Module 7b Flashcards
Functions of the Skin
Protection Body temperature regulation Psychosocial Sensation Vitamin D production Immunologic Absorption Elimination
Factors Affecting the Skin
Unbroken and healthy skin and mucous membranes
defend against harmful agents.
Resistance to injury is affected by age, amount of
underlying tissues, and illness.
Adequately nourished and hydrated body cells are
resistant to injury.
Adequate circulation is necessary to maintain cell life.
Developmental Considerations
In children younger than 2 years, the skin is thinner and
weaker than it is in adults.
An infant’s skin and mucous membranes are easily
injured and subject to infection; a child’s skin becomes
increasingly resistant to injury and infection.
The structure of the skin changes as a person ages; the
maturation of epidermal cells is prolonged, leading to
thin, easily damaged skin.
Circulation and collagen formation are impaired, leading
to decreased elasticity and increased risk for tissue
damage from pressure.
Causes of Skin Alterations
Very thin and very obese people are more susceptible to
skin injury.
o Fluid loss during illness causes dehydration.
o Skin appears loose and flabby.
Excessive perspiration during illness predisposes skin to
breakdown.
Jaundice causes yellowish, itchy skin.
Diseases of the skin, such as eczema and psoriasis, may
cause lesions that require special care.
Types of Wounds
Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
Principles of Wound Healing #1
Intact skin is the first line of defense against
microorganisms.
Careful hand hygiene is used in caring for a wound.
The body responds systematically to trauma of any of its
parts.
An adequate blood supply is essential for normal body
response to injury.
Normal healing is promoted when the wound is free of
foreign material.
Principles of Wound Healing #2
The extent of damage and the person’s state of health
affect wound healing.
Response to wound is more effective if proper nutrition is
maintained.
Phases of Wound Healing
Hemostasis
Inflammatory
Proliferation
Maturation
Hemostasis
Occurs immediately after initial injury
Involved blood vessels constrict and blood clotting
begins.
Exudate is formed, causing swelling and pain.
Increased perfusion results in heat and redness.
Platelets stimulate other cells to migrate to the injury to
participate in other phases of healing.
Inflammatory Phase
Follows hemostasis and lasts about 2 to 3 days
White blood cells, predominantly leukocytes and
macrophages, move to the wound .
Macrophages enter the wound area and remain for an
extended period.
They ingest debris and release growth factors that attract
fibroblasts to fill in the wound.
The patient has a generalized body response.
Proliferation Phase
Lasts for several weeks.
New tissue is built to fill the wound space through the
action of fibroblasts.
Capillaries grow across the wound.
A thin layer of epithelial cells forms across the wound.
Granulation tissue forms a foundation for scar tissue
development.
Maturation Phase
Final stage of healing; begins about 3 weeks after the
injury, possibly continuing for months or years.
Collagen is remodeled.
New collagen tissue is deposited.
Scar becomes a flat, thin, white line.
Local Factors Affecting Wound Healing
Pressure Desiccation (dehydration) Maceration (overhydration) Trauma Edema Infection Excessive bleeding Necrosis (death of tissue) Presence of biofilm (thick grouping of microorganisms)
Systemic Factors Affecting Wound Healing
Age: children and healthy adults heal more rapidly
Circulation and oxygenation: adequate blood flow is
essential
Nutritional status: healing requires adequate nutrition
Wound etiology: specific condition of the wound affects
healing
Health status: corticosteroid drugs and postoperative
radiation therapy delay healing
Immunosuppression
Medication use
Adherence to treatment plan
Wound Complications
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation
Psychological Effects of Wounds
Pain Anxiety Fear Impact on activities of daily living Change in body image
Factors Affecting Pressure
injury Development
Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders
Mechanisms in Pressure
Injury Development
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood
vessels
Stages of Pressure injuries
Stage 1: nonblanchable erythema of intact skin
Stage 2: partial-thickness skin loss with exposed dermis
Stage 3: full-thickness skin loss; not involving underlying
fascia
Stage 4: full-thickness skin and tissue loss
Unstageable: obscured full-thickness skin and tissue loss
Deep tissue pressure injury: persistent nonblanchable
deep red, maroon, or purple discoloration
Measurement of a Pressure injury
Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract
Cleaning a Pressure Injury/Wound
Clean with each dressing change.
Use new gauze for each wipe and clean from top to
bottom and/or from the center to the outside.
Use 0.9% normal saline solution to irrigate and clean the
injury.
Once the wound is cleaned, dry the area using a gauze
sponge in the same manner
Report any drainage or necrotic tissue.
