skin integrity and wound healing fall 2010. skin structure epidermis outermost layer...

SKIN INTEGRITY AND WOUND HEALING

FALL2010

SKIN STRUCTUREEPIDERMIS

• Outermost Layer

• Barrier-restricts water loss

• Prevents fluids, pathogens and chemicals from entering

SKIN STRUCTUREDERMIS

• Below epidermis and above subcutaneous tissue• Composed of connective tissue • Provides strength and elasticity to

skin• Contains blood vessels• Contains sweat glands, ceruminous

glands, hair and nail follicles, sensory receptors, elastin and collagen

SKIN STRUCTURESUBCUTANEOUS LAYER

• Composed of fat and connective tissue

• Provides insulation, protection and a reserve of calories in the event of severe malnutrition

• Thickness and distribution varies-influenced by hormones, genetics, age and nutrition

FACTORS INFLUENCING ABILITY TO MAINTAIN INTACT SKIN AND HEAL

WOUNDS

• Age• Mobility• Nutrition• Hydration• Diminished Sensation• Impaired Circulation• Medications

FACTORS INFLUENCING ABILITY TO MAINTAIN INTACT SKIN AND HEAL

WOUNDS

• Moisture on the skin• Fever• Contamination• Lifestyle (Smoking)• Disease processes• Radiation treatments• Immune function

WOUND CLASSIFICATIONS• Status of skin integrity

• Open• Closed

• Cause• Intentional• Unintentional

• Time for healing• Acute• Chronic

• Severity of injury• Superficial-epidermal• Partial thickness-dermal• Full thickness-into subcutaneous and

beyond

WOUND CLASSIFICATIONS cont.

• Cleanliness

• Clean• Clean-contaminated• Contaminated• Colonized• Infected

• Descriptive qualities• Abrasion• Laceration• Contusion

WOUND HEALING METHODS

• Regenerative• Affects only epidermal layer• No scar

• Primary Intention• Edges well approximated• Little scarring

WOUND HEALING METHODS cont

• Secondary Intention

• Wound edges not approximated• Heals from inner layer• Beefy red granulation tissue• More scar tissue• Increased chance of infection or

complications

WOUND HEALING METHODS cont.

• Tertiary Intention

•Delayed wound closure•Two surfaces of granulation

tissue brought together•More scarring than primary but

less than secondary

WOUND HEALING PHASES

• Inflammatory-Cleansing• 1-5 days• Homeostasis-Provides clotting• Inflammation-Provides sealing scab

• Proliferative-Granulation• 5-21 days

• Maturation-Epitheliazation• Until wound is completely healed

WOUND COMPLICATIONS

• Hemorrhage• Infection• Dehiscence• Evisceration• Fistula

Assessment of Wounds• Acute injury / wound

• Bleeding• Contaminant materials• Size• Recent tetanus

• Stable / chronic wound• Healing• Appearance• Drainage• Pain• Color• Location• Wound bed• Peri wound skin

Assessment of Wounds

• Types of drainage• Serous• Sanguinous• Serosanguinous• Purulent

• Presence of drains• Security of drain• Location in respect to wound• Character and amount of drainage

PRESSURE ULCERS

• Chronic wound• AKA bedsore, pressure sore,

decubitus ulcer

Pressure UlcerPrevention

• Intrinsic risk factors• Immobility• Impaired sensation• Malnourishment

• Extrinsic risk factors• Friction• Shearing• Moisture• Pressure

Pressure Ulcer Prevention

• Assess skin daily (q shift)• Pressure points

• Keep clean and dry• Warm water & mild soap

• Moisturizing lotions• Linen soft, clean, dry, no wrinkles• Adequate calories, protein, fluids• Reposition q 2 hours• Therapeutic Mattresses

• Air, gel, foam, water (AHRQ)

Pressure Ulcer Risk Assessment• Braden Scale (low score = high risk)

• Sensory perception• Moisture• Activity• Mobility• Nutrition• Friction & shear

Norton Scale (low score = high risk)• Physical condition• Mental state• Activity• Mobility• Incontinence

Pressure Ulcer Staging• Stage I Nonblanchable erythema

(>30mins after pressure removed)

– Intact skin• Stage II Partial thickness skin loss

– (epidermis / dermis)– Shallow crater, blister, or abrasion

• Stage III Full thickness skin loss– Necrosis of subcutaneous tissue;

undermining may be present• Stage IV Full thickness skin loss

– Extensive damage to muscle, bone; undermining and sinus tracts may be present

Pressure Ulcer Assessment

• Length• Width• Exudate/Drainage• Tissue

• Eschar• Granulation• Slough• Necrotic

ESCHARDead cells (Necrotic

tissue) and Plasma proteins

Cannot be staged

Nursing Diagnoses

• Impaired Skin Integrity R/T

• Impaired Tissue Integrity R/T

• Risk for Infection R/T

• Pain R/T

• Body Image Disturbance R/T

LABORATORY DATA

• Leukocyte Count

• Serum Protein Level

• Coagulation studies

• Wound Cultures

DELEGATION

• You may delegate the following to UAP:• Inspection of the skin for evidence of

breakdown. Instruct UAP to notify you of redness, tissue warmth, or drainage

• Turning and positioning

Wound CareRYB Color Code

• Red Protect• Keep moist & covered

• Yellow Cleanse• Irrigation, dressings

debridement?

• Blackac Debride• Sharp-Scalpel or scissors• Hydrotherapy-wet-to-dry dressing• Enzymatic-topical enzymes• Autolytic- occlusive dressing

Dressings• Gauze• Telfa• Transparent films

• Clear & semipermeable

• Hydrocolloids• Wafers, pastes, powders

• Hydrogels• Sheets, granules, gels with high water content

• Absorption Dressings• Beads, powders, pastes, ribbons, alginates

• Silver preparations

Cleansing Solutions

• Normal saline• Dilute antimicrobial solutions• Commercially prepared wound cleansers• NO (Dakins,Acetic acid, Hydrogen peroxide, Povidone-

iodine)

CONTROLLING INFECTION

• Closed Wounds-Standard Precautions• Open Wounds-Contact Precautions• Multiple Wounds-Treat least

contaminated wound first.• Acute wounds may require sterile

technique• Chronic wounds-clean technique

HEAT AND COLD THERAPY

• Avoid direct skin contact with heating or cooling device.

• Leave on patient no more than 15 minutes at a time in an area.

• Check skin frequently for extreme redness, blistering, cyanosis, or blanching.

HEAT AND COLD THERAPY

• Heat relieves stiffness and discomfort, promotes delivery of nutrients and removal of waste products from tissue, and promotes relaxation.

• Cold causes vasoconstriction and decreases capillary permeability, produces local anesthesia, reduces cell metabolism, increases blood viscosity, slows bacterial growth and decreases muscle tension

HEAT AND COLD THERAPY

• Heat can cause a drop in blood pressure and a feeling of faintness.

• Cold can elevate blood pressure, cause shivering, and produce tissue damage due to impaired circulation