Lecture 8 - Skin Integrity and Wound Care

‭Functions of the Skin‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ rotection‬ P ‭Body temperature regulation‬ ‭Psychosocial‬ ‭Sensation‬ ‭Vitamin D production‬ ‭Immunological‬ ‭Absorption‬ ‭Elimination‬ ‭Types of Wounds‬ ‭Descriptions‬ ‭ ‬ I‭ ntentional or unintentional‬ ● ‭●‬ ‭Open or closed‬ ‭○‬ ‭Ecchymosis:‬‭Skin lesions caused by capillary bleeding‬ ‭■‬ ‭Flat and non-palpable‬ ‭○‬ ‭Hematoma:‬‭Accumulation of blood in the skin or deeper‬‭tissues‬ ‭■‬ ‭Often raised, palpable, and tender‬ ‭●‬ ‭Acute or chronic‬ ‭○‬ ‭May defy conventional wound therapy‬ ‭○‬ ‭Difficult to heal and dress‬ ‭●‬ ‭Partial thickness loss:‬‭All or a portion of the dermis‬‭is intact‬ ‭●‬ ‭Full thickness loss:‬‭Entire dermis, sweat glands,‬‭and hair follicles are‬ ‭severed‬ ‭●‬ ‭Complex wounds:‬‭Acute or chronic wounds that defy‬‭conventional‬ ‭wound therapy; difficult to dress/heal‬ ‭Causes‬ ‭●‬ I‭ ncision:‬‭Cut by a sharp instrument; wound edges in‬‭close‬ ‭approximation and aligned‬ ‭●‬ ‭Laceration:‬‭Tearing of skin/tissue with a blunt or irregular instrument‬ ‭○‬ ‭Tissue unaligned; loose flaps of skin and tissue present‬ ‭●‬ ‭Avulsion:‬‭Tearing a structure from a normal anatomic‬‭position‬ ‭○‬ ‭Possible damage to blood vessels, nerves, and other structures‬ ‭●‬ ‭Abrasion:‬‭Friction; rubbing or scraping epidermal‬‭layers of skin‬ ‭○‬ ‭Top layer of skin abraded‬ ‭●‬ ‭Contusion:‬‭Blunt instrument; overlying skin intact‬‭but injury to underlying tissue‬ ‭●‬ ‭Puncture:‬‭Blunt or sharp instrument puncturing the‬‭skin‬ ‭○‬ ‭Intentional (venipuncture) or accidental‬ ‭●‬ P ‭ enetrating:‬‭Foreign object entering the skin or mucous membrane and lodging‬ ‭in underlying tissue; fragments possibly scattering throughout tissues‬ ‭ uestion:‬‭A client is admitted to the ER after a motorcycle‬‭accident that resulted in‬ Q ‭the client’s skidding across a cement parking lot. Since the client was wearing shorts,‬ ‭the skin is ripped off in large areas on the legs. This wound is best described as:‬ ‭a.‬ ‭Avulsion‬ ‭b.‬ ‭Puncture‬ ‭c.‬ ‭Laceration‬ ‭d.‬ ‭Eschar‬ ‭Wound Healing‬ ‭Systemic Factors‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ ge‬ A ‭Circulation and oxygenation‬ ‭Nutritional status‬ ‭Health status: ex. Corticosteroid drugs, diabetic patients‬ ‭Local Factors‬ ‭‬ P ● ‭ ressure:‬‭Disrupts blood supply to wound‬ ‭●‬ ‭Desiccation:‬‭Drying up; cells dehydrate and die in‬‭dry environment‬ ‭●‬ ‭Maceration:‬‭Softening and breakdown of skin from prolonged‬‭exposure to moisture‬ ‭○‬ ‭Urinary and fecal incontinence‬ ‭●‬ ‭Trauma:‬‭Repeated injury to wound delays injury‬ ‭●‬ ‭Infection:‬‭Bacteria in the wound stress the body‬ ‭by increasing need for immune response‬ ‭●‬ ‭Edema:‬‭Fluid at wound site can interfere with‬ ‭blood supply; facilitates bacterial growth‬ ‭●‬ ‭Excessive bleeding:‬‭Can result in large clots,‬ ‭which take up space and interfere with oxygen‬ ‭diffusion to tissue‬ ‭●‬ ‭Necrosis:‬‭Healing will not occur with necrotic‬ ‭tissue in the wound; must be removed‬ ‭○‬ ‭Slough: Moist, yellow, stringy tissue‬ ‭○‬ ‭Eschar: Black, dry, leathery tissue‬ ‭Phases of Wound Healing‬ 1‭ .