Skin Integrity and Wound Care

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Function of the Skin (5)
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1. Skin is the largest organ in the body 2. Protect underlying tissue from injury 3. Regulate body temperature 4. Secrete oily substance (sebum) that softens and lubricates the hair and skin 5. Produces and absorbs vitamin D
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Intact Skin
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Refers to the presence of normal skin and skin layers uninterrupted by wounds or breaks or openings
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Structure of skin
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1. Epidermis 2. Dermis 3. Subcutaneous
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Factors that Cause Wounds (5)
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1.Surgery/procedures 2. Trauma 3. Pressure 4. Friction 5. Shear Other causes
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Factors Affecting Skin Integrity (3)
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Genetics/Heredity Age Underlying health of the individual Disease – PVD,DM Medications and treatments Nutritional status Heredity determines skin color, sensitivity to sunlight, allergies Age: old and young have more fragil skin and increased susceptibility to trauma Chronic illnesses and their treatments can affect skin integrity Heredity determines skin color, sensitivity to sun light, allergies
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Types of Wounds
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Incisional – open wound Contussion – closed wound Abrasion – open wound Puncture – open wound Laceration – open wound Penetrating – open wound Pressure Ulcers
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Wound Classification
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According to cause (how they’re aquired) According to depth or tissue layers involved (Stage) Can be described according to likelihood of contamination
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Pressure Ulcers
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Any skin alteration caused by unrelieved pressure that results in damage to the underlying tissue Due to local ischemia Initially surface is pale, then reddened due to reactive hyperemia caused by vasodilatation Contributing forces: friction and shear
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Risk Factors for Pressure Ulcers
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Immobility Inadequate nutrition Fecal and/or urinary incontinence Decreased or altered mental status Diminished sensation Excessive body heat Advanced Age
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Stages of Pressure Ulcer Formation stage 1
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Stage I – Non-blanchable erythema of intact skin
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Stages of Pressure Ulcer Formation stage 2
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Stage II – Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial
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Stages of Pressure Ulcer Formation stage 3
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Stage III – Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
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Stages of Pressure Ulcer Formation stager 4
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Stage IV – Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to the muscle, bone or supporting structures, such as tendons and joints
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Types of Wound Healing primary intention healing
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Primary Intention Healing – Tissue surfaces have been closed and there is minimal or no tissue loss (closed surgical incision)
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secondary intention healing
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Secondary Intention Healing – Wound is extensive and involves considerable tissue loss and the edge can not or should not be closed (pressure ulcer); healing takes longer, scarring is greater, risk for infection is higher
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Tertiary Intention
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Tertiary Intention (Delayed Primary Intension) Healing – Initially left open; infection, edema, exudate resolve, then wound is closed
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Three Phases of Wound Healing
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inflammatory phase, proliferavtive phase, maturation phase
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Inflammatory Phase
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Inflammatory Phase – Immediately after wound 3 – 6 days Hemostasis Phagocytosis
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Proliferative Phase
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Proliferative Phase – from 3- 4 to about 21 days Collagen synthesis Granulation tissue formation
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Maturation Phase
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Maturation Phase – begins after about 21 days – may last 1 – 2 years Collagen organization Remodeling or contraction Scar stronger
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Types of Wound Drainage
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Serous exudate , Purulent exudate , Sanguineous exudate
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Sanguineous exudate
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– consists of large amounts of red blood cells, indicates severe damage to capillaries
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Purulent exudate
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thicker, indicates the presence of pus, color varies with organism
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Serous exudate
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looks watery and has few cells
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Complications of Wound Healing (3)
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Hemorrhage – Persistent bleeding Infection – Wound is infected with microorganisms at the time of injury, during surgery or pot-operatively Dehiscene – partial or total rupturing of a sutured wound
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Factors that Impair Wound Healing (3)
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Developmental Considerations – Healthy children and adults heal more quickly than older adults Nutrition – Wound healing places additional demands on the body Medications – Anti-inflammatory drugs, heparin, and anti-neoplastic agents interfere with healing
