Wounds and skinWounds and skin

Ch. 48Ch. 48

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STAGE I ULCER- GREATER TROCHANTERSTAGE I ULCER- GREATER TROCHANTER04/21/2304/21/23 NRS 105.320 NRS 105.320 55

Stage 1 Pressure UlcerStage 1 Pressure Ulcer

STAGE II ULCER – ISCHEAL TUBEROSITYSTAGE II ULCER – ISCHEAL TUBEROSITY

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Stage 2 UlcerStage 2 Ulcer

STAGE IIISTAGE III

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Stage 3 Pressure UlcerStage 3 Pressure Ulcer

STAGE IV ISCHEAL TUBEROSITY AND STAGE IV ISCHEAL TUBEROSITY AND SACRUMSACRUM

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Stage 4 UlcerStage 4 Ulcer

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Risks for Pressure UlcersRisks for Pressure Ulcers

• ImmobilityImmobility– Unable to move independentlyUnable to move independently

• Impaired PerceptionImpaired Perception [numbness, [numbness, paralysis]paralysis]– Unable to sense pain/pressureUnable to sense pain/pressure

• Altered LOCAltered LOC– Confused – perceive pressure/pain but Confused – perceive pressure/pain but

can’t communicate/ relieve pressure can’t communicate/ relieve pressure – Coma: no perception + immobilityComa: no perception + immobility

ShearingShearing

• Skeleton, muscle slide one way, skin Skeleton, muscle slide one way, skin stays or moves the other waystays or moves the other way– Raising HOB, transferring pt by slidingRaising HOB, transferring pt by sliding– stretching of skin, tears capillaries, stretching of skin, tears capillaries,

necrosis leads to undermining of tissuesnecrosis leads to undermining of tissues

FrictionFriction

• Top layers of skinTop layers of skin

• Sliding across coarse linens, seatsSliding across coarse linens, seats

• Position changes w/o liftsPosition changes w/o lifts

Wound healingWound healing

• Primary Intention [surgical wound]Primary Intention [surgical wound]– Clean edges, approximated [closed]Clean edges, approximated [closed]– Low risk of infectionLow risk of infection– Quick healing, fine scarQuick healing, fine scar

• Secondary IntentionSecondary Intention– Trauma, ulcer, dehisced woundTrauma, ulcer, dehisced wound– Open – wound healing, filled by scar tissue, Open – wound healing, filled by scar tissue,

granulation over time – deep scargranulation over time – deep scar– Slow healing, ↑ risk of infectionSlow healing, ↑ risk of infection

Wound DressingsWound Dressings

• ProtectionProtection– against contamination, pain from airagainst contamination, pain from air

• Homeostasis Homeostasis – [pressure, clot, edges][pressure, clot, edges]

• ↑ ↑ Healing Healing – Absorb drainage, debride depending on Absorb drainage, debride depending on

typetype

• Moist environment [+ or -]Moist environment [+ or -]– Healing by 2° intention [- if infected]Healing by 2° intention [- if infected]

Which Dressing?Which Dressing?

• Depends on wound assessment, Depends on wound assessment, purposepurpose– Purpose is to provide the right environment Purpose is to provide the right environment

to enhance & promote wound healing.to enhance & promote wound healing.– moist healing environment stimulates cell moist healing environment stimulates cell

proliferation & encourages epithelial cells to proliferation & encourages epithelial cells to migratemigrate

– Provide barrier against bacteria and absorb Provide barrier against bacteria and absorb fluidfluid

– Decrease or eliminate painDecrease or eliminate pain

Wound VacWound VacRemoves drainage, Removes drainage, increases perfusionincreases perfusion

AssessmentsAssessments

• Is the wound copiously draining? Is the wound copiously draining?

• Is it dry? Does it need added Is it dry? Does it need added moisture moisture

• Does it need debridement?Does it need debridement?

• Is it infected?Is it infected?

