Skin Integrity and Wound Care Dr. Abdul-Monim Batiha Assistant Professor Critical Care Nursing Philadelphia University

Factors Affecting Skin Integrity Genetics and heredity Age Chronic illnesses and their treatments Medications Poor nutrition Copyright 2008 by Pearson Education, Inc.

Risk Factors for Pressure Ulcers Friction and shearing Immobility Inadequate nutrition Fecal and urinary incontinence Decreased mental status Diminished sensation Excessive body heat Copyright 2008 by Pearson Education, Inc.

Risk Factors for Pressure Ulcers Advanced age Chronic mental conditions Poor lifting and transferring techniques Incorrect positioning Hard support surfaces Incorrect application of pressure-relieving devices Copyright 2008 by Pearson Education, Inc.

Risk Assessment Tools Braden Scale for Predicting Pressure Sore Risk Norton’s Pressure Area Risk Assessment Form Scale Copyright 2008 by Pearson Education, Inc.

The Braden Scale for Predicting Pressure Sore Risk consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A total score of 23 points is possible. An adult who scores below 18 points is considered at risk.

Figure 36-2 Braden Scale for Predicting Pressure Sore Risk Figure 36-2 Braden Scale for Predicting Pressure Sore Risk. (From “Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention,” by U.S. Department of Health and Human Services, PPPPUA Pub No. 92-0047, pp. 16–17, 1992, Rockville, MD: Public Health Service. Copyright © Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission.)

Figure 36-2 (continued) Braden Scale for Predicting Pressure Sore Risk Figure 36-2 (continued) Braden Scale for Predicting Pressure Sore Risk. (From “Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention,” by U.S. Department of Health and Human Services, PPPPUA Pub No. 92-0047, pp. 16–17, 1992, Rockville, MD: Public Health Service. Copyright © Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission.)

Four Stages of Pressure Ulcer Formation B Figure 36-1 Four stages of pressure ulcers. A, stage I: nonblanchable erythema signaling potential ulceration; B, stage II: partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis; C, stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue; D, stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present. C D Copyright 2008 by Pearson Education, Inc. 9

Four Stages of Pressure Ulcer Formation Stage I: nonblanchable erythema signaling potential ulceration Stage II: partial-thickness skin loss involving epidermis and possibly dermis 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 Copyright 2008 by Pearson Education, Inc.

Differentiate primary and secondary wound healing.

Primary Intention Healing Tissue surfaces closed Minimal or no tissue loss Formulation of minimal granulation and scarring It is also called primary union or first intention healing. An example is a closed surgical incision. Copyright 2008 by Pearson Education, Inc.

Secondary Intention Healing Extensive tissue loss Edges cannot be closed Repair time longer Scarring greater Susceptibility to infection greater An example is a pressure ulcer. Copyright 2008 by Pearson Education, Inc.

Tertiary Intention Healing (Delayed Primary Intention) Initially left open Edema, infection, or exudate resolves Then closed (Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention). Copyright 2008 by Pearson Education, Inc.

Describe the three phases of wound healing.

Inflammatory Phase of Wound Healing Immediately after injury; lasts 3 to 5 days Hemostasis (the cessation of bleeding) Phagocytosis (engulfing of microorganisms and cellular debris by macrophages). Copyright 2008 by Pearson Education, Inc.

Proliferative Phase of Wound Healing From post injury day 3 or 4 until day 21 Fibroblasts (connective tissue cells) begin to synthesize collagen, a protein that adds tensile strength to the wound. Capillaries grow across the wound, increasing the blood supply. Fibroblasts deposit fibrin, and granulation tissue is formed. Granulation tissue is a translucent red color. It is fragile and bleeds easily. Copyright 2008 by Pearson Education, Inc.

Maturation Phase of Wound Healing From day 21 until 1 or 2 years post injury Collagen organization Remodeling or contraction Scar stronger but is never as strong as the original tissue. Copyright 2008 by Pearson Education, Inc.

Identify three major types of wound exudate.

Exudate Material such as fluid and cells that have escaped from blood vessels during inflammatory process Deposited in tissue or on tissue surface 3 major types Serous Purulent Sanguineous (hemorrhagic) Copyright 2008 by Pearson Education, Inc.

Serous Exudate Mostly serum Watery, clear of cells E.g., fluid in a blister Copyright 2008 by Pearson Education, Inc.

