4.2 Fundamentals of Skin Integrity/Wound Care Flashcards
Skin Functions
- Protection from microorganisms
- Body temperature regulation (constriction and dilation of blood vessels and raising hair for insulation)
- Psychosocial changes (self esteem and appearance)
- Sensation of touch, pressure, temperature
- Vitamin D production
- Immunologic processes when break in skin
- Absorption of medications (local/systemic)
- Elimination of water and electrolytes through perspiration
Causes of Alterations to Skin
- Age causes decrease in resistance to injury due to loss of integrity of subcutaneous tissues.
- Adequate nutrition, hydration, and circulation aids in health of skin cells and ability to resist injury
Causes of Alterations to skin
- Thin/Obese more susceptible to skin injury
- Fluid loss during illness causes skin dehydration
- Skin appears lose and flabby
- Excessive perspiration during illness predisposes skin to breakdown. Jaundice causes yellow itchy skin.
- Disease of skin (eczema, psoriasis) cause lesions that require special care and may also open wounds from scratching
Types of wounds (Intentional/Unintentional)
Intentional
- Planned, carefully created for therapeutic purpose (Surgery)
- Wound edges are clean and come together easily
Unintentional
- Unplanned (accident/trauma)
- Jagged edges (do not come together easily)
- Higher chance of uncontrolled bleeding and infection
Open/Closed wounds
Open
- Wound edges are not approximate when treated
- Maybe left open due to significant tissue damage or to help clean wound and not trap infection under.
- Takes longer to heal.
Closed
- Trauma is under surface of skin (skin not broken)
- Ecchymosis (bruising) or hematomas.
Acute vs Chronic Wounds
Acute
- Heals quick (days to weeks)
- Edges well approximated and low risk of infection
Chronic
- Remain in inflammatory phase of healing and healing is delayed (More than 30 days)
- Healing delayed due to infection or issues with circulation
Partial/Full Thickness, Complex
Partial Thickness
- “Almost” all skin intact (loss of epidermis and dermis)
Full Thickness
- Skin, sweat glands, hair follicles gone. (subcutaneous)
- Muscle, bone, tendon exposed
Complex (Unstageable wound)
- So much damage to skin and deep tissues that true depth cannot be determined
Systemic Factors Affecting Wound Healing
- Wounds heal fastest with good circulation and o2
(Adequate blood flow is essential) - Children/Healthy adults heal faster than elderly
- Nutrition (Protein) helps grow new tissue
- Patients taking corticosteroids or post-op radiation therapy delay healing.
Wound Complications
Infection - Contamination of wound
Hemorrhage - Excessive bleeding at injury site
Dehiscence - Opening of wound after it has already partially healed. Due to poor tissue integrity or infection under scar.
Evisceration - Open wound with expulsion of organs (intestines)
Fistula Formation - Opening between 2 organs (ex. vagina and rectum if wound has not repaired properly)
Psychological Effects of Wounds
Psychological effects of wounds becoming worse or delayed healing
- Increased pain
- Anxiety/fear that wound will not get better
- Inability for patient to continue ADL’s independently
- Large wound/scar may alter self esteem
Phases of Wound Healing (Bleeding)
Hemostasis
- Begins immediately after injury
- Blood vessels constrict and clotting occurs using platelets. Surrounding tissue swell to stop bleeding.
- Accumulation of tissues (exudate) cause redness and heat to the area.
Phases of Wound Healing (Inflammatory)
- Begins 24 hours after damage occurs. (Lasts 2-3 days)
- White blood cells (leukocytes) come to wound and ingest bacteria
- Macrophages ingest cell debris to allow new epithelial cells to grow
- Fibroblasts fill wound to allow cells to grow
- Pain, heat, and swelling may occur at injury site
Phases of Wound Healing (Proliferation)
- Begins after several days and lasts several weeks
- Fibroblasts and collagen produced to reform blood vessels and endothelial cells.
