Skin Integrity and Wound Care 2023 PDF

Skin integrity and Wound care NUR 102 2023 1  Skin integrity Intact skin: presence of normal skin layers uninterrupted by wounds. Impaired skin integrity is a threat to: - Elders - Client with restricted mobili...

Skin integrity and Wound care NUR 102 2023 1  Skin integrity Intact skin: presence of normal skin layers uninterrupted by wounds. Impaired skin integrity is a threat to: - Elders - Client with restricted mobility - Chronic illness - Trauma - Those undergoing invasive health care procedure 2  Skin integrity The skin is the body’s largest organ and the primary defense against pathogenic invasion. The skin also contributes to temperature regulation, prevents loss of internal fluids, and provides sensory awareness. The appearance of skin and skin integrity are influenced by: - Internal factors( genetics, age and status of person’s health, malnutrition) - External ( activity, sun and medications as AB and chemotherapy, corticosteroids) 3  Types of wound Intentional: trauma occurs during therapy as operation, vein puncture and tumor excision Unintentional: are accidental as fracture from car accident and  Closed: tissue trauma without a break in the skin  Open: when the skin or mucous membrane surface is broken 4  Types of the wound according to the way they acquired 1. Incision: sharp instrument (open wound; deep or shallow) 2. Contusion: blow from a blunt instrument (closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels) 3. Abrasion: surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks) (open wound involving the skin) 5 3. Puncture: penetration of the skin &often the underlying tissue by a sharp instrument, either intentional or unintentional (open wound) 4. Laceration: tissue torn a part, often from accident( e.g., with machinery) (open wound; edges are often jagged) 5. Penetrating wound: penetration of the skin & the underlying tissue, usually unintentional (e.g., from bullet or metal fragments) (open wound) 6  Wound description according to degree of contamination Clean wound: are uninfected wound in which minimal inflammation is encountered and the respiratory, genital, urinary tract are not entered. Clean wound are primarily closed wound Clean-contaminated wounds: are surgical wounds in which respiratory, alimentary, genital or urinary tract has been entered, such wounds show no evidence of infection (high risk of infection) Contaminated wounds: include open, fresh, accidental wounds & surgical wounds involving a major break in sterile technique there is an evidence of inflammation Dirty or infected wounds: wounds containing dead tissue & wounds with evidence of a clinical infection, such as purulent drainage (old, accidental wounds) 7  Pressure ulcers Also called bedsores , pressure sores or decubitus ulcers: injury to skin (usually over a bony prominence) caused by unrelieved pressure. Etiology: – Tissue is compressed between two surfaces a deficiency in blood supply to these tissues the cells are deprived of O2 and nutrient (pale) + waste products accumulates in cells tissues die localized ischemia. (when pressure is relieved, the skin takes on a bright red flush called reactive hyperemia due to vasodilation. Reactive hyperemia lasts ½ - ¾ as long as the duration of impeded blood flow to the area) 8  Risk Factors for Pressure Ulcers Friction and shearing: – Friction: is a force acting parallel to the skin surface (sheets rubbing against skin create friction). – Shearing forces: is the combination of friction & pressure. It occurs commonly when a client assumes a sitting position. Immobility no control to change position Inadequate nutrition: causes wt. loss, muscle atrophy, loss of SC in which decrease the amount of padding between skin and bone. (diet low in protein, CHO, vit c, fluids, zinc) 9  Fecal & urinary incontinence: promotes skin maceration (tissue softened by prolonged wetting or soaking) Decrease mental status: pt. with reduced level of awareness unconscious or heavily sedative are less able to respond to pain perception. Diminished sensation paralysis, stroke, reduce ability to respond to heat or cold sensation Excessive body heat: fever increase BMR thus increase the cell need for o2 especially in the pressure area, fever with infection may affect the body ability to deal with the compressed area. Advanced age: aging process brings a lot of skin changes (loss of body mass, pain perception, thinning of epidermis, alteration in venous and arterial flow…) Chronic disease (CVD, DM.) compromise O2 delivery and delay healing Other factors: Poor lifting technique, incorrect positioning, repeated injections. 10  Complications of Wound Healing Hemorrhage: due to removal of clot, slipped stich, erosion of blood vessel, risks increase in the 1st 48hr’s after surgery - Internal ( swelling and distension under skin, may called hematoma, if it large may cause compression in the blood vessels) - External (blood appear under dressing or escape. So apply sterile pressure dressing + check V/S) Infection: impaired skin healing, become apparent 2-11 day post operative, cause change in wound color, pain, exudate, fever, increase WBC’s, hotness, tenderness and redness, foul odor 11 Dehiscence: Partial or total rupturing of sutured wound, occur 4-5 day post op, it is due to obesity, poor nutrition, multiple trauma, excessive coughing and sneezing, sudden straining and dehydration, it is managed by (large sterile dressing soaked in N|S, place pt in bed with knee bent, then notify doctor Evisceration: Protrusion of the intestines through the incision 12 13  Factors Affecting Wound Healing Age: Young, Adult, or Elderly Nutritional status: diet. Obesity Lifestyle: Exercise, smoking, poor hygiene Medications: anti-inflammatory drugs (steroids, aspirin) AB interfere with MO resistance. Contamination or infection 14  Nursing Process: Assessment Nursing history – Review of systems – Skin diseases – Previous bruising – General skin condition – Skin lesions – Usual healing of sores 15  Inspection and palpation – Skin color distribution – Skin turgor – Presence of edema – Characteristics of any skin lesions – Particular attention paid to areas that are most likely to break down Untreated wounds – Location – Extent of tissue damage – Wound length, width, and depth – Bleeding – Foreign bodies – Associated injuries – Last tetanus toxoid injection 16  Treated wounds – Appearance – Size – Drainage – Presence of swelling – Pain – Status of drains or tubes Pressure Ulcers - Location of the ulcer related to a bony prominence - Size of ulcer in centimeters including length (head to toe), width (side to side), and depth - Presence of undermining or sinus tracts - Stage of the ulcer - Color of the wound bed - Location of necrosis or Eschar - Condition of the wound margins - Integrity of surrounding skin - Clinical signs of infection 17 Laboratory Data:  Leukocyte count: decrease LEUKOCTE COUNT delay healing increase risk for infection. Hemoglobin level: Low Hgb poor O2 delivery to tissue  Blood coagulation: prolonged coagulation times result in severe bleeding, while hypercoagulability lead to intravascular clotting while intra-arterial clotting decrease bld supply to wound  Serum protein indicates nutritional status serum albumin indicate nutritional status less than 3.5 g/dl increase risk for infection, and delay healing  Wound culture :rule out presences of infection  Sensitivity tests: to select the proper AB 18  Nursing Diagnoses – Risk for Impaired Skin Integrity – Impaired Skin Integrity: – Impaired Tissue Integrity – Risk for Infection – Pain 19  Goals in Planning Client Care Risk for Impaired Skin Integrity – Maintain skin integrity – Avoid or reduce risk factors Impaired Skin Integrity – Progressive wound healing – Regain intact skin Client and family education – Assess and treat existing wound – Prevention of pressure ulcers 20  Dressings for DRY wounds Wet – to Moist Gauze 21  Implementation Supporting wound healing : maintain moist wound healing, nutrition and fluid, preventing infection and positioning Preventing pressure ulcer Treating pressure ulcer :RYB ( Red, Yellow, Black) Dressing wound Cleaning wound Supporting and immobilizing wound Heat and cold application 22  Dressing wound Purposes: - To protect the wound from mechanical injury - To protect the wound from infection - To maintain moist wound healing - To absorb drainage - To prevent hemorrhage - To splint or immobilize the wound 23  Types of Wound Dressings Transparent film Impregnated no adherent Hydrocolloids Clear absorbent acrylic Hydrogel Polyurethane foam Alginate 24  Types of Bandages Gauze – Restrain dressings on wounds – Bandage hands and feet Elasticized – Provide pressure to an area – Improve venous circulation in legs Binders – Support large areas of body Triangular arm sling; straight abdominal binder 25 Figure 36-10 The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The tape should adhere to intact skin. 26 Figure 36-11 Dressings over moving parts must remain secure in spite of the client ’s movement. Place the tape over a joint at a right angle to the direction the joint moves. 27 Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client ’s movement. Place the tape over a joint at a right angle to the direction the joint moves. 28 Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client ’s movement. Place the tape over a joint at a right angle to the direction the joint moves. 29 Figure 36-14 Starting a bandage with two circular turns. 30 Figure 36-15 Applying spiral turns. 31 Figure 36-16 Applying spiral reverse turns. 32 Figure 36-17 Starting a recurrent bandage. 33 Figure 36-18 Completing a recurrent bandage. 34 Figure 36-19 Applying a figure-eight bandage. 35 Figure 36-20 Large arm sling. 36 Figure 36-20 (continued) Large arm sling. 37 Figure 36-21 A straight abdominal binder. 38 Obtaining a Wound Specimen 39 Copyright 2008 by Pearson Education, Inc. Irrigating a Wound Skill 36-2 40 Copyright 2008 by Pearson Education, Inc.  Physiologic Effects of Heat Vasodilation Increases capillary permeability (edema) Increases cellular metabolism Increases inflammation Produces sedative effect 41  Physiologic Effects of Cold Vasoconstriction Decreases capillary permeability Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect 42  When heat or cold applied we should consider:  neurosensory function of the patient Impaired mental status Impaired circulation Immediate after surgery Open wound 43  Methods for Applying Dry and Moist Heat Dry heat Moist heat – Hot water bottle – Compress – Aquathermia pad – Hot pack – Disposable heat pack – Soak – Electric pad – Sitz bath 44  Methods for Applying Dry and Moist Cold Dry cold Moist cold – Cold pack – Compress – Ice bag – Cooling sponge bath – Ice glove – Ice collar 45 Figure 36-3 Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position. 46 Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position. 47 Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position. 48 Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position. 49 Thank you