‬ H ‭ emostasis‬ ‭2.‬ ‭Inflammatory‬ 3‭ .‬ P ‭ roliferation‬ ‭4.‬ ‭Maturation‬ ‭Hemostasis/Clotting Phase‬ ‭ ‬ I‭ njury to blood vessel occurs‬ ● ‭●‬ ‭Blood vessels in the area constrict to prevent‬ ‭blood loss‬ ‭●‬ ‭Platelets and immune cells respond to the affected‬ ‭area via increased perfusion‬ ‭●‬ ‭This inflammatory response can cause exudate and heat/redness to form‬ ‭●‬ ‭Platelets form a temporary plug, then fibrin is activated to form a stable clot‬ ‭Inflammatory Phase‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ ollows hemostasis and lasts ~4-6 days‬ F ‭Leukocytes move to wound; macrophages enter‬ ‭Macrophages ingest debris and release growth factors (attract fibroblasts that fill wound)‬ ‭Exudate forms from the dilation of blood vessels‬ ‭Pain, heat, redness, and swelling occur at the injury site‬ ‭Patient has a generalized bodily response‬ ‭Proliferation Phase‬ ‭‬ P ● ‭ hase begins within 2-3 days of injury and may last up to 2-3 weeks‬ ‭●‬ ‭New tissue is built to fill wound space through action of fibroblasts‬ ‭○‬ ‭Secrete collagen and growth factors‬ ‭●‬ ‭Capillaries grow across the wound, bringing oxygen and nutrients‬ ‭●‬ ‭A thin layer of epithelial cells forms across the wound, allowing blood flow‬ ‭●‬ ‭Granulation tissue forms a foundation for scar tissue development‬ ‭●‬ ‭Patient care considerations: Adequate nutrition, oxygenation, and prevention of strain‬ ‭Maturation/Remodeling Phase‬ ‭●‬ ‭Begins 3 weeks to 6 months after injury; can last months or years‬ ‭Collagen Remodeling:‬ ‭●‬ ‭Initially, deposited collagen is haphazard‬ ‭●‬ ‭Remodeling makes the wound stronger and more like adjacent tissue‬ ‭Collagen Dynamics‬ ‭●‬ ‭Continuous deposition of new collagen‬ ‭●‬ ‭Compression of blood vessels‬ ‭●‬ ‭Result: Scar becomes a flat, thin line‬ ‭Cellular Changes‬ ‭●‬ ‭Caused by emigration and apoptosis from the wound‬ ‭●‬ ‭Reduction in density of…‬ ‭○‬ ‭Macrophages‬ ‭○‬ ‭Blood vessels‬ ‭○‬ ‭Fibroblasts‬ ‭○‬ ‭Inflammatory cells‬ ‭Characteristics of Scar Tissue‬ ‭●‬ ‭Avascular: Does not sweat, grow hair, or tan‬ ‭●‬ ‭Elasticity: Less elastic than uninjured tissue‬ ‭●‬ ‭Strength: 70-80% that of normal tissue‬ ‭●‬ ‭Long-term: Never fully restored to original tissue strength‬ ‭Secondary Intention‬ ‭●‬ ‭When wounds are left to heal rather than sutured/stapled‬ ‭●‬ ‭Edges are not well approximated‬ ‭●‬ ‭Longer remodeling time‬ ‭●‬ ‭Resulting scar may be smaller than original wound‬ ‭●‬ ‭Form more scar tissue than primary intention‬ ‭Impact on Functionality‬ ‭●‬ ‭Scars over joints/body structures may limit movement‬ ‭●‬ ‭Potential for causing disability‬ ‭Wound Drainage‬ ‭‬ E ● ‭ xudate forms due to the inflammatory response and is referred to as wound drainage‬ ‭●‬ ‭Wound drainage appearance is based on the contents (ex. Blood, serum, bacteria, debris)‬ ‭●‬ ‭Drains inserted into the wound may prevent abcesses and aid with the healing process‬ ‭Types of Wound Drainage‬ ‭‬ S ● ‭ erous: Composed of serum from blood, making it clear and watery‬ ‭●‬ ‭Sanguineous: Bloody appearance due to the presence of RBCs‬ ‭○‬ ‭Bright red: Fresh bleeding‬ ‭○‬ ‭Dark red: Older bleeding‬ ‭●‬ ‭Serosanguineous: Light pink