Chapter 36: Skin Integrity and Wound Care

Pressure Ulcers

Have also been called: decubitus ulcers, pressure sores, bed sores

Is any lesion caused by unrelieved pressure that results in damage to underlying tissue. Usually occur over a bony prominence Are due to localized ischemia, a deficiency in the blood supply to the tissue. The tissue is compressed between 2 surfaces, and when blood cant reach the tissue, the cells are deprived of oxygen, waste products accumulate, and the tissue consequently dies.

Maintaining Skin Hygiene

Obtain baseline data using an established tool

(e.g., Braden):
reassess skin daily in hospital (often per shift)

Mild cleansing agents:

minimize irritation and dryness

Avoid hot water

Moisturizing lotions/skin protection Reduce irritants

massage over bony prominences should be avoided

Avoiding Skin Trauma

Smooth, firm surfaces: wrinkle-free Semi-Fowlers position: minimizes friction Frequent weight shifts: q 15 30 min. Exercise and ambulation: promotes circulation Lifting devices: rather than risk causing abrasions Reposition q 2 hours (at a minimum, may need to be more often)

Turning schedule: in written format

Pressure Ulcers
Tissue ischemia Obstructed blood flow to tissues causing tissue death Reactive hyperemia Dilation of superficial capillaries causing redness of skin Blanchable hyperemia An area that appears red and warm will turn a lighter color with palpation Nonblanchable hyperemia Redness that persists after palpation, indicting tissue damage This stage of skin injury is reversible if the pressure is relieved and and the tissue protected.

Non-blanchable hyperemia (p. 1060)

What are some of the Factors Contributing to Pressure Ulcer Formation?

Factors Contributing to Pressure Ulcer Formation

Shear
Force exerted against skin

Friction
Results from two surfaces rubbing against each other Most at risk for friction

Moisture

Poor nutrition

Reduces skins resistance to other forces such as pressure or Causes tissue to become susceptible shear to breakdown

Infection
Increases metabolic needs making tissue susceptible to ischemic injury

Age
Loss of dermal thickness and increases risk for skin tears

Risk Factors for Pressure Ulcers

Friction and shearing Immobility Inadequate nutrition Fecal and urinary incontinence Decreased mental status Diminished sensation Excessive body heat

Risk Factors for Pressure Ulcers

Advanced age Chronic mental conditions Poor lifting and transferring techniques Incorrect positioning Hard support surfaces Incorrect application of pressure-relieving devices

Shear Exerted in the Sacral Area

Origins of Pressure Ulcers

Caused by pressure exerted against skin surfaces Skin breakdown occurs when capillary pressure increases above normal

Two factors: duration of pressure and tissue tolerance 1. High pressure over a short time or low
pressure over a long time is a contributing factor

2. Tissue tolerance function of shear, friction, moisture

and internal factors (e.g., nutrition,
infection and age)

Wound Classification
Stage I
Intact skin Nonblanchable redness of a localized area, usually over a bony prominence

Stage II
Partialthickness loss of skin Shallow, open ulcer with a red/pink wound bed Intact or open/ruptured serum-filled blister

Stage III
Full-thickness loss of skin Subcutaneous fat may be visible May include undermining and tunneling Bone, tendon, muscle is not visible

Stage IV
Full-thickness loss of skin with exposure of bone, tissue or muscle Slough or eschar may be present Often includes undermining and tunneling

Four Stages of Pressure Ulcer Formation

Copyright 2008 by Pearson Education, Inc.

Assessment of Pressure Ulcers

Location of the ulcer related to a bony prominence Size of ulcer in centimeters including length (head to toe), width (side to side), and depth Presence of undermining or sinus tracts Stage of the ulcer

Color of the wound bed

Location of necrosis or eschar Condition of the wound margins Integrity of surrounding skin Clinical signs of infection - redness, warmth, swelling, pain, odor,
and exudate

Wound Healing Process

Factors Influencing Healing - see Box 36-2 on p. 1063 Primary intention
Skin edges close
Little to no tissue loss No infection

Secondary intention
Healing occurs gradually
Skin edges do not close Granulation occurs

e.g.,

e.g.,

Tertiary Intention Healing (Delayed Primary Intention)

Initially left open for 3 5 days To allow edema or infection to resolve, or exudate to drain Then closed with sutures, staples, or adhesive skin closures

Two Types of Wound Repair

Partial Thickness

Inflammatory Response
erythema and edema a scab may form this response is limited; usually subsides in < 24 hrs.