- Newly grown capillaries bring oxygen and nutrients to area and make new tissue (granulation tissue) (scar)
- Time for granulation to fill wound depends on size
Types of Proliferation Healing
Primary Intention
- Edges are approximated and only small amount of granulation tissue needed
Secondary Intention
- Wounds edges are not approximated. Takes longer to heal as wound is open
Tertiary Intension
- Wound left open on purpose to drain
Phases of Wound Healing (Maturation)
- Begins weeks after surgery and can continue for months
- New collagen continues to grow and develop.
- Scar thins and becomes normal tissue.
Local Factors Affecting Wound Healing
- Pressure on skin can cause hypoxia, ischemia and eventually necrosis due to no blood flow in area
- Avoid patients having pressure on one part of body
- Medical devices can also cause pressure resulting in ulcerations
(Oxygen tubing on back of ears, cast, or orthopedic devices). - Problem is averted by turning patient every 2 hours so blood returns to affected area.
- Assessment of pressure points
Friction and Shear
Friction
- Can be caused by patient sliding against bed sheets
Shear
- One layer of skin sliding against another layer causing skin to separate.
- Blood vessels break and cause damage plus decreased blood flow to area.
- Happens when patients are dragged up in bed and skin sticks to sheet. Underlying tissue slump down in bed with body due to gravity.
Pressure Injury/Pressure Ulcer
- First sign is blanching (paleness/whitening) of skin
(under pressure and becomes ischemic) - As pressure continues area will become red which may fade if pressure is relieved
- Dark skinned patients are difficult to assess. Heat is better determinant
- If pressure and decreased blood flow continues, tissue damage will eventually occur.
Stages of Pressure Ulcers
Stage 1
Lightly pigmented. Nonblanchable erythema of intact skin
Stage 2
Partial thickness skin loss with exposed dermis
Stage 3
Full thickness skin loss not involving underlying fascia (connective tissue)
Stage 4
Full thickness and tissue loss
Unstageable
Obscured Full thickness and tissue loss
Deep Tissue Pressure Injury
- Persistent nonblanchable deep red, maroon, or purple discoloration
Factors contributing to pressure wound - Aging Skin, Chronic Illness, Immobility, Malnutrition, Fecal and Urinary Incontinence, Altered Level of Consciousness, Spinal Chord/Brain Injuries, Neuromuscular Disorders.
How to Prevent Pressure Injuries
- Turn patient every 2 hours and assess areas patient was lying on. (Pay attention to skin with bony prominences)
- Good hydration and nutrition to maintain skin integrity
- Topical skin care and Incontinence management
- Those who cannot move due to injury, neuromuscular disorders, or decreased consciousness are at greatest risk
- Proper assessment of pressure points will prevent advancement of significant ulcers
Assessment of Pressure Sores
- Size and depth of wound.
- Presence of tunneling or sinus tracts.
- Tools like Pressure Ulcer Scale for Heating 3.0 (PUSH)
- Braden Scale
First Aid for Wounds
Step 1 - Control bleeding and allow hemostasis
- Punctures should be allowed to bleed to flush out pathogens.
- Do not remove penetrating objects
Step 2 - After hemostasis, do a basic clean from least contaminated area to surrounding skin.
- One swipe at a time with gauze saturated in NS or sterile water (New gauze each swipe)
Step 3 - Once clean dry area using gauze sponges in the same way
(Irrigation of wound is also done this way)
Step 4 - Bandage determined by time of wound
Report drainage or necrotic tissue
Assessment of Patient
- Assess situation and need for wound cleaning and dressing change. Confirm medical orders relevant to wound care
- Assess patient comfort level and need for analgesics before wound care.
- Assess current dressing (if there is one)
- Assess excess drainage, bleeding, saturation of dressing, approximation wound edges, color of wound or surrounding area, and signs of dehiscence.
Assessment of Patient (cont)
- Assess for sutures, staples, or adhesive closure strips
- Note stage of healing process and characteristics of drainage
- Assess surrounding skin for color, temperature, edema, and ecchymosis (discoloration of skin) or maceration (skin broken down by moisture)
Expected Outcomes of Wound Cleaning
- Wound cleaned without contamination or trauma without damaging proliferative cells and newly formed tissues and without causing pain/discomfort
- Wound shows progression of healing
- Patient demonstrates understanding of need for wound irrigation.
