Skin Integrity and Wound Care PDF

Skin Integrity and Wound Care R. Gilliard, DNP, MS, CRNP, CNE Copyright © 2011 Copyright Wolters © 2019 Kluwer Wolters Health All Kluwer | Lippincott...

Skin Integrity and Wound Care R. Gilliard, DNP, MS, CRNP, CNE Copyright © 2011 Copyright Wolters © 2019 Kluwer Wolters Health All Kluwer | Lippincott Williams & Wilkins Rights Reserved Functions of the Skin  Protection  Body temperature regulation  Psychosocial  Sensation  Vitamin D production  Immunologic  Absorption  Elimination Copyright © 2019 Wolters Kluwer All Rights Reserved Question #1 Tell whether the following statement is true or false. Blood vessels in the skin dilate to dissipate heat. A. True B. False Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #1 Answer: A. True Rationale: Blood vessels in the skin dilate to dissipate heat. Copyright © 2019 Wolters Kluwer All Rights Reserved Cross-Section of Normal Skin Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Affecting the Skin  Unbroken and healthy skin and mucous membranes defend against harmful agents.  Resistance to injury is affected by age, amount of underlying tissues, and illness.  Adequately nourished and hydrated body cells are resistant to injury.  Adequate circulation is necessary to maintain cell life. Copyright © 2019 Wolters Kluwer All Rights Reserved  Developmental Considerations  In children younger than 2 years, the skin is thinner and weaker than it is in adults.  An infant’s skin and mucous membranes are easily injured and subject to infection; a child’s skin becomes increasingly resistant to injury and infection.  The structure of the skin changes as a person ages; the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.  Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure. Copyright © 2019 Wolters Kluwer All Rights Reserved Causes of Skin Alterations  Very thin and very obese people are more susceptible to skin injury. o Fluid loss during illness causes dehydration. o Skin appears loose and flabby.  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. Copyright © 2019 Wolters Kluwer All Rights Reserved Types of Wounds  Intentional or unintentional  Open or closed  Acute or chronic  Partial thickness, full thickness, complex Copyright © 2019 Wolters Kluwer All Rights Reserved Question #2 Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? A. Contusion B. Abrasion C. Laceration D. Avulsion Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #2 Answer: A. Contusion Rationale: A contusion is caused by a blunt instrument and may result in bruising or hematoma. An abrasion is the rubbing or scraping of epidermal layers of skin. A laceration is the tearing of skin and tissue with a blunt or irregular instrument. Avulsion is the tearing of a structure from normal anatomic position. Copyright © 2019 Wolters Kluwer All Rights Reserved Asepsis Medical Asepsis Surgical Asepsis  All practices intended to  Sterile technique confine a specific microorganism to a specific area, limiting the number,  Refers to those practices growth, and transmission that keep an area or object of microorganisms free of all microorganisms  Objects are referred to as  It includes practices that “clean” or “dirty” destroy all microorganisms and spores. Copyright © 2019 Wolters Kluwer All Rights Reserved Aseptic Technique  Includes all activities to prevent or break the chain of infection  Two categories: o Medical asepsis - clean technique o Surgical asepsis - sterile technique Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Determining Use of Sterilization and Disinfection Methods  Nature of organisms present  Number of organisms present  Type of equipment  Intended use of equipment  Available means for sterilization and disinfection  Time Copyright © 2019 Wolters Kluwer All Rights Reserved Use of Surgical Asepsis  Operating room, labor and delivery areas  Certain diagnostic testing areas  Patient bedside o For example, for procedures that involve insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine Copyright © 2019 Wolters Kluwer All Rights Reserved Principles of Sterile Technique  Sterile