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Factors that may affect skin condition
- Illness
- Mobility status
- Nutrition/hydration
- Sensation level
- Impaired circulation
- Medications
- Moisture: -->massuration (skin degredation due to moisture saturation.)
- Infection
- Lifestyle
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Risk factors for Altered skin integrity
- Immobility
- Limited activity levels
- Incontinence
- Impaired nutritional status
- Infection
- Anemia
- Diminished sensations
- Altered level of consciousness
- Cachexia (emaciation)
- Friction and shear injury
- Obesity
- Hydration
- Aging skin
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Identifying level of impariment in skin integrity
- Tissue ischemia: lack of perfusion
- Blanching: red area turns white with pressure, then turns red again.
- Normal reactive hyperemia
- Abnormal reactive hyperemia
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Types of Wounds
- Pressure Ulcer
- Burns
- Traumatic
- Amputations
- Bites
- Bruises – better known as contusions
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Basic facts about pressure ulcers
- Prevention is KEY: they don't need to happen if you have good, regular assessment.
- High Cost
- Oasis…it’s not just an Island. Huh?
- What patients are most at risk?
- What would this patient look like?
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Locations for pressure ulcers...
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Stages of Pressure Ulcers...
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Stages of Pressure Ulcers
- 1) Nonreactive hyperemia
- 2) Partial loss of dermis. Will see pink/red wound bed. Could look like or be an abrasion.
- 3) Full thickness loss--> damage or loss of sucutaeous layer, but notthrough facia. Undermining may be present
- 4) Ulcer has progressed through facia possibly exposing bone. Necrosis is typical at stage 4.
- Unstagable: cannot tell which stage the pressure ulcer is at.
- For documenting purposes, cannot reverse stages. If it's a stage 4, it's always a stage 4 even when the stage 4 starts to heal.
- Going to measure, document, and track length, width, depth
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How does a pressure ulcer form?
- Pressure slows the blood flow to an area which leads to tissue death
- Friction and shear can add to the problem.
- --Friciton: removing epidermal layer. Skin looks raw.
- --Shearing: Underlying structures move perpedicular to skin above.
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Assessment of Risk for pressure ulcers.
- Focused skin assessment
- Research Based Risk Assessment Tool:
- -Braden scale* (most used)
- ---Numeric value for 6 risk factors related to impaired skin integrity
- ---Total score <18 = risk
- -Norton Scale
- ---Numeric value for 5 risk factors
- ---related to impaired skin integrity
- ---Total score <14 = risk
- Are these subjective or objective?
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Nursing Diagnosis related to skin integrity
Impaired Skin Integrity Related to Pressure/Shear Injury
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Pressure Ulcer Prevention
- A Braden Scale total score of 18 or lower indicates the patient is at risk and that prevention planning is needed.
- Start by identifying patient centered goals
- --Nutrition, activity, skin care
- Identify the consequences if the risk factors are not addressed
- Plan preventive interventions (usually multiple interventions are needed.)
- - Up in chair for meals
- - Ambulate
- - Turn q 2 hrs
- - Hydration/nutrition
- - Hygiene/cleanliness
- - Wound/nutrition consult
- - Teaching
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Outcome Identification and planning
- Individualized outcomes are based on the client’s overall physical condition, the stage of the wound, and the client’s risk factors, ie don't plan or anticipate an outcome that is physically or practically impossible. If pt refuses treatment, you MUST come up with an alternative plan that still addresses pt needs. If nothing else, must at least document pt education on risks/benefits of denyting/accepting treatment.
- Client teaching is an integral part of the planning process.
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Nursing intervetions for pressure ulcers
- Prevention: turn your pt.
- Meticulous skin care and moisture control: lotions have highest water content. Creams have more oil so will be more occlusive. Oinments last longer, but have the most oil content. Will be your protective treatments. Will contain lanolyn or petrolium.
- Adequate nutrition, especially vit c and zinc.
- Frequent repositioning
- Therapeutic mattresses
- Client/family teaching
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Treatment for stage I
- Ointments/lotions/creams
- Egg crate matresses
- Turn/reposition
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Intervensions for stage II
Maintain healing environment, ie saline/moisturizing, occlusive dressing.
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Stage III pressure ulcer intervension
- Clean
- debride: necrosis, exudate, sloath, etc via irrigation.
