1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 38 Skin Integrity and Wound Care

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Six Functions of the Skin Protection Body temperature regulation Sensation Excretion Maintenance of water and electrolyte balance Vitamin D production and absorption

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. Blood vessels in the skin dilate to dissipate heat. A. True B. False

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: A. True Blood vessels in the skin dilate to dissipate heat.

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Cross-Section of Normal Skin

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting the Skin Unbroken and healthy skin and mucous membranes defend against harmful agents Resistance to injury is affected by age, amount of underlying tissues, and illness Adequately nourished and hydrated body cells are resistant to injury Adequate circulation is necessary to maintain cell life

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Developmental Considerations Infant’s skin and mucous membranes are easily injured and subject to infection Child’s skin becomes increasingly resistant to injury and infection –Requires special care because of toilet and play habits Adolescent has enlarged sebaceous glands and increased secretions Adult’s tissue becomes thinner and wrinkles appear; liver spots occur

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Skin Alterations Very thin and very obese people are more susceptible to skin injury –Fluid loss during illness causes dehydration –Skin appears loose and flabby Excessive perspiration during illness predisposes skin to breakdown Jaundice causes yellowish, itchy skin Diseases of the skin cause lesions that require care

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Influencing Personal Hygiene Culture Socioeconomic class Spiritual practices Developmental and knowledge level Health state Personal preference

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Wounds Intentional or unintentional Open or closed Acute or chronic Partial thickness, full thickness, complex

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which one of the following types of wounds is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? A. Contusion B. Abrasion C. Laceration D. Avulsion

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: A. Contusion Rationale: A contusion is caused by a blunt instrument and may result in bruising or hematoma. An abrasion is the rubbing or scraping of epidermal layers of skin. A laceration is the tearing of skin and tissue with a blunt or irregular instrument. Avulsion is the tearing of a structure from normal anatomic position.

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Wound Healing Intact skin is the first line of defense against microorganisms Surgical asepsis is used in caring for a wound The body responds systematically to trauma of any of its parts An adequate blood supply is essential for normal body response to injury Normal healing is promoted when wound is free of foreign material

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Wound Healing (cont.) The extent of damage and the person’s state of health affects wound healing Response to wound is more effective if proper nutrition is maintained

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Wound Healing Inflammatory Proliferative Remodeling

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In which one of the following phases of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory phase C. Proliferation phase D. Maturation phase

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: C. Proliferation phase Rationale: In the proliferation phase, granulation tissue is formed to fill the wound. In hemostasis, involved blood vessels constrict and blood clotting begins. In the inflammatory phase, white blood cells move to the wound. In the maturation phase, collagen is remodeled forming a scar.

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Inflammatory Phase Begins at time of injury Prepares wound for healing –Hemostasis (blood clotting) occurs –Vascular and cellular phase of inflammation

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Proliferative Phase Phase begins within 2 to 3 days of injury and may last up to 2 to 3 weeks New tissue is built to fill wound space through action of fibroblasts Capillaries grow across wound Thin layer of epithelial cells forms across wound Granulation tissue forms foundation for scar tissue development

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Remodeling Phase Final stage of healing begins about 3 weeks after injury to possibly 6 months Collagen is remodeled New collagen tissue is deposited Scar becomes a flat, thin, white line

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting Wound Healing Age—children and healthy adults heal more rapidly Circulation and oxygenation—adequate blood flow is essential Nutritional status—healing requires adequate nutrition Wound condition–specific condition of wound affects healing Health status—corticosteroid drugs and postoperative radiation therapy delay healing

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Complications Infection Hemorrhage Dehiscence and evisceration Fistula formation

23. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which one of the following wound complications is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration

24. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: D. Maceration Rationale: Maceration is caused by overhydration related to incontinence that causes impaired skin integrity. Necrosis is dead tissue present in the wound that delays healing. Edema is swelling at a wound site that interferes with blood supply to the area. Desiccation is the process in which the cells dehydrate and die.

25. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Dehiscence and Evisceration

26. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychological Effects of Wounds Pain Anxiety Fear Change in body image

27. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting Pressure Ulcer Development Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders

28. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Mechanisms in Pressure Ulcer Development External pressure compressing blood vessels Friction or shearing forces tearing or injuring blood vessels

29. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Stages of Pressure Ulcers Stage I — nonblanchable erythema of intact skin Stage II — partial-thickness skin loss Stage III — full-thickness skin loss; not involving underlying fascia Stage IV — full-thickness skin loss with extensive destruction

30. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Measurement of a Pressure Ulcer Size of wound Depth of wound Presence of undermining, tunneling, or sinus tract

31. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins A Wound with Various Types of Wound Surface Tissue

32. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. A Stage III pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. A. True B. False

33. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer Answer: A. True A Stage III pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes.

34. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Cleaning a Pressure Ulcer Clean with each dressing change Use careful, gentle motions to minimize trauma Use 09% normal saline solution to irrigate and clean the ulcer Report any drainage or necrotic tissue

35. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Dressing the Pressure Ulcer Keep ulcer tissue moist and surrounding skin dry Place moist dressings only on the wound surface Use dressing that absorbs exudate but maintains moist environment Use skin sealant or moisture-barrier ointment on surrounding skin Secure dressing with the least amount of tape possible Use wet-to-dry dressings for debridement, when ordered Pack wound cavities loosely with dressing material

36. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Assessment Inspection for sight and smell Palpation for appearance, drainage, and pain Sutures, drains or tube, manifestation of complications

37. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Presence of Infection Wound is swollen Wound is deep red in color Wound feels hot on palpation Drainage is increased and possibly purulent Foul odor may be noted Wound edges may be separated with dehiscence present

38. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Wound Drainage Serous Sanguineous Purulent

39. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Purposes of Wound Dressings Provide physical, psychological, and aesthetic comfort Remove necrotic tissue Prevent, eliminate, or control infection Absorb drainage Maintain a moist wound environment Protect wound from further injury Protect skin surrounding wound

40. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Wound Dressings Telfa Gauze dressings Transparent dressings

41. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Bandages Roller bandages Circular turn Spiral turn Figure-of-eight turn Recurrent-stump bandage

42. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Binders Straight — used for chest and abdomen T-binder — used for rectum, perineum, and groin area Sling — used to support an arm

43. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Type of Drainage Systems Open systems –Penrose drain Closed systems –Jackson-Pratt drain –Hemovac drain Wound pouching

44. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Penrose Drain

45. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Jackson-Pratt Drain

46. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Color Classification of Open Wounds R = red—proliferative stage of healing; reflects color of normal granulation Y = yellow—characterized by oozing; needs to be cleansed B = black—covered with thick eschar; requires debridement Mixed wound—contains components of RY&B wounds

47. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Topics for Home Care Teaching Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination

48. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Affecting the Response to Hot and Cold Treatments Method and duration of application Degree of heat and cold applied Patient’s age and physical condition Amount of body surface covered by the application

49. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Effects of Applying Heat Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity and increases capillary permeability Reduces muscle tension Helps relieve pain

50. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Effects of Applying Cold Constructs peripheral blood vessels Reduces muscle spasms Promotes comfort

51. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Devices to Apply Heat Hot water bags or bottles Electric heating pads Aquathermia pads Heat lamps Heat cradles Hot packs Moist heat Sitz baths Warm soaks

52. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Devices to Apply Cold Ice bags Cold packs Hypothermia blankets Moist cold