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PNP EXAM 2

CHAPTER 48 – Skin Integrity and Wound Care 

A nurses most important responsibilities include assessing and monitoring skin integrity; identifying problems; and planning; implementing, and evaluating interventions to maintain skin integrity Scientific Knowledge Base

Skin 

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The thin stratum corneum protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents but allows for evaporation and absorption of certain topical agents The basal layer consists of cells that proliferate and divide and migrate toward the surface The dermis provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs o Consists of fibroblasts

Pressure ulcers 

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Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and or poor nutrition is at risk for pressure ulcer development

Pathogenesis of pressure ulcers o Pressure intensity   

o o

Pressure duration Tissue tolerance   

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Tissue ischemia can occur if the vessel is occluded for a prolonged period of time Redness is caused by vasodilation called hyperemia If skin blanches and erythema returns the tissue is trying to repair, if not deep tissue damage is possible

Shear, friction, and moisture affect the ability of the skin to tolerate pressure The ability of the underlying skin structures to assist in redistributing pressure Poor nutrition, increased aging, hydration status, and low blood pressure affect the tolerance of the tissue to externally applied force

Risk factors for pressure ulcer development o o o

Impaired sensory perception - cannot feel pain or pressure Impaired mobility Alteration in LOC - confused or unable to communicate discomfort

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Shear - sliding of skin and subcutaneous tissue; tissue damage occurs deeps Friction - mechanical force; superficial injury Moisture

Classification of Pressure Ulcers 

Assessment includes depth of tissue involvement, type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin o Stage 1: Nonblanchable redness of intact skin  Intact skin, nonblanchable, discoloration of the skin, warmth, edema, hardness, pain

o

Stage 2: Partial-thickness skin loss or blister 

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Partial-thickness loss of dermis, shallow open ulcer with a red-pink wound bed without slough, may be intact or ruptured blister

Stage 3: full-thickness skin loss (fat visible) 

o

Full-thickness tissue loss, fat may be visible, no bone/tendon/muscle, some slough, undermining or tunneling

Stage 4: full-thickness tissue loss (muscle/bone visible) 

Full-thickness tissue loss with exposed bone, muscle, tendon, slough or eschar, includes undermining or tunneling o Unstagable/unclassified: full-thickness skin or tissue loss - depth unknown  Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar  Stable eschar on the heels serves as "the natural cover of the body" and should not be removed

o

Suspected deep-tissue injury- depth unknown 

o

Purple/maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear Redness, warmth, maceration, or edema indicates wound deterioration

Wound Classifications  

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A wound is a disruption of the integrity and function of tissues in the body Wound classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive qualities of the wound tissue such as color

Process of wound healing Surgical incision heals by primary intention, skin edges are approximated (closed), and the risk of infection is low o A burn, pressure ulcer, or severe laceration heal by secondary intention, wound is open until filled by scar tissue o

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Wound repair o o

Partial thickness wounds heal by regeneration Full thickness wounds heal by scar formation

o

Partial Thickness  

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Use: inflammatory response, epithelial proliferation, and migration, and reestablishment of the epidermal layers Epidermal cells only migrate across a moist surface

Full Thickness        

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Hemostasis Injured blood vessels constrict and platelets gather to stop bleeding Clots from a fibrin matric that provide a framework for cellular repair Inflammatory Damaged tissue and mast cells secrete histamine Results in local redness, edema, warmth, and throbbing Neutrophils ingest bacteria and small debris Macrophages continue the process of clearing the wound of debris and release growth factors that attract fibroblasts, the cells that synthesize collagen Proliferative Filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization The wound contracts to reduce the area that requires healing The vascular bed is reestablished, the area is filled with replacement tissue, and the surface is repaired Remodeling Maturation

Complications of wound healing

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Hemorrhage: bleeding from a wound site   

o

After hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object Occurs externally or internally  Distension, hematoma, surgical drainage Greatest risk of hemorrhage is during the first 24-48 hours after surgery or injury

Infection     

o

A wound is infected if purulent material drains from it Wounds with more than 100,000 organisms/gram of tissue are infected Bacterial wound infection inhibits wound healing Traumatic wounds show signs of infection 2-3 days Surgical wounds show infection 4-5 days

Dehiscence   

o

The layers of skin and tissue separate When there is an increase in serosanguineous drainage from a wound, be alert for potential dehiscence Splint the area

Evisceration  

Protrusion of visceral organs through a wound opening Requires surgical repair Nursing Knowledge Base

Prediction and Prevention of Pressure Ulcers  

Maintenance of skin integrity

Braden scale: sensory perception, moisture, activity, mobility, nutrition, friction and shear 

The lower the number, the higher the risk

Factors Influencing Pressure Ulcer Formation and Wound Healing  Shear force, friction, moisture, nutrition, tissue perfusion, infection, and age  Nutrition o o

