Kozier Ch 36 Skin

deficiency in the blood supply to the tissue

bright red flush that skin takes on after it has been compressed

flush is due to vasodilation - extra blood rushed to area of compression to bring nutrients

• Reactive hyperemia lasts 1/2 to 3/4 as long as duration of impeded blood flow -
• -if redness diapears then no tissue damage
• -if redness persists- tissue damage has occured

tissue softened by prolonged wetting or soaking - makes epidermis more easily eroded and susceptible to injury

area of loss of the superficial layers of the skin -known as the denuded area

occurs where tissue surfaces have been approximated (closed) and there is minimal tissue loss

wound is extensive and involves considerable tissue loss - the edges cannot or should not be approximated

• 1) repair time is longer than primary intention healing
• 2) scarring is greater
• 3) risk for infection is greater

wound is left open for 3 - 5 days to allow drainage (edema, infection, exudate) and then closed with sutures, staples, or adhesive skin closures

blood-tinged drainage

fluid and cells that have escaped from blood vessels during the iflammatory process and is deposited in tissue or on tissue surfaces

purulent exudate - thicker than serous exudate because of the presence of pus

pus- consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria

suppuration - process of pus formation

pyogenic bacteria - bacteria that produce pus

localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise)

parial or total rupturing of a sutured wound - usually an abdominal wound in which the layers below the skin also seperate

-most likely occurs 4 to 5 days postop - sudden straining (coughing, sneezing) may proceed it

- put client in position to decrease pull on incision & notify surgeon immediately

protrusion of the internal viscera through an incision (commonly occurs with dehiscence)

• •Genetics & heredity
• •Age
• –Skin becomes more fragile with age
• –Wounds heal faster in infants & children
• •Chronic illnesses: poor circulation
• •Treatments: surgery, invasive lines
• •Medications: steriods
• •Poor nutrition

• •Intentional- surgery
• •Unintentional- accidental trauma
• •Also described by how they came about
• –Incision- surgery
• –Contusion- bruise from blunt instrument
• –Abrasion- surface scrape
• –Puncture- penetration of skin with sharp instrument
• –Laceration- tissues torn apart
• –Penetrating wound - penetration of skin &
• underlying tissues, bullet

• •Types
• –Primary
• –Secondary
• –Tertiary

• •Phases
• –Inflammatory
• –Proliferative
• –Maturation

• •Tissue surfaces closed (approximated)
• •Minimal or no tissue loss
• •Formulation of minimal granulation & scarring
• •Ex: surgical closure

• •Extensive tissue loss
• •Edges cannot be closed
• •Repair time longer
• •Scarring greater
• •Susceptibility to infection greater

• •Initially left open (3-5 days) for edema, infection, or exudate resolves
• •Then closed

• •Immediately after injury; lasts 3 to 6 days
• •Hemostasis
• –Cessation of bleeding
• –Blood clots form
• –Fibrin (connective tissue) forms
• –Scab forms
• –Epithelial layer under scab protects wound from
• invasion by MO

• •Post injury day 3 or 4 until day 21
• •Collagen (white protein) synthesis- strengthens wound
• •Granulation tissue formation- capillary growth increases blood supply to wound & fibrin deposited. Wound is red, fragile & bleeds easily.
• •Second intention wounds heal by granulation, then epithelialization. If epithelializaton does not happen the area becomes covered with dried plasma proteins & dead cells called eschar

• •From day 21 until 1 or 2 years post injury
• •Collagen organization
• •Wound is remodeled and contracts
• •Scar stronger
• •Scars shrink over time
• •Overgrowth of collagen causes a hypertrophied scar called a keloid

• •Material such as fluid and cells that have escaped from blood vessels during inflammatory process
• •Deposited in tissue or on tissue surface
• •3 major types

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

• –Purulent
• •Thicker
• •Presence of pus (suppuration)
• •Pus- WBCs, dead debris, bacteria
• •Color varies with organisms