appearance from serum and RBCs in the wound drainage‬ ‭●‬ ‭Prurulent: Made of WBCs, tissue debris, and bacteria (dead and alive)‬ ‭○‬ ‭Usually thick with odor‬ ‭○‬ ‭Dark yellow to green (indicating infection)‬ ‭Assessment of Drainage‬ ‭‬ O ● ‭ bserve the color, amount, consistency, and odor of wound drainage during assessment‬ ‭●‬ ‭Color and amount are based no location/size of wound; note drainage on dressing‬ ‭●‬ ‭Odor and consistency help determine if drainage is prurulent (presence of infection)‬ ‭Wound Assessment‬ ‭ ‬ I‭ nspection: Sight and smell‬ ● ‭●‬ ‭Palpation‬ ‭●‬ ‭Determine:‬ ‭○‬ ‭Status of wound‬ ‭○‬ ‭Barriers to healing process‬ ‭○‬ ‭Signs of complications‬ ‭Wound Complications‬ ‭Hemorrhage‬ ‭●‬ ‭Bleeding from a damaged blood vessel‬ ‭Types‬ ‭ ‬ I‭ nternal hemorrhage: Bleeding is trapped inside the body‬ ● ‭●‬ ‭External hemorrhage: Bleeding can flow outside the body from a wound/opening‬ ‭Causes‬ ‭●‬ ‭Damage to blood vessels during surgery/injury‬ ‭‬ U ● ‭ se of anticoagulant medications‬ ‭●‬ ‭Alcohol use disorders, coagulation disorders, blood disorders‬ ‭●‬ ‭Cancer‬ ‭Symptoms‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ izziness (due to low BP)‬ D ‭Fatigue and weakness‬ ‭Nausea, vomiting‬ ‭Dyspnea‬ ‭Tachycardia‬ ‭Management‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ ontrol bleeding through direct pressure‬ C ‭Surgical intervention may be required‬ ‭Blood transfuions in severe cases‬ ‭IV fluids‬ ‭Vitamin K injections‬ ‭Infection‬ ‭●‬ ‭Occur when pathogens enter a wound, and the immune system is unable to fight it‬ ‭Causes‬ ‭‬ C ● ‭ ontamination during surgery or injury‬ ‭●‬ ‭Poor hygiene or care of the wound‬ ‭●‬ ‭Compromised immune system‬ ‭Symptoms‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ edness, warmth, and swelling around the wound‬ R ‭Pain or tenderness‬ ‭Discharge and odor from wound‬ ‭Nausea, chills, and fever‬ ‭Management‬ ‭‬ A ● ‭ ntibiotic therapy (oral or IV)‬ ‭●‬ ‭Surgical debridement PRN‬ ‭●‬ ‭Proper wound care and hygiene‬ ‭Assessment‬ ‭●‬ ‭Wound is swollen and deep red‬ ‭‬ F ● ‭ eels hot upon palpation, and drainage is increased (possibly prurulent)‬ ‭●‬ ‭If dehiscence is impending/present, wound edges are separated‬ ‭●‬ ‭Assess for presence of odor after the wound has been cleaned‬ ‭○‬ ‭May indicate certain types of bacteria‬ ‭Dehiscence and Evisceration‬ ‭‬ D ● ‭ ehiscence: Partial or complete separation of the wound edges‬ ‭●‬ ‭Evisceration: Protrusion of internal organs through a wound‬ ‭Causes‬ ‭●‬ ‭Increased intra-abdominal pressure and stress on the wound‬ ‭○‬ ‭Ex. coughing, sneezing, and vomiting‬ ‭●‬ ‭Inadequate suturing or wound closure‬ ‭●‬ ‭Infection or poor wound healing‬ ‭Symptoms‬ ‭‬ S ● ‭ udden opening of the wound; broken sutures‬ ‭●‬ ‭Evisceration: Visible internal structures‬ ‭●‬ ‭Pain, increased drainage/bleeding, swelling, redness, and fever‬ ‭Management‬ ‭‬ E ● ‭ visceration: Immediate surgical intervention‬ ‭●‬ ‭Dehiscence: Wound closure/care and medication (antibiotics and pain meds)‬ ‭●‬ ‭Negative pressure wound therapy to remove fluid‬ ‭Fistula Formation‬ ‭●‬ ‭An abnormal connection of two body parts, usually from an injury