Skin Integrity & Wound Healing Flashcards
Integumentary System
Consists of:
Skin
- Largest body organ (covers an area of 20 sq/ft)
> Functions
* Protection of internal organs
* Unique individual identification
* Thermoregulation
* Metabolism of nutrients & metabolic waste products
* Sensation
Hair
Sweat glands
Subcutaneous tissue
Key Concepts
Skin integrity
- Intact skin
Wound
- Disruption of normal skin integrity
Wound healing
- Physiological process
Structure of the Skin
___ (outer portion)
?
- Outermost layer
Functions
> Barrier
> Restricts fluid loss
> Prevents fluids, pathogens, antigens, & chemicals from entering the body
Epidermis
Stratum corneum
?
- Innermost layer
- Functions : produces new cells
- ___ : cells containing proteins = skin strength & elasticity
- ___ : produce melanin = pigmentation = skin color & protection from UV light
- ___ : phagocytize foreign material
Stratum germinativum
Keratinocytes
Melanocytes
Langerhans cells
?
Below epidermis & above subcutaneous tissue
Irregular fibrous tissue = provides strength & elasticity
Supplied generously w/blood vessels
Contains sweat glands, sebaceous (oil) glands, ceruminous (wax) glands, hair & nail follicles, sensory receptors, elastin, & collagen
Dermis
Structure of the Skin - Subcutaneous Tissue
- Composed of connective tissue & adipose tissue
- Provides insulation, protection, & calorie reserve
Factors Affecting Skin Integrity
- Age
> Older adult skin - less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury
- Mobility status
> Increased pressure, shearing, & friction can lead to breakdown
- Patients @ risk for developing pressure injury are those w/immobility, friction & shear, moisture, incontinence, poor nutrition, perfusion, age, skin condition, & altered loc
Factors Affecting Skin Integrity cont’d
- Nutrition/hydration
* Protein - maintain the skin, repair minor defects, & preserve intravascular volume
* Vitamin C, zinc, copper (formation of collagen)
* Dehydration = poor turgor
- Sensation level
> Diminished sensation leads to increased risk for pressure & breakdown
Factors Affecting Skin Integrity cont’d
- Impaired circulation - negatively affects tissue metabolism
* Impaired ___ circulation
> Restricts activity, produces pain, & leads to muscle atrophy & thin tissue
* Impaired ___ circulation
> Results in engorged tissues containing high levels of metabolic waste products (prone to edema, ulceration, & breakdown)
arterial
venous
Both forms of circulatory impairment delay wound healing
In fact, circulatory impairment is one of the main causes of chronic wounds
Factors Affecting Skin Integrity cont’d
- Medications - side effects : itching, rashes
* BP rx’s
* Anti-inflammatory rx’s
* Anti-coagulants
* Chemotherapeutic agents
* Certain antibiotics, psychotherapeutic drugs, & chemotherapy agents
* Several herbal products
Rx’s that cause pruritus (itching), dermatoses (rashes), photosensitivity, allopecia, or pigmentation changes can result in changes that impair skin integrity or delay healing
Factors Affecting Skin Integrity cont’d
___
* Depletes moisture
* Increases metabolic rate
Fever
Factors Affecting Skin Integrity cont’d
___
* Leads to maceration
* Bowel incontinence
- Moisture-associated skin damage (MASD)
- Pressure injury infection
Moisture
Exposure to moisture leads to ___ (softening of the skin) & increases the likelihood of skin breakdown
Incontinence & fever are the most common sources of moisture
maceration
Factors Affecting Skin Integrity cont’d
___
* Impedes healing
* Colonization
* Critical colonization
* Implies that microorganisms are causing harm by releasing toxins, invading body tissues, and increasing the metabolic demand of the tissue
Infection
___ occurs when bacteria begin to overwhelm the body’s defenses. S/S may include increase in drainage, new foul odor, a change in color of the wound bed, new tunneling of the wound, or absence or friable granulation tissue
Critical colonization
Factors Affecting Skin Integrity cont’d
- Tanning
- Bathing or over-cleansing of the skin
- Smoking
- Piercings and/or tattoos
Clicker Check
Of the following factors, which would put a client at greatest risk for impaired skin integrity?
a. Medication, digoxin
b. Moisture
c. Decreased sensation
d. Dehydration
Correct Answer: c
Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness.
