Skin Integrity and Wound Care Lecture Notes PDF

Skin Integrity and Wound Care Dr. Idevania Costa RN, NSWOC, PhD Assistant Professor School of Nursing Lakehead University 2/28/23 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 2 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) Overview 01 02 03 Part I - Skin Anatomy, physiology and healing phases Part II – p...

Skin Integrity and Wound Care Dr. Idevania Costa RN, NSWOC, PhD Assistant Professor School of Nursing Lakehead University 2/28/23 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 2 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) Overview 01 02 03 Part I - Skin Anatomy, physiology and healing phases Part II – pressure injury prevention Part III – Wound assessment and management 3 Objectives ØReview the Anatomy and physiology of the skin Ø Explain the phases of wound d healing ØDifferentiate between primary- and secondary-intention wound healing. ØExplain factors that promote or impair normal wound healing. ØIdentify risk factors for development pressure injury ØUnderstand the principles of wound assessment and management Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 4 Part I: Skin Anatomy, Physiology and healing phases Ide Costa RN, NSWOC, PhD 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 5 Skin Anatomy Largest organ in the human body Weights 3kg in adults 2m2 surface area thickness varies: 0.5mm to 4-6mm FIGURE 46-1 Layers of skin. (From Applegate, E.. The anatomy and physiology learning system [3rd ed.]. St. Louis: Saunders.) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 6 Function of Skin Protection: epidermis, hair follicles, sebum, acidic PH Sensitivity: to touch, pain, heat, cold and pressure Thermal regulation: controlled by radiation, evaporation, conduction. Excretion and secretion: sweat by evaporation. Sebum lubricates the skin and hair. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 7 Skin layers Epidermis Dermis Subcutaneous Tissue 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 8 Physiology of Skin Protection: epidermis, hair follicles, sebum, acidic PH Sensitivity: to touch, pain, heat, cold and pressure Thermal regulation: controlled by radiation, evaporation, conduction. Excretion and secretion: sweat by evaporation. Sebum lubricates the skin and hair. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 9 Principles of wound healing A wound represents a disruption in the normal structure (skin layers) and functions of the skin and underlying soft tissues. It can be related to a variety of etiologies: ü Trauma, ü Surgery, ü sustained pressure, ü Vascular disease ü Infection etc. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 10 Types of wounds Human beings sustain wounds across their lifespan Wounds range from a simple knee abrasion to a major surgical incision or an open wound. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 11 Main types of wounds 1) Acute Wounds: acute wounds progress through the normal stages of wound healing and show clear signs of healing within four weeks. e.g., abrasions, lacerations, surgical incisions 2) Chronic wounds: chronic wounds do not progress normally through the stages of healing (often getting ‘stalled’ in one phase) and do not show evidence of healing within four weeks. e.g., venous, arterial or diabetic foot ulcers 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 12 Phases of Wound Healing During healing, a complex cascade of cellular events occur to achieve resurfacing, reconstitution and restoration of tensile strength of injured tissue. Wound healing occurs in 3 phases: 1. Hemostasis phase 2. Inflammatory phase 2. Proliferative phase 3. Remodeling phase 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 13 Phases of wound healing 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 14 Hemostasis phase The purpose of this phase is to stop bleeding 1.Starts immediately following the injury 2. Blood vessels constrict 3. Coagulation occurs to stop bleeding 4. Blood clot also acts as temporary barrier to bacteria 5. Platelets release growth factors and attracts cells essential to repair process 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 15 Inflammatory Phase 1. In the first 2-3 days vasodilation occurs The purpose of this phase is to clean the wound and defend it against bacteria 2. Plasma and blood cells leaks into the wound causing edema, erythema and exudate formation. 3. Leukocytes and macrophages (white blood cells) arrive in the wound to start the clean up and repair. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 16 Proliferative Phase The purpose of the formation of new tissue (granulation tissue) 1.New capillaries (angiogenesis) are created 2. Oxygen and nutrients are carried into the wound by capillaries 3. Fibroblast synthesize collagen to provide strength and structural integrity 4. Contractions occur to reduce wound size 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 17 Maturation (remodeling) Phase The purpose of the formation of scar 1.Collagen is remodelled into new and stronger tissue 2. In this phase wound is covered with epithelial tissue 3. The tensile strength of the healed tissue is almost 80% of its original skin 4. Although the wound is closed the healing will last up to 2 years 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 18 Types of Wound Healing Primary intention wound edges of a clean surgical incision remain close together wound heals quickly, minimal or no tissue loss Incision Healed Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 19 Types of Wound Healing Secondary Intention wounds are left open and allowed to heal by scar formation tissue loss and open wound edges granulation tissue gradually fills in the area Secondary intention Open wound Granulation/proliferation phase Remodelalling phase Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 20 Types of Wound Healing Tertiary intention also known as delayed primary intention or closure occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema and infection to diminish or abscess to be drained. Then the wound is left open to heal by scar formation. Open wound Wound drainage/clean Granulation/proliferation phase Lectured by Dr. Ide Costa (RN, NSWOC, PhD) Remodelling phase 21 FACTORS AFFECTING HEALING PROCESS Nutrition and hydration Advanced Age Extent of the injury Infection Chronic diseases Products cytotoxic for fibroblasts Pressure offloading Blood supply Smoking Medication 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 22 Homework Define each each of this terms and provide rationale/reason as it is a complication of wound Wound complications: Hemorrhage Infections Fistula Abscess formation Cellulitis Necrosis or Gangrene Keloids (raised pinkish scar tissue at the site of an injury) Pain Fluid collection Interference with organ function 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 23 Part II: Pressure Injury Prevention Ide Costa RN, NSWOC, PhD 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 24 Pressure Injury (pressure ulcer, bedsore) A localized area of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and friction Comprehensive skin assessment identifies the factors increasing patient’s risk for a pressure injury (Potter & Perry, 2018, 2019) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 25 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 26 Pressure injury classification (Potter & Perry, 2018, 2019) Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 27 Stage 1: Nonblanchable Erythema Intact skin with darkened areas. Changes in sensation, temperature, or firmness Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 28 PhD) Stage II: Partial Thickness Skin Loss With Exposed Dermis Wound bed is pink and viable, may have serum blister Adipose not visible, no slough or granulation Often associated with moisture, skin tears, medical devices Partial thickness Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 29 PhD) Stage III: Full Thickness Skin Loss Full thickness skin loss Adipose (fat) and granulation present, slough and eschar may be visible Areas with adipose tissue are deeper Undermining and tunneling may occur Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 30 PhD) Stage IV: Full Thickness Tissue Loss Full thickness tissue loss Exposed fascia, muscle, tendons, etc Slough and eschar may be visible Undermining and tunneling often present Note: If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury (Potter & Perry, 2018, 2019) Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 31 Deep Tissue Injury Intact or not intact skin with unblanchable deep red or maroon discolouration revealing blood filled blister Pain and temperature changes Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 32 PhD) Unstageable Pressure Injury Full thickness skin and tissue loss where the loss cannot be determined due to obscure slough and eschar Once those removed, may reveal Stage III or IV Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 33 PhD) Evidence-Based Practice for Pressure injury prevention “ADSD” Assess Document Perform and repeat risk assessments regularly and as frequently according to patient’s condition Document all risk assessments Score Score - use risk scores to plan care, and perform interventions accordingly Detect Ongoing skin assessment can detect early signs of pressure damage 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 34 PhD) Skin Assessment, Skin assessment and Prevention Strategies Skill 39-1 Prevention of pressure injury requires Early identification of at-risk patients Early implementation of prevention strategies (see Table 39.4) Implement cost-effective strategies/plans that prevent/treat pressure ulcers Perform risk assessment on entry to the health care setting, when patient is transferred to another unit or setting, and repeat on a scheduled basis or when a significant change in the patient’s condition is noted (see Table 39.3) Use risk assessment tools (Braden scale) Inspect the patient’s skin and bony prominences at least daily 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 35 PhD) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 36 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 37 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 38 Interpreting Braden Scale (Potter & Perry, 2018) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 39 Prevention Guidelines § Routinely assess patients for individual risks for development of pressure injury. See Table 39.1 for Braden Risk Assessment Scale See table 39.2 for interpretation of score § Perform pressure injury risk assessment on all patients who have one or more risk factors § Assess and inspect skin at least daily. Note all pressure points; document results. § Redistribute the amount and duration of pressure to prevent ischemic tissue injury and damage. § Turn and reposition a bedbound patient every 2 hours and a chairbound every 1h § The pressure redistribution pressure allow tissues to compensate for temporary ischemia. § Specialized beds, overlays, and mattresses redistribute pressure over the entire body to prevent excess pressure over bony prominences. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) (Potter & Perry, 2018) 40 Prevention Guidelines continued § Clean patients who are incontinent of stool or urine as soon as possible. § Use approaches to minimize friction and shear. § Adequate nutrition helps in prevention and treatment of pressure ulcers. § Understand risks of obesity § Clean drain using circular stroke § Be aware of factors that decrease oxygenation § Know the types of medications prescribed § Identify presence of chronic diseases that may impact issue perfusion (Potter & Perry, 2018) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 41 Comfort position to prevent pressure injury (Potter & Perry, 2018) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 42 Wound assessment and Management (dressings) Ide Costa RN, NSWOC, PhD 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 43 Wound assessment: Begining of Treatment Step 1 Wound care nurses (WCN): Ø Etiology Ø Clinical History Ø Physiology of healing Wound assessment skills Dressing & actions Ø Healing Phases Ø Factors delaying healing Ø Documentation 2023-02-28 Wound care Knowledge Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 44 Performing a wound assessment Assessment of the wound occurs before, during, and after the wound is cleaned and irrigated. The following parameters are included when performing a wound assessment: Wound assessment: Location: Note the anatomical position of the wound. Type of wound: If known, identify the etiology of the wound (i.e., surgical, pressure, trauma). Extent of tissue involvement: A full-thickness wound involves both the dermis and epidermis. A partialthickness wound involves only the epidermal layer. If it is a pressure injury, use the staging system (see Box 39.3). Type and percentage of tissue in wound base: Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate percentage of each type. Wound size: Follow employer policy to measure wound dimensions, which include width, length, and depth. Wound exudate: Describe the amount, colour, and consistency. Serous drainage is clear like plasma; sanguineous or bright red drainage indicates fresh bleeding; serosanguinous drainage is pink; and purulent drainage is thick and yellow, pale green, or white. Presence of odour: Note the presence or absence of odour, which may indicate infection. Wound edge: Determine if the wound edges are rolled, jagged, or smooth; pink (healing) or white (maceration) in colour. Periwound area: Assess the colour, temperature, and integrity of surrounding skin. Note any indication of reaction to dressing (e.g., redness from adhesive tape). Pain: Use a validated pain assessment scale to evaluate pain Tunneling/undermining – assess wound for any tunnel or undermining. Use cotton tipped applicators to determine the size of the tunnel. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 45 PhD) Wound and periwound Assessment l Wound measurement: Using a paper ruler – from open to open wound edges (longest points) ü ü ü Length (cm) (head to toe) – using the clock method (12:00 – 6:00) measure the longest points Width (cm) – side to side, using clock method (3:00 – 9:00) Depth – moisten a cotton-tip with saline – place the applicator into the deepest área of the wound (vertical). 