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- fileName "Wku Nursing: Skin Integrity"
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- What is the largest organ in the body?
Functions of Skin (6)
- First line of defense against microorganism
- Regulation of Body temperature
- Transmits sensations
- Vitamin D synthesis
Break or disruption in nomal integrity of the skin or tissues
Difference between an intentional wound and unintentional wound?
Unintentional-cut, pressure sore
Define: Pressure ulcer
Impaired skin integrity related to unrelieved, prolonged pressure. Localized to skin and underlying tissue usually above bony prominance
3 Names pressure ulcers are also known as:
- Pressure sores
- Decubitus ulcer
Define: Tissue ischemia
Obstructed blood flow to tissues causing tissue death
Define: Reactive hyperemia
Dilation of superficial capillaries causing redness of skin
Define: Blanchable hyperemia
An area that appears red and warm will turn a lighter color with palpation. Usually resolves if pressure is reduced or relieves.
Define: Nonblanchable hyperemia
Redness that persists after palpation, indicting tissue damage. (Pigmented people-darker skin, purplish/blue hue)
10 Major factors contributing to pressure ulcer formation:
- Moisture-reduces skin's resistance
- Poor nutrition-causes tissue to become susceptible to breakdown
- Impaired sensory perception
- Alteration in level of consciousness
- Low blood pressure-perfusion drops=less tolerance
Force exerted against the skin
Results from two surfaces rubbing against each other
What is the origin of pressure ulcers? (3)
- 1) Caused by pressure exerted against skin surfaces
- 2) Skin breakdown occurs when capillary pressure increases above normal
- 3) High pressure for short time/Low pressure for long time
Scab or dry crust that results from death of the skin. Thick hard and leathery
Shedding of dead tissue. Moist yellow or grey-ideal place for bacteria to grow
Removal of necrotic tissue so that healthy tissue can regenerate.
Define: Granulation Tissues
Newly formed tissue with small capillaries and connective tissue. Grows after debridment should be red, shiny, bumpy
Moist pink tissue appearing in the wound bed would be an example of?
Course or pathway that can extend in any direction from the wound.
Tissue destruciton underlying intact skin along wound margins
Define: Sinus Tract
Drainage pathway from a deep focus of acute infection through tissue or bone to an opening on the surface
Discolored maroon intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear. Preceded by tissue that is painful, firm, mushy, boggy, warmer, and/or colder than adjacent tissue. These symptoms/signs should make the nurse suspect?
Suspected deep tissue injury
What Stage pressure ulcer: Intact skin. Nonblanchable localized redness. Can be either warm or cooler than surrounding areas. May be painful
Treatment of a stage 1 ulcer includes? (5)
- Keep pressure off area by turning frequently
- Wash with mild soap and water, rinse, and gently pat dry
- Include protein, calories, vitamins A and C, iron, zinc, and water in diet
- Have protective transparent dressing
- Mangage incontinence
What stage pressure ulcer: partial loss of epidermis and/or dermis. Superficial lesion (abrasion, blister, crater). Drainage may be seen. Heals through reepilization
Stage 2 pressure ulcer
Treatment of a Stage 2 pressure ulcer includes: (4) plus some stage 1 treatments (4)
- Transparent dressing
- Hydrocoloid dressing
- Saline dampened gauze
- Assess for infection
- (Dressings that retain moisture)
- Keep hydrated
- Nutritional support
- Manage incontinence
- Turn and keep off area
What stage pressure ulcer? Deep crater tissue loss. Subcutaneous fat may be visible. Slough may be present. Undermining and Tunneling may be included. Heals through granulation and reepitheliazation.
Stage 3 pressure ulcer
What stage pressure ulcer? Major tissue loss with exposed bone, tendon, or muscle. Extensive destruction with tissue necrosis. Slough and eschar may be present. Often includes undermining and tunneling. Heals through granulation and reepithelialization after it is cleaned.
Stage 4 pressure ulcer
Treatment for Stage 4 ulcers may include:
Surgery: direct closure, skin grafting, skin flaps
Risks of surgery for pressure ulcers:
Rate of recurrence of surgically closed pressure ulcers is high (often stage 4 ulcers heal over a long time with local wound care)
What stage pressure ulcer? Full thickness tissue loss with the base of ulcers covered with slough and/or eschar in wound bed. Depth of wound can not be determined until eschar is removed.(stable eschar should not be removed)
Unstagable pressure ulcer
Types of wound healing: (2)
Primary and secondary intention
Difference between primary intention vs. Secondary intention:
Primary intention: skin edges close with little to no tissue loss. No infection. Reepithelization. Sunburns, surgical wounds. Heal in 4-14 days with minimum scaring. Risk for infection slight.
