Chapter 36 Skin Integrity and Wound Healing

36-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  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.

36-3 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  Epidermis Outermost layer of the skin Primary function is to maintain a barrier against loss of internal fluids and pathogenic invasion.

36-4 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  Dermal-Epidermal Junction Anatomic point at which the epidermis connects with the dermis Characterized by interdigitating connections that provide resistance to superficial skin injury.

36-5 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  Dermis Innermost layer of the skin Nourishes the basal layer of the epidermis. Provides sensory awareness. Contributes to temperature regulation. Composed primarily of collagen and elastin fibers.

36-6 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  Hypodermis (Subcutaneous layer) Consists primarily of adipose tissue and connective tissue. Critical role of providing “padding” and even weight distribution over bony prominences.

36-7 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  Fascia/Muscle Layer Fascia is a thin layer of connective tissue covering the muscle. Muscle layer is composed of contractile fibers that control position and movement. Muscle layer is the most metabolically active layer of the skin and soft tissues. Muscle layer is most vulnerable to ischemic damage.

36-8 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Structures and Function of Healthy Skin  Changes Across the Lifespan Neonates and Infants Elderly Adults

36-9 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Strategies to Maintain Healthy Skin  Nutrition and Hydration  Bathing and Lubrication  Managing Pruritic Skin

36-10 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Strategies to Maintain Healthy Skin  Common Skin Lesions Bacterial Infections Fungal Infections Viral Infections

36-11 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Strategies to Maintain Healthy Skin  Inflammatory Conditions  Cutaneous Malignancies

36-12 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Pressure Ulcer Formation  A pressure ulcer is an area of skin and tissue loss caused by prolonged or excessive soft tissue pressure.  Results in skin breakdown.  Increasingly common problem among clients in all health care settings.

36-13 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Pressure Ulcer Formation  Pathology of Pressure Ulcers Tunneling Friction Maceration

36-14 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Pressure Ulcer Formation  Assessment Use of a research-based risk assessment tool to screen all non-ambulatory clients -Braden scale -Norton scale Nonblanching erythema Induration with palpation Extensive tissue damage

36-15 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Pressure Ulcer Formation  Assessment Etiologic Risk Factors Prolonged or High-Intensity Pressure Shear Force Compromised Tissue Tolerance

36-16 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Pressure Ulcer Formation  Nursing Diagnosis Impaired Skin Integrity Related to Pressure/Shear Injury

36-17 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Outcome Identification and Planning  Individualized outcomes are based on the client’s overall physical condition, the stage of the wound, and the client’s risk factors.  Client teaching is an integral part of the planning process.

36-18 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Pressure ulcers can be prevented through a variety of measures.  Early identification of high-risk individuals and contributing factors decrease the possibility of pressure ulcer formation.

36-19 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Appropriate Use and Selection of Support Surfaces A variety of support surfaces for bed and chair are designed to reduce interface pressures or to constantly change the pressure points.

36-20 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Measures to Control Moisture and Maceration  Nutritional and Fluid Support  Routine Skin Assessment  Management for Shear Force  Avoidance of Massage of Tissue at Risk

36-21 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Evaluation  Physical signs of healing and the status of the pressure ulcer  Client’s adaptation to the altered skin integrity  Each intervention should be evaluated for its effectiveness.  Plan of care is revised to reflect most beneficial actions.

36-22 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Healing  Definitions and Classifications of Wounds Acute Chronic

36-23 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Healing  Definitions and Classifications of Wounds Partial-thickness wounds involve partial loss of the skin layers but do not involve the deeper tissues. Full-thickness wounds involve total loss of the epidermis and dermis with extension into the subcutaneous tissue and possibly the muscle.

36-24 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Healing  Partial-Thickness Wound Repair Brief inflammatory phase Epithelial cell proliferation and migration Vertical migration Collagen synthesis (formation of new connective tissue)

36-25 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Healing  Full-Thickness Wound Repair Inflammatory phase -Control bleeding -Establish clean wound bed -Release of growth factors -Inflammatory response

36-26 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Healing  Full-Thickness Wound Repair Proliferative phase -Granulation tissue -Epithelialization -Contraction Maturation phase (remodeling phase) -3 months to 2 years -Hypertrophic scarring (keloid formation)

36-27 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Management  Identify and address etiologic factors.  Establish appropriate goals.  Provide systemic support and topical therapy.