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 46 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 47 Dressings, Bandages, and Binders Correct use promotes wound healing Nurses must have knowledge of proper wound dressing techniques Selection of dressing: Based on characteristics of wound Expected outcomes desired If acute or chronic wounds Practicality and feasibility of dressing changes in the home setting 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 48 PhD) Principles for Practice Understand wound healing process Hemostasis Inflammation Proliferation Maturation 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 49 PhD) Principles for Practice – (Cont.) Wound bed preparation – is a systematic approach to cleanse the wound to correct the molecular and cellular abnormalities, which is critical to promoting healing of chronic wounds Its systematic approach addresses 4 key principals known by the acronym TIME: Tissue debridement Infection/inflammation Moisture balance Edge of the wound 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 50 PhD) Principles for Practice (Cont.) Physiological wound environment principles Effective dressings Primary wound healing Secondary wound healing Dressing material to promote wound healing 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 51 PhD) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 52 PhD) Patient-Centered Care Select dressings according to the needs and preferences of patient Provide analgesic doses 30 minutes prior to dressing change Select dressings that help reduce pain Accommodate different cultures and religious practices Assess patient or caregiver knowledge of wound care 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 53 PhD) Principles of wound management 1. Know the cause and type of wound. 2. Identify appropriate wound cleansing agents. 3. Know the expected amount and type of wound exudate or drainage. 4. Determine if wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing. 5. Perform hand hygiene prior to and after a dressing change. 6. Use the appropriate type of gloves when changing a dressing. 7. Make sure that patients in the home setting know infection control principles. 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 54 PhD) Gauze drsg Transparent film drsg Hydrocolloid drsg 2023-02-28 Hydrogel Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 55 PhD) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 56 PhD) 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) (Potter & Perry, 2018, 2019) 57 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 58 PhD) Foam drsg Hydrofiber 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 59 PhD) Packing Some wounds require packing to promote feeling Purpose: fill dead space and avoid potential abscess formation Gauze impregnated with hydrogel used for undermining or tunnelling Ribbon gauze used to fill narrow areas 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 60 PhD) packing 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 61 PhD) Cleansing a Wound 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 62 PhD) Applying a Pressure Bandage Skill 40-2 Pressure bandages Temporary treatment to control excessive, unanticipated bleeding Stop blood flow and promote clotting Aseptic technique is secondary during an episode of acute bleeding 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, (Potter & Perry, 2018, 2019) 63 PhD) Applying an Abdominal Binder Procedural Guideline 41-2 Binders Elastic or cotton Supports large abdominal incisions from tension/stress; lessens pain post op Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 64 Nursing Diagnosis Inadequate peripheral tissue perfusion Insufficient knowledge regarding pressure injury prevention Inadequate nutrition Reduced mobility Reduced skin integrity Potential for impaired skin integrity 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 65 Planning Establish patient needs and baseline for future assessment Identify prevention interventions verify patient social support for continuity of care relieve anxiety and educate patients 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 66 Implementation Use of evidenced-based guidelines Optimal treatment option (types of products) Health promotion Topical Skin care positioning support surfaces (therapeutic Beds and Matresses) Education Management of injury 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 67 Evaluation Reassess skin for signs and symptoms related to impaired skin integrity and wound healing check patient’s understanding and perception about skin integrity and internvention Check expectations 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 68 Documentation Wound appearance: be objective Location Size & shape Amount & type of wound bed tissue 50% granulation tissue 50% yellow slough Amount & type of exudate Wound edges (macerated, red, dermatitis) Dressing/treatment applied 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 69 Summary Nurses play an important role in wound healing Wound healing is a dynamic process Generalist nurses should consult with wound nurse specialist when managing complex/chronic wounds Understand treatment modalities is important to help in the decision making Assess the effectiveness of the wound management regimen periodically If a wound is not responding (measurement) the dressing is not appropriate and need to be changed Document wound features and care provided 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 70 2023-02-28 Lectured by Dr. Ide Costa (RN, NSWOC, PhD) 71 Contact information Idevania (Ide) Costa (RN,NSWOC, Ph.D.) Assistant Professor E-mail: [email protected] Office: SN1034 Phone: 807-343-8340 Office Hours: 8:30am to 4:30pm Lectured by Dr. Ide Costa