mgccc nursings

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mgccc nursings
2010-10-27 12:50:19
Skin integrity would care

ms fain's lecture: skin integrity & wound care
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  1. functions of skin
    • protection (from infection)
    • temp regulation
    • pschosocial
    • sensation
    • vitamin d production
    • immunological
    • absorption
    • elimination
  2. factors affecting skin integrity
    *diabetics must be very careful w/skin integrity
  3. factors affecting skin integrity
    • -healthy skin is the first line of defense against harmful agents
    • -resistance to injury varies among people. (age, illness, etc.)
    • -nourished and hydrated cells are more resistant to injury
    • -adequate circulation is necesary to maintain cell life
  4. What happens when you have a cast on?
    You get skin infections from scratching.
  5. medications, patches
    can irritate skin
  6. factors placing an ind. at risk for skin alterations
    • -lifestyle variables
    • -body piercing
    • -changes in health state/illness
    • -diagnostic measures (ex: colonoscopy-diarrhea)
    • -theraputic measures
  7. developmental considerations
    • -less than 2 y.o. skin is thinner/weaker
    • -infants skin is easily injured
    • -children become increasingly resistant to injury w/age
    • -the structure of the skin changes as a person ages
  8. state of health
    • -very thin/very obese more susceptible to irritation & injury
    • -dehydration reduces the fluid volume
    • -excessive perspiration predisposes the skin to breakdown.
    • -jaundice pts more likely to scratch, leading to potential for infection
    • -diseases of the skin req. special care
  9. wound:
    • a break or disruption in the integrity of the skin
    • -wounds can be mechanical (surgical incisions) or physical (burns)
  10. Planned wound
  11. unplanned wound
  12. example of an intentional wound
  13. Acute wound
    • -planned/unplanned event
    • -healing proceeds in an orderly and timely fashion
    • examples: surgical, abrasion/laceration
  14. wounds can be:
    • -open or closed
    • acute (heals faster)
    • chronic (longer to heal)
  15. partial thickness wound
    all or a portion of the dermis is intact
  16. chronic wound
    • exists 2 weeks or longer
    • does nt proceed thru normal healing process
    • ex: pressure ulcers & diabetic/neuropathic ulcers
  17. full thickness wound
    entire dermis, sweat glands, and hair follicles are severed
  18. complex thickness-
    the dermis and underlying subcutneous fat tissue are damaged or destroyed.
  19. chronic wound
    post-operative dehisced wound
  20. wound repair
    • -primary intention-well approximated; minimal tissue loss
    • -secondary intention-not well approximated; require more tissue replacement; often contaminated
    • -tertiary intention-left open for several das to allow edema or inf. to resolve, then closed
  21. what causes a diabetic pressure ulcer
    • -nerve damage
    • -lack of circulation
  22. types of skin damage
    • mechanical: pressure, friction, shear, epidermal stripping
    • chemical: incontinence, drainage, harsh solutions, improper use of products
    • vascular: arterial, venous, diabetic
    • neuropathic:
    • Infectious: candidaiasis, impetigo, herpes
    • allergic
  23. normal skin
    • -elastic
    • -lubricated
    • -acid mantle: pH 4.5-5.5
    • -largest organ of the body
    • -weighs 6-8 pounds
    • -varied thickness
  24. anatomy: human skin
    • -epidermal-dermal junction
    • -basement membrane: separates epidermis from dermis
    • -top layer
  25. dermis
    provides support and nutrition to the top of the epidermis
  26. normal changes with aging: Structure
    • -loss of subcutaneous fat
    • -loss of elastin
    • -dermal thinning
    • -loss of collagen-sagging
    • -altered epidermal-dermal junction
    • -atherosclerosis of cutaneous vessels
  27. Normal changes with aging: Function
    • -less resistant to trauma
    • -less resistant to temp changes 2degree decrease in sebaceous glands
    • -decrease in immune response
    • -changes in thermoregulation
    • -unable to withstand stress/friction/shear
  28. normal changes with aging: Appearance
    • -dry, cracked
    • -wrinkled
    • -thin
    • -increased number of lesions
    • -changes in hair color/distribution
    • -nail hypertrophy
  29. Pressure Ulcers: prevention of wounds
    • -focus on prevention
    • -early identification of at-risk pt