Wounds
- Disruptions in the normal integrity of the skin
- Wounds can be intentional (surgical wound) or unintentional (cut or pressure injury)
Classification of Wounds
Wounds can be classified according to:
* Skin integrity
- Open / Closed
* Length of time healing
- Acute / chronic
* Level of contamination
- Clean / contaminated / infected
* Depth of wound
- Superficial / partial or full thickness / penetrating
If there are no breaks in the skin, the wound is described as ___
___ (bruises) or tissue swelling from fractures are common ___ wounds
Review Table 35-1 Types of wounds
closed
Contusions; closed
A wound is considered ___ if there is a break in the skin or mucous membranes
They include abrasions, lacerations, puncture wounds, and surgical incisions
open
___ wounds are expected to be of short duration
In a healthy person, these wounds heal spontaneously without complications through the 3 phases of wound healing (___, ___, & ___)
Acute
inflammation, proliferation, maturation
Wounds that exceed the expected length of recovery are classified as ___ wounds
chronic
Review Table 35-2 Chronic Wounds
___ wounds are uninfected wounds w/minimal inflammation
Clean
___ wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred; risk of infection is high for these wounds
Contaminated
___ wounds are surgical incisions that enter the GI, respiratory, or GU tracts
There is an increased risk of infection for these wounds, but there is no obvious infection
Clean-contaminated
Wounds are considered ___ when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue
However, the presence of beta-hemolytic streptococci, in any number, is considered an infection
infected
___ wounds extend into the subcutaneous tissue and beyond
Full-thickness
___ wounds involve only the epidermal layer of skin
The injury is usually the result of friction, shearing, or burning
Superficial
___ wounds extend through the epidermis but not through the dermis
Partial-thickness
The descriptor ___ is sometimes added to indicate that the wound involves internal organs
penetrating
Wound Healing Processes
Regeneration
- In epidermal wounds
- No scar
Primary intention
- Clean surgical incision/edges approximated
- Minimal scarring
___
When a wound involves minimal or no tissue loss and has edges that are well approximated (closed), ___ (___) ___ healing takes place
Little scarring is expected
A clean surgical incision heals by this method
Primary intention
primary (first) intention
When a wound affects only the epidermis and dermis, ___/___ healing takes place
No scar forms, and the new (___) ___ and dermal cells form new skin that cannot be distinguished from the intact skin
Partial-thickness wounds heal by this (___)
regenerative/epithelial
(regenerated) epithelial
regeneration
Wound Healing Processes cont’d
Secondary intention
- Wound edges not approximated
- Tissue loss
- Heals from inner layer to surface
Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red ___ tissue (a form of connective tissue with an abundant blood supply)
Wounds that heal by secondary intention heal more slowly, are more prone to infection, and develop more scar tissue
e.g. pressure injury, infected wounds
granulation
Wound Healing Processes cont’d
Tertiary intention
- Granulating tissue brought together
- Delayed closure of wound edges
A wound heals by tertiary (third) healing, also called delayed primary closure, which occurs when 2 surfaces of granulation tissue are brought together
This technique may be used when the wound is clean-contaminated or contaminated
Initially, the wound is allowed to heal by secondary intention
When there is no evidence of edema, infection, or foreign matter, the wound edges are closed by bringing together the granulating tissue and suturing the surface
Such wounds require strict aseptic technique during all dressing changes because they are prone to infection
Tertiary intention healing creates less scarring than does secondary, but more than primary intention healing
Phases of Wound Healing
Inflammatory - Cleansing
* Hemostasis
* Inflammation
Proliferative - Granulation
* Fibroblasts
* Collagen
Maturation - Epithelialization
* Remodeling
?
This is a phase that lasts from 1 to 5 days and consists of two major processes: hemostasis and inflammation
Cleansing
?
Is characterized by edema, erythema, pain, temperature elevation, and migration of WBC’s into the wound tissues
Within 24 hours, macrophages begin engulfing bacteria (___) and clearing debris
Along with plasma proteins and fibrin, they form a scab on the wound surface, which seals the wound and helps prevent microbial invasion
Inflammation
phagocytosis
?
