to restore skin integrity - Many times, cleaning of the wound and use of a dressing as a protective covering over the wound is needed - Wound cleansing is performed to remove debris, contaminants, and excess exudate - Sterile normal saline is the preferred cleaning solution - R = Red – protect o wound bed should be beefy red = granulation tissue = protect with dressing, moisture, keep clean with prescribed dressing changes. Surgical mean sterile technique, pressure is usually clean. - Y = Yellow – cleanse o Yellow exudate, dead cells, could be infection - B = Black – debride o Necrotic eschar – could be grey or tan but primarily black and dry - Mixed wound – contains components of Red, Yellow, and Black wounds. Cleaning A Wound – implementation - Clean with each dressing change - Use careful, gentle motions to minimize trauma - Pre-medicate for pain management - Use 0.9% normal saline solution or wound cleanser spray to irrigate and clean the ulcer - Report any drainage or necrotic tissue Applying Dressing – implementation - Sterile dressing - Clean dressing - Occlusive dressing - Wet to dry dressing - Frequency of dressing changes depends on the type of dressing used Types of dressings Transparent, hydrocolloid, hydrogel, alginate, foam, antimicrobial, contact layer, composite Nursing Process: Evaluation Continue process of evaluation Non-healing wound require changes to plan of care Multi-disciplinary – what team members should be included? - Nurse, wound care nurse, dietician, PT, OT, social worker Pressure Ulcers represent a failure in nursing care There should be ZERO tolerance for pressure ulcer formation Chapter 41 – Fluid and Electrolytes Functions of water in the body Transporting nutrients to cells and wastes from cells Transporting hormones, enzymes, blood platelets, and red and white blood cells Facilitating cellular metabolism and proper cellular chemical functioning Acting as a solvent for electrolytes and nonelectrolytes Helping maintain normal body temperature Facilitating digestion and promoting elimination Acting as a tissue lubricant Body Fluid Compartments Intracellular Fluid (ICF) o Fluid within cells 70% Extracellular Fluid (ECF) o Fluid outside cells 30% o Includes intravascular and interstitial fluids