Assessment to Prevent Injury
- Assess pressure points where blood circulation is decreased
- Turn patient every 2 hours
- Pad areas prone to pressure (elbows, hips, between knees, support body for proper alignment)
- PUSH 3.0 and Braden Scale assess other factors contributed to injury (mobility, level of consciousness, moisture to skin, sensory perception, nutrition, friction/shearing)
Assessment to Prevent Injury (cont)
Other Factors for Assessing Wound
- Palpation for pain
- Inspection of redness and exudate
- Smelling odors related to infection
Drainage of Wounds
- Serous (Initial Bleeding)
- Sanguineous (Bloody Discharge as Forming Clot)
- Serosanguineous (Pink liquid of blood combined with fluid from surrounding tissue)
- Purulent (Pus caused by infection)
- Also check for sutures, staples, drains, manifestations of complications
Assessment of Dressed Wound
- If dressing on wound has drainage, outline and mark with date, time, and initials
- Should always be re-assessed and re-marked
- Stabilization of drainage may not need intervention but continuous drainage will need to be evaluated in detail
- Surgical wounds with no dressing should be assessed for infection, approximation of edges and drainage.
- Patient education (how to keep wound free from infection)
Assessment of Open Wounds
Color of tissue indicates treatment necessary
Red - New blood vessels, dress and provide protection from further injury or infection
Yellow - Needs cleansing. Tissue is sloughing as it heals and needs to be removed to heal properly
Black - Necrotic tissue that needs debriding (removal)
Usually wounds are a mix of colors
Presence of Infection
- Wound is swollen
- Wound is deep red
- Wound feels hot on palpation
- Drainage is increased and possibly purulent (pus)
- Foul odor
- Wound edges separated. Dehiscence (edges of wound no longer meet)
Collection of Wound Culture
If wound is infected culture should be taken
- Collect specimen before wound is cleaned
- Obtained with cotton swab and placed in sterile tube
- Strict Asepsis so pathogen in wound is isolated
Wound Dressings
- Provides physical/psychological/aesthetic comfort
- Prevent/eliminate/control infection
- Absorb drainage
- Maintain moisture balance in wound
- Protect wound from further injury
- Protect skin surrounding wound
- Debride (remove) damaged/necrotic tissue
- Stimulate/optimize healing response
- Ease of use and cost effective
Types of Wound Dressings
- First dressing removed in 24-48 hours
- After time is determined by healing process
3 TYPES OF DRESSINGS - Maintain moisture
- Absorb moisture
- Add moisture
Number and type depend on location, size, type, depth of wound, presence of infection, need for debridement, and amount of drainage.
Types of Wound Dressings (Telfa)
- Non adherent dressing with shiny outer surface.
- Used as absorbent material that does not stick to skin
- Often used as first layer of dressing
Types of Wound Dressing (Gauze)
- Used for absorption and padding of wound
- Can be applied directly to skin or on top of Telfa
- Special pre-cut gauze used with peg tubes and tracheostomy.
- Large padded dressing, Abdominal Pad (ABP) placed over small thin gauze to absorb drainage and protect wound
Types of Wound Dressing (Transparent)
- Transparent film, semipermeable and waterproof
- Protects from contamination and ability to visualize wound
- Used for peripheral IV sites, Central Venous lines, and healing wounds
Securing Dressing
- Bandages/Binders apply pressure for hemostasis (stop bleeding and repair damage)
- Tape can be used to secure around the edges of a dressing that needs to be changed frequently
- Large wounds that need to be changed frequently, removing tape can damage skin so bandages and binders are used
Roller Bandages
- Continuous strip of material wound onto itself
- Gauze, elastic webbing, stretchable bandage
- Hold with free hand and roll bandage around body with equal tension
Circular Turn
- Used to anchor a bandage.
- Wrap bandage around, completely overlapping previous bandage turn.
