1. SKIN INTEGRITY AND WOUND HEALING FALL 2010

2. SKIN STRUCTURE EPIDERMIS Outermost Layer Barrier-restricts water loss Prevents fluids, pathogens and chemicals from entering

3. SKIN STRUCTURE DERMIS Below epidermis and above subcutaneous tissue Composed of connective tissue Provides strength and elasticity to skin Contains blood vessels Contains sweat glands, ceruminous glands, hair and nail follicles, sensory receptors, elastin and collagen

4. SKIN STRUCTURE SUBCUTANEOUS LAYER Composed of fat and connective tissue Provides insulation, protection and a reserve of calories in the event of severe malnutrition Thickness and distribution varies-influenced by hormones, genetics, age and nutrition

5. FACTORS INFLUENCING ABILITY TO MAINTAIN INTACT SKIN AND HEAL WOUNDS Age Mobility Nutrition Hydration Diminished Sensation Impaired Circulation Medications

6. FACTORS INFLUENCING ABILITY TO MAINTAIN INTACT SKIN AND HEAL WOUNDS Moisture on the skin Fever Contamination Lifestyle (Smoking) Disease processes Radiation treatments Immune function

7. WOUND CLASSIFICATIONS Status of skin integrity Open Closed Cause Intentional Unintentional Time for healing Acute Chronic Severity of injury Superficial-epidermal Partial thickness-dermal Full thickness-into subcutaneous and beyond

8. WOUND CLASSIFICATIONS cont. Cleanliness Clean Clean-contaminated Contaminated Colonized Infected Descriptive qualities Abrasion Laceration Contusion

9. WOUND HEALING METHODS Regenerative Affects only epidermal layer No scar Primary Intention Edges well approximated Little scarring

10. WOUND HEALING METHODS cont Secondary Intention Wound edges not approximated Heals from inner layer Beefy red granulation tissue More scar tissue Increased chance of infection or complications

11. WOUND HEALING METHODS cont. Tertiary Intention Delayed wound closure Two surfaces of granulation tissue brought together More scarring than primary but less than secondary

12. WOUND HEALING PHASES Inflammatory-Cleansing 1-5 days Homeostasis-Provides clotting Inflammation-Provides sealing scab Proliferative-Granulation 5-21 days Maturation-Epitheliazation Until wound is completely healed

13. WOUND COMPLICATIONS Hemorrhage Infection Dehiscence Evisceration Fistula

14. Assessment of Wounds Acute injury / wound Bleeding Contaminant materials Size Recent tetanus Stable / chronic wound Healing Appearance Drainage Pain Color Location Wound bed Peri wound skin

15. Assessment of Wounds Types of drainage Serous Sanguinous Serosanguinous Purulent Presence of drains Security of drain Location in respect to wound Character and amount of drainage

16. PRESSURE ULCERS Chronic wound AKA bedsore, pressure sore, decubitus ulcer

17. Pressure Ulcer Prevention Intrinsic risk factors Immobility Impaired sensation Malnourishment Extrinsic risk factors Friction Shearing Moisture Pressure

18. Pressure Ulcer Prevention Assess skin daily (q shift) Pressure points Keep clean and dry Warm water & mild soap Moisturizing lotions Linen soft, clean, dry, no wrinkles Adequate calories, protein, fluids Reposition q 2 hours Therapeutic Mattresses Air, gel, foam, water (AHRQ)

19. Pressure Ulcer Risk Assessment Braden Scale (low score = high risk) Sensory perception Moisture Activity Mobility Nutrition Friction & shear Norton Scale (low score = high risk) Physical condition Mental state Activity Mobility Incontinence

20. Pressure Ulcer Staging Stage I Nonblanchable erythema (>30mins after pressure removed) – Intact skin Stage IIPartial thickness skin loss – (epidermis / dermis) – Shallow crater, blister, or abrasion Stage III Full thickness skin loss – Necrosis of subcutaneous tissue; undermining may be present Stage IV Full thickness skin loss – Extensive damage to muscle, bone; undermining and sinus tracts may be present

21. Pressure Ulcer Assessment Length Width Exudate/Drainage Tissue Eschar Granulation Slough Necrotic

22. ESCHAR Dead cells (Necrotic tissue) and Plasma proteins Cannot be staged

23. Nursing Diagnoses Impaired Skin Integrity R/T Impaired Tissue Integrity R/T Risk for Infection R/T Pain R/T Body Image Disturbance R/T

24. LABORATORY DATA Leukocyte Count Serum Protein Level Coagulation studies Wound Cultures

25. DELEGATION You may delegate the following to UAP: Inspection of the skin for evidence of breakdown. Instruct UAP to notify you of redness, tissue warmth, or drainage Turning and positioning

26. Wound Care RYB Color Code Red Protect Keep moist & covered Yellow Cleanse Irrigation, dressings debridement? Blackac Debride Sharp-Scalpel or scissors Hydrotherapy-wet-to-dry dressing Enzymatic-topical enzymes Autolytic- occlusive dressing

27. Dressings Gauze Telfa Transparent films Clear & semipermeable Hydrocolloids Wafers, pastes, powders Hydrogels Sheets, granules, gels with high water content Absorption Dressings Beads, powders, pastes, ribbons, alginates Silver preparations

28. Cleansing Solutions Normal saline Dilute antimicrobial solutions Commercially prepared wound cleansers NO (Dakins,Acetic acid, Hydrogen peroxide, Povidone-iodine)

29. CONTROLLING INFECTION Closed Wounds-Standard Precautions Open Wounds-Contact Precautions Multiple Wounds-Treat least contaminated wound first. Acute wounds may require sterile technique Chronic wounds-clean technique

30. HEAT AND COLD THERAPY Avoid direct skin contact with heating or cooling device. Leave on patient no more than 15 minutes at a time in an area. Check skin frequently for extreme redness, blistering, cyanosis, or blanching.

31. HEAT AND COLD THERAPY Heat relieves stiffness and discomfort, promotes delivery of nutrients and removal of waste products from tissue, and promotes relaxation. Cold causes vasoconstriction and decreases capillary permeability, produces local anesthesia, reduces cell metabolism, increases blood viscosity, slows bacterial growth and decreases muscle tension

32. HEAT AND COLD THERAPY Heat can cause a drop in blood pressure and a feeling of faintness. Cold can elevate blood pressure, cause shivering, and produce tissue damage due to impaired circulation