Upload
marilynn-summers
View
218
Download
1
Tags:
Embed Size (px)
Citation preview
SKIN INTEGRITY AND WOUND HEALING
FALL2010
SKIN STRUCTUREEPIDERMIS
• Outermost Layer
• Barrier-restricts water loss
• Prevents fluids, pathogens and chemicals from entering
SKIN STRUCTUREDERMIS
• 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
SKIN STRUCTURESUBCUTANEOUS 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
FACTORS INFLUENCING ABILITY TO MAINTAIN INTACT SKIN AND HEAL
WOUNDS
• Age• Mobility• Nutrition• Hydration• Diminished Sensation• Impaired Circulation• Medications
FACTORS INFLUENCING ABILITY TO MAINTAIN INTACT SKIN AND HEAL
WOUNDS
• Moisture on the skin• Fever• Contamination• Lifestyle (Smoking)• Disease processes• Radiation treatments• Immune function
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
WOUND CLASSIFICATIONS cont.
• Cleanliness
• Clean• Clean-contaminated• Contaminated• Colonized• Infected
• Descriptive qualities• Abrasion• Laceration• Contusion
WOUND HEALING METHODS
• Regenerative• Affects only epidermal layer• No scar
• Primary Intention• Edges well approximated• Little scarring
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
WOUND HEALING METHODS cont.
• Tertiary Intention
•Delayed wound closure•Two surfaces of granulation
tissue brought together•More scarring than primary but
less than secondary
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
WOUND COMPLICATIONS
• Hemorrhage• Infection• Dehiscence• Evisceration• Fistula
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
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
PRESSURE ULCERS
• Chronic wound• AKA bedsore, pressure sore,
decubitus ulcer
Pressure UlcerPrevention
• Intrinsic risk factors• Immobility• Impaired sensation• Malnourishment
• Extrinsic risk factors• Friction• Shearing• Moisture• Pressure
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)
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
Pressure Ulcer Staging• Stage I Nonblanchable erythema
(>30mins after pressure removed)
– Intact skin• Stage II Partial 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
Pressure Ulcer Assessment
• Length• Width• Exudate/Drainage• Tissue
• Eschar• Granulation• Slough• Necrotic
ESCHARDead cells (Necrotic
tissue) and Plasma proteins
Cannot be staged
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
LABORATORY DATA
• Leukocyte Count
• Serum Protein Level
• Coagulation studies
• Wound Cultures
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
Wound CareRYB 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
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
Cleansing Solutions
• Normal saline• Dilute antimicrobial solutions• Commercially prepared wound cleansers• NO (Dakins,Acetic acid, Hydrogen peroxide, Povidone-
iodine)
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
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.
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
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