or surgery‬ ‭Causes‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ I‭ nfection of abcess formation‬ ‭Injury or trauma to the body‬ ‭Complication of surgery‬ ‭Side effect of a treatment (ex. Radiation therapy)‬ ‭Symptoms‬ ‭‬ A ● ‭ bnormal drainage from the wound‬ ‭●‬ ‭Discomfort or pain‬ ‭●‬ ‭Possible signs of infection‬ ‭Management‬ ‭‬ M ● ‭ edication and wound care‬ ‭●‬ ‭Surgical repair if it does not close itself‬ ‭●‬ ‭Addressing underlying conditions‬ ‭Open Wound Classification‬ ‭Color (RYB)‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ ed: Protect, in proliferative stage of healing‬ R ‭Yellow: Cleanse, presence of exudate requires cleaning‬ ‭Black: Debride, presence of eschar requires removal‬ ‭Mixed wound: Contains components of red, yellow, and black wounds‬ ‭Types of Wound Surface Tissue‬ ‭Types of Drainage Systems‬ ‭Open Systems‬ ‭Iodoform Gauze (NuGauze)‬ ‭‬ R ● ‭ educes wound debris‬ ‭●‬ ‭Aids in wound healing‬ ‭●‬ ‭Allows for visualization of wound bed‬ ‭Penrose Drain‬ ‭‬ S ● ‭ oft, flexible rubber tube that helps prevent fluid from building up in a wound‬ ‭●‬ ‭Passive drain, uses gravity rather than suction‬ ‭Closed Systems‬ ‭Jackson-Pratt Drain‬ ‭‬ R ● ‭ emoves excess fluid and blood from a surgical site‬ ‭●‬ ‭Uses suction and pulls out fluid when squeezed‬ ‭Hemovac Drain‬ ‭●‬ ‭Tube inserted under the skin during surgery to remove fluids and blood from a wound‬ ‭Wound VAC‬ ‭●‬ ‭VAC: Vacuum-assisted closure‬ ‭Pressure Injuries‬ ‭Development‬ ‭‬ P ● ‭ ressure injury: Refers to a pressure ulcer‬ ‭●‬ ‭External pressure compresses blood vessels‬ ‭●‬ ‭Friction or shearing stress tears and injures blood vessels‬ ‭Common Sites‬ ‭ uestion:‬‭Which of the following actions would place‬‭a client at the greatest risk for a shearing‬ Q ‭force injury to the skin?‬ ‭a.‬ ‭Walking without shoes‬ ‭b.‬ ‭Sitting in Fowler’s position‬ ‭c.‬ ‭Lying supine in bed‬ ‭d.‬ ‭Using a heating pad‬ ‭Factors Affecting Development‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ I‭ mmobility‬ ‭Malnutrition and dehydration‬ ‭Moisture (fecal and urinary incontinence)‬ ‭Altered LOC‬ ‭Spinal cord/brain injuries‬ ‭Neuromuscular disorders‬ ‭Before a Pressure Injury‬ ‭‬ N ● ‭ ot yet considered a pressure injury‬ ‭●‬ ‭Skin blanching: Becoming pale and white‬ ‭○‬ ‭Low blood perfusion‬ ‭●‬ ‭Ischemia followed by reactive hyperemia‬ ‭○‬ ‭Restricted to excess blood present‬ ‭●‬ ‭Blanchable erythema‬ ‭●‬ ‭Warning sign of potential injury development‬ ‭Stages of Pressure Ulcers‬ ‭●‬ ‭Stage I: Non-blanchable erythema of intact skin‬ ‭○‬ ‭Localized patch of discoloration‬ ‭●‬ ‭Stage II: Partial-thickness skin loss‬ ‭●‬ ‭Stage III: Full-thickness skin loss; not involving underlying fascia‬ ‭●‬ ‭Stage IV: Full-thickness skin loss with extensive destruction (undermining and tunneling)‬ ‭Additional Categories‬ ‭Unstageable/Unclassified Stage‬ ‭●‬ ‭Depth unknown‬ ‭●‬ ‭Full-thickness skin/tissue loss‬ ‭●‬ ‭Base of ulcer covered by slough and/or eschar in wound bed‬ ‭Suspected Deep-Tissue Injury‬ ‭●‬ ‭Depth unknown‬ ‭●‬ ‭Discolored, intact skin (purple/maroon) or blood-filled blister‬ ‭●‬ ‭Painful, firm, or boggy‬ ‭●‬ ‭Warmer/cooler