Chapter 36 Skin Integrity N Wound Care Flashcards
Functions of the skin
Protection
Temperature regulation
Sensation
Factors Affecting Skin Integrity
Genetics and heredity Age Chronic illnesses and their treatments ex diabetics can be affected because of sensation not able to feel (touch) Medications ex protozoan Poor nutrition Trauma
Define wounds
An injury to living tissue (especially an injury involving a cut or break in the skin)
Types of Wounds
Incision
Laceration
Abrasion
Incision sharp instrument
Laceration tissues torn apart often from accidents
Abrasion surface scrape either unintentional ex scraped knee from a fall
Types of Wounds
Contusion
Avulsion
Penetrating wound
Contusion blow from a blunt instrument
Avulsion injury of which the body structure is forceful detached by either trauma or injury
Penetrating wound penetration of the skin and the underlying tissues usually unintentional ex from a bullet or mental fragments
Assessment of Wounds
Objective judgement
Wound assessment charts provide a useful framework
Wound measurement is an important aspect of the assessment
Photographs
Ex week or two of no healing contact physician
Assessments of wounds
Related to lab work
WBCS decrease leukocyte count can delay healing and increase possibility of infection
Hemoglobin indicates poor oxygenation delivery to the tissues
Coagulation tests indicates excessive blood loss and prolonged clothing absorption
Serum protein indicates nutritional reserves for rebuilding cells
Albumin indicates nutritional status
Wound cultures confirm or rule out the presence of infection
Pressure Ulcers
Are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces
Safety Alert
From the joint commission 2010 national patient safety goals (NPSGs)
Goal 14 prevent health care associated pressure ulcers (decubitus ulcers)
Rationale pressure ulcers continue to be problematic in all health care settings Most pressure ulcers can be prevented and deterioration at state 1 can be halted
Healthy skin vs Fragile skin
Healthy skin the subcutaneous layer contains blood vessels and cushioning fat new cells are made in the dermis
Fragile skin the subcutaneous layer has fewer and flatter fat cells the dermis produce cells slowly
Skin Integrity
Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds
What are the four stages of pressure ulcers?
Stage 1 nonblanchable erythema signaling potential ulceration
Stage 2 partial thickness skin loss (abrasion,blister,or shallow crater) involving the epidermis and possibly the dermis
Stage 3 full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
Stage 4 full thickness skin loss with tissue necrosis or damage to muscle bone or supporting structures such as a tendon or joint capsule
Assessment of Pressure Ulcers
Location r/t a bony prominence Size Stage (can't stage in Fl) Color of the wound bed Necrosis or Escher Wound margins Surrounding skin Clinical signs of infection
Pressure Ulcers Interventions
Obtaining wound culture ex aerobic or anaerobic
Administer analgesic ex remove moist or outer dressing
Discard in bad
Cleanse wound ex irrigate or cleanse wound with NS
Assessment Risk Assessment Tools
Braden Scale predict risk a total 23 points below 18 considered at risk
Norton’s Pressure Area Risk Assessment total score of 24, 15-16 considered indications not predictions of risk
Push pressure ulcer scale for healing national pressure ulcer advisory panel
Pressure Ulcer Risk Factors
Friction and shearing Immobility Fecal/ Urinary incontinence Inadequate Nutrition Decreased mental status/ diminished awareness Elevated body heat
Treating Pressure Ulcers
Minimize/ reduce pressure Scheduled position changes Pressure reducing devices Surgical asepsis for wound care Obtain C&S if infected Educate client ROM
What are the four types of debridement
Sharp use of scalpel
Mechanical scrubbing force and damp to damp dressing
Chemical collagenase enzyme agents
Autolytic hydrocolloid and clear absorbent dressing fly larvae (maggots)
Arterial Ulcers
Location
Associated Skin Assessment
Associated Wound Assessment
Arterial Ulcers is caused by impaired arterial blood flow
Location is the toes foot malleolus area
Associated skin assessment is cool skin temp,thin shiny skin,painful, decreased pulse strength
Associated wound assessments is minimal exudate, pale wound bed,well defined wound margins
Venous Ulcer
Decrease in blood flow return from the lower extremities to the heart can cause a blood clot
Location lower calf and ankle in the area covered by a sock
Associated Skin Characteristics brown discoloration of lower calf and ankle skin edema dry scaly skin
Associated Wound Characteristics
Irregular margins n drainage
Diabetic Ulcers
Often caused by sensory motor and autonomic neuropathy
Usual location metatarsal heads tops of the toes and the foot
Associated Skin Assessments
Dry cracked skin warm skin decreased sensation
Name the Stages of wound healing
Inflammatory Phase 3-6 days
Proliferation Phase 3-21 days
Maturation Phase 21-1 year or longer
Primary intention healing
Tissue surfaces closed
Minimal or no tissue loss
Formation of minimal granulation and scarring
Secondary Intention Healing
Extensive tissue loss Edges cannot be closed Repair time longer Scaring greater Susceptibility to infection greater
Tertiary Intention Healing (Dealing Primary Intention)
Initially left open
Edema infection or exudate resolves
Then closed
Exudate is to drain the heal wounds after they are left open
Wound Exudate
Material such as fluid and cells that have escaped from blood vessels during inflammatory process deposited in tissue or on tissue surface
Serous Exudate
Mostly serum
Looks watery
Few cells
Ex fluid in blister
Sangulineous Exudate
Bloody
Large amount of RBCs
Seen in open wounds
Purulent Exudate
Pus
Thicker than serous
Blue green or yellow color
Suppurations process of pus formation
Factors affecting wound healing
Poor surgical techniques Poor wound management Lifestyle ex smoking Age Impaired nutritional status Dehydration Diabetes Impaired bloody supply Stress and anxiety or depression
Factors to support wound healing
Maintain moist healing
Provide sufficient nutrition and hydration
Prevent wound infection
Proper positioning
Purpose for Dressing Wounds
Protection from mechanical injury against microbial contamination
Provide moist wound healing thermal insulation
Absorbs drainage
Debridement
Pressure hemorrhage
Splint or immobilize site
Maggot Debridement Therapy
Medical use of live maggots (fly larvae) for treating no healing wounds
Disinfected medicinal fly larvae applied to wound
Maggots secrete a proteolytic (tissue dissolving) enzyme
There primary actions
1. Clean wound by dissolving dead and infected tissue debridement
2. Disinfect wound
3. spread rate of healing
3,
Rebound Phenomenon Using Heat and Cold Therapies
Maximum therapeutic effect is achieved then opposite effect begins
Heat produces vasodilation
Max 20-30 minutes
30-45 minutes = tissue congestion then vessels constrict
Cold application produces vasoconstriction
Review pg 951 table 36-7
Complications of Wound Healing
Hemmorrhage massive bleeding
Infection REED Assessment
Dehiscence
Evisceration
Nursing Diagnoses and Goals
Risk for impaired skin integrity
* Maintain skin integrity n avoid or reduce risk factors
Impaired Skin Integrity
* Progressive wound healing n regain intact skin
Impaired Tissue Integrity
* risk for infection n pain
Physician official effects of heat *not in PowerPoint but chart in chpt
Vasodilation Increases capillary permeability Increases cellular metabolism Increases inflammation Sedative effect
Physiological effects of cold *not in PowerPoint but in book
Vasoconstriction Decreases capillary permeability Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect
