Presentation on theme: "Skin Integrity and Wound Care"— Presentation transcript:
1 Skin Integrity and Wound Care Dr. Abdul-Monim BatihaAssistant ProfessorCritical Care NursingPhiladelphia University
2 Factors Affecting Skin Integrity Genetics and heredityAgeChronic illnesses and their treatmentsMedicationsPoor nutritionCopyright 2008 by Pearson Education, Inc.
3 Risk Factors for Pressure Ulcers Friction and shearingImmobilityInadequate nutritionFecal and urinary incontinenceDecreased mental statusDiminished sensationExcessive body heatCopyright 2008 by Pearson Education, Inc.
4 Risk Factors for Pressure Ulcers Advanced ageChronic mental conditionsPoor lifting and transferring techniquesIncorrect positioningHard support surfacesIncorrect application of pressure-relieving devicesCopyright 2008 by Pearson Education, Inc.
5 Risk Assessment Tools Braden Scale for Predicting Pressure Sore Risk Norton’s Pressure Area Risk Assessment Form ScaleCopyright 2008 by Pearson Education, Inc.
6 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.
9 Four Stages of Pressure Ulcer Formation BFigure 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.CDCopyright 2008 by Pearson Education, Inc.9
10 Four Stages of Pressure Ulcer Formation Stage I: nonblanchable erythema signaling potential ulcerationStage II: partial-thickness skin loss involving epidermis and possibly dermisStage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissueStage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structuresCopyright 2008 by Pearson Education, Inc.
11 Differentiate primary and secondary wound healing.
12 Primary Intention Healing Tissue surfaces closedMinimal or no tissue lossFormulation of minimal granulation and scarringIt is also called primary union or first intention healing. An example is a closed surgical incision.Copyright 2008 by Pearson Education, Inc.
13 Secondary Intention Healing Extensive tissue lossEdges cannot be closedRepair time longerScarring greaterSusceptibility to infection greaterAn example is a pressure ulcer.Copyright 2008 by Pearson Education, Inc.
14 Tertiary Intention Healing (Delayed Primary Intention) Initially left openEdema, infection, or exudate resolvesThen 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.
16 Inflammatory Phase of Wound Healing Immediately after injury; lasts 3 to 5 daysHemostasis (the cessation of bleeding)Phagocytosis (engulfing of microorganisms and cellular debris by macrophages).Copyright 2008 by Pearson Education, Inc.
17 Proliferative Phase of Wound Healing From post injury day 3 or 4 until day 21Fibroblasts (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.
18 Maturation Phase of Wound Healing From day 21 until 1 or 2 years post injuryCollagen organizationRemodeling or contractionScar stronger but is never as strong as the original tissue.Copyright 2008 by Pearson Education, Inc.
20 ExudateMaterial such as fluid and cells that have escaped from blood vessels during inflammatory processDeposited in tissue or on tissue surface3 major typesSerousPurulentSanguineous (hemorrhagic)Copyright 2008 by Pearson Education, Inc.
21 Serous Exudate Mostly serum Watery, clear of cells E.g., fluid in a blisterCopyright 2008 by Pearson Education, Inc.
22 Purulent Exudate Thicker Presence of pus Color varies with organisms Copyright 2008 by Pearson Education, Inc.
23 Sanguineous Exudate Hemorrhagic Large number of RBCs Indicates severe damage to capillariesCopyright 2008 by Pearson Education, Inc.
24 Mixed ExudateSerosanguineous (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.
25 Complications of Wound Healing HemorrhageInfectionDehiscenceEviscerationCopyright 2008 by Pearson Education, Inc.
26 Factors Affecting Wound Healing AgeNutritional statusLifestyleMedicationsCopyright 2008 by Pearson Education, Inc.
27 Identify assessment data pertinent to skin integrity, pressure sites, and wounds.
28 Nursing Process: Assessment Nursing historyReview of systemsSkin diseasesPrevious bruisingGeneral skin conditionSkin lesionsUsual healing of soresCopyright 2008 by Pearson Education, Inc.
29 Assessment Data Inspection and palpation Skin color distribution Skin turgorPresence of edemaCharacteristics of any skin lesionsParticular attention paid to areas that are most likely to break downCopyright 2008 by Pearson Education, Inc.
30 Assessment Data Untreated wounds Location Extent of tissue damage Wound length, width, and depthBleedingForeign bodiesAssociated injuriesLast tetanus toxoid injectionCopyright 2008 by Pearson Education, Inc.
31 Assessment Data Treated wounds Appearance Size Drainage Presence of swellingPainStatus of drains or tubesCopyright 2008 by Pearson Education, Inc.
