CH 48-skin integrity:wound care PDF

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NR224 Chapter Skin Integrity and Wound Care Objective: Discuss the risk factors that contribute to pressure ulcer formation A variety of factors predispose a patient to pressure ulcer formation. These factors are often directly related to disease such as decreased level of consciousness, the presenc...

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NR224 Chapter 48- Skin Integrity and Wound Care Objective: Discuss the risk factors that contribute to pressure ulcer formation A variety of factors predispose a patient to pressure ulcer formation. These factors are often directly related to disease such as decreased level of consciousness, the presence of a cast, or secondary to a. illness (e.g., decreased sensation following cerebrovascular accident) 1. Impaired Sensory Perception  Patients with impaired sensory perception of pain and pressure are unable to feel when a part of their body undergoes increased, prolonged pain or pressure. Thus, a patient who can’t feel or sense that there is pain or pressure is at risk for the development of pressure ulcers 2. Impaired mobility  Patients unable to independently change positions are at risk for pressure ulcer development. For example, a morbidly obese patient who is seriously ill will be weakened and less likely to turn independently. 3. Alteration in Level of Consciousness  Patients who are confused or disoriented, those who have expressive aphasia or the inability to verbalize, or those with changing levels of consciousness are unable to protect themselves from pressure ulcer development. A patient in a coma cannot perceive pressure and is unable to move voluntarily to relieve pressure. 4. Shear 

Shear force is the sliding movement of the skin and subcutaneous tissue while the underlying muscle and bone are stationary. For example, shear force occurs when the head of the bed is elevated, and the sliding of the skeleton starts but the skin is foxed because of friction with the bed. It also occurs when transferring a patient from bed to stretcher and the patient’s skin is pulled across the bed. When shear is present, the skin and subcutaneous layers adhere to the bed surface, and the layers of muscle and bone slide in the direction of body movement.

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The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linins is called friction. Unlike shear injuries, friction injuries affect the epidermis or the top layer of the skin. The denuded skin appears red and painful and is sometimes referred to as sheet burn.

5. Friction

Friction injuries occur in patients who are restless or have uncontrollable movements, and in patients that are dragged rather than lifted from bed. 6. Moisture 

The presence and duration of moisture on the skin increases the risk for ulcer formation. Moisture reduces the resistance of the skin to other physical factors such as pressure and/or shear force. Prolonged moisture softens skin, making it more susceptible to damage. Skin moisture originates from wound damage, excessive perspiration, and fecal/urinary incontinence

Objective: Describe the pressure ulcer staging system Stage 1: Non-blanchable Redness 

Intact skin present with non-blanchable redness of localized area, usually over bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching, but its coloring may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Stage 2: Partial-Thickness 

Partial thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister. It presents as shiny or dry shallow ulcer without slough or bruising. The presence of bruising indicates a deep tissue injury.

Stage 3: Full-thickness Tissue Loss 

In full thickness tissue loss subcutaneous fat may be visible; but bone tendon and muscle are NOT exposed. It may include undermining and tunneling.

Stage 4: Full-thickness skin or tissue loss 

Full-thickness tissue loss in which actual depth of an ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black). Bone, tendon or muscle are exposed.

Objective: Discuss the normal phases of wound healing

1. Hemostasis Phase  A series of events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury. During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair 2. Inflammatory Phase  Damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and white blood cells into the damaged tissues. Leukocytes reach a wound within a few hours. The primary-acting WBC is neutrophils, which begin to digest bacteria and small debris. The second most important leukocyte is a monocyte which transforms into macrophages. Macrophages are the “garbage cells” that clean a wound of bacteria, dead cells, and debris with phagocytosis 3. Proliferative Phase  With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3-24 days. The main activities during this phase are filling of a wound with granulation tissue, wound contraction, and wound resurfacing by epithelialization. Collagen mixes with the granulation tissue to from a matrix that supports the reepithelialization. Collagen provides strength and structural integrity to the wound. 4. Maturation Phase  The final stage of wound healing. Sometimes takes more than a year, depending on the depth and extent of the wound. The collagen scar continues to re-organize and gain strength for several months. Collagen fibers undergo re-modeling or re-organization before assuming their normal appearance. Usually scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. In dark-skinned individuals the scar tissue may be more highly pigmented that surrounding skin.