Full Thickness Hemostasis (control of bleeding)

(when involving a wound healing by primary intention) this does not occur in wounds healing by secondary intention

Epidermal Repair
peek epithelial repair within 2472 hrs. after injury wounds kept in a moist environment will heal in approx. 4 days

Inflammation Phase
goal is to establish a clean wound bed ;obtain bacterial balance

Proliferative Phase
production of new tissue, epithelialization, and contraction

Dermal Repair
new epidermis is pink and fragile if needed, dermal repair occurs concurrently

Remodeling Phase
lasts up to a yr.; scar tissue is never more than 80% of the strength of non-wounded tissue

Complications of Wound Healing

Hemorrhage

Evisceration

Internal or external Hematoma

Infection

Prevents healing Increases tissue damage Develops in 2-5 days depending on the type

It is a medical emergency requiring the placement of sterile towels soaked in sterile saline Wound layers separate below the fascial layer and visceral organs protrude

Fistula

Dehiscence

Partial or total separation of layers of skin and tissue above the fascia Most commonly occurs 3-11 days after injury

Abnormal opening between two organs or between an organ and skin

result from wound healing problems assoc. with, e.g., trauma, infection, cancer

Prediction and Prevention

Guidelines for Prevention and Management of Pressure Ulcers (2003)

Predictive tool for pressure ulcer development Identification of patients at risk

hospitalized pt with a Braden scale of score <16 older adult <18

Braden Scale see Table 36-1 on p. 1065

Six subscales used to identify patients at risk for pressure ulcer development sensory perception moisture activity mobility nutrition friction/shear

Critical Thinking as Relates to Skin Care

Be familiar with the norms of wound healing. Be familiar with the clinical signs of complications in healing. Be familiar with assessing accurately the skin of a patient with darkly pigmented skin.

Dont minimize the importance of a thorough skin assessment (this is not the place to take short cuts).
In the immediate post-op period, the dressing may not be changed, but you will be responsible for ensuring that the dressing remains dry and intact.

Assessment

Pressure ulcers

Skin Baseline assessment, 24-48 after admission, regular intervals, and

when there is a significant change in status Braden Scale Especially important for hi-risk pts. diabetes, stroke, malnutrition Skin of the older adult is more fragile see Box 36-6 on p. 1070

Mobility Level of mobility, ROM, quality of muscle tone and strength Can the person roll onto the side so as to life weight off of ischial
tuberosities

Nutritional status Caloric intake

The Importance of Positioning as Relates to Pressure Ulcer Prevention

Wound Assessment

Emergency Setting

Stable Setting

Abrasion
Laceration damage to dermis and epidermis

Dressing dry? wet? Presence of ecchymosis Wound drainage-next slides how to estimate the volume? The number and types of dsgs used over what interval of time Odor often an indicator of infection Drains presence of? Wound culture need for?

Puncture bleed in relation to the depth and size of the wound

Wound contamination due to foreign substances such as broken glass, soil Need for tetanus toxoid received within the past yr.?