objects can become unsterile by prolonged exposure to airborne microorganisms  Fluids flow in the direction of gravity (wet forceps should be held with tip below handle) Copyright © 2019 Wolters Kluwer All Rights Reserved Principles of Sterile Technique  Sterile field – micro-organism free area  All objects used in a sterile field must be sterile  Sterile objects become unsterile when touched by unsterile objects  Sterile items that are out of vision or below the waist are considered unsterile Copyright © 2019 Wolters Kluwer All Rights Reserved Establishing a Sterile Field  Ensure that package is intact, clean and dry  Check the sterilization expiration dates  Follow agency practice about proper disposal of package Copyright © 2019 Wolters Kluwer All Rights Reserved Principles of Sterile Technique  Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action  The edges of a sterile field are considered unsterile (one inch border)  The skin cannot be sterilized…wear sterile gloves to handle sterile items. Copyright © 2019 Wolters Kluwer All Rights Reserved Donning Sterile Gloves  Sterile gloves are packaged with a 2 inch cuff and palms facing upward  Package indicates size of glove (6, 6.5, 7, 7.5, 8)  Latex, nitrile, and vinyl sterile gloves are available - latex and nitrile are more flexible. Copyright © 2019 Wolters Kluwer All Rights Reserved Principles of Wound Healing #1  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. Copyright © 2019 Wolters Kluwer All Rights Reserved Principles of Wound Healing #2  The extent of damage and the person’s state of health affect wound healing.  Response to wound is more effective if proper nutrition is maintained. Copyright © 2019 Wolters Kluwer All Rights Reserved Phases of Wound Healing  Hemostasis  Inflammatory  Proliferation  Maturation Copyright © 2019 Wolters Kluwer All Rights Reserved Question #3 In which phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory phase C. Proliferation phase D. Maturation phase Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #3 Answer: C. Proliferation phase Rationale: In the proliferation phase, granulation tissue is formed to fill the wound. In hemostasis, involved blood vessels constrict and blood clotting begins. In the inflammatory phase, white blood cells move to the wound. In the maturation phase, collagen is remodeled, forming a scar. Copyright © 2019 Wolters Kluwer All Rights Reserved Hemostasis  Occurs immediately after initial injury  Involved blood vessels constrict and blood clotting begins.  Exudate is formed, causing swelling and pain.  Increased perfusion results in heat and redness.  Platelets stimulate other cells to migrate to the injury to participate in other phases of healing. Copyright © 2019 Wolters Kluwer All Rights Reserved Inflammatory Phase  Follows hemostasis and lasts about 2 to 3 days  White blood cells, predominantly leukocytes and macrophages, move to the wound.  Macrophages enter the wound area and remain for an extended period.  They ingest debris and release growth factors that attract fibroblasts to fill in the wound.  The patient has a generalized body response. Copyright © 2019 Wolters Kluwer All Rights Reserved Proliferation Phase  Lasts for several weeks.  New tissue is built to fill the wound space through the action of fibroblasts.  Capillaries grow across the wound.  A thin layer of epithelial cells forms across the wound.  Granulation tissue forms a foundation for scar tissue development. Copyright © 2019 Wolters Kluwer All Rights Reserved Maturation Phase  Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years.  Collagen is remodeled.  New collagen tissue is deposited.  