Skin integrity and Wound care Fall semester 2014

Skin integrity Intact skin: presence of normal skin layers uninterrupted by wounds. Impaired skin integrity is a threat to: Elders Client with restricted mobility Chronic illness Trauma Those undergoing invasive health care procedure

Skin integrity The skin is the body’s largest organ and the primary defense against pathogenic invasion. The skin also contributes to temperature regulation, prevents loss of internal fluids, and provides sensory awareness. The appearance of skin and skin integrity are influenced by: Internal factors( genetics, age and status of person’s health, malnutrition) External ( activity, sun and medications as AB and chemotherapy, corticosteroids)

Types of wound Intentional: trauma occurs during therapy as operation, vein puncture and tumor excision Unintentional: are accidental as fracture from car accident and Closed: tissue trauma without a break in the skin Open: when the skin or mucous membrane surface is broken

Types of the wound according to the way they acquired Incision: sharp instrument (open wound; deep or shallow) Contusion: blow from a blunt instrument (closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels) Abrasion: surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks) (open wound involving the skin)

Puncture: penetration of the skin &often the underlying tissue by a sharp instrument, either intentional or unintentional (open wound) Laceration: tissue torn a part, often from accident( e.g., with machinery) (open wound; edges are often jagged) Penetrating wound: penetration of the skin & the underlying tissue, usually unintentional (e.g., from bullet or metal fragments) (open wound)

Wound description according to degree of contamination Clean wound: are uninfected wound in which minimal inflammation is encountered and the respiratory, genital, urinary tract are not entered. Clean wound are primarily closed wound Clean-contaminated wounds: are surgical wounds in which respiratory, alimentary, genital or urinary tract has been entered, such wounds show no evidence of infection (high risk of infection) Contaminated wounds: include open, fresh, accidental wounds & surgical wounds involving a major break in sterile technique there is an evidence of inflammation Dirty or infected wounds: wounds containing dead tissue & wounds with evidence of a clinical infection, such as purulent drainage (old, accidental wounds)

Wound classification according to the depth of the wound 1. Partial thickness: confined to the skin, that is, the dermis and epidermis; heal by regeneration 2. Full thickness: involving the dermis, epidermis, subcutaneous tissue, &possibly muscle &bone; require connective tissue repair

Pressure ulcers Etiology: Also called bedsores , pressure sores or decubitus ulcers: injury to skin (usually over a bony prominence) caused by unrelieved pressure. Etiology: Tissue is compressed between two surfaces a deficiency in blood supply to these tissues the cells are deprived of O2 and nutrient (pale) + waste products accumulates in cells tissues die localized ischemia. (when pressure is relieved, the skin takes on a bright red flush called reactive hyperemia due to vasodilation. Reactive hyperemia lasts ½ - ¾ as long as the duration of impeded blood flow to the area)

Risk Factors for Pressure Ulcers Friction and shearing: Friction: is a force acting parallel to the skin surface (sheets rubbing against skin create friction). Shearing forces: is the combination of friction & pressure. It occurs commonly when a client assumes a sitting position. Immobility no control to change position Inadequate nutrition: causes wt. loss, muscle atrophy, loss of SC in which decrease the amount of padding between skin and bone. (diet low in protein, CHO, vit c, fluids, zinc)

Fecal & urinary incontinence: promotes skin maceration (tissue softened by prolonged wetting or soaking) Decrease mental status: pt. with reduced level of awareness unconscious or heavily sedative are less able to respond to pain perception. Diminished sensation paralysis, stroke, reduce ability to respond to heat or cold sensation Excessive body heat: fever increase BMR thus increase the cell need for o2 especially in the pressure area, fever with infection may affect the body ability to deal with the compressed area. Advanced age: aging process brings a lot of skin changes (loss of body mass, pain perception, thinning of epidermis, alteration in venous and arterial flow…) Chronic disease (CVD, DM.) compromise O2 delivery and delay healing Other factors: Poor lifting technique, incorrect positioning, repeated injections.