Assessment of Wound Drainage
Serous
Sanguineous
Serosanguineous
Purulent
Wound Assessment
Inspection for sight and smell Palpation for appearance, drainage, and pain o Serous drainage o Sanguineous drainage o Serosanguineous drainage o Purulent drainage Sutures, drains or tubes, and manifestation of complications
Purposes of Wound Dressings
Provide physical, psychological, and aesthetic comfort
Prevent, eliminate, or control infection
Absorb drainage
Maintain moisture balance of the wound
Protect the wound from further injury
Protect the skin surrounding the wound
Debride (remove damaged/necrotic tissue), if appropriate
Stimulate and/or optimize the healing response
Consider ease of use and cost-effectiveness
Presence of Infection
Wound is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated, with dehiscence
present.
Types of Wound Dressings
Telfa
Gauze dressings
Transparent dressings
Types of Bandages
Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn
Types of Binders
Slings
Abdominal binders
Chest binders
T-binders
Type of Drainage Systems
Open systems o Penrose drain Closed systems o Jackson-Pratt drain o Hemovac drain
Pressure injury Assessment
Risk assessment Mobility Nutritional status Moisture and incontinence Appearance of existing pressure injury Pain assessment
Topics for Home Health Care Teaching
Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination
Factors Affecting the Response
to Hot and Cold Treatments
Method and duration of application
Degree of heat and cold applied
Patient’s age and physical condition
Amount of body surface covered by the application
Effects of Applying Heat
Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity and increases capillary permeability Reduces muscle tension Helps relieve pain
Effects of Applying Cold
Constricts peripheral blood vessels
Reduces muscle spasms
Promotes comfort
Devices to Apply Heat
Hot water bags Electric heating pads Aquathermia pads Hot packs Warm, moist compresses Sitz baths Warm soaks
Devices to Apply Cold
Ice bags
Cold packs
Hypothermia blankets
Cold compresses to apply moist cold
Some developmental
considerations:
> In children younger than 2 years, the skin is thinner and weaker than it
is in adults.
An infant’s skin and mucous membranes are easily injured and subject
to infection; a child’s skin becomes increasingly resistant to injury and
infection.
The structure of the skin changes as a person ages; the maturation of
epidermal cells is prolonged, leading to thin, easily damaged skin.
Older age: Circulation and collagen formation are impaired, leading to
decreased elasticity and increased risk for tissue damage from
pressure.
Some causes of skin alterations:
• Very thin and very obese people are more susceptible to skin injury.
-Fluid loss during illness causes dehydration.
-Skin appears loose and flabby.
• Excessive perspiration during illness predisposes skin to breakdown.
• Jaundice causes yellowish, itchy skin.
• Diseases of the skin, such as eczema and psoriasis, may cause lesions
that require special care.
Factors placing a person at risk for
skin alterations
•
-Age
• Lifestyle variables (homosexuality, history of multiple partners, IV drug use)
• Occupation or activity that gives prolonged exposure to the sun
• Body Piercings
• Changes in health state (dehydration, malnutrition)
• Reduced sensation (paralysis, local nerve damage, circulatory insufficiency)
• Illness (diabetes)
• Therapeutic measures (bed rest, cast, medications, radiation therapy)
The Nurses major role:
• -Identifying risk factors that predispose a patient to a break in
integrity
• -Intervening to prevent or reduce a patient’s risk for impaired skin
integrity
• -Providing specific wound care when breaks in integrity arise
• Measuring wounds
• Obtaining wound specimens
Wound Healing Process Phases
- Hemostasis
- Inflammation
- Proliferation
- Maturation
Hemostasis
• Occurs immediately after initial injury
• Involved blood vessels constrict and blood clotting begins.
• Exudate is formed, causing swelling and pain.
• Increased perfusion results in heat and redness.
• Platelets stimulate other cells to migrate to the injury to participate in
other phases of healing.
Inflammatory Phase
• Follows hemostasis and lasts about 2 to 3 days
• White blood cells, predominantly leukocytes and macrophages, move
to the wound.
• Macrophages enter the wound area and remain for an extended
period.
• They ingest debris and release growth factors that attract fibroblasts
to fill in the wound.
• The patient has a generalized body response
Proliferation Phase
• Lasts for several weeks.
• New tissue is built to fill the wound space through the action of
fibroblasts.
• Capillaries grow across the wound.
• A thin layer of epithelial cells forms across the wound.
• Granulation tissue forms a foundation for scar tissue development.
Maturation Phase
• Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years. • Collagen is remodeled. • New collagen tissue is deposited. • Scar becomes a flat, thin, white line.
