Skin Integrity & Wound Care Ch. 13 Fundamentals – Flashcards

-Largest organ of the body -Protective barrier against disease causing organisms -Sensory organ for pain, temperature, & touch -Synthesizes vitamin D

Epidermis (top layer) Dermis (inner layer)

-Nurses must assess & monitor skin integrity -Identify actual & potential problems in skin integrity -Plan, implement, & evaluate interventions to maintain skin integrity

-Localized injury to skin & tissue resulting from PRESSURE in combination with shear &/or friction Where do pressure ulcers occur? --Impaired skin integrity r/t unrelieved, prolonged pressure --Contributing factors - pressure leading to tissue ischemia and tissue death

1.) Impaired sensory perception 2.) Alterations in level of consciousness 3.) Impaired mobility 4.) Shear 5.) Friction 6.) Moisture

--Patients with IMPAIRED SENSORY PERCEPTION for pain and pressure are at risk because they cannot feel their body sensations. --Patients who are unable to independently change position are at risk because they cannot change or shift off of bony prominences. (IMPAIRED MOBILITY) --Patients who are confused or disoriented or who have ALTERATIONS IN LEVEL OF CONSCIOUSNESS are unable to protect themselves. --SHEAR is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface. --FRICTION is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface. --The presence and duration of MOISTURE on the skin reduce the skin's resistance to other physical factors. [Box 48-2 on p. 1178 discusses characteristics of dark skin with impaired integrity.]

Pressure intensity Pressure duration Tissue tolerance

is the pressure enough to collapse a capillary

low pressure over a long period and high pressure over a short period are both of concern

how healthy is the skin ; underlying structures

What is the normal mechanism of protection against this? How to recognize stages of damage: --Hyperemia/erythema --Blanching vs. non blanching hyperemia

Normal mechanism of protection is movement/area starts to "fall asleep" and we move to alleviate the sensation this is how we heed the warning. What if we don't feel the warning or can't move? We stay in the position and tissue ischemia can occur, worse leading to tissue death. Hyperemia - after a period of tissue ischemia, if pressure is relieved and the skin turns red this signals that the blood flow has returned to the area Blanching hyperemia - if you press on the affected area, the skin blanches and then returns to the reddened color, your good, if the reddened area does not blanch when you apply pressure, deep tissue damage is probable

-Long and short times can cause damage -Extended pressure occludes blood flow ; nutrients -If the delivery of blood and nutrients is impeded, cell death may occur

-The ability of the skin to endure pressure -How healthy is the skin and underlying structures -Is there shear, friction, or moisture present? -Can the blood vessels ; collagen assist in redistributing pressure?

--PREVENTION --Relieve pressure --Reposition your patient --Assess your patient for reactive hyperemia/erythema and blanching --Make sure that there is adequate "give" or slack on cords and tubes --Reduce/eliminate instances of shear and friction by properly repositioning patients --Keep the skin dry --Provide patients with proper nutrition & adequate hydration --Be mindful that older patients and patients with low blood pressure may have a decreased ability to tolerate pressure

Intact skin with non-blanchable redness

Partial-thickness skin loss involving epidermis, dermis, or both

Full-thickness tissue loss with visible fat

Full-thickness tissue loss with exposed bone, muscle, or tendon

The National Pressure Ulcer Advisory Panel (NPUAP) has defined pressure ulcers. The European Pressure Ulcer Advisory Panel (EPUAP) and the NPUAP have developed a definition for an ulcer in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of injury is unknown. An unstageable ulcer is a full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Suspected deep-tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Slough is a stringy substance attached to the wound bed; it must be removed by a skilled clinician before the wound is able to heal. Black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed. [Figure 48-4 on p, 1180 provides a diagram of the stages.]

-Priority in caring for patients -When a pressure ulcer occurs, LOS and cost of health care increases Costly to patients in terms of --Disability --Pain & suffering CMS no longer reimburses for stage III & IV!!!

--Assess the skin for S&S of ulcer development both visually and with touch --Pay particular attention to areas over bony prominences or under casts or any foreign devices --If you note hyperemia document the location, size, and color - reassess in one hour --Touch the skin gently to check for blanching and induration

-Disruption of integrity ; function of tissues -Etiology? -Ways to classify—pg. 1181 Table 48-1 Types of wounds --Loss of tissue --No or little loss of tissue

-Describe the status of skin integrity, the cause of the wound, the severity or extent of injury or damage, and the cleanliness of the wound (see Table 48-1 on p. 1181) -Describe qualities of the wound tissue such as color (see Table 48-2 on p. 1183)

--Shallow wounds with loss of epidermis and possibly partial loss of dermis --Heal by regeneration Three components of healing: -- 1.) Inflammatory response -- 2.) Epithelial proliferation & migration -- 3.) Reestablishment of epidermal layers

-Involve the epidermis ; the dermis -Heal by scar formation Four phases involved: -- 1.) Hemostasis -- 2.) Inflammatory -- 3.) Proliferative -- 4.) Remodeling

A, Wound healing by primary intention such as a surgical incision. Wound healing edges are pulled together and approximated with sutures or staples; healing occurs by connective tissue deposition. B, Wound healing by secondary intention. Wound edges are not approximated, and healing occurs by formation of granulation tissue and contraction of wound edges. [Shown is Figure 48-6 from text p. 1182.]

--Hemorrhage --Hematoma --Infection --Dehiscence --Evisceration

Hemorrhage, or bleeding from a wound site, is normal during and immediately after initial trauma. A hematoma is a localized collection of blood underneath the tissues. Wound infection is the second most common health care-associated infection. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent and causes a yellow, green, or brown color, depending on the causative organism. [See Table 48-2 Types of Wound Drainage on p. 1183.] Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing is at risk for dehiscence. With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency that requires surgical repair.

Place a pillow over the incision site when the patient is deep breathing or coughing

-Nutrition -Tissue Perfusion -Infection -Age

Extrinsic Factors (Primary) --Moisture --Friction --Shear Intrinsic Factors (Secondary) --Nutrition --Demographics --Oxygen Delivery --Skin Temperature --Chronic Illness

Type of wound will guide the assessment: --Abrasion - superficial, little bleeding, "weepy" r/t plasma leakage and damaged capillaries --Laceration --Puncture Describe the amount, color, consistency, and odor of wound drainage is part of the wound assessment

--Look for foreign bodies --Contaminant material --Is the wound dirty? --Is there anything embedded in the wound? --What is the size, shape, and depth of the wound? --Does the patient need a tetanus shot?

These photos show wounds by color assessment: A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-color wound. You need to assess the type of tissue in the wound base, and this information is used to plan appropriate interventions. Assessment of tissue type includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Recall that granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing; soft yellow or white tissue is characteristic of slough (stringy substance attached to the wound bed), and it must be removed by a skilled clinician before the wound is able to heal; black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed. [Shown is Figure 48-5, A, B, C, D, from text p. 1182.]

--Are wound edges closed? --Is the wound clean? --Is the wound opened or closed? --Are there sutures or staples? How many? --Is there drainage? What color, odor, how much? --Does it appear infected? Why? --Is there granulation tissue in the wound bed?

-Amount -Color -Odor -Consistency

-Stainless steel staples -Nylon sutures -Silk sutures -Absorbable sutures -Dermabond

-Not 100% reliable -Must use fresh drainage -Bacteria may be in the wound or just in the exudate -Aerobic or anaerobic organisms -Gram stains -Tissue biopsy - gold standard

Actual or risk for impaired skin integrity Assessment will help reveal r/t factors Multiple nursing diagnoses for impaired skin integrity and wounds

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Multiple nursing diagnoses associated with impaired skin integrity and wounds are shown on the slide. Consider that the nature of a wound can cause problems unrelated to wound healing. Alteration in comfort and impaired mobility are problems that have implications for the patient's eventual recovery. Write patient goals and outcomes specific to the patient's needs. [Box 48-8 on p. 1192 covers Impaired Skin Integrity Related to Infection Diagnosis.] [Figure 48-13 on p. 1192 covers planning in detail.] The nursing care plan on pp. 1193 and 1194 reviews a plan for resolving Impaired skin integrity. Figure 48-14 on p. 1195 provides a concept map for the process.

--Select nursing interventions to promote improved skin integrity and/or wound healing --Consult others to enhance treatment/care --Involve pt. & family in using interventions

--See wound improvement in a specific time frame --Higher percentage of granulation tissue in the wound base --No further skin breakdown in any location --A 10% increase in caloric intake Increase protein consumption

Support Surfaces: --Specialty mattresses --Adjuncts like foam or air-filled cells --Air-fluidized beds --Lateral rotation (Pg. 1198 Table 48-7)

--Use a holistic approach --Reassess the wound often --Use documentation and a systematic approach

1.) Prevent/manage infection 2.) Clean the wound 3.) Remove nonviable tissue 4.) Manage exudate 5.) Maintain a moist environment for the wound 6.) Protect the wound

A Penrose drain lies under a dressing; at the time of placement, a pin or clip is placed through the drain to prevent it from slipping farther into the wound. [Figure 48-10 on p. 1191 shows a Penrose drain.]

Evacuator units such as a Hemovac or Jackson-Pratt (shown here) exert constant low pressure as long as the suction device (bladder or container) is fully compressed. [This is Figure 48-11 on p. 1191.]

Irrigation is a common method of delivering a wound cleaning solution to the wound. [Shown is Figure 48-17 from text p. 1199.]

-Bandage/Cloth -Cover and immobilize -*Do not remove penetrating object

--Protect a wound from microorganism contamination --Aid in hemostasis --Promote healing by absorbing drainage and debriding a wound --Support or splint the wound site --Protect patients from seeing the wound (if perceived as unpleasant) --Promote thermal insulation of the wound surface

For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops. In contrast, when dressing a wound that is healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or assisting in debridement. The dressing technique varies, depending on the goal of the treatment plan for the wound. If the goal is to maintain a moist environment for a clean granulating wound, it is important to not let the saline-moistened gauze dressing dry and stick to it. This is in direct contrast to the dressing technique that you use if the goal of care is to mechanically debride the wound using a saline wet-to-dry dressing. When wounds such as a necrotic wound require debriding, use a wet-to-dry dressing technique. Place the moist dressing (contact dressing) into the wound, and allow it to dry. The contact dressing debrides necrotic tissue and debris. In this case, the contact dressing is allowed to dry so it sticks to underlying tissue, and debridement occurs during removal.

--Dry or moist --Gauze --Film dressing --Hydrocolloid—protects the wound from surface contamination --Hydrogel—maintains a moist surface to support healing --Wound vacuum assisted closure (V.A.C.)—uses negative pressure to support healing

The use of dressings requires an understanding of wound healing and factors that influence healing. A variety of dressing materials are available. You will learn various dressing techniques in the nursing skills lab. The choice of dressings and the method of dressing a wound influence healing. Before placing a dressing on a pressure ulcer, it is important to know the stage of the pressure ulcer; to have done a thorough assessment of it; and to understand the goal of the treatment, the mechanism of action of the dressing, and principles of wound care. [See also Table 48-8 Dressings by Pressure Ulcer Stage.] Gauze sponges are absorbent and are especially useful in wounds to wick away the wound exudate. Gauze is available in different textures and in various lengths and sizes; 4 × 4 is the most common size. Gauze can be saturated with solutions and used to clean and pack a wound. When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out, unfolded, and lightly packed into the wound. Use a film dressing as a secondary dressing and for autolytic debridement of small wounds. It has the following advantages: Adheres to undamaged skin Serves as a barrier to external fluids and bacteria but still allows the wound surface to "breathe" because oxygen passes through the transparent dressing Promotes a moist environment that speeds epithelial cell growth Can be removed without damaging underlying tissues Permits viewing a wound Does not require a secondary dressing Hydrocolloid dressings are dressings with complex formulations of colloid, elastomeric, and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds; they are available in a variety of sizes and shapes. This type of dressing has the following functions: Absorbs drainage through the use of exudate absorbers in the dressing Maintains wound moisture Slowly liquefies necrotic debris Is impermeable to bacteria and other contaminants Is self-adhesive and molds well Acts as a preventive dressing for high-risk friction areas May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing Hydrogel dressings are gauze or sheet dressings impregnated with water- or glycerin-based amorphous gel. Hydrogel has the following advantages: Is soothing and can reduce wound pain Provides a moist environment Debrides necrotic tissue (by softening necrotic tissue) Does not adhere to the wound base and is easy to remove [See also Box 48-12 on text p. 1202 Dressing Considerations; and Box 48-13 on text p. 1202 Evidence-Based Practice: Moisture-Associated Skin Damage.]