Exudate

Material such as fluid and cells that have escaped from blood vessels during inflammatory process Deposited in tissue or on tissue surface Nature and amount vary according to the tissue involved, the intensity and duration of the inflammation, and the presence of microorganisms

3 major types: serous, purulent, sanguineous

Serous Exudate

Mostly serum Watery, clear of cells E.g., fluid in a blister

Purulent Exudate

Thicker due to Presence of pus

the process of pus formation is referred to as suppuration and the bacteria that produce pus are called pyogenic bacteria

Color varies (tinges of blue, green, yellow) depending on the organism

Sanguineous Exudate

Aka, Hemorrhagic exudate Large number of RBCs Indicates severe damage to capillaries Frequently seen in open wounds

Mixed Exudate

Serosanguineous exudate

Clear and blood-tinged drainage

Purosanguineous discharge

Consisting of pus and blood Often seen in a new wound that is infected

Nursing Diagnosis

Risk for infection Impaired bed mobility or physical mobility

Imbalanced nutrition: less than body requirements

Acute or chronic pain Situational low self-esteem Impaired skin integrity

Risk for impaired skin integrity

Ineffective peripheral tissue perfusion

Planning

Goals and outcomes

aimed at preventing or reducing impaired skin integrity or
promoting wound healing individualize care establish specific patient-centered goals and outcomes which are realistic and obtainable

Setting priorities
priorities should revolve around the patients immediate needs

Collaborative care
include pt., family, d/c planners, social workers, physical
therapists

Implementation: Health Promotion

Topical skin care

Inspect bony prominences, lubricate skin, incontinent care using a skin barrier See Box 36-5 Pressure Ulcer Prevention Points

Positioning

Reposition every one to two hours Encourage people to shift positions q. 15 min when able Follow WOCN guidelines p. 1075 (head of bed < 30 deg., use a footboard, use assistive devices when turning

Support surfaces

Decreases amount of pressure exerted over bony prominences; examples on p. 1077 dont need to know them all!

Acute Care Management

Pressure ulcers

Nutrition protein intake supports new blood vessels and

collagen synthesis

Medications such as steroids influence healing

Control infection, cleansing and debridement Cleanse at each dressing change Necrotic tissue slows wound healing because it becomes a source for infection

Box 36-11 on p. 1079 provides a nice overview of Healing Principles You do not need to know all of the Txment Options in Table 36-4

Treating Pressure Ulcers

Minimize direct pressure Schedule and record position changes Provide devices to reduce pressure areas Clean and dress the ulcer using surgical asepsis Never use alcohol or hydrogen peroxide: toxic to tissues Obtain C&S, if infected: checking sensitivity to antibiotics Teach the client to move, even if only slightly Provide ROM exercise and OOB as condition permits

Emergency Management

Wounds

Hemostasis Control bleeding, suture, dress Allow a puncture wound to bleed to remove dirt/contaminants Do not remove a penetrating object; apply pressure around the object Cleansing Remove contaminants Protection Sterile or clean dressing Immobilize body part if indicated

Dressings

Choice of dressing and method of dressing Influence wound healing Provides moist environment to promote normal epidermal cell migration Absorbs drainage to prevent pooling exudate

Purpose of Wound Dressings

To protect the wound from mechanical injury

To protect the wound from microbial contamination To provide or maintain moist wound healing To provide thermal insulation To absorb drainage or debride, or both To prevent hemorrhage (e.g., when applied as a
pressure dsg.)

To splint or immobilize the wound site

Type of Wound Dressings

Depends on:
*location, size, type of the wound
* the amount of exudate

*whether the wound requires debridement or is infected

*frequency of change, *ease/difficulty of application *cost

Types of Dressings

Gauze

Hydrogel

most common dsg. used Best for wounds with mod. Drainage, deep wounds, undermining, and tunnels Dry or moist,

Maintains a moist environment

Negative pressure wound therapy

Transparent film

NPWT evacuates wound fluids, stimulating granulation, reducing bacteria

Traps moisture over the wound Used with wound having minimal tissue loss; little drainage

Hydrocolloid

Maintains a moist environment

Care of Dressings

Changing

Need to know the type of dressing and supplies needed

Securing

Tape, ties, binders

Comfort measures

Pain scale before changing/removal of dressings Administer pain med 30-60 min. in advance

Cleansing

Removes surface bacteria Do not use Betadine, hydrogen peroxide, acetic acid Cleanse in a direction of least contaminated area to most contaminated area

