Information
AI Chat

This is a Premium Document. Some documents on Studocu are Premium. Upgrade to Premium to unlock it.

Chapter 36 Skin integrity and wound care

Lecture Notes

Course

Fundamentals (NUR155)

38 Documents

Students shared 38 documents in this course

University

Galen College of Nursing

Academic year: 2021/2022

Uploaded by:

Anonymous Student

This document has been uploaded by a student, just like you, who decided to remain anonymous.

Galen College of Nursing

Comments

Please sign in or register to post comments.

Related Studylists

Nur155 theory notes NSG3100 Exam 2 - Vital Signs Unit3, Asepsis Unit4, Skin Integrity Unit5 Funds

Preview text

Chapter 36 Skin integrity and wound care

Functions of the integumentary system

 Protection  Temperature regulation  Sensation

Factors affecting skin integrity

 Age o Lose lean body mass they are losing their cushion. o Older adults do not make the new skin as fast and due to shedding their skin becomes thinner o Skin also becomes dry o Older patients lose sensation o Issues with circulation due to aging, losing oxygenation to the skin  Chronic illness/treatments o Conditions such as diabetes and cardiovascular disease are risk factors for skin breakdowns and delay healing.  Break down oxygen delivery to the tissues due to poor perfusion, thus delay healing and cause risk for pressure sores  Fecal/urine incontinence o Added moisture can cause breakdown of skin and tares  Poor nutrition o Not enough nutrition for the skin to complete cycle  Trauma o Friction is a force acting parallel to the skin surface. For example, sheets rubbing against skin create friction. Friction can abrade the skin by removing the superficial layers, making it more prone to breakdown. o Shearing force is a combination of friction and pressure. Think of the client sitting on the bed, causing the body to side down to the foot of the bed.  Others? o Poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices.

Types of wounds

An injury to living tissue

A break in the skin

 Clean wounds o Uninfected wounds in which there is minimal inflammation, and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds.  Clean-contaminated wounds o Are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.  Contaminated wounds o Include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Contaminated wounds show evidence of inflammation.  Dirty or infected wounds o Include wounds containing dead tissue and wounds with evidence of a clinical infection, such a purulent drainage.  Wounds, excluding pressure ulcers and burns, are classified by depth, the tissue layers involved in the wound.

Classifying wounds by depth

 Partial thickness o Confined to the fist two layers of skin and is healed by generation  Full thickness o Involves more, all layers of the skin and possibly the muscle and bone, requires connective tissue repair.

Types of wounds

 Laceration/incision o Cause : sharp instrument (i., knife) o Description : Open wound; deep or shallow; once the edges have been sealed together as a part of treatment of healing the incision becomes a closed wound.

 WBCs o A decreased leukocyte count can delay healing and increase the possibility of infection. (immunocompromised) o Elevated an infection present  Hemoglobin o Hemoglobin level below the normal range indicates poor oxygen delivery to the tissues. o Blood coagulation studies also are significant. Prolong coagulation times can result in excessive blood loss and prolonged clot absorption.  Serum protein o Provides an indication of the body’s nutritional resources for rebuilding cells.  Albumin o Important indicator of nutritional status. Below 3 g/dL indicates poor nutrition increasing risk for healing and infection.  Wound cultures o Can confirm or rule out the presence of infection.

Normal Labs

 WBC : 5-10 mm  Hgb : male 14-18 g/dl Female 12-16 g/dl  Serum protein : 6.4-8 g/dl  Albumin : 3-5 g/dl  Wound cultures : negative

Pressure Ulcer

Death of the skin due to lack of oxygenation

 Areas of necrosis and ulceration  Occurs when tissues are compressed  Boney prominences and hard surfaces

 Patient is supine o Areas at risk : heels, sacrum, elbows, scapula, and the back of the head  Patient is prone

o Areas at risk : toes, knees, genitalia, breast, acromion process, check and ear.  Patient is Lateral o Areas at risk : malleolus, medial and lateral condyle, greater trochanter, ribs, acromion process, ear



Stages of Pressure Ulcers

o RN decides the stage of the wound  Color of the wound bed  Necrosis or eschar  Wound margins  Surrounding skin  Clinical signs of infection o Extrudate (draining)

Pressure Ulcers: Interventions

 Obtaining wound culture  Administer analgesic o You want to give it adequate time to kick in  Remove moist, outer dressing  Discard in bag  Cleanse wound  Irrigate or cleanse wound with NS

Risk Assessment Tools

 Braden Scale – predict risk (page 833) o Total of 23 points, below 18 considered at risk  Norton’s pressure area risk assessment form scale (page 834) o Total score of 24, 15-16 considered indications not predictors of risk.  Push o Pressure Ulcer Scale for Healing  Friction and shearing  Friction is a force acting parallel to the skin surface. For example, sheets rubbing against skin create friction. Friction can abrade the skin by removing the superficial layers, making it more prone to breakdown.  Shearing force is a combination of friction and pressure. Think of the client sitting on the bed, causing the body to side down to the foot of the bed.   Immobility  Refers to reduction in the amount and control of movement a person has.  Fecal/urinary incontinence