• –Sanguineous (hemorrhagic)
• •Hemorrhagic
• •Large number of RBCs
• •Indicates severe damage to capillaries

• •Serosanguineous
• –Clear and blood-tinged drainage
• –Surgical incisions

• •Purosanguineous
• –Pus and blood
• –New infected wound

• •Hemorrhage -
• –Greatest risk is 1st 48 hours after surgery
• –Frank bleeding
• –May see hematoma - looks like swollen bruise - blood collection under skin - can obstruct blood flow

• •Infection
• –Change in appearance of wound - color, pain level, drainage - fever or elevated WBC count
• –Determined by culture

• •Dehiscence
• - sutured wound edges separate. Usually abdominal wound 4-5 days post-op

• •Evisceration
• - internal viscera comes through incision
• •Cause:
• –Obesity
• –Poor nutrition
• –Coughing
• –Vomiting
• –Other

•Treatment: saline dressing

• •Age-
• –elders may heal slower. See Box 36-2, p. 912
• •Nutritional status
• –Healing needs more nutrients
• –Obesity cause slower healing because adipose tissue
• has less blood supply
• •Lifestyle
• –Exercise good, smoking not
• •Medications-
• –anti-inflammatories (steroids & ASA)
• –Antibiotics- risk infection

• Pressure ulcers (Decubitis ulcers, bed sores):
• any lesion caused by unrelieved pressure that results in damage to underlying tissue.

• •Friction & shearing- sheets, sliding down from Fowler’s position
• •Immobility
• •Inadequate nutrition
• •Fecal and urinary incontinence
• •Decreased mental status
• •Diminished sensation
• •Excessive body heat
• •Advanced age
• •Chronic mental conditions
• •Poor lifting and transferring techniques
• •Incorrect positioning
• •Hard support surfaces
• •Incorrect application of pressure-relieving devices

• High Numbers = less risk
• Low Numbers = greater risk
• •Braden Scale for Predicting Pressure Sore Risk

• •Norton’s Pressure Area Risk Assessment Form Scale- score of 15/16 indicators of risk
• –General physical health
• –Mental state
• –Activity
• –Mobility
• –Incontinence
• –Medication

•Stage I:–nonblanchable erythema signaling potential ulceration

•Stage II: –partial-thickness skin loss involving epidermis and possibly dermis

•Stage III: –full-thickness skin loss involving damage or necrosis of subcutaneous tissue

•Stage IV: –full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures

• •Nursing history
• –Review of systems
• –Skin diseases
• –Previous bruising
• –General skin condition
• –Skin lesions
• –Usual healing of sores

• •Inspection and palpation
• –Skin color distribution
• –Skin turgor
• –Presence of edema
• –Characteristics of any skin lesions
• –Particular attention paid to areas that are most
• likely to break down

• •Untreated wounds
• –Location
• –Extent of tissue damage
• –Wound length, width, and depth
• –Bleeding
• –Foreign bodies
• –Associated injuries
• –Last tetanus toxoid injection

• •Treated wounds (sutured)
• •Assess for progress of healing
• –Appearance
• –Size
• –Drainage
• –Presence of swelling
• –Pain
• –Status of drains or tubes

• •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 (dead tissue) or eschar (usually black)
• •Condition of the wound margins - surrounding skin
• •Integrity of surrounding skin
• •Clinical signs of infection

• •Inspect
• –for discoloration & capillary refill or blanche response
• –inspect pressure areas for abrasions and excoriations

• •Palpate
• –surface temperature over the pressure area sites
• –bony prominences and dependent body areas for the
• presence of edema

• •Leukocyte count - WBC's
• –Decreased: delays healing, risk of infection
• –Increased: infection?

• •Hemoglobin level
• –Low Hgb: poor O2 delivery to tissues

• •Blood coagulation studies
• •Serum protein analysis
• –Albumin level: low indicates poor nutrition

• •Results of wound culture and sensitivities - what organism is it?