- Once circular turn anchors the bandage continue to ascend in spiral manner
Spiral Turn/Figure 8 turn
Spiral - Useful for wrist, fingers and trunk
Figure 8 - Used for joints. Makes oblique overlapping turns that ascend and descend alternatively.
Binders
Slings - Supports arm, folded triangle that ties behind neck
Straight Binders - Large pieces of material with support. Either pinned or Velcroed. Typical around chest/abdomen. When applying elastic bandage, check extremities for temperature/sensation change.
Binders (cont)
T Binders - Used to secure dressing on rectum, perineum, and groin. Single T Binder for females, double T Binder for Males.
Montgomery Straps - Uses ties attached to adhesive backing to hold dressing in place
Abdominal Binder - Goes around abdomen.
Types of Drainage Systems (Penrose Drain)
- Hollow, soft, flexible, open ended rubber tubes used after surgery to allow fluid to drain passively via capillary action into absorbent dressing.
- Held in place by safety pin placed on part outside of wound. (Prevents drain from slipping into body)
- Patency and placement is assessed for this drain
Closed systems
Jackson Pratt Drain/Hemovac Drain
- Promotes healing through constant, controlled, uniform, low pressure suction to wound surface after surgery.
- Results in reduction of bacteria and removal of excess fluid while providing moist wound healing environment.
- Negative pressure on wound stimulates cell proliferation, increased blood flow to wound, and allows for growth of new blood vessels.
- Assessment includes volume and character of drainage fluid every shift. Provider should be notified of abrupt changes in amount or color.
Changing Dressings
- Patients with large wounds may need pain medication before dressing change
- ## Describe what will happen step by step and answering questions will alleviate anxiety.
Wet to Dry Dressing Change
- Removes drainage/necrosis from wound
- Remove old dressing (make sure to count amount of gauze) Drop old dressings in RED BAG
- Leaving gauze in can breed infection
- After this, setup sterile field
- When pouring liquids into container, ask partner to pour. Otherwise you can unglove, poor, and reglove
- Clean from cleanest to dirtiest (middle of wound to outside)
- Pack wet gauze (NS) into wound. Do not want to be super saturated
- Pack dry gauze on top and then cover with ABD Dressing (Blue Line on Outside)
Central Line Dressing
- Very important to keep sterile because goes straight to heart
- Patient needs a mask on as well as you
- Take dressing off with regular clean gloves
- Use swab to clean at insertion side then move outward then let it dry
- Use sponge (chlorhexidine) for 30 seconds
Removing Staples/Sutures
Sutures
- Grab knot of suture and pickup
- Cut suture close to skin on one side and pickup
(avoids bacteria from suture being pulled under skin)
Staples
- Use staple removing tool and snap in middle. 2 prongs underneath and 1 prong on top.
(After removal use sterile strips to hold suture and staples together)
- Patients can wash over strips and they are removed usually in 2-3 days.
Heat Therapy
- Assess for burns or tissue damage with prolonged use
Heat application - Dilates peripheral blood vessels, increases metabolism, reduces blood viscosity, reduces muscle tension, relieves pain.
- Vasodilation increases blood flow, oxygen, and nutrients to an area and removes waste.
- Maximum effect time 20-30min
- Applied by moist and dry methods.
Cold Therapy
- Constricts blood vessels, reduces muscle spasms, relieves pain.
- Vasoconstriction reduces edema and inflammation
- 60F for vasoconstriction
Sitz Bath
- Bowl of warm water to sit on.
- Heat therapy to perineum or rectum
- Put tube at bottom of bowl
- Fill bowl with warm water
- Clamp tube of bag closed.
- Fill bag with warm water
- Sit down and release clamp.
Sitz Bath Assessment
- Can patient ambulate to bathroom and maintain sitting position for 15-20 minutes
- Inspect perineal/rectal area for swelling, drainage, redness, warmth, and tenderness
- Assess bladder fullness and encourage patient to use bathroom before
Electronically controlled cooling device
- Constant cooling effect
- Used for post-op patients and acute musculoskeletal injuries
- Medical order required
- Initial assessment of extremities involved and ongoing.
- Ongoing monitoring of proper function and temperature regulation is necessary.