At the time of injury, tissue and capillaries are destroyed, causing blood and plasma to leak into the wound
Area vessels constrict to limit blood loss
Platelets aggregate (clump together) to slow bleeding
At the same time, the clotting mechanism is activated to form a blood clot
Hemostasis
?
This phase occurs from days 5 to 21
Cells develop to fill the wound defect and resurface the skin
___ (connective tissue cells) migrate to the wound where they form ___, a protein substance that adds strength to the healing wound
New blood and lymph vessels sprout from the existing capillaries at the edge of the wound
Result is the formation of ___ tissue, a beefy red tissue that bleeds readily and is easily damaged
Proliferative phase: granulation
Fibroblasts; collagen
granulation
As the clot or scab is dissolved, epithelial cells begin to grow into the wound from surrounding healthy tissue and seal over the wound (___)
epithelialization
?
This phase, also known as remodeling, is the final phase of the healing process
It begins in the 2nd or 3rd week and continues even after the wound has closed
Over the next 3 to 6 months, the initial collagen fibers that were laid in the wound bed during the proliferative phase are broken down and remodeled into an organized structure (e.g. scar tissue), increasing the tensile strength of the wound
Maturation phase: epithelialization
Wound Closures
- Adhesive strips
- Sutures
- Surgical staples
> Wounds on the hands, feet, neck, or face should not be stapled
- Surgical glue
> For use in clean, low-tension wounds; ideal closure method for skin tears
Types of Wound Drainage
- Serous exudate : straw-colored
- Sanguineous exudate : bloody drainage
- Serosanguineous : mix of bloody and straw-colored fluid
- Purulent exudate : yellow, contains pus
- Purosanguineous exudate : contains blood & pus
?
Straw-colored exudate
Clean wounds typically drain this
Watery in consistency and contains very little cellular matter
Serous
Consists of serum, the straw-colored fluid that separates out of blood when a clot is formed
?
Is a combination of bloody and serous drainage
Serosanguineous
?
Is bloody drainage
With deep wounds or wounds in highly vascular areas
Indicates damage to capillaries
Fresh bleeding produces bright red drainage, whereas older, dried blood is a dark, red-brown color
Sanguineous
?
Is thick, often malodorous drainage that is seen in infected wounds
Contains pus, a protein-rich fluid filled with WBC’s, bacteria, and cellular debris
Commonly caused by infection from ___ (pus-forming) bacteria, such as streptococci or staphylococci
Normally, pus is yellow in color, although it may take on a blue-green color if the bacterium Pseudomonas aeruginosa is present
Purulent
pyogenic
?
Is red-tinged pus
Indicates that small vessels in the wound area have ruptured
Purosanguineous
Types of Wound Drainage cont’d
Complications of Wound Healing
* Hemorrhage
- Hemostasis
* Infection
- Localized swelling
- Redness
- Heat / pain / fever / foul-smelling or purulent drainage / change in drainage color
* Dehiscence
* Evisceration
* Fistula formation
Hemorrhage (bleeding): implies a profuse or rapid loss of blood
Occurs when a capillary network is interrupted, or a blood vessel is severed
Hemostasis is the cessation of bleeding and usually occurs within minutes of an injury
Hemostasis may be delayed when large vessels are injured, a clotting disorder exists, or the client is on anticoagulant therapy
The risk of hemorrhage is greatest in the first 24 to 48 hours following surgery or injury
Swelling of the affected body part, pain, and changes in VS (e.g. decreased BP, elevated pulse) may indicate internal bleeding
By internal bleeding, we are referring to a ___, a red-blue collection of blood under the skin, which forms as a result of bleeding that cannot escape to the surface
External hemorrhage is easier to recognize
You will see bloody drainage on the dressings and in the wound drainage devices
When there is a brisk hemorrhage, blood often pools underneath the client as the dressings become saturated
hematoma
Infection
Localized swelling, redness, heat, pain, fever (temperatures higher than 38ºC [100.4ºF], foul-smelling or purulent drainage, or a change in the color of the drainage may also indicate infection
Rupture (separation) of one or more layers of a wound is called ___ (Fig 35-6)
Is most likely to occur in the inflammatory phase of healing, before large amounts of collagen have been deposited in the wound to strengthen it
Most common causes are poor nutritional status, inadequate closure of the muscles, wound infection, increased tension on the suture line from coughing or lifting a heavy object, and obesity
Usually associated with abdominal wounds
Dehiscence
Nursing interventions may include maintaining bed rest with the head of the bed elevated at a 20º angle and the knees flexed; application of a binder to prevent evisceration; and notifying the provider of the dehiscence
?
