Skin Integrity and wound care

Tissue Integrity Definition Tissue integrity is the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes.

Categories of Impaired Skin Integrity

Epidermis SC: Cells are flattened & dead Protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents. It allows evaporation of water from the skin and permits absorption of certain topical medications

Dermis Inner Layer Provides tensile strength, mechanical support, and protection to the underlying muscles, bones and organs. It contains mostly connective tissue and few skin cells

Pressure Ulcer A localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction.

Pathogenesis of Pressure Ulcers Pressure Intensity – Tissue ischemia – Blanching Pressure Duration Tissue Tolerance

Risk Factor for Pressure Ulcer Development Prolong pressure Shearing Friction

Classification of Pressure Ulcers Stage I Intact skin with nonblanchable redness Stage II Partial-thickness skin loss involving epidermis, dermis, or both Stage III Full-thickness tissue loss with visible fat Stage IV Full-thickness tissue loss with exposed bone, muscle, or tendon

Classification of Pressure Ulcers Stage I: Nonblanchable Redness of Intact Skin Stage II: Partial-thickness Skin Loss or Blister Stage III: Full-thickness Skin Loss (Fat Visible) Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible) Unstageable/Unclassified: Full-thickness Skin or Tissue Loss-Depth Unknown Deep-Tissue injury: Full-thickness Skin or Tissue Loss-Depth Unknown

Wounds and Wound Care

Complications of Wound Healing Hemorrhage – Initial trauma: normal during and immediately after. – After hemostasis: Slipped surgical suture Dislodged clot Infection Erosion of a blood vessel

Complications of Wound Healing May be internal or external – Internal Distention or swelling of the affected body part Type and amount of drainage drain surgical drain Signs of hypovolemic shock Hematoma: localized collection of blood underneath the tissue – External Obvious! Risk of hemorrhage is great during first hours after surgery or injury

Complications of Wound Healing Infection: wound infection is the second most common health care-associated infection – A wound is infected if purulent material drains from it – Wound infection is greater when Wound contains death or necrotic tissue There are foreign bodies in or near the wound Blood supply and local tissue defense are reduced – Bacterial wound infection inhibits wound healing

Complications of Wound Healing – Signs and symptoms of wound infection Contaminated or traumatic wounds: 2-3 days Post op surgical wound: 4-5 days Fever, tenderness and pain at wound site Elevated WBC count Wound edges appear inflamed Drainage may be present: odorous and purulent (yellow, green, or brown)

Infection Redness, warmth, pain, and an elevated WBC count Serous – Clear, watery plasma Purulen t – Thick, yellow, green, Tan, or brown Serosanguineou s – Pale, pink, watery: – Mixture of clear and red Fluid Sanguineous – Bright red: indicates Active bleeding

Complications of Wound Healing Dehiscence: partial or total separation of wound layers

Complications of Wound Healing Evisceration: With total separation of wound the visceral organ protrudes through the wound opening

Wound Management Principles to maintain a healthy wound environment: – Prevent and manage infection – Clean the wound – Remove nonviable tissue – Manage exudate – Maintain the wound in a moist environment – Protect the wound

Prevent and Manage Infection Cleaning the wound – Pressure ulcers: use noncytotoxic wound cleaners – NS: preferred cleaning agent, does not harm tissue – Commercial wound cleaners – Other wounds: cytoxic wound cleaners Dakin’s solution Acetic acid Povidone-iodine Hydrogen peroxide Irrigation is a common method of delivering wound-cleaning solution to the wound.

Debridement Debridement is the removal of nonviable, necrotic tissue. – Wet to dry dressings – Autolytic debridement – Chemical debridement – Surgical debridement

Protection Protect the wound by applying a sterile or clean dressing. For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops. For wounds healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or assisting in debridement.

Purposes of Dressings  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

Dressings  Dry or moist  Gauze

Dressing Film dressing

Dressing Hydrocolloid—protects the wound from surface from from surface contamination

Dressings Hydrogel—maintains a moist surface to support healing

Dressings  Wound vacuum assisted closure (V.A.C.)— uses negative pressure to support healing

Dressings  Changing  Know type of dressing, placement of drains, and equipment needed.  Prepare the patient for a dressing change  Evaluate pain.  Describe procedure steps.  Gather supplies.  Recognize normal signs of healing.  Answer questions about the procedure or wound.

During a Dressing Change  Assess the skin beneath the tape.  Perform thorough hand hygiene before and after wound care.  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.

Dressings  Packing a wound  Assess size, depth, and shape  Securing  Tape, ties, or binders  Comfort measures  Carefully remove tape.  Gently clean the wound.  Administer analgesics before dressing change.

Cleaning Skin 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.

PICC Line Dressing Changing Kit

Cleaning around the insertion site

Putting on the new dressing

Completed dressing change with date