Purulent Exudate Thicker Presence of pus Color varies with organisms Copyright 2008 by Pearson Education, Inc.

Sanguineous Exudate Hemorrhagic Large number of RBCs Indicates severe damage to capillaries Copyright 2008 by Pearson Education, Inc.

Mixed Exudate Serosanguineous (hemorrhagic) exudate consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from the plasma. Mixed exudates include serosanguineous (consisting of clear and blood-tinged drainage) and purosanguineous discharge (consisting of pus and blood). Copyright 2008 by Pearson Education, Inc.

Complications of Wound Healing Hemorrhage Infection Dehiscence Evisceration Copyright 2008 by Pearson Education, Inc.

Factors Affecting Wound Healing Age Nutritional status Lifestyle Medications Copyright 2008 by Pearson Education, Inc.

Identify assessment data pertinent to skin integrity, pressure sites, and wounds.

Nursing Process: Assessment Nursing history Review of systems Skin diseases Previous bruising General skin condition Skin lesions Usual healing of sores Copyright 2008 by Pearson Education, Inc.

Assessment Data 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 Copyright 2008 by Pearson Education, Inc.

Assessment Data Untreated wounds Location Extent of tissue damage Wound length, width, and depth Bleeding Foreign bodies Associated injuries Last tetanus toxoid injection Copyright 2008 by Pearson Education, Inc.

Assessment Data Treated wounds Appearance Size Drainage Presence of swelling Pain Status of drains or tubes Copyright 2008 by Pearson Education, Inc.

Click here to view a video on pressure ulcers. Pressure Ulcers Video Click here to view a video on pressure ulcers. Copyright 2008 by Pearson Education, Inc. Back to Directory 32

Assessment of 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 Presence of undermining or sinus tracts 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 Copyright 2008 by Pearson Education, Inc. 33

Assessment of Pressure Sites Inspect pressure areas for discoloration and capillary refill or blanche response Inspect pressure areas for abrasions and excoriations Palpate the surface temperature over the pressure area sites Palpate bony prominences and dependent body areas for the presence of edema Copyright 2008 by Pearson Education, Inc.

Figure 36-3 Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Assessment of Laboratory Data Leukocyte count Hemoglobin level Blood coagulation studies Serum protein analysis Albumin level Results of wound culture and sensitivities Copyright 2008 by Pearson Education, Inc.

Nursing Diagnoses Risk for Impaired Skin Integrity Impaired Tissue Integrity Risk for Infection Pain Copyright 2008 by Pearson Education, Inc.

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 Copyright 2008 by Pearson Education, Inc.

Measures to Prevent Pressure Ulcers Providing nutrition Maintaining skin hygiene Avoiding skin trauma Providing supportive devices Copyright 2008 by Pearson Education, Inc.

Providing Nutrition Maintain fluid intake of at least 2500 mL per day unless contraindicated, sufficient protein, vitamins C, A, B1, B5, and zinc. Dietary consultation and nutritional supplements should be considered for nutritionally compromised clients. Weight should be monitored as should lab data monitoring e.g. lymphocyte count, protein (especially albumin), and hemoglobin levels. Copyright 2008 by Pearson Education, Inc.

Maintaining Skin Hygiene Use mild cleansing agents that do not disrupt the skin’s “natural barriers,”_ avoid using hot water, exposure to cold and low humidity; apply moisturizing lotions while the skin is moist after bathing; keep skin clean, dry and free of irritation and maceration by urine, feces, sweat, and dry skin completely after a bath. Apply skin protection (dimethicone-based creams or alcohol-free barrier films) if indicated._Avoid massaging over bony prominences since massage may lead to deep tissue trauma. Copyright 2008 by Pearson Education, Inc.

Avoiding Skin Trauma Smooth, firm surfaces Semi-Fowler’s position Frequent weight shifts Exercise and ambulation Lifting devices Reposition q 2 hours Turning schedule Avoid the use of baby powder and cornstarch which create harmful abrasive grit and are a respiratory hazard Copyright 2008 by Pearson Education, Inc.

Providing Supportive Devices Mattresses Beds Wedges, pillows Miscellaneous devices Copyright 2008 by Pearson Education, Inc.

Figure 36-6 Heel protector. (Courtesy of Gaymar Industries, Inc.)

Figure 36-7 Alternating pressure mattress (Ease).