Serum albumin is a biochemical indicator of malnutrition Patients need to consume an adequate amount of calories, protein, vitamin C, Vitamin A, Zinc, fluid. The roles of each of these are:  Calories: fuel for cell energy  Protein: fibroplasia (fibrous tissue), angiogenesis (blood vessels), collagen formation, wound remodeling, and immune function  Poultry, fish, eggs, beef

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Tissue Perfusion o

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Oxygen requirements depend on the phase of wound healing

Infection o

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Vitamin C: Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant  Citrus fruits, tomatoes, potatoes, fortified fruit juice Vitamin A: epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation, can reverse the effects of steroid or delayed wound healing  Green leafy vegetables, spinach, broccoli, carrots, sweet potatoes, liver Zinc: collagen formation, protein synthesis, cell membrane and host defense  Vegetables, meats, legumes Fluid: essential fluid environment for all cell functions  Noncaffeine, nonalcoholic, without sugar, water is best

Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization and increases the production of proinflammatory cytokines

Psychosocial Impact of Wounds o

Stress alters body's adaptive mechanisms Nursing Process

Assessment   

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Baseline and continual assessment data provide critical information about a patient's skin integrity and the increased risk for pressure ulcer development Focus on level of sensation, movement and continence Through the Patients eyes o Know the patients expectations Skin o When you note hyperemia, document the location, size, and color and reassess the area after 1 hour Pressure ulcers o Assess the patient's mobility, nutrition, presence of body fluids, and comfort level o Mobility: If a patient has some degree of mobility independence, reinforce the frequency of position changes and measures to relieve pressure; Note the patients activity tolerance o Nutritional status: A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 pounds in a brief period are all signs of actual or potential nutritional problems o Body fluids: Reduce contact with body fluids Wounds o Type: Abrasion, laceration, puncture o Contamination

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o o o o

Size Observe whether the wound edges are closed Note the amount, color, odor, and consistency of drainage Assess the number of drains, drain placement, character of drainage, and condition of collecting equipment o Observe the security of the drain and its location with respect to the wound

Diagnosis        

Risk for infection Imbalanced nutrition: less than body requirements Acute or chronic pain Impaired physical mobility Impaired skin integrity Risk for impaired skin integrity Ineffective peripheral tissue perfusion Impaired tissue integrity

Planning  

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Goal and outcomes Setting priorities o Stable or emergent? o Preventative interventions o Promotion of healing Teamwork and collaboration o The nurse and patient work together to establish ways of maintaining patient involvement in nursing care and promoting wound healing

Implementation  Most effective is prevention 1. 2. 3. 1. 2.

3.

Skin care and management of incontinence Mechanical loading and support devices; which include proper positioning and the use of therapeutic surfaces Education Ensure patients skin is clean and dry, and assessment is done daily Make an effort to control, contain, or correct incontinence, perspiration, or wound drainage  Thick moisture barrier to exposed areas Positioning interventions reduce pressure and shearing forces to the skin

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A support surface is a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and or other therapeutic functions

Acute Care 1.

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Management of pressure ulcers  Reassess the wound for location, stage, size, tissue type and amount, exudate, and surrounding skin condition Wound management  Maintain a healthy wound: prevent and manage infection, clean the wound, remove nonviable tissue, manage exudate, maintain the wound in a moist environment, and protect the wound  A wound does not move through the phases of healing if it is infected  Cytotoxic solutions are not used to clean granulating wounds  Irrigation is a common method of delivering a wound-cleaning solution to the wound  Debridement: removal of nonviable, necrotic tissue  Rids the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing  Methods: mechanical (wet-to-dry, irrigation, whirlpool treatments), autolytic (synthetic dressings [transparent film and hydrocolloid dressings]), chemical (topical enzyme preparation, darkin's solution, sterile maggots), and sharp/surgical (scalpel, scissors, sharp instrument)  Excessive exudate provides an environment that supports bacterial growth, macerates the periwound skin, and slows the healing process  A moist environment supports the movement of epithelial cells and facilitates wound closure  Nutrition is fundamental to normal cellular integrity and tissue repair  A patient can lose as much as 50 g of protein per day from an open weeping pressure ulcer (daily need ~50g/day)  Increased protein intake helps rebuild epidermal tissue

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tissue A low hemoglobin level decreases delivery of oxygen to the tissues and heads to further ischemia

First Aid for Wounds Traumatic wound interventions include stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury  Hemostasis: apply pressure, bandages, and elevate  Cleaning: use saline to maintain the moist surface needed to promote the development and migration of epithelial tissue Dressings  Purposes: protects a wound from microorganism contamination; aids in hemostasis; promotes healing by absorbing drainage and debriding a wound; supports or splits the wound site; protects patients from seeing the wound; promotes thermal insulation of the wound surface; provides a moist environment  Pressure dressings promote hemostasis  Dressings applied to a draining wound require frequent changing to prevent microorganism growth and skin breakdown  ****Different types of dressings  Chronic pressure ulcer wounds use a clean technique; fresh surgical wounds require sterile technique so as not to introduce microorganisms into a healing wound  The first step in packing a wound is to assess its size, depth, and shape  The entire surface of the wound needs to be in contact with the packed dressing  A V.A.C. is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together  NPWT supports wound healing by edema reduction and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion 

4.