Is total separation of the layers of a wound in which internal viscera protrude through the incision (Fig. 35-7)
This is a rare complication and is a surgical emergency
Immediately cover the wound with sterile towels or dressings soaked in sterile saline solution to prevent the organs from drying out and becoming contaminated with environmental bacteria
Have the patient stay in bed with knees bent to minimize strain on the incision
Do not put a binder on the patient; notify the surgeon and ready the patient for a surgical procedure
Evisceration
?
Is an abnormal passage connecting two body cavities or a cavity and the skin
Often result from infection
An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway
Chronic drainage from this may lead to skin breakdown and delayed wound healing
Most common sites where these form are the GI and GU tracts
(Fistula) formation
Complications of Wound Healing cont’d
?
Evisceration
Complications of Wound Healing cont’d
?
Dehiscence
Clicker Check
The client calls the nurse to the room and states, “Look, my incision is popping open where they did my hip surgery!” The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse’s best action is to
a. Notify the surgeon STAT
b. Place a clean, sterile 4x4 over the incision and monitor the drainage
c. Wrap an Ace bandage firmly around the area and have the client maintain bedrest
d. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon
Answer: b
A 1-cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no “internal viscera” to protrude
Nursing Assessment: Skin and Wounds
Focused skin assessment
* Braden scale: sensory perception, moisture, activity, mobility, nutrition, and friction or shear
- Total score less than 18 = risk
* Norton scale: patient’s physical condition, mental state, activity, mobility, & incontinence
To assess wound healing ability and the risk for skin breakdown, you will need to gather data on factors that affect skin integrity: age, mobility, nutrition, hydration, sensation, circulation, medications, moisture, lifestyle, underlying health & disease status, & the presence of microorganisms
The psychosocial issues r/t coping w/chronic wounds also need to be considered
?
Assesses risk based on the patient’s physical condition, mental state, activity, mobility, and incontinence
A low score indicates a high risk
Some have suggested that this be modified by adding categories for skin appearance, medication, & nutrition
Norton scale
?
This numeric value for six risk factors r/t impaired skin integrity evaluates 6 major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction & shear
The final score reflects the patient’s risk; the lower the score, the more likely the patient will develop a pressure injury
A score of 18 or less for hospitalized patients indicates risk
Braden scale
Nursing Assessment: Skin and Wounds cont’d
Wound assessment
- Location / size
- Undermining / appearance
- Drainage / redness / swelling
- Pain / nutritional status
Location influences the rate of healing
Location affects movement
Location can give you clues to the wound etiology
Review Table 35-4 Types of tissue in wound bed
Assessment cont’d
Tetanus Immunization
> Tetanus-prone wounds
- Compound fx’s / gunshot wounds / crush injuries
- Burns / punctures / foreign object / injuries
- Wounds contaminated with soil
- Wounds neglected for more than 24 hours
Tetanus Immunization
- If last immunization was 10 years or over
- Contaminated wound with dirt or debris or a burn
- If patient is uncertain of last immunization
Laboratory Data
Blood studies
Wound cultures
* Swabbing
* Needle aspiration
* Tissue biopsy
The most common laboratory assessments r/t skin integrity are:
protein levels, CBC, ESR, glucose, thyroid & iron levels, coagulation studies, & wound cultures
Wound cultures may be ordered to determine the types of bacteria present
Local or systemic signs of infection, suddenly elevated glucose levels, pain in a neuropathic extremity, or lack of healing after 2 weeks in a clean wound may indicate the need for a wound culture
Cultures may be obtained by swab, aspiration, or tissue biopsy
Analysis/Nursing Diagnosis
Risk for Impaired Skin Integrity (use Norton or Braden scale to ID these patients)