Wound Complication
• Infection • Hemorrhage • Dehiscence and Evisceration • Fistula Formation fistula: an abnormal passage from an internal organ to the skin or from one internal organ to another
Pressure Injuries
• Pressure injuries are staged based on their depth, exudate, and/or
eschar development.
• A pressure injury is defined as localized damage to the skin and
underlying tissue that usually occurs over a bony prominence or is
related to the use of a (medical or other) device.
• Most pressure injuries develop when soft tissue is compressed
between a bony prominence and an external surface for a prolonged
period of time, or when soft tissue undergoes pressure in
combination with shear and/or friction.
Stages of pressure injuries
• Stage 1: non-blanchable erythema of intact skin
• Stage 2: partial-thickness skin loss with exposed dermis
• Stage 3: full-thickness skin loss; not involving underlying fascia
• Stage 4: full-thickness skin and tissue loss
• Unstageable: obscured full-thickness skin and tissue loss
• Deep tissue pressure injury: persistent non-blanchable deep red,
maroon, or purple discoloration
How to measure a pressure injury:
- Size of wound
- Depth of wound
- Presence of undermining, tunneling, or sinus tract
Measuring wounds & Obtaining
specimens
• Measuring (length, width, and diameter)
• Wound specimens are best obtained from the center of the wound
site with live tissue. Collecting the specimen from the suspected
source of infection ensures that neighboring microbes do not
contaminate the specimen. Collecting from dead tissue or tissue
outside the wound with give inaccurate results.
What are some signs and symptoms of wound infection?
- Wound is swollen.
- Wound is deep red in color.
- Wound feels hot on palpation.
- Drainage is increased and possibly purulent.
- Foul odor may be noted.
- Wound edges may be separated, with dehiscence present.
- Fever
- Pain
Types of drainage symptoms:
• Open systems -Penrose drain • Closed systems - Jackson-Pratt drain - Hemovac drain
Pressure injury assessment consist
of:
- Risk assessment
- Mobility
- Nutritional status
- Moisture and incontinence
- Appearance of existing pressure injury
- Pain assessment
Psychological Considerations
Actual and potential emotional stressors related to wounds include:
- pain
- Anxiety
- Fear
- activities of daily living
- changes in body image
Wound treatment
Affects of applying heat:
• Dilates peripheral blood vessels
Affects of applying heat:
• Increases tissue metabolism • Reduces blood viscosity and increases capillary permeability • Reduces muscle tension • Helps relieve pain
Affects of applying cold: • Constricts peripheral blood vessels • Reduces muscle spasms • Promotes comfort
Pressure Ulcer Care Plan
• Pathophysiology
Pressure ulcers are also called decubitus ulcers or bedsores. These are
injuries to the skin and underlying tissues that develop after prolonged
pressure in a particular area. Bedsores are common on the heels,
sacrum and over bony prominences such as the elbows and shoulder
blades. Pressure ulcers can develop and progress very quickly, but are
preventable and treatable.
Etiology
• Pressure ulcers are caused by three main factors.
• Pressure: Constant or prolonged pressure that restricts blood flow to any
part of the body. If blood is restricted to an area, nutrition, oxygenation
and tissue perfusion cannot take place. Without these essentials, the skin
and nearby tissue is damaged and may eventually become necrotic.
• Friction: As skin rubs against clothing or bedding, it can make weakened
areas in the skin that are vulnerable to injury. This occurs often if the skin
is consistently moist.
• Shear: When skin slides against a surface, such as sliding down in the
bed when the head only is elevated or transferring or positioning a
patient by allowing the skin to move across the bedding. Fragile skin is
easily ripped or torn this way.
Desire outcome/goal with pressure wound
Patient will experience healing of current pressure wounds, prevention of further skin injury and maintain optimal skin integrity Subjective Data Outcome • Tender areas of skin • Pain, burning of skin • Itching Objective Data • Changes in skin color or texture • Swelling • Drainage from wounds • Stage 1 – non-blanchable redness • Stage 2 – open skin, pink/red, blister • Stage 3 – Exposed subcutaneous tissue • Stage 4 – Exposed muscle/bone
Assess skin for signs of hydration pressure injury, and note areas of increased risk • Monitor for signs of infection (plan) Interventions: Note odor and appearance of exudate Fever Warmth to touch Obtain wound cultures as needed Monitor white blood count (WBC) Administer antibiotics as required • Provide appropriate wound care (plan) Interventions: Cleaning Debridement Dressings Emollients Skin barriers Negative pressure wound therapy • Promote nutrition and education (plan) Interventions: Consult dietitian Offer high-protein, high-calorie diet Encourage hydratio