Stages of Pressure Ulcer Formation Stage I: non-blanchable erythema of intact skin signaling potential ulceration Stage II: partial-thickness skin loss involving epidermis and possibly dermis

Stages of Pressure Ulcer Formation Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue Stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures

Wound Healing Healing is a quality of living tissue, it is also called regeneration (renewal) of tissues. 1- Primary Intention (primary union or 1st intension healing): occur when tissue surface have been approximated (closed), and there is minimal or no tissue loss, characterized by Formulation of minimal granulation and scarring (surgical incision)

The difference between 2nd and 1st intention healing: 2- Secondary intention healing: Extensive wound, involves tissue loss, the edges cannot or should not be approximated such (as pressure ulcer) The difference between 2nd and 1st intention healing: The repair time is longer Scarring greater Susceptibility to infection greater

3- Tertiary Intention Healing (Delayed Primary Intention): wound left open for 3-5 days to allow edema or infection to resolve or exudates to drain and then closed with suture

Phases of Wound Healing It is the same for all wound but the rate of healing depend on: Type of healing Location and size of wound Client health status Phases of wound healing: Inflammatory Phase Proliferative Phase Maturation Phase

Inflammatory Phase Immediately after injury; lasts 3 to 6 days. 2 processes occur during this phase: Hemostasis (cessation of bleeding): results from vasoconstriction of larger vessels in affected area, retraction of injured blood vessels, the deposition of fibrin (connective tissue) and the formation of blood clots which provide a matrix of fibrin that becomes the framework for cell repair. Phagocytosis: leukocytes (neutrophils) move into interstitial space. Theses are replaced by macrophages which engulf microorganisms and cellular debris.

Proliferative Phase From post injury day 3 or 4 until day 21 Fibroblasts in wound start to synthesize collagen (a whitish protein substance adds strength to wound Capillaries grow across wound increasing Bld supply and fibrin deposits in wound . The capillary network develops tissue becomes red color called granulation tissue. Epithelization: proliferation of epithelial tissue over the granulation, if failed dried plasma proteins and dead cells formed eschar

Maturation Phase From day 21 until 1 or 2 years post injury Fibroblasts continue to produce collagen Remodeling of the wound occur Scar formation occur which is strong

Types of wound exudates Exudate: is a fluid that are escaped from blood during inflammatory process and deposited in the tissue or in the tissue surface. 3 types: A- Serous Exudate: consist of serum (clear protein of blood) derived from blood &serous membrane of body (watery& has few cells) (e.g., fluid in the blister from burn) B- Purulent exudate: is thicker, presence of pus (leukocytes, dead tissue debris,& dead and living bacteria) blue, green, or yellow color depend on causative agents C- Sanguineous (hemorrhagic) exudate: large amount of RBC indicate damage to capillaries (in open wounds, may be bright( fresh bleeding) or dark (old bleeding

Mixed Exudate Serosanguineous Purosanguineous Clear and blood-tinged drainage, commonly seen in surgical incision Purosanguineous Pus and blood, commonly seen in new wound that is infected

Complications of Wound Healing Hemorrhage: (massive bleeding) due to removal of clot, slipped stitch, erosion of blood vessel, risks increase in the 1st 48hr’s after surgery Internal ( swelling and distension under skin, may called hematoma, if it large may cause compression in the blood vessels) External (blood appear under dressing or escape. So apply sterile pressure dressing + check V/S) Infection: impaired skin healing, become apparent 2-11 day post operative, cause change in wound color, pain, exudate, fever, increase WBC’s, hotness, tenderness and redness, foul odor

Dehiscence: Partial or total rupturing of sutured wound, occur 4-5 day post op. Evisceration: Protrusion of the intestines through the incision. Risk factors including: obesity, poor nutrition, multiple trauma, excessive coughing and sneezing, sudden straining and dehydration, it is managed by (large sterile dressing soaked in N|S, place pt in bed with knee bent, then notify doctor

Factors Affecting Wound Healing Age: Young, Adult, or Elderly Nutritional status: diet. Obesity Lifestyle: Exercise, smoking, poor hygiene Medications: anti-inflammatory drugs (steroids, aspirin) prolong use of antibiotics. Contamination or infection