-Educate patient and family -Pre-medicate when possible -Group effort -Gather all of your equipment -Assess the skin -Hand hygiene—when?

Wear sterile gloves before directly touching an open or fresh wound Remove or change dressings over closed wounds when they become wet or if the patient has signs or symptoms of infection, and as ordered

The health care provider's order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. An order to "reinforce dressing prn" (add dressings without removing the original one) is common right after surgery, when the health care provider does not want accidental disruption of the suture line or bleeding. The medical or operating room record usually indicates whether drains are present and from what body cavity they drain. After the first dressing change, describe the locations of drains and the types of dressing materials and solutions to be used in the patient's care plan. Follow the guidelines on the slide during a dressing change procedure. Often it is necessary to teach patients how to change dressings in preparation for home care. In this situation, demonstrate dressing changes to the patient and family, and then provide an opportunity for them to practice.

The vacuum-assisted closure (V.A.C.) is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. Modifications have been made to the V.A.C. The V.A.C. Instill allows intermittent instillation of fluids into the wound, especially those wounds not responding to traditional (negative-pressure wound therapy (NPWT). NPWT is used in treating acute and chronic wounds. The schedule for changing NPWT dressings varies, depending on the type of wound and the amount of drainage. Wear time for the dressing is anywhere from 24 hours to 5 days. As the wound heals, granulation tissue lines its surface. The wound has a stippled or granulated appearance. The surface area sometimes increases or decreases, depending on wound location and the amount of drainage removed by the NPWT system. NPWT is also used to enhance the take of split-thickness skin grafts. It is placed over the graft intraoperatively, decreasing the ability of the graft to shift and evacuating fluids that build up under it. An airtight seal must be maintained. [See also Box 48-14 Maintaining an Airtight Seal.] [Shown is Figure 48-19 from text p. 1204.]

Shown is a V.A.C. system that uses negative pressure to remove fluid from areas surrounding the wound, reducing edema and improving circulation to the area. [Box 48-14 on p. 1205 reviews maintaining an airtight seal.] [Shown is Figure 48-21 from text p. 1205.]

This photo shows setting of suction on the drainage evacuator. 1. With drainage port open, raise level on diaphragm. 2. Push straight down on lever to lower diaphragm. 3. Closure of port prevents escape of air and creates vacuum pressure. Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and the tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder, and immediately reset the evacuator to apply suction. [Shown is Figure 48-29 from text p. 1208.]

1. Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin. 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to the most contaminated area

--Removal of nonviable/necrotic tissue Why? --Rid the wound of source of infection --Enable visualization of wound bed --Provide a clean base needed for healing

Check the policies ; procedures where you work. Have you had special training?

--Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified; and did the plan of care decrease the contribution of each of these components? --Was wound healing supported by providing the wound base with a moist protected environment? --Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing?

Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine whether the patient has met the identified outcomes or goals. If the identified outcomes are not met for a patient with impaired skin integrity, possible questions to ask are shown on the slide. Care of patients with a pressure ulcer or wound requires a multidisciplinary team approach. [Figure 48-32 on p. 1213 diagrams the evaluation process.]