Scar becomes a flat, thin, white line. Copyright © 2019 Wolters Kluwer All Rights Reserved Copyright © 2019 Wolters Kluwer All Rights Reserved Local Factors Affecting Wound Healing  Pressure  Desiccation (dehydration)  Maceration (overhydration)  Trauma  Edema  Infection  Excessive bleeding  Necrosis (death of tissue)  Presence of biofilm (thick grouping of microorganisms) Copyright © 2019 Wolters Kluwer All Rights Reserved Systemic Factors Affecting Wound Healing  Age: children 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 affects healing  Health status: corticosteroid drugs and postoperative radiation therapy delay healing  Immunosuppression  Medication use  Adherence to treatment plan Copyright © 2019 Wolters Kluwer All Rights Reserved Wound Complications  Infection  Hemorrhage  Dehiscence and evisceration  Fistula formation Copyright © 2019 Wolters Kluwer All Rights Reserved Question #4 Which wound complication is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #4 Answer: D. Maceration Rationale: Maceration is caused by overhydration related to incontinence that causes impaired skin integrity. Necrosis is dead tissue present in the wound that delays healing. Edema is swelling at a wound site that interferes with blood supply to the area. Desiccation is the process in which the cells dehydrate and die. Copyright © 2019 Wolters Kluwer All Rights Reserved Wound Dehiscence and Evisceration Copyright © 2019 Wolters Kluwer All Rights Reserved Psychological Effects of Wounds  Pain  Anxiety  Fear  Impact on activities of daily living  Change in body image Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Affecting Pressure injury Development  Aging skin  Chronic illnesses  Immobility  Malnutrition  Fecal and urinary incontinence  Altered level of consciousness  Spinal cord and brain injuries  Neuromuscular disorders Copyright © 2019 Wolters Kluwer All Rights Reserved Mechanisms in Pressure Injury Development  External pressure compressing blood vessels  Friction or shearing forces tearing or injuring blood vessels Copyright © 2019 Wolters Kluwer All Rights Reserved Pressure injury Assessment  Risk assessment  Mobility  Nutritional status  Moisture and incontinence  Appearance of existing pressure injury  Pain assessment Copyright © 2019 Wolters Kluwer All Rights Reserved Pressure Ulcer Scale for Healing (PUSH) PUSH Tool 3.0 Copyright © 2019 Wolters Kluwer All Rights Reserved Braden Scale Copyright © 2019 Wolters Kluwer All Rights Reserved Stages of Pressure injuries  Stage 1: nonblanchable erythema of intact skin  Stage 2: partial-thickness skin loss with exposed dermis  Stage 3: full-thickness skin loss; not involving underlying fascia  Stage 4: full-thickness skin and tissue loss  Unstageable: obscured full-thickness skin and tissue loss  Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration Copyright © 2019 Wolters Kluwer All Rights Reserved Copyright © 2019 Wolters Kluwer All Rights Reserved Measurement of a Pressure injury  Size of wound  Depth of wound  Presence of undermining, tunneling, or sinus tract Copyright © 2019 Wolters Kluwer All Rights Reserved Question #5 Tell whether the following statement is true or false. A stage 3 pressure injury requires débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. A. True B. False Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #5 Answer: A. True Rationale: A stage 3 pressure injury requires débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. Copyright © 2019 Wolters Kluwer All Rights Reserved Cleaning a Pressure Injury/Wound  Clean with each dressing change.  Use new gauze for each wipe and clean from top to bottom and/or from the center to the outside.  Use 0.9% normal saline solution to irrigate and clean the injury.  Once the wound is cleaned, dry the area using a gauze sponge in the same manner  Report any drainage or necrotic tissue. Copyright © 2019 Wolters Kluwer All Rights Reserved COVID-19 Hypercoagulability Deep vein thrombosis (DVT) 60-year-old healthy male, no comorbidities (Prof. Hannafin’s cousin) Copyright © 2019 Wolters Kluwer All Rights Reserved Result of COVID- 19 DVT What nursing interventions could have prevented this stage IV pressure ulcer? Copyright © 2019 Wolters Kluwer All Rights Reserved COVID -19 post DVT & stage IV Osteomyelitis Porta Cath placement: several rounds of eight- week antibiotic treatment Skin graft to heel 8 months treatment in hyperbaric chamber May never place high level impact on this heel again, had to give up many former activities Copyright © 2019 Wolters Kluwer All Rights Reserved Wound Assessment  Inspection for sight and smell  Palpation for appearance, drainage, and pain o Serous drainage o Sanguineous drainage o Serosanguineous drainage o Purulent drainage  Sutures, drains or tubes, and manifestation of complications Copyright © 2019 Wolters Kluwer All Rights Reserved Assessment of Wound Drainage  Serous  Sanguineous  Serosanguineous  Purulent Copyright © 2019 Wolters Kluwer All Rights Reserved Presence of Infection  Wound is swollen.  