than surrounding skin‬ ‭Predicting Pressure Sore Risk: Braden Scale‬ ‭‬ S ● ‭ ensory perception‬ ‭●‬ ‭Moisture‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ ctivity‬ A ‭Mobility‬ ‭Nutrition‬ ‭Friction and shear‬ ‭Total score: Ranges from 6-23‬ ‭Braden Scale Scores‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ 1‭ 9-23: Normal, not at risk‬ ‭15-18: At risk‬ ‭13-14: Moderate risk (ransparent wound barrier)‬ ‭10-12: High risk‬ ‭6-9: Very high risk‬ ‭Preventative Interventions‬ ‭●‬ ‭When patient is at risk (15-18)‬ ‭●‬ ‭Regular turning schedule‬ ‭●‬ ‭Enable as much activity as possible‬ ‭●‬ ‭Protect the heels‬ ‭●‬ ‭Manage moisture, friction, and shear‬ ‭Measuring Wounds/Pressure Injuries‬ ‭‬ D ● ‭ raw shape and describe it‬ ‭●‬ ‭Measure LxW (and diameter if circular)‬ ‭●‬ ‭Measure depth‬ ‭Cleaning a Pressure Injury‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ se careful, gentle motions to minimize trauma‬ U ‭Clean with each dressing change‬ ‭Use 0.9% normal saline to irrigate and clean‬ ‭Report any drainage or necrotic tissue‬ ‭Cleaning Wounds with Approximated Edges‬ ‭●‬ ‭-‬ ‭Cleaning Wounds with Unapproximated Edges‬ ‭●‬ ‭-‬ ‭Types of Debridement‬ ‭‬ W ● ‭ et-to-dry dressings are no longer considered good practice‬ ‭●‬ ‭Mechanical: Physical force to remove necrotic tissue‬ ‭○‬ ‭Ex. whirlpool therapy, ultrasound, laser, surgical‬ ‭●‬ ‭Autolytic: Occlusive dressing (ex. hydrocolloid)‬ ‭●‬ ‭Enzymatic: Speeds up body’s autolytic process‬ ‭Securing Wound Dressings‬ ‭‬ T ● ‭ ape: Adhesive, paper, or microfoam‬ ‭●‬ ‭Bandages: Strips of cloth, gauze, or elasticized material‬ ‭(ex. ACE wrap)‬ ‭●‬ ‭Binders: Larger, straight piece of material (ex.‬ ‭Abdominal binder)‬ ‭Techniques for Applying Roller Bandages‬ ‭Circular Turn‬ ‭‬ W ● ‭ rap bandage around body part‬ ‭●‬ ‭Completely overlap the previous bandage turn‬ ‭Spiral Turn‬ ‭‬ W ● ‭ ith a spiral manner, each turn should overlap the last‬ ‭●‬ ‭By ½ or ⅔ bandage width‬ ‭Figure-Eight Turn‬ ‭●‬ ‭Oblique overlapping turns that ascend and descend alternatively‬ ‭Recurrent Stump Bandage‬ ‭‬ U ● ‭ se circular turns to anchor the bandage‬ ‭●‬ ‭Place the initial end at the center of the body part‬ ‭●‬ ‭Pass the bandage back and forth over the tip on either side of the center‬ ‭Types of Binders‬ ‭‬ S ● ‭ traight: Used for chest and abdomen‬ ‭●‬ ‭T-binder: Used for rectum, perineum, and groin area‬ ‭●‬ ‭Sling: Used to support an arm‬ ‭Montgomery Straps‬ ‭●‬ ‭Used to facilitate frequent dressing changes without having to remove and reapply tape‬ ‭●‬ ‭Prevent skin trauma by minimizing skin irritation at the incision site‬ ‭ uestion:‬‭You are at the scene of an accident and‬‭find the victim has a bleeding lower leg‬ Q ‭wound. After flushing it with water and covering it with a clean dressing, you find the dressing‬ ‭has been saturated with blood. Which of the following would be the best action to take?‬ ‭a.‬ ‭Lower the extremity while applying pressure to the wound‬ ‭b.‬ ‭Take off the first dressing and apply another clean/sterile one‬ ‭c.‬ ‭Encircle the client’s ankle with your hands and apply pressure‬ ‭d.‬ ‭Reinforce the first layer of dressing with a second‬