    • -appropriate skin care (especially in the elderly and high risk pt)
    • -use of devices for turning/positioning
  30. dehiscence
    partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
  31. evisceration
    • where wound completely separates with protrusion of viscera thru the incisional area
    • this is the most serious comlication of dehiscence

    • *obese pts, malnourised pts, smokers are all at greater risk for this happening
    • * pt on anticoagulants are at risk
    • *pt who has infection
    • * pt who coughs alot
  32. dehiscence
    normally occurs 4-14 days after surgery
  33. signs that dehiscence could be impending:
    • -fluid in wound between post op day 4-5
    • -pt may feel like something has suddenly given way (ex:if they feel like stitches came loose)
  34. nursing interventions for dehiscence: (this is a prioritization test Q)
    • -place pt in a low fowlers position (this position will cause least pressure on the wound)
    • -cover wound w/towels that are moistened w/sterile saline
    • -call the doctor (this is a medical emergency)

    *if another nurse is around-have them call doctor when you go get the normal saline & towels
  35. prevention of wounds (pressure ulcers)
    • -focus on prevention
    • -early identification of the at risk pt
    • -appropriate skin care (esp. for the elderly & high risk pt)
    • -use of devices for turning/positioning
  36. risks for pressure ulcer development:
    • -immobility
    • -nutrition and hydration
    • -moisture
    • -mental status
    • -age
  37. it should take a minimum of how many moves to move a pt. out of bed
    • 3
    • -middle of 1st bed to edge of bed
    • -edge of 1st bed to edge of 2nd bed
    • -edge of 2nd bed to middle of 2nd bed.
  38. pressure ulcer prevention:
    • -assess on a daily basis, paying close attn to bony prominences
    • -cleanse routinely and whenever soiling occurs
    • -maintain high humidity and use moisturizers for dry skin
    • -avoid massage over bony prominences
    • -protect from moisture assoc. with incontinence or wound drainage
    • -minimize friction/shearing
    • -nutritional intervention
    • -improve mobility/activity (ROM)
    • -document pressure ulcers and the results.
  39. Incidence of pressure ulcers:
    • -not every pressure ulcer is preventable, but many are
    • -if it was not documented on admission, by legal standards, it wasnt there; therefore it happened at your facility or under your supervision of care.
  40. Incidence of pressure ulcers
    -documentation of skin integrity, altered or otherwise, is very important; however, documentation of interventions provided is equally important, especially in the at-risk pt.
  41. Cost of pressure ulcers
    • -money
    • -morbidity
    • -mortality
    • -malpractice
    • -pain/suffering
  42. Improving Clinical Outcomes
    • -risk assessment
    • -goal: indentify at-risk individuals needing prevention and the specific factors placing them at risk.
  43. Intervention
    • -perform risk assessment (needs screening) Braden scale-p. 1205
    • -assess and document skin condition on admission and at regular intervals
  44. Skin care and Early Treatment
    • -inspection
    • -bathing
    • -moisturize
    • -no massage
    • -positioning and turning
    • -reduce friction
    • -rehabilitate
    • -monitor and document
  45. Skin integrity and treatment
    goal: to maintain and improve tissue tolerance to pressure in order to prevent injury.
  46. skin care and early treatment:
    • -assess and treat incontinence
    • -prevent or moisturize try skin
    • -no vigorous massage
    • -nutritional assessment
  47. Nursing Interventions:
    • -dietition consult
    • -nutritional support
    • -fluid management
    • -vitamin and mineral supplementation
  48. Improve mobility and activity:
    • -incorporate physical/occupational therapy as soon as possible
    • -use devices that will assist the pt in turning/repositioning/mobility, ie, overhead trapeze, Hoyer lift, walker, cane, etc.
  49. A pressure ulcer is....
    • -any lesion:
    • -caused by unrelieved pressure
    • -resulted in damage to underlying tissue
    • -located over bony prominences
    • -staged by depth
  50. Stage 1 of pressure ulcer-
    -epidermis intact with changes in skin temp, tissue consistency, sensation. The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whearas in darker skin tones, the ulcer may appear as a defined area of persistant red, blue, or purple hues.
