WOUND CARE

SKIN The skin is the largest organ in the body with five functions: o First line of defense of the body against microorganism interrupted if the skin is not intact. o Regulates the body temperature o Serves as a sense organ transmitting the sensations of pain, temperature, touch and pressure. o It produces and absorbs vitamin D o Secretes sebum which softens and lubricates skin and hair Layers of skin o Epidermis outermost layer of skin made of stratified squamous epithelial cells o Dermis second layer of the skin composed of connective tissue; the layer that gives elasticity to the skin; blood vessels, nerve fibers, glands and hair follicles are embedded in this layer. o Subcutaneous tissue consists of adipose tissue and provides support and blood flow to the dermis.

Skin Glands o Sebaceous glands found within the dermis; secrete sebum which are made up of fats, cholesterol, proteins and salts; sebum protects hair from drying, prevents excessive evaporation of water, inhibits the growth of certain bacteria o Sweat glands produces watery secretion; the body has 5 million of this. Apocrine primarily in the skin of axilla and pubic regions; begin functioning at puberty Eccrine distributed throughout the skin; chiefly found on the palms of the hands and soles of the feet and forehead; produce a watery discharge that helps cool the body through evaporation. o Ceruminous glands secretes cerumen

Nursing Functions: o MAINTAINING SKIN INTEGRITY o PROMOTING WOUND HEALING Impaired Skin Integrity 1. Older people 2. Clients with restricted mobility 3. Chronic illness or trauma 4. Undergoing invasive H. care procedure To protect the skin and manage wounds effectively, nurse must understand: 1. Factors affecting skin integrity 2. Physiology of wound healing 3. Specific measures that promote optimal skin conditions

I.

SKIN INTEGRITY INTACT SKIN Presence of N. Skin & skin layers uninterrupted by wounds. Appearance of skin and skin integrity are influenced by: Internal Factors: a. Genetics & Heredity Determine many aspects of persons skin: COLOR, SENSITIVITY TO LIGHT & ALLERGIES. b. Age Influences skin integrity that the skin of both very young and very old is more fragile and susceptible to injury. However, wounds in infants & children heal more rapidly. c. Underlying H. Many chronic illnesses and their treatments affect skin integrity. People with Impaired Peripheral Arterial Circulation = Skin on the legs that appears shiny, lost hair distribution, & damages easily. Corticosteroids = Thinning of the skin which can easily be harmed. Many medications sensitivity to sunlight severe burns. Antibiotics, Chemotherapeutic, psychotherapeutic. External Factor: a. Activity b. Poor Nutrition Interfere with the appearance & function of N. Skin.

II.

WOUNDS 1. Intentional Occurs during Therapy. (Operation/Venipuncture) 2. Unintentional Accidental 3. Open Skin or mucous membrane surface is broken. 4. Close Without a break in the skin According to Likelihood & Degree of Contamination: 1. Clean/Class I Uninfected wounds minimal inflammation Closed wounds 2. Clean-contaminated/Class II Surgical wounds No evidence of infection 3. Contaminated/Class III Open, fresh, accidental and surgical wounds Major break in sterile technique Has Evidence of inflammation 4. Dirty or Infected/Class IV Contains dead tissue With evidence of clinical infection (purulent drainage) According to Depth (Tissue Layers Involved): 1. Partial Thickness Confined to the skin Dermis & Epidermis Heal by Regeneration 2. Full Thickness Dermis, Epidermis, SQ, possibly Muscle & Bone Requires Connective Tissue Repair. According to How They Acquired:

Type 1. Incision

Cause Sharp instrument

Description Open wound Deep or shallow

2. Contusion 3. Abrasion 4. Puncture

Blow from a blunt instrument Surface scrape (intentional or unintentional) Penetration of the skin & often underlying tissue by sharp instrument (intentional or unintentional) Tissues torn apart from accidents Penetration of the skin & underlying tissues (unintentional) Bullet or Metal Tearing a structure from normal anatomic position

Closed wound Ecchymotic skin d/t damaged blood vessels Open wound involving skin Open wound

5. Laceration 6. Penetrating wound

Open wound Edges are often jagged Open wound

7. Avulsion

Open wound

III. PRESSURE ULCERS Previously called Decubitus Ulcers, Pressure sores, Bedsores. Any lesion caused by unrelieved pressure (a compressing downward forces on body area that result to damage to underlying tissue). Problem in both acute care settings & long-term care settings (homes). Localized ischemia (Deficiency in the blood supply to tissue) (Tissue is caught between 2 hard surfaces-bed & bony skeleton-) Blood cannot reach the tissues Cells will be deprived of O2 & nutrients Waste products of metabolism accumulate in the cells Tissue dies Damages to small blood vessels (prolonged) Skin appears PALE Relieved, REACTIVE HYPEREMIA (Bright Red flush) (Bodys mechanism for preventing pressure ulcers, lasts - ) Flush d/t VASODILATION (extra blood floods to the area to compensate impeding blood flow) (-) redness, no tissue damage (+) redness, tissue damage 2 Other Factors (frequently acts in conjunction with pressure): 1. Friction Force acting parallel to the skin surface Can abrade skin removing the superficial layers more prone 2. Shearing Force Combination of friction & pressure. Fowlers position Body tends to slide downward toward the foot of the bed Transmitted to sacral bone & deep tissues Skin over the sacrum, superficial tissues tends not to move Deeper tissues are firmly attached to skeleton & move downward Shearing force in the area where deeper tissues & superficial meet Force damages the blood vessels & tissues in the area. RISK FACTORS 1. Immobility Reduction in N. amt. & control of movement person has.

