skin integrity and wound care Flashcards
Promoting healthy skin
- Self assessment
- Bathing
- Nutrition
- Hydration
- Sunscreen
- Moisturizing
- Perfusion
- Mobility
Skin care strategies for infants
- gentle bathing
- avoid alcohol based products
- no direct adhesives
- limit topical agents
- maintain adequate nutrition
Skin care strategies for adults
- complete bath every other day
- tepid water temperature
- pat dry
- no tight or rubbing clothes
- maintain adequate nutrition
- avoid caffeine & alcohol
Cultural Considerations
- Darker skinned individuals may be subject to drier hair, scalps, and skin
- Use of skin moisturizers, hair oils and different cleansers may be necessary
- Some products contain shea butter, olive oil, petrolatum and more
- caution products that are oil or alcohol based may also increase damage to skin
Types of impaired skin integrity
Disorders (inflammatory, papulosquamous, vesiculobullous, vascular), lesions, insect bites, infections, tumors (begin, malignant), burns, pressure ulcer, surgery & trauma
Wound classifications
- Acute wound- occurred suddenly, trauma, heal in orderly sequence of events
- Chronic wound- caused by chronic condition & don’t heal in orderly manner
- Partial thickness wound- involves partial loss of skin layers, not deeper tissues, superficial & painful due to exposed nerve endings, scarped knee, heals quickly
- Full thickness wound- involves total loss of epidermis & dermis, plus extends into subcutaneous & occasional muscle, heals by complex process of scar formation
Normal wound healing
Intentions; primary, secondary, tertiary
Regeneration
Scarring
Phases of wound healing
- Inflammatory (control bleeding, establish clean wound bed, clot dissolution releases growth factors, release vasoactive substances, 1-5 days)
- Proliferative (rebuilding phase, days 6-21, granulation- tissue fills the wound with vessels & connective tissue, epithelialization, contraction- wound edges pull together to reduce the size of the wound opening)
- Remodeling (final phase pf fun thickness repair 3 weeks up to 2 full years, replacing connective tissue- strength is acquired within 3 months- but tissue is never as strong as original tissue 80% optimal, fill thickness repair, keloid scar- tissue extending beyond boundaries of the original wound heal)
Factors affecting wound healing
tissue perfusion, nutritional status, diabetes mellitus, corticosteroids, age
Factors affecting wound healing (tissue perfusion & nutritional status & Nutritional Status & Corticosteroids)
- Tissue perfusion: fibroblast proliferation, collagen synthesis, leukocyte activity, phagopcytosis, reepithelialization
- Nutritional status: connective tissue needs- proteins, vitamins, minerals
- Diabetes mellitus: leukocytosis, growth factor, collagen synthesis, tensile strength
- Corticosteroids: inhibits repair, 20-40 mg/day
Factors affecting healing- older adult
- Reduced macrophage functioning
- Delayed inflammatory response
- Delayed collagen synthesis
- Slower epithelialization
- Increased incidence of chronic illnesses that compromise circulation & tissue oxygenation
Wound healing complications
- infection
- hemorrhage
- dehiscence
- evisceration
- fistula
S/S of infection
Drainage (purulent, increasing in quantity), pain, redness & swelling, elevated temperature, increased WBC
Hemorrhage
1st 48-hours (occurs most in this period); check wound frequently Excessive bleeding (pressure with sterile dressing, sterile packing, fluid replacement, surgical repair)
Dehiscence & Evisceration
Dehiscence (disrupted wound layers, increased serousanguinous drainage, “something given way”)
Evisceratin (protrusion of viscera)
Fistula development
Abnormal passage- internal organ to skin, one organ to another
Wound assessment
Location- where on the body
Dimensions & depth- length, width, depth, tunneling
Stage- what layers of tissue are involved
Status of wound bed- presence of eschar (dry brownish or black tissue), slough
Exudate- fluid how much, what does it look like,
Status of wound edges- open, proliferative, closed
Status of surrounding skin- redness, warmth, is it inflamed
Pain- intense pain is associated with wound care, treat aggressively
Types of dressings
Xeroform; gauze; tegasorb; tegaderm; bioclusive transport dressing; montgomery straps; ABD binder
Wound drainage
- Serous; clear/ watery plasma
- Purulent; thick, yellow, green, tan, brown
- Serousanguinous; pale, red, watery, mixture of clear and red fluid
- Sanguinous; bright red, indicates active bleeding
Wound management
Abrasions- non adherent, absorptive dressing
Lacerations- clean (closed primarily), contaminated (open to heal)
Surgical incisions- closed by sutures or staples, heal quickly
Skin tears- viable flap (cleanse wound & roll flap back into place & secure with adhesive strips), no flap (cleanse & apply non adherent, adsorptive dressing)
Wound care facts
Wound care should be performed:
- From an area that is the least contaminated to the most contaminated area
- With a new gauze pad for each wipe
- This means that you should start from top to bottom, inner to outer, using a new pad for each wipe
Wound irrigation