Impaired Skin Integrity
Impaired Tissue Integrity
Risk for Impaired Tissue Integrity
Nursing Interventions Related to Wound Care
* Cleansing
Use universal precautions to minimize the risk of cross-contamination when cleansing peri-wound or other non-wound skin
* Irrigating
* Caring for a drainage device
- Penrose, Jackson-Pratt, Hemovac
* Debriding a wound
- Sharp
- Mechanical
- Enzymatic
- Autolysis
- Biotherapy
Cleansing wounds involves removing exudate, slough, foreign materials and microorganisms from the wound and helps promote healthy tissue healing
* Always clean a wound initially and with each dressing change
* To cleanse a wound gently, pat the surface with gauze soaked with saline or other prescribed wound cleanser
The ideal solution would be an isotonic solution
* Examples of solutions include anti-septic solutions, normal saline, portable drinking tap water, purified water, liquid or foam skin cleansers
Nurses commonly use irrigation (lavage) to:
- Cleanse wounds gently by flushing debris in bacteria on the surface
- Hydrate the site
- Remove debris for better visualization of the wound & peri-wound
- Facilitate progression from the inflammatory to the proliferative phase of healing
- Improve wound healing from the inside tissue layers to the skin surface
- Reduce infection by preventing premature surface healing
> Selecting irrigation solution - the most common irrigation solution is normal saline
> Sterile water may often be used when other solutions aren’t available
> To remove debris from a wound, you must introduce the irrigation solution with a mild amount of force. Ideal irrigation pressures range from 4 lbs per square inch (psi) to 15 psi
> To remove material adhering to the wound bed, use a 35-mL syringe attached to a 19-gauge angiocatheter and deliver the solution at approximately 8 psi. Pressures above 15 psi increase the risk of driving bacteria into the tissues, as well as causing mechanical damage
Debriding a wound
This is the removal of devitalized tissue or foreign material from a wound
It also helps remove cells that are alive but not functioning (___) from the wound bed and edges
Removal of necrotic tissue, exudate, and infective material helps stimulate wound healing & prepares the wound bed for advanced therapies or biological agents
senescent
Sharp debriding
Is the use of a sharp, sterile instrument, such as a scalpel or scissors, to remove devitalized tissue
This method provides an immediate improvement of the wound bed and preserves granulation tissue
Monitor the patient for S/S of sepsis (e.g. fever, tachycardia, hypotension, & altered loc) after sharp debridement
Remember, only specially trained providers can do sharp debridement
Mechanical debriding
May be performed via lavage, the use of wet-to-dry dressings, or hydrotherapy (whirlpool)
Enzymatic debriding
Uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound
To use an enzymatic product, clean the wound with normal saline, apply a thin layer of the cream, and cover with a moisture-retaining dressing
?
Is the use of an occlusive, moisture-retaining dressing and the body’s own enzymes and defense mechanisms to break down necrotic tissue
This process takes more time than the other techniques, but it is tolerated better
Procedure involves applying the dressing and observing the fluid that collects under it (wound fluid may be tan in color)
Dressing is normally changed every 72 hours; at that time, the wound is cleansed before a new dressing is applied
Autolysis (debriding)
Biotherapy or Maggot debridement therapy
Is the use of medical-grade larvae of the green bottle fly to dissolve dead and infected tissue from wounds
Larvae secretes enzymes that liquefy dead tissue and create an alkaline environment
Enzymes are neutralized when they come in contact with normal tissue, so healthy tissue is unharmed
Larvae also digest bacteria from the wound
This therapy is effective and simple to use, though containing the larvae within the dressing can be problematic
Nursing Interventions Related to Wound Care cont’d
- Applying negative pressure wound therapy
- Dressing a wound
> Gauze/transparent film
> Hydrocolloids/hydrogels
- Supporting/immobilizing a wound
> Binders/bandages
- Applying heat & cold
?