Increased caloric intake helps replace subcutaneous

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Secondary effects include angiogenesis, granulation tissue formation, and reduction in bacterial bioburden  Use tape, ties, or a secondary dressing and cloth binders to secure a dressing over a wound site; the choice of anchoring depends on the wound size, location, presence of drainage, the frequency of dressing changes and the patients level of activity  Common adhesive tape adheres to the surface of the skin; elastic adhesive tape compresses closely around pressure bandages and permits more movement of a body part  When applying tape, ensure that it adheres to several inches of skin on both sides of the dressing and that it is placed across the middle of the dressing  Remove parallel with the skin and toward the wound/ direction of hair growth 5.   6.

Suture Care  Threads or metal used to sew body tissues together  The patient's history of wound healing, the site of surgery, the tissues involved, and the purpose of the sutures determine the suture material used  Never pull the visible portion of a suture through underlying tissue

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Cleaning Skin and Drain Sites Requires aseptic technique Clean from least to most contaminated

Drainage Evacuation Convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage

Bandages and Binders  Binders and bandages applied over or around dressings provide extra protection and therapeutic benefits  Creating pressure over a body part  Immobilizing a body part

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Supporting a wound Reducing or preventing edema Securing a splint Securing dressings  Assesses circulation, skin integrity, comfort level and body function  Rolls of bandage secure or support dressings over irregularly shaped body parts Heat and Cold Therapy  Heat is contraindicated in bleeding patients, localized inflammation such as appendicitis, cardiovascular problems  Cold is contraindicated if the site already is edematous, patients with impaired circulation, neuropathy patients, shivering patients  Before using these therapies you need to understand normal body responses to local temperature variations, assess the integrity of the body part, determine the patient's ability to sense temperature variations and ensure proper operation of equipment  Body can handle between 15-45C

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Heat Application  Improves blood flow

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Cold Application  Diminishes swelling and pain

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Types  Moist/Dry - depend on the type of wound or injury, the location of the body part, and the presence of drainage or inflammation  Warm/moist compress - improve circulation, relieve edema, promote consolidation or purulent drainage  Warm soaks - promotes circulation, lessens edema, increases muscle relaxation, provides a means to apply medicated solution  Sitz baths - the patient who has had rectal surgery, an episiotomy during childbirth, painful hemorrhoids, vaginal inflammation - pelvic immersion

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Commercial hot packs - disposable Cold/moist/dry compresses - relieves inflammation and swelling  Cold soaks  Ice bags/collars - patient with muscle sprain, localized hemorrhage, hematoma, or has undergone dental surgery - ideal to prevent edema formation, control bleeding, and anesthetize the body part Evaluation    

Determine the patients response to nursing therapies and whether he or she achieved each goal The optimal outcomes are to prevent injury to the skin and tissues, reduce injury to the skin and underlying tissues, and possible wound healing with restoration of skin integrity Develop plan of care to provide education and support depending on how pt. feels Evaluate need for additional referrals to other experts

Vocab  Granulation tissue- is red, moist tissue composed of new blood vessels - progression toward healing  Slough- soft yellow and white tissue  Eschar- black or brown necrotic tissue  Exudate- describe the color, amount, consistency, and odor of the drainage

SKILLS NOTES CHAPTER 48 - 30-degree lateral position - Use only noncytotoxic agents to clean ulcers - In some settings aspects of wound care such as changing dressing using clean technique for chronic wounds are delegated - Black foam has larger pores and is more effective in stimulating granulation tissue and wound contraction; white foam is denser with smaller pores and is used when growth of granulation tissue needs to be restricted - Irrigate with 19 gage 35 mL - The skill of applying an abdominal binder can be delegate to nursing assistive personnel o Observe patients ability to breathe deeply and cough - The skill of applying an elastic bandage can be delegated to NAP - Apply bandages to lower extremities before patient sits or stands; elevate dependent extremities for 20 min before bandage application to enhance venous return

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Bandage is applied in manner that conforms evenly to body part and promotes venous return

CHAPTER 31 – Medication Administration  

Nurses play an essential role in safe medication preparation, administration, and evaluation of medication effects Nurses are respo...