Skin Integrity n Wound Care

7/28/2019 Skin Integrity n Wound Care

1/26

Skin Integrity and Wound

CareTeresa V. Hurley, MSN, RN


2/26

Skin Integrity

Largest organ in the body Functions

First line of defense against microorganisms Regulation of body temperature

Transmits sensations of pain, temperature,touch and pressure

--Vitamin D production and absorption--secretes sebum


3/26

Wounds

What are wounds ? Break in skin or mucous membranes


4/26

Wound Classification

Superficial

Deep (blood vessels, nerves, muscle,tendons, ligaments, bones) Open Wound

Superficial or deep break in skin (abrasion,puncture, laceration)


5/26

Wound Classification Closed: blunt force; twisting, turning, straining,

bone fracture, visceral organ tear Acute: trauma sharp object or blow

Surgical incision, gun shot, venipuncture Chronic: pressure ulcers Causality

Intentional: surgical incision Unintentional: traumatic

Knife Burn


6/26

Pressure Wounds

Damage to tissues due to pressure Factors

Immobility Elderly Skin moisture Malnutrition (protein)

Shearing Forces Friction Risk Factors as outlined on Braden Scale


7/26

Pressure Ulcer Stages

Stage I: No Skin Break Skin temperature, consistency (firm),

sensation (pain or itching) Persistent redness in light skin tones Persistent red, blue or purple hue in darker

skin tones


8/26

Pressure Ulcer Stages

Stage II: Superficial Partial-thickness skin loss (epidermis and/or

dermis

Abrasion, blister or shallow crater

Stage III Full-thickness skin loss (subcutaneous damage

or necrosis and may extend down to but notthrough fascia

Deep crater


9/26

Pressure Ulcer Stages Stage IV: full thickness skin loss and destruction,

necrosis of the tissue, damage to muscle, bone,tendons and joint capsules and sinus tract

Types of Dressings Transparent film (Tegraderm, Bioclusive) Hydrocolloid (Duoderm, Comfeel) Hydrogel Gauze Roll (Kerlix)

Provide moist environment Loosen slough and necrotic tissue Wick drainage from wound


10/26

Pressure Ulcer Assessment

Tissue Type Granulation Tissue: red and moist Slough: yellow stringy tissue attached to

wound bed; removal essential for healing Eschar: necrotic tissue which is brown or

black appearance must be debrided


11/26

Pressure Ulcer Assessment

Wound Dimensions (L, W, D) Wound Deterioration

Skin surrounding ulcer Redness, warmth, edema

Exudate Amount, color, consistency, odor


12/26

Wound Healing

Primary Intention skin edges are approximated (closed) as in a surgical

wound

Inflammation subsides within 24 hours (redness,warmth, edema) Resurfaces within 4 to 7 days

Secondary Intention: tissue loss Burn, pressure ulcer, severe lasceration Wound left open Scar tissue forms


13/26

Wound Healing Inflammatory Response

Serum and RBCs form fibrin network Increases blood flow with scab forming in 3 to 5 days

Proliferative Phase: 3-24 days Granulation tissue fills wound Resurfacing by epithelialization

Remodeling: more than 1 year collagen scar reorganizes and increases in strength Fewer melanocytes (pigment), lighter color


14/26

Some Factors Influencing WoundHealing

Age Nutrition: protein and Vitamin C intake Obesity decreased blood flow and increased risk for

infection

Tissue contamination: pathogens compete with cells for oxygen and nutrition Hemorrhage Infection: purulent discharge Dehiscence: skin and tissue separate Evisceration: protrusion of visceral organs Fistula: abnormal passage through two organs or to

outside of body


15/26

Therapeutic Modalities Contingent on location, size, wound type,

exudate, infection, dressed or undressed

Assessment Inspect and palpate surrounding area Wound edge approximation (healing ridge noted) Presence and characteristics of drainage

Serous

Sanguineous Serosanguineous Purulent Consistency, odor and amount


16/26

Wound Assessment

Wound Closure Staples Sutures Steri-strips

Drains Penrose Hemovac or Jackson Pratt exert low pressure


17/26

Some Dressing Types and Assistive Devices

Dry Dressings Wet-to-Dry Dressings Packing

Wound Vacuum Assisted Closure: apply localnegative pressure to draw wound edgestogether; healing acclerated with the formationof granulation, collagen etc. to close wound or prepare for skin grafting

Electrical Stimulation Abdominal Binders Montgomery Straps


18/26

Heat and Cold Therapies

Heat Vasodilation

Increases blood flow Nutrient delivery Removal of waste Decreases venous congestion

Blood Viscosity Decreased leuokocytes

antibiotics


19/26

Heat and Cold Applications

Heat Muscle relaxation with decrease in pain from

spasm and stiffness Tissue Metabolism increased with increased

warmth and blood flow Increased capillary permeability promotes

nutrient delivery and waste removal


20/26

Cold Applications

Vasoconstriction Reduce blood flow preventing edema

formation and decreases inflammation

Local anesthesia Cell metabolism decreased with o2 demands

decreased Increased blood viscosity promotes

coagulation Pain relief with decrease in muscle tension Direct Trauma; superficial lacerations, arthritis


21/26

Complications

Heat application leads to reflexvasoconstriction within 1 hour Complications

Epithelial cells damaged Redness, tenderness, blistering


22/26

Complications

Cold Reflex vasodilation

Tissue ischemia Skin redness Bluish purple mottling Numbness Burning pain Tissues may freeze


23/26

Modalities MD order: body site, type, frequency and

duration of application Moist or dry

Warm/Cold Compresses Warm Soaks (relaxation, debride wounds) Sitz Baths (rectal or vaginal surgery,

hemorrhoids, episiotomy) Aquathermia pads (muscle sprains,

inflammation or edema) Commerical Hot and Cold Packs


24/26

Contraindications

Heat Site with active bleeding Acute localized pain (appendicitis) leads to

rupture Cardiovascular (vasodilation to large areas

leads to decrease blood supply to vital organs


25/26

Contraindications

Cold Site pre-existing edema prevents absorption

of intersitial fluid Neuropathy (unable to sense) Shivering will intensify with acute elevations in

temperature


26/26

Critical Thinking

What other factors need to be assessedbefore application of heat and coldtherapies?

Circulatory? LOC? Sensory?

Documents

Skin Integrity n Wound Care