Secondary intention: healing occurs gradually, skin edges do not close, granulation occurs. Pressure ulcers, severe laceration. Wound closes with a scar
Wound repair: Is it needed for partial thickness and/or full thickness tissue loss
Partial: wound repair only if needed, shallow with loss of epidermis possibly into dermis. Repair of clean surgical wound.
Full: is needed because of loss of epidermis and dermis. May involve subcutanous tissue and burns. Pressure ulcers, burns
Reduction in amount/control of movement
Factors influencing wound healing (10)
- Mobility smoking
- Inadequate nutrition immunosuppression
- Fecal/urinary incontinence radiation
- Diminished sensation wound stress
- Decreased mental status
- Excessive body heat
- Chronic medical conditions/ tissue perfusion
Tissue softened by prolonged wetting or soaking. Makes epidermis more suceptible to injury due to epidermis more easily erroded.
Area of loss of the superficial layers of skin. Digestive enzymes in fecal and gastric drainage and urine contribute.
Two chronic medical conditions infuencing wound healing of pressure ulcers
- Diabetes mellitus
- Cardiovascular disease
Complications of Wound healing
- Hemorrhage (Internal, External, Hematoma)
- Infection (prevents healing, increases tissue damage)
Abnormal opening between two organs or between an organ and skin
Two Tools for Prediction and prevention of pressure ulcers:
Guidelines for Prevention and Management of Pressure Ulcers (2003)
What Braden Scale is:
Has six subscales used to identify patients at risk for pressure ulcers. 23 low risk. 6 high risk. 18 is onset of pressure ulcers. Most used scale in USA.
Pressure Ulcer Prevention Points (5)
- Risk assessment
- Skin care/Early treatment
- Support surfaces/Pressure reduction
Measurement of an ulcer includes:
Surface area: centimeter ruler *width, length, depth* size, and location determining stage and condition of wound, bed. Presence of tunneling, undermining, skin surrounding. Signs/sympotoms of infection
Exudate: èstimate portion of ulcer bed covered by drainage
Appearance: estimate portion of ulcer for each tissue type (epithelial, granulation, slough, necrotic)
Record what about exudate: (3)
Odor: strong, foul, pudent, fecal, musty, or sweet
Four types of exudate (fluid and cells)
Serous exudate vs. Purulent exudate
- Serous: clear and watery consists of serum
- Purulent: thick, foul odor, pus (protein rich with WBC, protein debris. Can be green or blue tinged)
The difference between Sanguineous vs. Serosanguineous
Sanguineous: characterized by bloody drainage that can be bright (fresh) or dark (older). Indicates damage to capillaries
Serosanguineous: mixture of serum and RBC. Bloody and serous most commonly seen in new wounds.
8 NANDA approved nursing diagnoses
- Risk for infection
- Impaired tissue integrity
- Acute pain
- Imbalanced nutrition: less than body requirements
- Ineffective peripheral tissue perfusion
- Risk for and paired skin integrity
- Impaired skin integrity
- Impaired physical mobility
Planning dealing with the prevention of pressure ulcers (5)
- Maintain skin integrity
- Avoid potential risks
- Know sites of body pressure areas
- Set priorities- address acute needs first
- Reasonable, achievable outcomes
Planning dealing with promotion of wound healing (6)
- Adequate nutrition.
- Training schedule.
- Skin protective devices.
- Wound care.
- Plan for discharge on admission.
- Collaborate with other disciplines for care.
What is the RYB Code?
Red, yellow, black. Goals of wound care based on color of an open wound:
Protect red with cover-granulation tissue. Protect by gently cleaning with wound cleaner. Apply without pressure. Filling dead space with hydrogel or calcium alginate and cover with appropriate dressing.
Cleanse yellow-slough, purulent drainage. Previously infected, cleanse to remove nonviable tissue. Moist-moist normal saline dressing. Irrigating wound using absorpten dressing material.(hydrogel/alginate) topical antimicrobial to minimize growth
Debrid black-eschar covers. Removal of necrotic tissue before wound can be staged or healed. Sharp, mechanical, autolytic, chemical debridement.