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Nursing Management – Assessment of Skin Integrity nursing history
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Information regarding skin diseases Previous bruising Skin lesions Unusual healing Medications Past medical history
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Assessment of Skin Integrity Physical Assessment Inspection and palpation
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Skin color distribution Skin turgor Presence of edema Characteristics of any skin lesions Note especially areas at risk for break down
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Risk Assessment Tool
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Systematic means of identifying client at high risk for pressure ulcer development Bradens’ Scale for Predicting Pressure Sore Risk Norton’s Pressure Area Risk Assessment Form Scale
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Assessment of Wounds Untreated wounds
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Control bleeding, prevent infection, control swelling and pain, assess for foreign bodies, assess for shock if bleeding severe
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Assessment of Wounds Treated Wounds
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Usually assessed during a dressing change Frequency of documentation varies Transparent dressings offer advantage of visualization
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Assessment of Wounds Pressure Ulcers
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Pressure Ulcers Note location, size, stage, color of wound bed, condition of wound margins, integrity of surrounding skin, clinical signs of infection
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Assessment of Wounds Laboratory Data (4)
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Decreased leukocyte counts – delayed healing -Prolonged blood coagulation – results in excessive blood loss and prolonged clot formation -Protein analysis – indication of the body’s nutritional reserves for rebuilding cells -Wound culture – confirms or rules out the presence of infection
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Nursing Diagnoses
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Risk for impaired skin integrity Impaired skin integrity Impaired tissue integrity Additional Dx Risk for infection Pain
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Planning
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Maintain skin integrity Prevent pressure ulcers Promote wound healing
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Implementing Nursing Interventions for maintaining skin integrity
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Sufficient nutrition Sufficient fluids Asepsis to prevent wound infections Proper positioning
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Implementing
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Nursing Interventions for preventing pressure ulcers Provide adequate nutrition Fluids, protein, vitamins, zinc; dietary consult; weight and lab data Maintain skin hygiene Mild cleansers, avoid irritants, moisture/skin barriers, avoid hot water Avoid skin trauma Fowler’s position Turn every 2 hours Exercise and ambulation Assistive devices Provide supportive surfaces Client/ Family teaching
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Implementing Wound Care (RYB)
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Variety of products available- choice depends on location, size, exudate and condition of underlying wound bed In general: R – Red Protect/cover RED Y – Yellow Cleanse YELLOW B – Black Debride BLACK
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Types of Dressings
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Transparent Adhesive Films – Provide protection against contamination and friction, maintain moist wound bed, and to facilitate wound assessment – Useful to superficial wounds (stage I), IV sites Impregnated Nonadherent Dressings – Cover and protect partial and full thickness wounds without exudate – Useful post – op and with superficial burns
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Types of Dressings
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Hydrocolloids – Absorb exudate, provide moisture without causing maceration of surrounding skin, protect from contamination Hydrogels – Liquefy necrotic tissue or slough, rehydrate the wound bed and fill in dead space Polyurethane Foams – Absorb light to moderate amounts of exudate and debride wounds
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Types of Dressings
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Exudate Absorbers Provide a moist wound surface by interacting with exudate Absorb exudate Can be used to eliminate dead space or pack wounds Support debridement
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Implementing
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Application of heat and cold Determine the client’s ability to tolerate the therapy Explain the procedure to the client Assess the skin Ask client to report any discomfort Return to assess client 15 minutes after the application of heat, observe local skin Remove equipment at the designated time Examine the area
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Evaluation
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The goals established during the planning phase are evaluated according to specific desired outcomes
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desiccation
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(dehydration),
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maceration
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(overhydration),
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fistula
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an abnormal passage from an internal organ tothe outside of the body or from one internal organ to another.Fistulas may be created purposefully;
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ischemia
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(deficiency of blood in a particular area),
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A pressure ulcer may form in
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1-2 hr
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Eschar
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a thick layer of dead tissue and tissue fluid that develops over a deep burn area

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