 Moisture from incontinence promotes skin maceration ( tissue softened by prolonged wetting or soaking ) and makes the epidermis more easily eroded and susceptible to injury.  Digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute to skin excoriation (area of loss of the superficial layers of the skin also known as denuded area)  Inadequate nutrition  Prolong inadequate nutrition causes weight loss, loss of subcutaneous tissue, and muscle atrophy which reduced the amount of padding.  Hypoproteinemia (abnormally low protein content in the blood) predisposes the client to edema.  Edema makes the skin more prone to injury by decreasing its elasticity, resilience, and vitality.  Decreased mental status/diminished awareness  Individuals with a reduced level of awareness are at risk for pressure ulcers because they are less able to recognize and respond to pain associated with prolonged pressure.  Elevated body heat  Increase body heat increases metabolic rate thus increasing the cells need for oxygen. This increased need is particularly severe in cells of an area under pressure, which are already oxygen deficient.  Severe infections and elevated body temperature pay affect the body’s ability to deal with the effects of tissue compression.  Advanced age  Loss of lean muscle  Generalized thinning of the epidermis  Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis  Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands

provider about the need for a topical antimicrobial to minimize bacterial growth. o Black – Debride (removal of necrotic material)  Black wounds are covered with thick necrotic tissue, or eschar. Black wounds require debridement. Removal of nonviable tissue from a wound must occur before the wound can be staged or healed.

Four Types of Debridement

 Sharp o A scalpel or scissors is used to separate and remove dead tissue.  Mechanical o Accomplished though scrubbing force or dump-to-damp dressings.  Chemical o More selective than shape or mechanical techniques.  Autolytic o Dressings such as hydrocolloid and clear absorbent acrylic dressing trap the wound drainage against the eschar.

Phases of wound healing

 Inflammatory Phase o Begins immediately after injury o Last 3 to 6 days o Maintain hemostasis ( the cessation of bleeding). Hemostasis results from vasoconstriction of the larger blood vessel in the affected area, retraction of injured blood vessel, the position of fibrin ( connective tissue) , and the formation of blood clots in the area. o Phagocytosis ( macrophages engulf microorganisms and cellular debris)  Proliferative Phase o Follows the inflammatory phase o Lasts to about day 21  Fibroblast (connective tissue cells) which migrate into the wound starting about 24 hours after injury begin to synthesize collage. Collagen is a whitish protein substance that adds tensile strength to the wound helping it stay closed.

o Granulation tissue formation  Capillaries grow across the wound, increasing the blood supply. Fibroblast move from the bloodstream into the wound, depositing fibrin. As the capillary network develops, the tissue becomes a translucent red color. This tissue is called granulation tissue , it is fragile and bleeds easily.  Maturation Phase o Occurs from about day 21 on. o Fibroblasts continue to synthesize collagen  The collagen fibers themselves which are initially laid in a haphazard fashion, reorganize into a more orderly structure. o Wound is remodeled and contracted o Scar formation may occur  The scar becomes stronger but the repaired area never as strong as the original tissue. In some individuals particularly dark- skinned individuals an abnormal amount of collagen is laid down. This can result in hypertrophic scar or keloid.

Types of Wound Healing (pages 834-835)

 Primary intention Healing - occurs when the tissue surfaces have been approximated (closed). Primary union or first intention healing. o Tissue surfaces approximated o Minimal or no tissue loss o Formulation of granulation and scarring  Secondary Intention Healing (i., ulcer) o Extensive tissue loss o Edges cannot be closed o Repair time longer o Scarring greater o Susceptibility to infection greater  Tertiary Intention Healing (delayed primary intention) o Initially left open (3-5 days) o Edema, infection, or exudate resolves o Then closed with sutures, staples, or adhesive skin closures

Why do we dress

 They wafers are designed to be worn up to 7 days  Purpose : absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; protect from bacterial infection  Indication : pressure ulcers stage II-IV

 They last 3-7 days  They do not need a cover dressing and are water resistant, so the client can shoer or bathe  They can be molded to uneven body surfaces  They act as temporary skin and provide an effective bacterial barrier  They decrease pain and thus reduce the need for analgesics  They absorb moderate drainage and therefore can be used on slowly draining wounds  They contain wound odor  LIMITATIONS: o They are occlusive, are opaque and obscure wound visibility o They have limited absorption capacity o They can facilitate anaerobic bacterial growth o They can soften and wrinkle the edges with wear and movement o They can be difficult to remove and may leave a residue on the skin o Do not use for infected wounds or deep tracts