Uses a closed system that applies suction to the wound surface
The wound surface is packed with a foam or gauze dressing and sealed using an occlusive tape
Wound dressing is connected to a vacuum pump that provides either continuous or intermittent suction
Liquid waste is collected in a waste container
Is used to treat chronic wounds, such as pressure injury
Negative pressure wound therapy (NPWT)
?
Are wafers, pastes, or powders that contain water-loving particles
When applied to a wound, the water-loving particles interact with exudate to form a gel that keeps the wound moist
The dressing forms a protective layer against friction and bacteria
This type of dressing is ideal for wounds with minimal drainage, such as partial-thickness wounds or stage 2 pressure injury
Hydrocolloids
?
Are sheets, granules, or gels with a high water content, creating a jelly-like consistency that does not adhere to the wound bed
Their soft, cooling texture promotes patient comfort
Enhances epithelialization by providing moisture to the wound bed
May also be used to soften slough or eschar in necrotic wounds, and can be used in infected wounds
Hydrogels
Supporting/immobilizing a wound
Binders and bandages are used to hold a dressing in place, apply pressure to a wound to impede hemorrhage, and support and immobilize an injured area, thereby promoting healing and comfort
Before applying a bandage or binder, determine the intended purpose of the application and assess the part being bandaged
Response to heat or cold depends on the area being treated, the nature of the injury, duration of the treatment, age, physical condition, and the condition of the skin
HEAT APPLICATION
Is used to relieve stiffness and discomfort associated with musculoskeletal problems
When heat is applied to a large area of the body, vasodilation may cause a drop in BP and a feeling of faintness
Warn patients to be alert for this effect if they will be administering heat at home
Heat therapy increases blood flow to an area, promotes the delivery of nutrients and removal of waste products, and promotes relaxation
Moist heat includes washcloth or towel gauze, compress, soaks, baths
Dry heat includes electric heating pads, Aquathermia pads, disposable hot packs and hot water bags or bottles
COLD APPLICATION
Causes vasoconstriction and decreases capillary permeability, produces local anesthesia, reduces cell metabolism, increases blood viscosity, and decreases muscle tension
Is used to prevent or limit edema, reduce inflammation and pain, reduce oxygen requirements, help control bleeding, treat fevers, treat musculoskeletal injuries, and prevent swelling after surgery
Cold applications may have side effects including elevated BP, shivering, and tissue damage
A Wound for Special Consideration: Pressure Injury
* Nurses play a major role in prevention & treatment
* Pressure injury affects 15% of hospitalized clients
* Pressure injuries are caused by unrelieved pressure to an area, resulting in ischemia
An estimated 1 million people in the US have pressure injury: about 15% of hospital patients, 10% of home-care patients, and 20% of long-term care patients
Pressure Injury
* Localized injury to the skin and underlying tissue over a bony prominence
* Stages by type of tissue involved
Risk Factors
- Impaired circulation (i.e. from diabetes, atherosclerosis, or low BP, especially in older adults)
- Reduced oxygen (i.e. those who use tobacco or are anemic)
- Limited mobility (or reduced sensation to feel pressure points)
- Head injury, stroke, spinal cord injury
- Contractures
- Diabetes
- Impaired cognition (i.e. Alzheimer disease, dementia, altered loc)
?
Localized injury to the skin and underlying tissue usually over a bony prominence
Pressure injury
Formerly called decubitus ulcers, pressure ulcers, bedsores
Stages
Staged by type of tissue involved
Become progressively shallow by filling with granulation tissue
Lose muscle, subcutaneous fat
Dermis not replaced
Key Point
Healing ulcers are not “reverse” staged. The healing process cannot cause a stage 4 pressure injury to become a stage 3. They are described, for example, as “stage 4 ulcer: healing.”