steady flow of a solution across an open wound surfaceto achieve wound hydration, to remove deeper debris, and to assist with the visual examination
Wound culture
a test to find germs (such as bacteria or a fungus) that can cause an infection. A sample of skin, tissue, or fluid is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs that can cause an infection grow, the culture is positive
Pressure Ulcers stage 1
- pressure-related skin alteration
- changes may include: skin temperature, tissue consistency, sensation, color
- intact skin
- non-blanchable
- affects epidermis
- redness
- warm skin
- softer than normal
Pressure Ulcers stage 2
- partial thickness skin loss: epidermis, dermis
- presents clinically as: abrasion, blister, shallow crater
- open epidermis & may include the dermal layer
- looks like blister
- blanchabe
Pressure Ulcers stage 3
- full thickness skin loss: subcutaneous tissue, fascia
- clinically presents as: deep crater, undermining
- down to the fascia w/ tunneling
Pressure Ulcers stage 4
- full thickness skin loss: tissue necrosis, muscle, bone, supporting structures, sinus tracts
- through to the bone, may be necrotic- big infection risk
- looks like holes
Pressure ulcers
Etiology- shearing & friction: layers slide against one another, pressure: reduces or eliminates blood flow (prolonged, high intensity)
Location- over bony protection
Results in subcutaneous compressions- blood vessel compression, ulcer development, tunneling extension up under top layer
Pressure ulcer risk factors
Altered LOC, immobility, maceration, pain, malnourished, debilitation, impaired sensory perception, shear & friction
Pressure ulcer risk assessment
Physical assessment
Wound & ostomy care nurse- guidelines
Standard-risk assessment tools- Braden scale for predicting pressure sore risk, Norton scale for prediction of pressure ulcer risk
Barden Scale
19-23= no risk 15-18= low risk 13-14= mod. Risk 10-25= high risk < or equal to= very high risk
Norton Scale
< 14 is at risk
- Assesses client risk factors for pressure ulcer formation
- Clients are scored 1-4 points for: physical condition, mental condition, activity, mobility, incontinence
- Higher the score, the better the patient is and the lower their risk factor is for developing a pressure ulcer
Pressure ulcer assessment
- location
- stage & tissue involvement
- drainage
- measurements: size, depth, undermining & tunnels
Consequences of pressure ulcer
Pain (provide analgesics prior to dressing changes)
Anxiety (over change in body image)
Economics (increases cost of care & length of hospitalization)
Quality of care (used as a quality or lack of quality indictor for facilities)
Use of resources (increase in nursing, costs, & support service care)
Prevent pressure ulcer
Identify high-risk clients, identify contributing factors, ongoing assessment, hygiene & skin care, repositioning with support, reduce shear & friction, control moisture, nutrition & fluid support
Independent nursing interventions for pressure ulcer care
Skin care, teaching, pressure relief, reduction of shear & friction, don’t massage over bony prominences, nutrition & hydration
Dependent & independent nursing interventions
Cleaning of wound bed, dressing type & frequency per order, pressure relief specialized mattresses, surgical procedures debridement/reconstruction/skin flaps, controlling infection with antibiotics, nutrition & fluid support enteral or parenteral
Lower extremity ulcer
Arterial (caused by arterial insufficiency, results in ischemic tissue, heals by improving tissue perfusion, lifestyle changes, baby aspirin & avoiding the cold)
Venous (cause by venous insufficiency, one-way vale damage, dark red ulcer bed, edema, ulceration, exudate, DVT’s, treatment is compression wraps)
Neuropathic ulcer (found in pt w/ diabetes or neurological damage; treatment is keep blood glucose normal, foot care, & routine exams)
Nursing process for wound management
Assessment, nursing diagnosis, goal & outcomes, establish plan, implement plan, evaluation
Wound care plan
Nursing diagnosis- impaired skin integrity R/T immobility and poor nutrition AEB: 4cm reddened area on patient’s left hip
Goal (opposite of diagnosis)- skin integrity will improve by time of discharge from facility
Outcomes- patient will exhibit improved or healed left hip, patient will have minimal complications, patient will verbalized precipitating factors and appropriate skin care measures
Nursing interventions & rationales
Assess: Inspect skin q-shift, document findings. Provides evidence of effectiveness of skin care regimen and signs of further complications.
Do: Provide wound care as prescribed and report adverse response. Maintain or modify treatment plan. Turn/reposition patient every two hours. Provides uniform pressure over bony prominences and promotes uniform blood flow to tissues.
Teach: Explain wound and skin care to client and caregiver. Promotes compliance with treatment regimen.
Evaluate (review the outcomes): the outcomes): what worked? Changes? Patient will exhibit improved or healed left hip wound. Patient will have minimal complications. Patient will verbalize precipitating factors as well as appropriate skin care measures.