  51. Stage 2 pressure ulcer
    partial thickness skin loss involving epidermis and/or dermis. Ulcer is superficial and presents an abraision, blister, or superficial crater.
  52. Stage 3-
    -full thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of an adjacent tissue.
  53. Stage 4-
    -full thicness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structurs (e.g. tendon, joint capsule, etc)
  54. Unstageable Ulcer-
    -An unstageable ulcer is covered with eschar or slough which prohibits complete assessment of the wound.
  55. Measuring Wounds and Pressure Ulcers
    • -size of the wound
    • -depth of the wound
    • -wound tunneling
    • -RYB Wound Classification
    • r-red=protect
    • y-yellow=cleanse
    • b-black=debride
  56. Unstageable Ulcer
    -an unsatgeable ulcer is covered with eschar or slough which prohibits complete assessment of the wound
  57. eschar-
    necrotic tissue, usually black...can be brown or tan...does require deridement
  58. partial-thickness wounds
    • -shallow
    • -involves epidermis, dermis
    • -moist
    • -painful
    • -pink-red color
  59. full thickness wounds
    • -extends to subcutaneous layer or deeper
    • -may include necrotic tissue or infection
    • -often extensive tissue damage
  60. Wound care myths
    • -"leave it open to air"
    • -"the more often you change the dressing the better"
    • -"if the wound is draining, its infected"
    • -"swab cultures are adequate diagnostic tools for infections"
  61. Factors affecting would healing
    • -pressure
    • -dessication (aka dehydration)
    • -maceration (aka overhydration)
    • -trauma
    • -edema
    • -infection (redness, drainage, swelling)
    • -necrosis (tissue death)
  62. Mechanical factors
    -tissue load: pressure, friction, shear
  63. Pressure:
    goal: protect against adverse effects of external mechanical forces: pressure, friction, shear
  64. Pressure reduction:
    • -turning schedules (every 2 hrs)
    • -reduction/relief surfaces
    • -use of pillows/splits for heel pressure relief
  65. Support Surfaces
    • -pressure relief: device which consistently reduces pressure less than capillary closure.
    • -pressure reduction: device which does not consistently reduce pressure to less than capillary closure, but does provide pressure readings less than a standard mattress or chair.
  66. dont use donut devices
    they add pressure to certain areas
  67. pressure reduction:
    • -use pillows/wedges to separate bony prominences
    • -totally relieve heel pressures "float"
    • -no donuts
  68. Temperature Reduction
    • capillary constriction:
    • -decreased blood flow
    • -reduced phagocytic activity
    • -altered cellular mitosis
  69. Wound Bed Preparation (WBP)
    • the process of preparing the wound bed to promote optimal healing
    • -removal of slough and necrotic tisssue,
    • -reduction of bacterial burden
    • -removing local barriers to healing
  70. Cleaning wounds
    • -cleaning a linear wound
    • -cleaning an open wound
  71. Dressing Wounds:
    • -protecting covering placed over a wound
    • -debridement=removing dead or necrotic tissue (usually done by a dr, if not must be specifically trained & have dr order)l
    • -dry gauze dressings
    • -wet-to-dry dressings
  72. Surgical Debridement advantages:
    • -fast
    • -selective
    • -access to tissue/bone cultures
  73. Disadvantages of surgical debridement
    • -specialized training
    • -analgesia/anesthesia
    • -requires sterile instruments
  74. Sharp/Surgical Debridement-the use of instruments to remove non-viable tissue
    • -methods:
    • -scalpel
    • -scissors
    • -curettes
    • -laser
    • -recommended for removal of thick, adheret eschar and devitalized tissue in large ulcers.
  75. mechanical debridement-the removal of foreign material and dead or damaged tissue by the use of physical forces
    • methods:
    • -hydrotherapy
    • -irrigation
    • -wet-to-dry dressings
  76. Advantages of mechanical debridement:
    • use in large full thickness wounds
    • -agressive
  77. disadvantages of mechanical debridement
    • -may be painful
    • -frequent dressings
  78. Debridement
    (selecting appropriate method)
    • -wound charachteristics-size and location, degree of hydration, amt of exudate, signs and symptoms of infection
    • -degree of selectivity desired to avoid damage to healthy tissue
    • -skill of clinician
    • -care setting
    • -time avalible for debridement