• –Risk for Impaired Skin Integrity
• –Impaired Skin Integrity: dermis & epidermis
• –Impaired Tissue Integrity - sub-Q or further
• –Risk for Infection
• –Pain

• •Risk for Impaired Skin Integrity
• –Maintain skin integrity
• –Avoid or reduce risk factors

• •Impaired Skin Integrity
• –Progressive wound healing
• –Regain intact skin

• •Moist wound healing
• –Wound beds heal best moist
• •Nutrition & fluids
• •Preventing infection
• –Prevent entry of microorganisms
• –Prevent transmission of pathogens
• •Proper positioning
• –Keep pressure off wound
• –Change position/transfer properly
• –Encourage mobilization as it enhances circulation

• •Providing nutrition
• •Fluid intake- 2,500 ml
• •Protein, vitamins (A, C, B1, B5, zinc)
• •Dietary consult
• •Weight/lab data monitoring
• •Nutritional supplements
• •Monitor weight/lab values

• •Maintaining skin hygiene
• •Mild cleansing agents
• •Keep skin from drying: Avoid hot water, use moisturizers
• •Clean & free of urine & feces
• •Moisturizing lotions/skin protection
• •Reduce irritants

• •Avoiding skin trauma
• •Smooth, firm surfaces
• •Semi-Fowler’s position
• •Frequent weight shifts
• •Exercise and ambulation
• •Lifting devices
• •Reposition q 2 hours
• •Turning schedule

• •Providing supportive devices
• •Mattresses
• •Beds
• •Wedges, pillows
• •Miscellaneous devices

• •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
• •Obtain C&S, if infected
• •Teach the client
• •Provide ROM exercise

• •Red- protect, delayed granulation tissue
• •Yellow- cleanse, purulent drainage or previous infection, see yellow slough
• •Black- debride eschar (necrotic tissue)
• –Debridement is to remove dead tissue so new can form

• •Transparent film
• –Acts like temp. skin. Protects against contamination
• •Impregnated nonadherent
• –Woven with agents to soothe wounds w/o exudate
• •Hydrocolloids
• –Absorb exudate
• •Clear absorbent acrylic
• –Transparent, moist healing
• •Hydrogel
• –Liquifies necrotic tissue
• •Polyurethane foam
• –Absorbs exudate, maintains moist wound healing
• •Alginate
• –Moist wound surface, absorbs exudate

• •Irrigation (lavage)
• –Use sterile technique
• –Use piston syringe, not bulb
• •Packing
• –Gauze & saline using wet-to-dry technique. Debrides wounds. Don’t let dry out.
• –Advanced dressing do same, heal better, but are $$$

• •Dressings are secured with tape, bandages, binders
• •Tape - paper for elderly
• •Bandages
• –Gauze
• •Lightweight, porous, molds to body
• •Use to:
• –Hold dressings on wounds
• –Bandage hands and feet
• –Elasticized
• •Provide pressure to an area
• •Improve venous circulation in legs

• •Binders
• –Designed for specific body part
• –Support large areas of body
• •Triangular arm sling
• •Straight abdominal binder

• •Vasodilation
• •Increases capillary permeability
• •Increases cellular metabolism
• •Increases inflammation
• •Produces sedative effect

• •Indications for heat
• –Muscle spasms
• –Inflammation
• –Pain
• –Contracture
• –Joint stiffness

• •Vasoconstriction
• •Decreases capillary permeability
• •Decreases cellular metabolism
• •Slows bacterial growth
• •Decreases inflammation
• •Local anesthetic effect

• •Indications for cold
• –Muscle spasms
• –Inflammation
• –Pain
• –Traumatic injury

• •Dry heat
• –Hot water bottle
• –Aquathermia pad
• –Disposable heat pack
• –Electric pad

• •Moist heat
• –Compress
• –Hot pack
• –Soak
• –Sitz bath

• •Dry cold
• –Cold pack
• –Ice bag
• –Ice glove
• –Ice collar

• •Moist cold
• –Compress
• –Cooling sponge bath