can hinder persons ability to move. 2. Inadequate Nutrition Prolonged inadequate nutrition causes wt. loss, muscle atrophy, & loss of SQ amount of padding between skin and bones risk Inadequate intake CHON, CHO, Fluids, & Vit. C. Hypoproteinemia dependent edema elasticity, vitality Injury Edema distance between capillaries and cells slowing O2 diffusion to cells & metabolites away from cells. 3. Fecal & Urinary Incontinence Any accumulation of secretions or excretions in irritating to the skin, harbor microorganisms & prone to skin breakdown & infection Moisture from incontinence Skin Maceration (tissue softening from prolonged soaking) epidermis more easily eroded & risk for injury Digestive enzymes in feces Skin Excoriation/Denuded Area (area of loss of superficial layers) 4. Decreased Mental Status Unconscious or Heavily Sedated because they are less able to recognize & respond to pain assoc. with prolonged pressure 5. Diminished Sensation Paralysis, Stroke, etc. Persons ability to respond to injurious heat & cold & to tingling sensation that signals loss of circulation. 6. Excessive Body Heat Body temp. metabolic rate cells need for O2 Severe in the cells of an area under pressure which are already O2 deficient. Severe infection + Body temp. Affect the bodys ability to deal with effects of tissue compression. 7. Advanced Age Aging process brings about several changes in the skin making the older person prone to impaired skin integrity. a. Loss of lean body tissues. b. generalized thinning of the epidermis c. strength and elasticity d. dryness due to in the amount of oil e. Diminished pain perception f. Diminished venous and arterial flow due to aging vascular wounds 8. Chronic Medical Conditions Diabetes and cardiovascular dse compromise oxygen delivery to tissues poor perfusion delayed healing 9. Other factor Poor lifting and transferring techniques Incorrect positioning Hard support surfaces Incorrect application of pressure-relieving devices Stages of Pressure Ulcer

Resulting from Paralysis, Extreme Weakness, Pain or any activity that

 Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints. Mechanical Device for Reducing Pressure on body part Gel Flotation Pads Pillows and wedges (foam, gel, air, fluid) Water bed Low-air-loss bed (LAL) Static LAL Active LAL Description Silicone or silastic pads filled with a gelatinous substance similar to fat Supports positioning and offloads bone on bone contact Support surface filled with water. Water temperature can be controlled Consist of many air-filled cushions divided into four or five sections. Separate controls permit each section to inflate to a different level of firmness

Static high LAL Alternating pressure mattress Memory foam mattress/chair pad

Composed of a number of cells in which the pressure alternately increases and decrease; uses a pump Polyurethane foam mattress distribute weight over bony areas evenly. Foam molds to the body

IV. WOUND HEALING Referred as regeneration A process of tissue response to injury Repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue Normally occurs without assistance Phases of wound Healing a. Inflammatory phase begins at the time of injury and prepares the wound for healing Last for 3 to 6 days Two major process is hemostasis and phagocytosis o Hemostatis (cessation of bleeding) results from vasoconstriction,deposition of fibrin (connective tissue) and formation of blood clots in the area o Phagocytosis process by which macro b. Proliferative Phase second phase of healing Extend from 3 or 4 to about day 21 postinjury

V.

Granulation develops synthesize collagen (whitish protein substance that adds tensile strength to the wound) Contraction wound edges pull together to reduce defect Epithelialization cell travel about 3 cm from point of origin in all direction c. Remodeling Phase / Maturation begins about day 21 and extend to up to 2 years New collagen forms Fibroblast continue to synthesize collagen Note:scar tissue is only 80% as strong as original Factors affecting Wound Healing a. Age children and healthy adult heals more rapidly than older adult because of diminished fibroblastic activity and circulation among older adult b. Circulation and Oxygenation adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria and other debris Obese may slow wound healing because tissue fat has fewer blood vessels in anemia or chronic resp. d/o and those who smoke c. Nutritional Status requires adequate CHON, CHO, fats, vit., and minerals Calories and CHON necessary to rebuild cells and tissues Vitamin A and C for re-epithelialization and collagen synthesis Zinc proliferation of cells d. Condition of the wound large, contaminated and infected wounds or wounds that retain foreign bodies heal slowly e. Health status patient taking corticosteroid drugs are high risk for delayed healing Corticosteroid decrease inflammatory process Wound Complications Infection contamination of wound surface with microorganism Hemorrhage greatest during the first 48 hours Dehiscence partial or total disruption of wound layers Evisceration protrusion of viscera through the incisional area Fistula formation abnormal passage from an internal organ to the skin or from one internal organ to another

NURSING PROCESS FOR WOUNDS Assessment Inspect (sight and smell) and palpation for appearance, drainage and pain Assessment of sutures, any drains or tubes Ay manifestations of complications Approximation of wound edges, color of the wound and surrounding area (initially the edges are reddened and slightly swollen) Signs of dehiscence or evisceration Amount, color, odor and consistency of wound drainage Increased and constant pain from the wound (incisional pain in severe for the 1st 2 to 3 days) Evaluate patients general condition and laboratory test results Be alert for the signs and symptoms of infection Nursing Diagnosis Impaired Skin integrity Risk for infection Acute pain Disturbed Body Image Outcome Identification and Planning Directed toward facilitating the patients return to health by providing interventions that facilitate wound healing, reduce the risk for complications and promote psychosocial adaptation. Implementation Changing dressings Cleaning wound Collecting a wound culture

 Irrigating a wound Evaluation Evaluated based on the expected outcome