32 Click here to view a video on pressure ulcers. Pressure Ulcers VideoClick here to view a video on pressure ulcers.Copyright 2008 by Pearson Education, Inc.Back to Directory32
33 Assessment of Pressure Ulcers Location of the ulcer related to a bony prominenceSize of ulcer in centimeters including length (head to toe), width (side to side), and depthPresence of undermining or sinus tractsStage of the ulcerColor of the wound bedLocation of necrosis or escharCondition of the wound marginsIntegrity of surrounding skinClinical signs of infectionCopyright 2008 by Pearson Education, Inc.33
34 Assessment of Pressure Sites Inspect pressure areas for discoloration and capillary refill or blanche responseInspect pressure areas for abrasions and excoriationsPalpate the surface temperature over the pressure area sitesPalpate bony prominences and dependent body areas for the presence of edemaCopyright 2008 by Pearson Education, Inc.
35 Figure Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.
36 Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.
37 Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.
38 Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.
39 Assessment of Laboratory Data Leukocyte countHemoglobin levelBlood coagulation studiesSerum protein analysisAlbumin levelResults of wound culture and sensitivitiesCopyright 2008 by Pearson Education, Inc.
40 Nursing Diagnoses Risk for Impaired Skin Integrity Impaired Tissue IntegrityRisk for InfectionPainCopyright 2008 by Pearson Education, Inc.
41 Goals in Planning Client Care Risk for Impaired Skin IntegrityMaintain skin integrityAvoid or reduce risk factorsImpaired Skin IntegrityProgressive wound healingRegain intact skinClient and family educationAssess and treat existing woundPrevention of pressure ulcersCopyright 2008 by Pearson Education, Inc.
42 Measures to Prevent Pressure Ulcers Providing nutritionMaintaining skin hygieneAvoiding skin traumaProviding supportive devicesCopyright 2008 by Pearson Education, Inc.
43 Providing NutritionMaintain 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.
44 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.
45 Avoiding Skin Trauma Smooth, firm surfaces Semi-Fowler’s position Frequent weight shiftsExercise and ambulationLifting devicesReposition q 2 hoursTurning scheduleAvoid the use of baby powder and cornstarch which create harmful abrasive grit and are a respiratory hazardCopyright 2008 by Pearson Education, Inc.
46 Providing Supportive Devices MattressesBedsWedges, pillowsMiscellaneous devicesCopyright 2008 by Pearson Education, Inc.
47 Figure 36-6 Heel protector. (Courtesy of Gaymar Industries, Inc.)
50 Figure Low-air-loss and air-fluidized combo bed (Clinitron/Rite Hite). (Courtesy of Hill-Rom Services, Inc. Reprinted with permission. All rights reserved.)
51 Treating Pressure Ulcers Minimize direct pressureSchedule and record position changesProvide devices to reduce pressure areasClean and dress the ulcer using surgical asepsisNever use alcohol or hydrogen peroxideObtain C&S, if infectedTeach the clientProvide ROM exerciseCopyright 2008 by Pearson Education, Inc.
52 RYB Color Guide for Wound Care Red (protect)Yellow (cleanse)Black (debride)Copyright 2008 by Pearson Education, Inc.
53 Red woundsNeed 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.
54 Yellow woundsare characterized primarily by liquid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection.
55 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.
56 Black woundsare 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.
57 Promoting Wound Healing Fluid intakeProtein, vitamin, and zinc intakeDietary consultNutritional supplementsMonitor weight/lab valuesCopyright 2008 by Pearson Education, Inc.
58 Controlling wound infection Prevent entry of microorganismsPrevent transmission of pathogensCopyright 2008 by Pearson Education, Inc.
59 Types of Wound Dressings Transparent filmImpregnated nonadherentHydrocolloidsClear absorbent acrylicHydrogelPolyurethane foamAlginateCopyright 2008 by Pearson Education, Inc.
60 Transparent filmis 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.
61 Impregnated nonadherent dressings are used to cover, soothe, and protect partial- and full-thickness wounds without exudate.
62 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.
63 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.
64 Hydrogelsare used to liquefy necrotic tissue or slough, rehydrate the wound bed, and fill in dead space.
65 Polyurethane foamsabsorb up to heavy amounts of exudate, providing and maintaining moist wound healing.
66 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.
67 Types of Bandages Gauze Elasticized Binders Retain dressings on wounds Bandage hands and feetElasticizedProvide pressure to an areaImprove venous circulation in legsBindersSupport large areas of bodyTriangular arm sling; straight abdominal binderCopyright 2008 by Pearson Education, Inc.
68 Figure 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.
69 Figure 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.
70 Figure (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.
71 Figure (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.
72 Figure Montgomery straps, or tie tapes, are used to secure large dressings that require frequent changing.
73 Figure 36-13 Vacuum-assisted closure (VAC) system for wounds.
74 Figure 36-14 Starting a bandage with two circular turns.