Figure 36-8 Low-air-loss bed.

Figure 36-9 Low-air-loss and air-fluidized combo bed (Clinitron/Rite Hite). (Courtesy of Hill-Rom Services, Inc. Reprinted with permission. All rights reserved.)

Treating Pressure Ulcers Minimize direct pressure Schedule and record position changes Provide devices to reduce pressure areas Clean and dress the ulcer using surgical asepsis Never use alcohol or hydrogen peroxide Obtain C&S, if infected Teach the client Provide ROM exercise Copyright 2008 by Pearson Education, Inc.

RYB Color Guide for Wound Care Red (protect) Yellow (cleanse) Black (debride) Copyright 2008 by Pearson Education, Inc.

Red wounds Need to be protected to avoid disturbance to regenerating tissue. The nurse protects the wound by gentle cleansing, covering periwound skin with alcohol-free barrier film, filling dead space with hydrogel or alginate, covering the wound with an appropriate dressing such as transparent film, hydrocolloid dressing, or a clear absorbent acrylic dressing, and changing the dressing as infrequently as possible.

Yellow wounds are characterized primarily by liquid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection.

The nurse cleanses yellow wounds to remove nonviable tissue The nurse cleanses yellow wounds to remove nonviable tissue. Methods used may include applying moist-to- moist normal saline dressings, irrigating the wound, using absorbent dressing materials such as impregnated hydrogel or alginate dressings, and consulting with the primary care provider about the need for a topical antimicrobial to minimize bacterial growth.

Black wounds are covered by thick necrotic tissue or eschar. They require debridement (removal of dead tissue). Debridement may be achieved in four different ways: sharp, mechanical, chemical, autolytic, and use of fly larvae (maggots). Once eschar is removed, the wound is treated as yellow, then red.

Promoting Wound Healing Fluid intake Protein, vitamin, and zinc intake Dietary consult Nutritional supplements Monitor weight/lab values Copyright 2008 by Pearson Education, Inc.

Controlling wound infection Prevent entry of microorganisms Prevent transmission of pathogens Copyright 2008 by Pearson Education, Inc.

Types of Wound Dressings Transparent film Impregnated nonadherent Hydrocolloids Clear absorbent acrylic Hydrogel Polyurethane foam Alginate Copyright 2008 by Pearson Education, Inc.

Transparent film is used to provide protection against contamination and friction, to maintain a clean moist surface that facilitates cellular migration, to provide insulation by preventing fluid evaporation, and to facilitate wound assessment.

Impregnated nonadherent dressings are used to cover, soothe, and protect partial- and full-thickness wounds without exudate.

Hydrocolloid dressings are used to absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; to protect the wound from bacterial contamination, foreign debris, and urine or feces; and to prevent shearing.

Clear absorbent acrylic dressings maintain a transparent membrane for easy wound bed assessment, provide bacterial and shearing protection, maintain moist wound healing, and can be used with alginates to provide packing to deeper wound beds.

Hydrogels are used to liquefy necrotic tissue or slough, rehydrate the wound bed, and fill in dead space.

Polyurethane foams absorb up to heavy amounts of exudate, providing and maintaining moist wound healing.

Alginates (exudate absorbers) are used 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, and to support debridement.

Types of Bandages Gauze Elasticized Binders Retain 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 Copyright 2008 by Pearson Education, Inc.

Figure 36-10 The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The tape should adhere to intact skin.

Figure 36-11 Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

Figure 36-12 Montgomery straps, or tie tapes, are used to secure large dressings that require frequent changing.

Figure 36-13 Vacuum-assisted closure (VAC) system for wounds.

Figure 36-14 Starting a bandage with two circular turns.

Figure 36-15 Applying spiral turns.

Figure 36-16 Applying spiral reverse turns.

Figure 36-17 Starting a recurrent bandage.

Figure 36-18 Completing a recurrent bandage.

Figure 36-19 Applying a figure-eight bandage.

Figure 36-20 Large arm sling.

Figure 36-20 (continued) Large arm sling.

Figure 36-21 A straight abdominal binder.

Obtaining a Wound Specimen A culturette tube for a wound specimen. Copyright 2008 by Pearson Education, Inc. 83

Irrigating a Wound Skill 36-2 Irrigating an open wound. Copyright 2008 by Pearson Education, Inc. 84