Objective: Describe the differences in wound healing by primary and secondary intention 1. Primary intention wounds:  Incision line poorly approximated with abnormal healing  Drainage present more than 3 days after closure  Inflammation increased in first 3-5 days after injury  No epithelialization of wound edges by day 4 2. Secondary intention wounds:  Pale or fragile granulation tissue, granulation tissue bed excessively dry or moist  Purulent exudate present  Necrotic or slough tissue present in wound base  Epithelization not continuous fruity, earthy, or putrid odor present  Presence of fistulas, tunneling, undermining HEALING: Primary wound closure is the fastest type of closure- is also known as healing by primary intention. ... Secondary Closure – Secondary wound closure, also known as healing by secondary intention, describes the healing of a wound in which the wound edges cannot be approximated.

Objective: Describe complications of wound healing 1. Hemorrhaging:  Bleeding from a wound site, normal during and immediately after initial trauma. Can occur internally or externally. 2. Infection  Wound show up 4th or 5th postoperative day. Fever, tenderness and pain at the wound site. Elevated WBC count, edges of wound will appear inflamed; odorous and purulent 3. Dehiscence  Partial or total separation of wound layers. Often occurs before collagen formation, 3-11 days after injury. People who have obesity are more susceptible because of the constant strain placed on the wound and the poor healing qualities of fat tissue. 4. Evisceration  Separation of wound layers. Protrusion of visceral organs through a wound opening occurs. It is an emergency that will require surgical repair.

Objective: Explain the factors that impede or promote wound healing

Impede Healing:  

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When there’s too little inflammation that occurs during inflammatory phase (cancer or after administration of steroids When there’s too much inflammation, because arriving cells compete for available nutrients. (would infection in which increased metabolic energy requirements compete for available calorie intake) Systemic Factors: Age, anemia, hypoproteinemia, and zinc deficiency Poor nutritional status, infection or obesity Dry wound left open to air can resurface within 6 to 7 days; cells will migrate down into a moist level.

Promote Healing:         

Wound that is kept moist can resurface in 4 days, because epidermal cells only migrate across a moist surface. Calories: Fuel for cell energy “protein protection” Protein: Fibroplasia, angiogenesis, collagen formation and would remodeling, immune function Vitamin C: collagen synthesis, capillary wall integrity, immunological function, antioxidant. Vitamin A: Reduces the negative effects of steroids on wound healing, epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation. Zinc (trace element): Epithelialization, collagen synthesis, cell membrane and host defenses Copper: Collagen fiber linking Fluid: essential fluid environment for all cell function Oxygen

Objective: Describe the differences between nursing care of acute and chronic wounds ACUTE WOUNDS  wound heals promptly and without complications; easily cleaned and repaired; wound edges are clean and intact.  needs immediate intervention; require close monitoring (every 8 hours)  skill of applying dry and moist dressings to the new acute wound can't be delegated to nursing assistive personnel (NAP)  Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity  trauma, a surgical incision CHRONIC WOUNDS

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course of treatment is lengthy and costly patient's hygiene is more important assessment occurs less frequently (usually not more than 1 time per day) stable, but difficult to heal uses clean technique wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity vascular compromise, chronic inflammation, or repetitive insults to tissue continued exposure to insult impedes wound healing

Objective: List appropriate nursing interventions for a patient with impaired skin integrity/ State evaluation criteria for a patient with impaired skin integrity Pressure Management     

Reposition every 90 minutes Offer pain medication as needed When patient transfers from bed to chair, remind them not to slide over sheets but to pick up pelvis and relocate from one position to another Be careful not to slide patient on sheets Elevate head of bed no more than 30 degrees

Pressure Ulcer Care  

keep skin dry and clean; avoid rubbing area. use moisture barrier ointment over ulcer at least 3 times a day to decrease friction and provide moisture to open tissue.

Surgical Wound Care   

Irrigate wound with saline solution twice per day per wound care provider's order. apply dressing (gauze moistened with antibiotic solution twice a day after irrigation) according to wound care provider's order. at frequent intervals, evaluate patient's pain level and offer pain medication as indicated by assessment.

Pressure Ulcer Prevention **Decreased sensory perception: assess pressure points for signs of nonblanching reactive hyperemia. provide pressure-redistribution surface. 

**Moisture:

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assess need for incontinence management. following each incontinent episode, clean area with no-rinse perineal cleaner and protect skin with moisture-barrier ointment.

**Friction and shear:  reposition patient using drawsheet and lifting off surface.  provide trapeze to facilitate movement.  position patient at a 30-degree lateral turn and limit head elevation to 30 degrees.

**Decreased activity/mobility:  establish and post individualized turning schedule.

**Poor nutrition:  provide adequate nutritional and fluid intake; assist with intake as necessary.  consult dietitian for nutritional evaluation....