Alginate

 Nonadherent dressings of powder, beads or granulates, ropes, sheets or paste conform to the wound surface.  dsg absorbs 20 times its weight  require secondary dressing  Purpose : To provide a moist wound surface by interacting with exudate to form a gelatinous mass; to absorb exudate; to eliminate dead space or pack wounds  Indications : Pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents

Wound Exudate

 Deposit in tissue or on tissue surface consisting of fluid and cells that have escaped from blood vessels during the inflammatory process.  Types o Serous  Consists of serum (clear portion of the blood). It looks watery and has few cells. o Purulent  Thicker than serous because of the presence of pus, which consists of leukocytes. The process of pus formation is called suppuration. It varies in color from blue, green to yellow. o Sanguineous  Consist of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This is usually seen in open wounds. o Serosanguineous  Consisting of both clear and blood-tinged drainage  Serous exudate o Mostly serum o Looks watery o Few cells  Sanguineous exudate o Bloody o Large amount of RBCs o Seen in open wounds  Purulent Exudate o Pus o Thicker than serous o Blue, green, or yellow color o Suppuration  Mixed exudate

Factors affecting wound healing

 Poor wound management  Lifestyle

 Proper positioning o To promote healing clients must be positioned to keep pressure off the wound (off-loading) o Addition to proper positioning, the client should be assisted to be as mobile as possible because activity enhances circulation

Purpose for Dressing Wounds

 Protection: o From mechanical injury o Against microbial contamination  Provide: o Moist wound healing o Thermal insulation  Absorb drainage  Debridement  Pressure – i., hemorrhage  Splint or immobilize site

Complications of Wound Healing

 Hemorrhage  Infection  Dehiscence  Evisceration

Risk factors of complications (page 836)

 Hemorrhage – dislodged clot, slipped stitch, or erosion of blood vessel, risk greatest in first 48 hours after surgery o Hematoma is a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise).  Infection - contamination, clients immunosuppressed increased risk  Dehiscence – is the partial or total rupturing of a sutured wound. It usually involves the abdominal wound in which the layers below the skin also separate. o obesity, poor nutrition, multiple traumas, failure of suturing, excessive coughing, vomiting, and dehydration, more likely to occur 4-5 days post-op  Evisceration – same as dehiscence, increased risk if has any dehiscence.

Nursing Diagnoses & Goals

 Risk for impaired skin integrity o Maintain skin integrity o Avoid or reduce risk factors o Increase daily activity to improve circulation  Impaired skin integrity o Progressive wound healing o Regain intact skin o Increase daily activity to improve circulation  Impaired Tissue Integrity  Risk for infection  Pain

Heat and Cold therapies

 Heat therapy produces vasodilation o Max 20-30 minutes o > 30-45 minutes = tissue congestion then vessels constrict o Not used during first 24 hours after injury  Cold therapy produces vasoconstriction o See page 847 table 36-  Rebound Phenomenon o Occurs when maximum therapeutic effort of hot and cold achieved o opposite effect begins

Multiple Choice

Multiple Choice

Was this document helpful?

Premium

This is a Premium Document. Some documents on Studocu are Premium. Upgrade to Premium to unlock it.

Chapter 36 Skin integrity and wound care

Course: Fundamentals (NUR155)

38 Documents

Students shared 38 documents in this course

University: Galen College of Nursing

Multiple Choice

Multiple Choice

Was this document helpful?

This is a preview

Do you want full access? Go Premium and unlock all 17 pages

Access to all documents
Get Unlimited Downloads
Improve your grades

Upload

Share your documents to unlock

Already Premium?

Chapter 36 Skin integrity and wound care

Functions of the integumentary system

Protection

Temperature regulation

Sensation

Factors affecting skin integrity

Age

oLose lean body mass they are losing their cushion.

oOlder adults do not make the new skin as fast and due to shedding

their skin becomes thinner

oSkin also becomes dry

oOlder patients lose sensation

oIssues with circulation due to aging, losing oxygenation to the skin

Chronic illness/treatments

oConditions such as diabetes and cardiovascular disease are risk factors

for skin breakdowns and delay healing.

Break down oxygen delivery to the tissues due to poor

perfusion, thus delay healing and cause risk for pressure sores

Fecal/urine incontinence

oAdded moisture can cause breakdown of skin and tares

Poor nutrition

oNot enough nutrition for the skin to complete cycle

Trauma

oFriction is a force acting parallel to the skin surface. For example,

sheets rubbing against skin create friction. Friction can abrade the skin

by removing the superficial layers, making it more prone to

breakdown.

oShearing force is a combination of friction and pressure. Think of the

client sitting on the bed, causing the body to side down to the foot of

the bed.

Others?

oPoor lifting and transferring techniques, incorrect positioning, hard

support surfaces, and incorrect application of pressure-relieving

devices.