Principles of wound healing: Protect wound and provide moist wound environment by: (4)
- Cover wound
- Fill in wound cavity
- Moisten dry wounds( moist is good if on wound bed. Too much causes macerations though)
- Control excessive moisture
The reason for dressings: (4)
- Cover the wound.
- Influence wound healing.
- Provide moist environment to promote normal epidermal cell migration.
- Absorb drainage to prevent pooling exudate.
Types of dressings: (6)
- Gauze (dry or moist)
- Transparent film
- Negative pressure wound therapy
Examples of Transparent adhesive dressings: (2)
Purpose of Transparent adhesive dresssings?
They are semipermeable occlusive dressings for stage 1 or 2 wounds without debris. Allow gaseous exchange/water vapor transfer from the skin, prevent peri-wound maceration. Adhesive side will not stick to wound because of moisture but with trap moisture over the wound bed providing a moist environment. Can see wound without removing. Stimulates granulation tissue.
Not bulky used as primary dressing. Wounds with minimum tissue lost and little drainage. Requires less frequent changes. Wounds with eschar to promote autolytic debridement. Change when seal is broken. Used for stage one or stage 2 wounds.
When not to use tranparent adhesive dressings? (2)
If wound is exudative or patient is diaphoretic
Purpose of Hydrogels?
For moist and draining wounds. Facilitates debridement by softening dead tissue. Used to fill the wound. Contain high percentage of water and for wounds that require moisture (wound with granulation, high percentage of necrotic tissue, maintaining moist wound environment for healing.
Facilitates debridement by softening the dead tissue. When you clean the gel out it takes out some debridement.
What a nurse should know about hydrogel dressings when applying?
Easy to apply and less painful to remove. It turns to gel but comes in tube and sheets. Change dressing according to amount of dressing. (From daily to every 3 days) Lightly pack into wound, secondary dressing applied over the hydrogel.
Purpose of Hydrocolloid dressings:
They fill the wound and moisten it by interacting with wound exudate forming a gel. It keeps wound surface moist and enhances healing while protecting wound from secondary infection. Help minimize shear.
An example of hydrocolloid dressings
By minimizing shear, hydrocolloid dressings are good for what kind of pressure ulcers?
Shallow stage 3 sacral ulcers
Documentation of wounds includes: (8)
- Wound location
- Type of tissue RYB
- Amount of exude
- Condition of skin around wound (maceration, induration, erythema)
- Conditions that can imped healing (incontinence, immobility)
- Use of barrier cream
- Type of treatment performed
7 things you need to know about Negative Pressure-KCI Wound VAC (Vacuum Assisted Closure) including how it works, when it needs to be changed, benefits, and costs
- Wound filled with sterile foam. Covered with occlusive drape and attach to negative pressure pump.
- Removes exudate from wound.
- Promotes granulation and wound contraction
- Changed 3 times per week
- Reduces exposure to contamination and pain
- Can be used at home with insurance approval. Not covered at home by Medicaid
Kara patients with a pressure ulcer or wind requires what type of approach?
Questions you need to ask yourself during the evaluation stage of the nursing process. (7)
- Has the physical condition changed
- Were appropriate devices used?
- Were risk factors indentified?
- Was turning done?
- Was nutritional intake adequate?
- Were measures taken to control incontinence?
- Was appropriate wound care done?
How age affects wound healing: (5)
- Blood circulation in oxygen delivery to wound, clotting, and phagocytes impaired.
- Cell growth and diffferentiation are slower
- Scar tissue never regains tensile strength increasing risk for altered body function
- Deline in number of WBC
- Risk for infection greater
How nutrition affects wound healing: (2)
- Surgery, severe wounds, serious infections, and preoperative nutritional deficits increase nutritional requirements.
- Nutrients provide raw materials needed for cellular activities that contribute to wound healing.
How infection affects wound healing?
Prolons the inflammatory phas, delays collagen synthesis, prevents epithelialization.
How obesity affects wound healing?
Less abundant supply of blood vessels in fatty tissue impairs delivery of nutrients and cellular elements needed for healing.
How Tissue perfusion affects wound healing?
Chronic tissue hypoxia is assoicated with impaired collagen synthesis and reduced