Kozier Ch 36 Skin

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Author:
cswett
ID:
102685
Filename:
Kozier Ch 36 Skin
Updated:
2011-09-22 11:24:02
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Kozier 36 Skin Integrity wound care
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Description:
Kozier Ch 36 Skin Integrity and Wound Care
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  1. ischemia
    deficiency in the blood supply to the tissue
  2. Reactive hyperemia
    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
  3. Maceration
    tissue softened by prolonged wetting or soaking - makes epidermis more easily eroded and susceptible to injury
  4. Excoritaiton
    area of loss of the superficial layers of the skin -known as the denuded area
  5. primary intention healing
    approximated
    occurs where tissue surfaces have been approximated (closed) and there is minimal tissue loss
  6. secondary intention healing
    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
  7. serosanguineous drainage
    blood-tinged drainage
  8. exudate
    fluid and cells that have escaped from blood vessels during the iflammatory process and is deposited in tissue or on tissue surfaces
  9. purulent exudate
    pus
    suppuration
    pyogenic bacteria
    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
  10. hematoma
    localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise)
  11. dehiscence
    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
  12. evisceration
    protrusion of the internal viscera through an incision (commonly occurs with dehiscence)
  13. Factors affecting skin integrity
    • •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
  14. Types of Wound
    • •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
  15. Types & Phases of wound healing
    • •Types
    • –Primary
    • –Secondary
    • –Tertiary

    • •Phases
    • –Inflammatory
    • –Proliferative
    • –Maturation
  16. Primary Intension Healing
    • •Tissue surfaces closed (approximated)
    • •Minimal or no tissue loss
    • •Formulation of minimal granulation & scarring
    • •Ex: surgical closure
  17. Secondary Intension Healing
    • •Extensive tissue loss
    • •Edges cannot be closed
    • •Repair time longer
    • •Scarring greater
    • •Susceptibility to infection greater
  18. Tertiary Intention Healing
    (Delayed Primary Intention)
    • •Initially left open (3-5 days) for edema, infection, or exudate resolves
    • •Then closed
  19. Infalmmatory Phase
    • •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
  20. Proliferative Phase
    • •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
  21. Maturation Phase
    • •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
  22. Exudate & Types of Exudate
    • •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
  23. Mixed Exudate
    • •Serosanguineous
    • –Clear and blood-tinged drainage
    • –Surgical incisions

    • •Purosanguineous
    • –Pus and blood
    • –New infected wound
  24. Complications of Wound Healing
    • •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
  25. Factors Affecting Wound Healing
    • •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
  26. Pressure Ulcers
    • Pressure ulcers (Decubitis ulcers, bed sores):
    • any lesion caused by unrelieved pressure that results in damage to underlying tissue.
  27. Risk Factors for Pressure Ulcers
    • •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
  28. Risk Assessment Tools
    • 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
  29. Four Stages of Pressure Ulcer Formation
    •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
  30. Assessing Skin
    • •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
  31. Assessment of Pressure Ulcers
    KNOW THIS
    • •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
  32. Assessment of Pressure Sites
    • •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
  33. Assessment of Laboratory Data
    • •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?
  34. Nursing Diagnoses Related to Skin
    • –Risk for Impaired Skin Integrity
    • –Impaired Skin Integrity: dermis & epidermis
    • –Impaired Tissue Integrity - sub-Q or further
    • –Risk for Infection
    • –Pain
  35. Possible Goals for Skin
    • •Risk for Impaired Skin Integrity
    • –Maintain skin integrity
    • –Avoid or reduce risk factors

    • •Impaired Skin Integrity
    • –Progressive wound healing
    • –Regain intact skin
  36. Supporting Wound Healing
    • •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
  37. Preventing Pressure Ulcers
    • •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
  38. Treating Pressure Ulcers
    (Possible Interventions)
    • •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
  39. RYB Color Guide for
    Wounds (open)
    • •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
  40. Types of Wound Dressing
    • •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
  41. Cleaning wounds
    • •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 $$$
  42. Securing Dressings
    • •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
  43. Physiologic Effects of Heat
    • •Vasodilation
    • •Increases capillary permeability
    • •Increases cellular metabolism
    • •Increases inflammation
    • •Produces sedative effect

    • •Indications for heat
    • –Muscle spasms
    • –Inflammation
    • –Pain
    • –Contracture
    • –Joint stiffness
  44. Physiologic Effects of Cold
    • •Vasoconstriction
    • •Decreases capillary permeability
    • •Decreases cellular metabolism
    • •Slows bacterial growth
    • •Decreases inflammation
    • •Local anesthetic effect

    • •Indications for cold
    • –Muscle spasms
    • –Inflammation
    • –Pain
    • –Traumatic injury
  45. Methods for Applying Heat
    • •Dry heat
    • –Hot water bottle
    • –Aquathermia pad
    • –Disposable heat pack
    • –Electric pad

    • •Moist heat
    • –Compress
    • –Hot pack
    • –Soak
    • –Sitz bath
  46. Method for Applying Cold
    • •Dry cold
    • –Cold pack
    • –Ice bag
    • –Ice glove
    • –Ice collar

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

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