36-28 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Wound Management  Assessment Location, dimensions and depth Stage of the wound Status of wound bed (eschar, slough) Exudate Status of wound edges (flat, red, moist, closed) Status of surrounding skin Pain

36-29 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Factors Affecting Wound Healing Perfusion and Oxygenation Nutritional Status Diabetes Mellitus Corticosteroids Aging

36-30 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Laboratory Data Cultures of wound drainage Elevated WBC count Decreased leukocyte Albumin

36-31 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Diagnoses  Impaired Tissue Integrity  Risk for Infection  Pain  Disturbed Body Image  Deficient Knowledge (wound care)

36-32 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Outcome Identification and Planning  Targeted outcomes are based on client’s identified needs and individualized on basis of client’s condition.  Focus is on promoting wound healing, preventing infection, and educating the client.

36-33 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Systemic Support Measures Tissue perfusion and oxygenation Nutritional support Glucose levels within normal limits Compensation for chronic steroid intake

36-34 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Topical Therapy Wound cleansing Dressing selection Debridement of necrotic tissue

36-35 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Topical Therapy Monitor drainage of wounds -Penrose drains -Jackson-Pratt drains -Hemovac drains Maintenance of open proliferative wound edges

36-36 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Drainage Systems: Closed System

36-37 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Drainage Systems: Tube and Reservoir System

36-38 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Evaluation  Achievement or Maintenance of Skin Integrity Wound healing Prevention of infection Client education

36-39 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Management Guidelines for Specific Wounds  Abrasions and Lacerations  Surgical Incisions  Skin Tears

36-40 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Wounds

36-41 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Management Guidelines for Specific Wounds  Lower Extremity Ulcers Venous ulcers Arterial ulcers Neuropathic ulcers Atypical ulcers

36-42 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Management Guidelines for Specific Wounds  Burns Thermal, chemical, or electrical causes Epidermal burns Superficial partial-thickness burns Deep partial-thickness burns Full-thickness burns

36-43 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Contusions, Strains, and Sprains: Management Guidelines  Contusions are bruises of the soft tissues with no break in the skin surface.  Contusions resolve spontaneously and require no active management.  Application of ice for 24 hours following injury can reduce the amount of edema and bruising.

36-44 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Contusions, Strains, and Sprains: Management Guidelines  Strains represent “stretch” injuries of muscles, tendons, or ligaments.  Application of ice for 24 hours to reduce swelling and bleeding, elevation to reduce swelling, use of an elastic wrap or sling, and aspirin or acetaminophen as needed.

36-45 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Contusions, Strains, and Sprains: Management Guidelines  First- and second-degree sprains involve trauma to ligaments, tendons, or bones around a joint.  Caused by twisting or pulling forces.  Nonsteroidal anti-inflammatory drugs, ice, elastic wrap or sling, and restricted activity until symptoms resolve

36-46 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Contusions, Strains, and Sprains: Management Guidelines  Third-degree sprains represent a more serious injury.  Characterized by separation of tendons and ligaments from their bony attachments.  Produce severe bleeding, swelling, pain, and loss of function.

36-47 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Contusions, Strains, and Sprains: Management Guidelines  Management of Third-Degree Strains Rest Crutch to prevent weight bearing during ambulation Ice for 24 to 72 hours Compression with an elastic wrap Soft cast or sling Elevation

36-48 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Contusions, Strains, and Sprains: Management Guidelines  Management of Third-Degree Sprains Narcotic analgesics for severe pain Restricted mobility for up to 3 weeks Surgery may be required for reattachment or removal of torn tendons and ligaments. Potential for developing post-traumatic arthritis

36-49 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Administer Heat and Cold Therapy  Heat and cold therapies require nursing care that assesses both the vasoconstriction and vasodilation of an individual.

36-50 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Administer Heat and Cold Therapy  Conditions that necessitate precautions in the use of heat and cold applications: Neurosensory impairment Impaired mental status Impaired circulation Open wounds, broken skin, scar formation, edema

36-51 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Administer Heat and Cold Therapy  Heat Therapy Promotes vasodilation Decreases blood viscosity Increases tissue metabolism Increases capillary permeability Reduces muscle tension

36-52 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Administer Heat and Cold Therapy  Cold Therapy Promotes vasoconstriction Increases blood viscosity Decreases tissue metabolism Local anesthetic effect Decreases muscle tension