Surgical Wound - CDISurgical Wound - CDI

Infected surgical woundInfected surgical wound

Dehiscence Dehiscence

Infected & dehisced woundInfected & dehisced wound

Types of dressings and UsesTypes of dressings and Uses

• GauzeGauze– draining wounds; necrotic woundsdraining wounds; necrotic wounds– those requiring debridement or packingthose requiring debridement or packing– wounds with tunnels, tracts, or dead spacewounds with tunnels, tracts, or dead space– surgical incisions; burnssurgical incisions; burns– dermal ulcers; and pressure ulcersdermal ulcers; and pressure ulcers

• May be impregnated w/ antimicrobial –May be impregnated w/ antimicrobial –– IV sites, trach, drains, full-thickness woundsIV sites, trach, drains, full-thickness wounds

Wound Dressing TrayWound Dressing Tray

Transparent filmsTransparent films

• let oxygen pass through to the let oxygen pass through to the wound and moisture vapor escapewound and moisture vapor escape– Partial-thickness woundsPartial-thickness wounds– Stage I and II pressure ulcersStage I and II pressure ulcers– superficial burns superficial burns – donor sites. donor sites. – as a secondary dressingas a secondary dressing

• Not always absorbent Not always absorbent

TegadermTegaderm

FoamFoam• Nonadherent and nonocclusiveNonadherent and nonocclusive

– Hydrophilic, polyurethane or film-coated gelHydrophilic, polyurethane or film-coated gel– Stages II through IV pressure ulcersStages II through IV pressure ulcers– partial- and full-thickness wounds with partial- and full-thickness wounds with

minimal to heavy drainageminimal to heavy drainage– surgical woundssurgical wounds– dermal ulcers, dermal ulcers, – under compression wrapsunder compression wraps

• Check to see if indicated for infected Check to see if indicated for infected woundwound

Nonadhesive Foam DressingNonadhesive Foam Dressing

Composite dressingsComposite dressings

• Combinations of two or more Combinations of two or more different products in one different products in one – bacterial barrier, absorptive layer, foam, bacterial barrier, absorptive layer, foam,

hydrocolloid, or hydrogelhydrocolloid, or hydrogel– semi-adherent or nonadherentsemi-adherent or nonadherent– Partial and full-thickness wounds, Partial and full-thickness wounds,

minimally to heavily draining wounds, minimally to heavily draining wounds, dermal ulcers, and surgical incisionsdermal ulcers, and surgical incisions

– Check package for pressure ulcersCheck package for pressure ulcers(Baranoski , S. (2008) (Baranoski , S. (2008) Nursing2008 v1No. 1 pg 60-61)Nursing2008 v1No. 1 pg 60-61)

Heat and Cold TherapyHeat and Cold Therapy

• HeatHeat increases blood flow increases blood flow– Limit time… eventually → Limit time… eventually →

vasoconstrictionvasoconstriction

• ColdCold decreases swelling and pain decreases swelling and pain– Limit to 10-20 minutes r/t ischemia, Limit to 10-20 minutes r/t ischemia,

eventual vasodilatationeventual vasodilatation

Pressure UlcerPressure Ulcer

•Impaired skin integrity (damage Impaired skin integrity (damage to the skin) R/T unrelieved, to the skin) R/T unrelieved, prolonged pressure AEB full-prolonged pressure AEB full-thickness pressure ulcer on L heelthickness pressure ulcer on L heel

– AKA: Pressure sore, decubitus ulcer, AKA: Pressure sore, decubitus ulcer, bedsore bedsore

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Nursing DiagnosisNursing Diagnosis

•Impaired Skin Integrity r/t Impaired Skin Integrity r/t pressure/ischemia 2* to pressure/ischemia 2* to immobility AEB stage III ulcer immobility AEB stage III ulcer on L leg, on bedrest, Braden on L leg, on bedrest, Braden score = 5score = 5

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Nursing Diagnoses for Skin/ Nursing Diagnoses for Skin/ WoundWound

• Risk for infectionRisk for infection

• Imbalanced nutrition: less than body req.Imbalanced nutrition: less than body req.

• Pain [acute/chronic]Pain [acute/chronic]

• Impaired MobilityImpaired Mobility

• Impaired skin integrity [+ risk for…]Impaired skin integrity [+ risk for…]

• Ineffective tissue perfusionIneffective tissue perfusion

• Impaired tissue integrityImpaired tissue integrity

• Alteration in body imageAlteration in body image

PlanPlan

•On-going skin assessment On-going skin assessment

•Nutritional assessmentNutritional assessment

•Pressure relief for affected areasPressure relief for affected areas

•Preventative care for intact skinPreventative care for intact skin

•Restorative care for woundsRestorative care for wounds

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GoalsGoals1.1. Pressure ulcer will not increase in size [this Pressure ulcer will not increase in size [this

shift] / during hospitalization [baseline = shift] / during hospitalization [baseline = 1cmX2cm]1cmX2cm]