Wound is deep red in color.  Wound feels hot on palpation.  Drainage is increased and possibly purulent.  Foul odor may be noted.  Wound edges may be separated, with dehiscence present. Copyright © 2019 Wolters Kluwer All Rights Reserved Purposes of Wound Dressings  Provide physical, psychological, and aesthetic comfort  Prevent, eliminate, or control infection  Absorb drainage  Maintain moisture balance of the wound  Protect the wound from further injury  Protect the skin surrounding the wound  Debride (remove damaged/necrotic tissue), if appropriate  Stimulate and/or optimize the healing response  Consider ease of use and cost-effectiveness Copyright © 2019 Wolters Kluwer All Rights Reserved Types of Wound Dressings  Telfa  Gauze dressings  Transparent dressings Copyright © 2019 Wolters Kluwer All Rights Reserved Basic Dressing Change  Gather needed wound care supplies  Perform hand hygiene  Don clean gloves  Remove the old wound dressing (if present)  Remove gloves and perform hand hygiene  Don clean gloves  Cleanse the wound with specified solution  Let the wound dry  Apply specified dressing material  Secure the dressing in place Copyright © 2019 Wolters Kluwer All Rights Reserved Types of Bandages  Roller bandages  Circular turn  Spiral turn  Figure-of-eight turn Copyright © 2019 Wolters Kluwer All Rights Reserved Types of Binders  Slings  Abdominal binders  Chest binders  T-binders Copyright © 2019 Wolters Kluwer All Rights Reserved Type of Drainage Systems  Open systems o Penrose drain  Closed systems o Jackson-Pratt drain o Hemovac drain Copyright © 2019 Wolters Kluwer All Rights Reserved Penrose Drain Copyright © 2019 Wolters Kluwer All Rights Reserved Penrose Drain cont. Copyright © 2019 Wolters Kluwer All Rights Reserved Jackson-Pratt Drain Copyright © 2019 Wolters Kluwer All Rights Reserved Jackson-Pratt Drain cont. Copyright © 2019 Wolters Kluwer All Rights Reserved Hemovac drain Copyright © 2019 Wolters Kluwer All Rights Reserved Negative Pressure Wound Therapy (NPWT) Copyright © 2019 Wolters Kluwer All Rights Reserved NPWT Mechanism of Action Copyright © 2019 Wolters Kluwer All Rights Reserved NPWT Process of Wound Healing Copyright © 2019 Wolters Kluwer All Rights Reserved Color Classification of Open Wounds  R = red—protect  Y = yellow—cleanse  B = black—débride  Mixed wound—contains components of RY&B wounds Copyright © 2019 Wolters Kluwer All Rights Reserved Topics for Home Health Care Teaching  Supplies  Infection prevention  Wound healing  Appearance of the skin/recent changes  Activity/mobility  Nutrition  Pain  Elimination Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Affecting the Response to Hot and Cold Treatments  Method and duration of application  Degree of heat and cold applied  Patient’s age and physical condition  Amount of body surface covered by the application Copyright © 2019 Wolters Kluwer All Rights Reserved Effects of Applying Heat  Dilates peripheral blood vessels  Increases tissue metabolism  Reduces blood viscosity and increases capillary permeability  Reduces muscle tension  Helps relieve pain Copyright © 2019 Wolters Kluwer All Rights Reserved Effects of Applying Cold  Constructs peripheral blood vessels  Reduces muscle spasms  Promotes comfort Copyright © 2019 Wolters Kluwer All Rights Reserved Devices to Apply Heat  Hot water bags  Electric heating pads  Aquathermia pads  Hot packs  Warm, moist compresses  Sitz baths  Warm soaks Copyright © 2019 Wolters Kluwer All Rights Reserved Devices to Apply Cold  Ice bags  Cold packs  Hypothermia blankets  Cold compresses to apply moist cold Copyright © 2019 Wolters Kluwer All Rights Reserved