Nursing Process: Assessment Nursing history Review of systems Skin diseases Previous bruising General skin condition Skin lesions Usual healing of sores

Inspection and palpation Skin color distribution Skin turgor Presence of edema Characteristics of any skin lesions Particular attention paid to areas that are most likely to break down Untreated wounds Location Extent of tissue damage Wound length, width, and depth Bleeding Foreign bodies Associated injuries Last tetanus toxoid injection

Treated wounds Pressure Ulcers Appearance Size Drainage Presence of swelling Pain Status of drains or tubes Pressure Ulcers Location of the ulcer related to a bony prominence Size of ulcer in centimeters including length (head to toe), width (side to side), and depth Stage of the ulcer Color of the wound bed Location of necrosis or eschar Condition of the wound margins Integrity of surrounding skin Clinical signs of infection

Laboratory Data: Leukocyte count: decrease LEUKOCTE COUNT delay healing increase risk for infection. Hemoglobin level: Low Hgb poor O2 delivery to tissue Blood coagulation: prolonged coagulation times result in severe bleeding, while hypercoagulability lead to intravascular clotting and decrease bld supply to the wound Serum protein indicates nutritional status (for rebuilding cells). Albumin if less than 3.5 g/dl increase risk for infection and delay healing Wound culture: confirm or rule out presences of infection Sensitivity tests: to select the apropriate AB

Nursing Diagnoses (NANDA) Risk for Impaired Skin Integrity: applies to pressure ulcers and wounds extending through the epidermis but not through the dermis. Impaired Skin Integrity: altered epiderms and/or dermis Impaired Tissue Integrity: applies to pressure ulcers and wounds extending into SC tissues, muscles, or bones. Risk for Infection: with severe skin impairment, pt is immunosuppressed Pain: RT nerve involvement within the tissue impairment

Goals in Planning Client Care Risk for Impaired Skin Integrity Maintain skin integrity Avoid or reduce risk factors Impaired Skin Integrity Progressive wound healing Regain intact skin Client and family education Assess and treat existing wound Prevention of pressure ulcers

Implementation Supporting wound healing : maintain moist wound healing, nutrition and fluid, preventing infection and positioning Preventing pressure ulcer Treating pressure ulcer :RYB (Protect (cover) red, cleanse yellow, and debride black) Dressing wound Cleaning wound Supporting and immobilizing wound Heat and cold application

Dressing wound Purposes: To protect the wound from mechanical injury To protect the wound from infection To maintain moist wound healing To absorb drainage To prevent hemorrhage To splint or immobilize the wound

Types of Wound Dressings Transparent film Impregnated no adherent Hydrocolloids Clear absorbent acrylic Hydrogel Polyurethane foam Alginate

Types of Bandages Gauze Elasticized Binders Restrain dressings on wounds Bandage hands and feet Elasticized Provide pressure to an area Improve venous circulation in legs Binders Support large areas of body Triangular arm sling; straight abdominal binder

Heat and cold application Heat and cold are applied for local and systemic effects. Local Effects of Heat Vasodilation & increase bld flow bringing O2, nutrients, antibodies & leukocytes. Increases capillary permeability (may result in edema) Often used for musculoskeletal problems. Produces sedative effect

Local effects of cold Vasoconstriction Decreases capillary permeability Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect by slowing nerve conduction rate and blocking nerve impulses

Contraindication of heat and cold application Neurosensory function of the patient. Impaired mental status: need monitoring to ensure safety. Impaired circulation: risk for tissue damage Immediately after injury or surgery: heat increases bleeding and swelling Open wound: cold decreases blood flow to the wound thus inhibit healing.

Methods for Applying Dry and Moist Heat Dry heat Hot water bottle Aquathermia pad Disposable heat pack Electric pad Moist heat Compress Hot pack Soak Sitz bath

Methods for Applying Dry and Moist Cold Dry cold Cold pack Ice bag Ice glove Ice collar Moist cold Compress Cooling sponge bath