2.2. Pt will be free of s/sx of Infection in pressure Pt will be free of s/sx of Infection in pressure ulcer this shift / during hospitalizationulcer this shift / during hospitalization

3.3. Pt will eat a balanced, high protein diet today Pt will eat a balanced, high protein diet today / while in facility/ while in facility

4.4. Patient and family will develop a plan (with Patient and family will develop a plan (with nursing staff/ dietician) for preventing further nursing staff/ dietician) for preventing further skin breakdown within 2 daysskin breakdown within 2 days

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TYPES OF TYPES OF INTERVENTIONSINTERVENTIONS

• NURSE INITIATEDNURSE INITIATED– INDEPENDENTINDEPENDENT

• PHYSICIAN INITIATEDPHYSICIAN INITIATED– DEPENDENTDEPENDENT

• COLLABORATIVE COLLABORATIVE – INTERDEPENDENTINTERDEPENDENT

NRS 105.320 NRS 105.320

InterventionsInterventions• RN to assess skin q shift, document including size RN to assess skin q shift, document including size

and appearance of wound[s]and appearance of wound[s]

• RN will provide Wound care per policy q shift and RN will provide Wound care per policy q shift and prnprn

• Dietician to complete nutritional assessment and Dietician to complete nutritional assessment and recommend a diet within 24 hoursrecommend a diet within 24 hours

• RN/ CNA to offer health shake/ protein cup RN/ CNA to offer health shake/ protein cup between mealsbetween meals

• CNA will Reposition patient q 2 hours: supine, left, CNA will Reposition patient q 2 hours: supine, left, right; prop w/ pillows; document on position recordright; prop w/ pillows; document on position record

• RN will Meet w/ pt and family, dietician by Friday RN will Meet w/ pt and family, dietician by Friday to discuss meal planto discuss meal plan

• RN will Educate pt/ family re: immobility, skin, RN will Educate pt/ family re: immobility, skin, pressure today and reinforce with handout/demopressure today and reinforce with handout/demo

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Rationales (with Citations)Rationales (with Citations)

• Decreasing the duration of pressure Decreasing the duration of pressure on skin will prevent further skin on skin will prevent further skin breakdown. (breakdown. (Perry and Potter, p. 1281Perry and Potter, p. 1281))

• Wound healing requires proper Wound healing requires proper nutrition. (nutrition. (Perry and Potter, p. 1290Perry and Potter, p. 1290))

• Family caregivers require education Family caregivers require education and counseling to be effective. (and counseling to be effective. (MSU MSU 2009)2009)

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Outcome EvaluationOutcome Evaluation1.1. Goal not metGoal not met: By discharge date, patient had : By discharge date, patient had

developed stage I ulcer on Rt hip, L heel still full developed stage I ulcer on Rt hip, L heel still full thicknessthickness

– Revise/Revise/ update update planplan for ulcer prevention for ulcer prevention [because [because it isn’t working]it isn’t working]; elevate heels while in bed; elevate heels while in bed

2.2. Goal met: Goal met: pt afebrile, wound culture negative. pt afebrile, wound culture negative. Continue with planContinue with plan

3.3. Goal metGoal met: Patient has gained 3lbs this month and : Patient has gained 3lbs this month and serum proteins have increased. serum proteins have increased.

- Continue w/ plan- Continue w/ plan

4.4. Goal metGoal met: Family has decided on transfer to LTC for : Family has decided on transfer to LTC for further patient care. further patient care.

- Plan: provide skin history and assessment to LTC - Plan: provide skin history and assessment to LTC facilityfacility

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IMAGES DisclaimerIMAGES Disclaimer

• Some of these images are upsettingSome of these images are upsetting

LacerationsLacerations

Degloving pre-opDegloving pre-op

Key Points Chapter 48Key Points Chapter 48• Pressure ulcersPressure ulcers → pain, ↓ mobility, ↑cost → pain, ↓ mobility, ↑cost

and length of stay. and length of stay. They are preventableThey are preventable

• Learn Braden Scale and Staging Learn Braden Scale and Staging

• Assess Assess allall pts for risks to skin integrity pts for risks to skin integrity

• Wound assessment and documentation Wound assessment and documentation

• Control bleeding, clean, protect [1Control bleeding, clean, protect [1stst aid] aid]

• Wound care – least to most contaminatedWound care – least to most contaminated

• ↑↑protein, Vit C, calories for healingprotein, Vit C, calories for healing