Chapter 32 - Skin Integrity and Wound Care Flashcards
Body Defenses Against Injury
Primary-nervous, respiratory, GI, Integumentary
Secondary-vascular
Tertiary-Immune
Layers of Skin
Functions
Protection, Temperature Regulation, Sensation, Absorption, Elimination, Vit D production, Immunological
Factors Affecting Skin Integrity
Developmental considerations State of health Immobility Incontinence Decreased sensory perception Poor nutrition Peripheral vascular disease
Common Types of Wounds
Incision Contusion Abrasion Laceration Puncture Penetrating Avulsion Chemical Thermal Irradiation
hematoma tends to be larger and palpable
Wound Classification
Intentional-planned, clean, decreased risk
Unintentional-accidental, contaminated, increased risk of infections
Open-intentional or unintentional, increased risk of infection
Closed-damaged sof tissue
Clean vs. Contaminated vs. Infected
Acute-usually heals w/in days to weeks, decreased risk of infection
Chronic-longer healing time, increased risk of infection
Skin Thickness loss
venous ulcer treatment - compression
arterial ulcer treatment - plasty or surgical intervention
Principles of Healing
+Recovery is dependent on
- Extent of damage
- General state of health
- Proper nutrition
- Adequate blood supply
+Intact skin and mucous membranes are best defense against microorganisms.
+Healing is promoted when wound is free of foreign material
+Body responds systemically to local trauma
Wound Healing Process
Primary Intention-clean, approximate edges, little tissue loss, minimal scarring, wound closure is performed w/sutures, staples or adhesive
Secondary Intention-edges are not approximated, form granulation tissue, surgeon may pack the wound with gauze or use drainage system, longer healing time, more scar tissue
Tertiary Intention-wound is purposely left open, cleaned, debrided and observed before closure.
Phases of Wound Healing-Hemostasis
Occurs at time of injury
Blood vessels constrict, clotting begins
Blood vessels dilate, ↑ capillary permeability (results in heat and redness)
Exudate formation (causes swelling & pain)
Phases of Wound Healing-Inflammatory
Day 0 to 4-6 Stages Inflammation (pain, heat, redness & swelling) Phagocytosis (leukocytes, macrophages Epithelialization begins Systemic symptoms Elevated temperature ↑ WBC & Erythrocyte Sedimentation Rate (ESR) Generalized malaise
WBC - banded are immature (know by lab test differentials)
Phases of Wound Healing-Proliferation (Fibroblastic)
To day ~ 21
New tissue is built by action of fibroblasts
Revascularization and granulation
Wound is lighter in color
Systemic symptoms disappear
Need adequate nutrition, oxygen, prevention of strain of wound tissue
Phases of Wound Healing-Maturation (Remodeling)
Day 21 to 1-2 years
Collagen deposition and remodeling
Scar tissue becomes smaller
Keloid scars
WBC Differentials
-Basophils (1%) Release histamine and heparin -Eosinophils (2-4%) Counteract histamine -Neutrophils (60-70%) Phagocytosis -Lymphocytes (20-25%) Produce antibodies -Monocytes (3-8%) Phagocytosis of large particles
OR
N-60 L-30 M-6 E-3 B-1
Local Factors Affecting Wound Healing
Type, size, location of wound Pressure Hydration Trauma Edema Infection Necrosis
Systemic Factors Affecting Wound Healing
Age Oxygenation & Circulation Nutritional status Wound condition Health status
Wound Complications
- Infection
- Within 2 – 7 days
- S&S: purulent drainage, ↑ drainage, pain, redness, swelling, ↑ temp, ↑ WBC
- Septicemia vs. Sepsis
- Hemorrhage
- Dehiscence (↑ pain, ↑ serosanguineous fluid ~ days 4 & 5)
- Evisceration (risk factors? What to do?)
- Fistula Formation
- Infections: red, discharge, edema, warm, odor
Wounds: Psychological Effects
Pain
Anxiety/Fear
Body Image Alterations
Pressure (Decubitus) Ulcers
Causes
External Pressure (applied over an area, may form in 1-2 hrs)
Friction (two surfaces rub against each other)
Shearing (one layer of tissue slides over another layer)
Risks
Immobility
Nutrition and Hydration
Moisture
Mental status
Age
Braden Scale
Braden Scale
19-23 Not at risk 15-18 Low risk 13-14 Moderate risk 10-12 High risk ≤ 9 Very high risk
Open Wound Classifications
RED
YELLOW
BLACK
MIXED
RED-proliferative stage, granulation, PROTECT
YELLOW-purulent oozing, CLEANSE
BLACK
MIXED
Principles of chronic wound care
Keep wound debrided of non-viable tissue and cleansed of foreign debris
Provide a moist environment
Prevent further injury
Provide essential substrates for healing
Wound Assessment
Appearance Location and Size Approximation of wound edges Erythema, bruising Swelling Temperature If wound open: Tunneling or Undermining R,Y,B, or mixed Odor
Wound Assessment
Drainage-amount, consistency, color
***exudate: serous, serosanguineous, sanguineous, purulent
Pain
Closure material
Sutures
Staples
Fibrin sealant
Wound Assessment
Drains/tubes Open drain systems (Penrose) Closed drain systems ( J-P, Hemovac) Wound pouch Vacuum-assisted closure (Wound VAC) Systemic evaluation V.S., labs Patient response
Wound Drains Assessment
Open drainage systems
Promote drainage passively, empties into absorptive dressing
Penrose drain
Closed drainage systems
Connect to reservoir to maintain constant low suction
Jackson-Pratt
Hemovacs
Wound Photography
Have patient lying in same position each time photo is taken
The photo is taken from the same distance
Place a sign with name, MRN, date, measurement tool next to wound when photo is taken. ( this information will be part of photo)
Any hands in photo must be gloved
Patient genitalia must be draped
Cleaning Agents
Normal Saline-best choice but not bacteriocidal
Betadine-surgical and procedural preps, infected wounds, retards healing
Hydrogen Peroxide-germicidal, debrides, removes blood clots, retards healing
Dakin’s Solution-germicidal, controls odor, very irritating to skin, retards healing
Proteolytic enzymes-chemical debridement
Dermal wound cleanser-gentle cleanser prayed into wound
Purposes of Dressings
Comfort Debridement Infection protection/control Absorption Maintain moisture Protect wound Protect skin
Examples of Wound Dressings
Transparent films Hydrocolloids Hydrogels Alginates Foams Collagens Nonadherent dressings Gauze dressings for packing
Taping Guidelines
Use porous hypoallergenic tape Tape width - usually 1” Less is best Do not occlude air circulation Rotate sites Use skin sealant first Avoid frequent removal Don’t restrict movement Don’t encircle extremity Pull toward dsg to remove. Support skin.
When should dressings be changed?
When ordered
When wet through
When medication or special agent no longer effective
No Touch Technique
Combination of sterile and non-sterile methods
Appropriate for low risk wounds
Uses clean gloves
Avoids touching side or part of dressing that come in contact with wound
Chronic wound
Nearly healed
Low risk wound
Removing Staples and Sutures
Staple removal Use of staple remover Remove every other staple Use of steri strips Suture removal Use of suture removal kit Scissor/blade Cut below the knot Pull through the healed wound only the portion of the suture that has been inside the tissue
Documentation
Describe: Any drainage (kind, amount) Wound appearance Presence of drains Dressing material used Tape/binder used Surrounding skin Pt response Complicated wound care detailed on care plan
Sterile Wound Dressing
Set up Sterile Field
Clean wound and apply dry/sterile dressing
Clean wound and apply saline-moistened dressing
Collect a wound culture