Pressure injury occurring on a mucosal membrane should be documented but not staged
Risk Factors: Pressure Injury Development
* Intrinsic factors
- Immobility
- Impaired sensation
- Poor nutrition
- Dehydration
- Aging
- Fever, infection
- Edema
* Extrinsic factors
- Friction
- Pressure
- Shearing
- Moisture
Intrinsic factors
Certain intrinsic (internal) factors alter skin and tissue integrity or oxygen delivery capabilities, decreasing the amount of force required to create a pressure injury
Examples include immobility and impaired sensation, as occur with spinal cord injuries, stroke, or coma; poor nutrition; edema; aging; low arteriolar pressure; and fever
Poor nutrition or dehydration can weaken the skin and lead to pressure injury
Adequate intake of calories, protein, Vitamin C, and zinc is necessary to prevent pressure injury and promote healing
Extrinsic factors
___ occurs when the epidermal layer slides over the dermis, causing damage to the vascular bed
It most commonly occurs when the head of the bed is elevated and the patient slides downward, causing shear to develop in the sacral area
Shearing
Exposure to moisture: especially in the form of urine or feces, macerates the skin and also decreases the amount of pressure required to produce ulceration
Friction damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions
Pressure
Pressure injury most commonly develops over bony prominences but can occur under casts, splints, or other assistive devices
Skin is compressed between the bone and the hard surface of the bed or chair, reducing blood flow to the area
When the patient is supine, these pressure points are the occiput, scapulae, elbows, sacrum, and heels
Nursing Assessment: Pressure Injury
Determine a stage
* Stages 1 to 4 : classified by tissue involvement
* Stages 3 and 4 : involve tissue necrosis
Suspected deep tissue injury
Unstageable pressure injury
Use PUSH tool
Assessment
Ischemia
Inspect skin daily
Braden scale
Norton scale
PUSH tool
Physical Findings
When ischemia first occurs, the skin over the area is pale and cool
When pressure is relieved (e.g. by turning the patient), vasodilation occurs, extra blood goes to the area, and the area flushes bright red (reactive hyperemia)
If the redness does not disappear quickly, tissue damage has occurred
Inspect Skin Daily
Skin care begins with regular inspection of the skin for appearance, temperature, texture, and color
Ensure adequate light to detect subtle, early skin changes
Check pressure points for erythema, tenderness, or edema
Instruct caregivers how to detect early signs of skin problems
In obese patients, breakdown occurs under breasts, in abdominal folds, and where skin contacts skin
?
Reports the progression of a pressure injury
Surface area, exudate, and type of wound tissue are scored and totaled
As the injured area heals, the total score falls
PUSH tool
Prevention is the Priority Intervention!
* Pressure injury monitoring
* Manage moisture
- Incontinence
- Bathing
- Barrier cream
- Lotion & massage
- Linens
- Dressings
- Negative pressure wound therapy
* Minimize pressure : turn & reposition
* Optimize nutrition & hydration
Go to’s
Chapter 35, Procedure 35-6: Applying a Negative Pressure Wound Therapy (NPWT) in Volume 2
Chapter 35, Procedure 35-7: Applying and Removing a Transparent Film Dressing, in Volume 2
Chapter 35, Procedure 35-8: Applying a Hydrating Dressing (Hydrocolloid or Hydrogel), in Volume 2
Key Point: Must provide frequent position changes to prevent tissue damage from ischemia
Optimize Nutrition and Hydration
Patients at risk: rapid weight loss, ↑ metabolic demands, limited intake, or ↓ serum albumin
Clicker Check
The client has a wound that is 0.4 cm long and 3.2 cm wide. There is only a light amount of exudate, and granulation tissue is seen. The “PUSH” score for this would be
a. 9
b. 18
c. 15
d. 22
Correct answer: C
Points: 2 length x 6 width = 12
Exudate = 1
Granulation = 2
Total = 15 points
Nursing Interventions: Pressure Injury
Prevention
Meticulous skin care and moisture control
Adequate nutrition
Frequent repositioning
Therapeutic mattresses
Client/family teaching
* Conduct a pressure injury admission assessment for all patients
* Reassess risk for all patients daily
* Inspect skin daily
* Manage moisture
* Optimize nutrition and hydration
* Minimize pressure
Patient Teaching
Characteristics of healthy skin
Protection of skin
Skin care & hygiene
Nutrition
Turn & reposition
Home Care : W-O-U-N-D
Tips for taking care of wounds at home:
Wet ⇒ dry it
Open ⇒ cover it
Unclean ⇒ clean it
Necrotic ⇒ don’t scrub it
Dry ⇒ moisten it