Wound Care

Irrigation

Removes exudate, sterile procedure see p. 1105

Suture care

stitches, staples, Steri-strips Consult health care facility policy/procedure

Drainage evacuation

Drains or drain evacuators such a Jackson-Pratt

Bandages and Binders

Binder

Types: Breast, abdominal, sling Before applying a binder, you will always:

1. inspect the skin for abrasions, edema, discoloration, or exposed wound edges; 2. cover open wounds; 3. assess the underlying dressing and change when soiled; 4. assess skin of underlying body parts for signs of impaired circulation. See Table 36-5 and Box 36-13 for Guidelines re: Binder application

Bandage see Box 36-14 on p. 1087 for application

Types of Bandages

Gauze

Retain dressings on wounds Bandage hands and feet

Elasticized

Provide pressure to an area Improve venous circulation in legs

Binders

Support large areas of body Triangular arm sling; straight abdominal binder

4 Major Areas of Nursing Interventions to Promote Wound Healing

Maintaining moist wound healing:

dressing and frequency of dsg. change should support moist wound bed conditions; beds that are too dry often fail to heal

Nutrition and fluids:

at least 2500 mL of fluids per day is recommended dietician consult is very helpful to ensure correct supplementation

Preventing infection:
1. prevent micro-organisms from entering the wound 2. preventing the transmission of pathogens to or from client to others

Positioning:
must be positioned to keep pressure off of wound client should be as mobile as possible, or provide ROM

Heat and Cold Therapy

see Table 36-7 on p. 1088

Effects of heat and cold

Heat therapy best used for patients afflicted with degenerative joint disease, localized muscle strain, menstrual cramping, hemorrhoid and perianal inflammation, local abscess Application of cold is best used for patients afflicted with a sprain, strain, fracture, muscle spasm, superficial laceration, minor burn, arthritis, after an injection, or joint trauma Heat is generally therapeutic- if heat is applied for >1 hr., a reflex vasoconstriction occurs Prolonged exposure to cold results in a reflex vasodilation e.g.,

Heat and Cold Therapy

see Table 36-7 on p. 1088

Factors influencing tolerance see. p. 1086

duration of application body part damage to body surface prior skin temperature body surface area age and physical condition

Assessing temperature tolerance

observe first so that you can evaluate therapy-related skin changes
later assess sensory function, i.e., ability of person to respond to temperature changes

Heat and Cold Therapy

see Table 36-7 on p. 1088

Patient education and safety

before the application of heat or cold therapy, make sure the pt. understands its purpose, the sxs of temperature exposure, and the precautions taken to prevent injury
Box 36-15 on p. 1088 provides hints for safely applying heat and cold therapy

Types of Heat and Cold Therapy

A pre-requisite to using heat or cold application is a health care providers order.

The order includes the body site to be txed and the type, frequency, and duration of the application.

Heat

Cold

Warm compress Warm soak Sitz bath pelvic area bath Aquathermia pad Commercial hot pack Hot water bottle Electric heating pad

Moist cold compress Cold soak Ice bag or collar Commercial cold pack

Physiologic Effects Of
Heat

Cold

Vasodilation

Vasoconstriction

Increases capillary permeability

Increases cellular metabolism Increases inflammation

Decreases capillary permeability

Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect

Sedative effect

Indications For
Heat

Cold

Muscle spasms Inflammation Pain Contracture

Muscle spasms

Inflammation
Pain Traumatic injury

Joint stiffness

Contraindications to the Use of Heat and Cold

Heat

Cold

First 24 hrs. after trauma

Open wounds

Active hemorrhage
Localized malignant tumor

Impaired circulation
Allergy or hypersensitivity to cold

Skin disorder that causes redness or blisters .

Restorative and Continuing Care and Evaluation

Restorative and Continuing Care

wound health will not occur if the pt. is malnourished the surgical pt. who is well-nourished and has no complications requires at least 0.8 g or protein/kg daily

Patient care
primary goals: prevent injury or further injury to the skin and tissues
to reduce injury to the skin and underlying tissues restore skin integrity

Patient expectations
pt./caregiver need to understand how to prevent/tx pressure ulcers as well as have realistic expectations re: the duration of care