- Will want to give pt analgesic 20-30 min before debridement.
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Stage IV
- Hydrochaloidal
- Aquacele
- Hydrate
- Those gigantic, medicated bandaids.
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Evaluation of pressure ulcer intervensions
- Physical signs of healing and the status of the pressure ulcer
- Client’s adaptation to the altered skin integrity
- Each intervention should be evaluated for its effectiveness.
- Plan of care is revised to reflect most beneficial actions.
- PUSH Tool (look up PUSH tool in book).
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Wound Classification
- Open
- --Incision
- --Laceration
- --Abrasion
- --Puncture Penetration
- --Gunshot
- Closed
- --Contusion
- --Hematoma
- --Crush
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Classification by duration of wound
- Acute
- New
- Healing
- Disruption in tissue
- Approximated
- Chronic (usually more complicated than acute)
- Not healing
- Ulcers
- Unapproximated
- Complications
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Classification by depth
- Superficial/partial
- full-thickness
- Measurements are more important than classification by depth.
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Classification by color
- Red: You're ahead. Red is good because it indicates circulation.
- Yellow (mellow): take it easy, ie use caution. Is it yellow because of granulation tissue (healing) or because it's slough (needs to be removed/debrided).
- Black. Need to debride, Clyde, even if you conceed it will bleed. It's dead, indeed.
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Healing wounds
Primary intension
 - Read all about it!
- Primary: can be put back together with a staple or suture.
- Should start recovering in about 72 hrs.
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secondary intension
- Heals with granulation tissue (pinkish/redish cream of wheat). Fills in fissures, gaps.
- Sometimes wounds will pop back open. That's okay.
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Tertiary Intension
- Kind of a combo between primary and secondary.
- Dr. will report no further infection or continuing trauma, and then it can be closed.
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What is the purpose of the inflamatory phase?
- Circulation increases
- Phygocytosis--> engulf bacteria, clear debris.
- Forms a scab that protects against further bacterial infiltration.
- SnSs:
- edema, erythema, pain, temp increase, migration of wbc into wound tissue.
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Proliferative phase
- Wound begins healing at day 5-21.
- Fibroblasts-->collagen to add strength to healing wound.
- New blood lymph vessels sprout-->granulation tissue.
- New epithelia cells form under the scab to seal wound.
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Maturation phase
- Marked shrinkage of wound
- Collagen-->scar tissue in wound bed.
- Site of scar is only 80% as strong as skin without compromised integrity.
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Factors that affect healing of wounds
- Nutrition. Remeber vitamin c and zinc?
- Oxygenation: enables leukocyts to destroy bacteria.
- Infection
- Age: everything slows down as you age.
- Chronic health condition: diabetes, PVD
- Medications
- Smoking: Maaaaaaaaybe you want to quit. Most hospitals will provide a patch or some form of smoking sessation
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Complicaitons of wound healing
- Hemorrhage
- Infection: exudate, discharge, odor.
- Dehiscence: separation of skin at closure.
- Evisceration: Like dehiscence, but with protrusion of underlying organs. If found, DO NOT SHOVE IT BACK IN. Cover, moisturize, and call Dr.
- Fistula formation: abnormal passage between two organs.
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Planning for wound care
- Know what type of dressing change you are about to perform.
- Listen to report/read chart concerning previous dressing change and needed materials
- Gather everything together prior to starting wound care
- Explain to the patient the procedure.
- GIVE PAIN MEDICATIONS 30 minutes prior.
- Provide privacy position patient for comfort and access. Shut the door/close the curtain
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Why remove the old tissue?
- To remove necrotic debris or dried wound exudate
- To promote wound healing by preventing damage to the wound
- To protect new skin growth from disruption
- Remove contact layer at 90degree angle to lift loose tissue and exudate
- Slowly peel back contact layer at 180degree angle to wound –prevents detachment
- Contact dressing layer picked up at wound edge& pulled toward center of the lesion
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Removal of current dressing
- Loosen tape by pulling parallel with and towards incision/wound. If dressing adheres to wound moisten
- Careful inspection
- Fold dressing inward on itself and dispose in bag
- May use forceps or hemostat to remove dressing
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Wound assessment
- Location?
- Staging (if pressure ulcer)
- If wound
- Drainage
- Wound bed
- Surrounding skin
- Pain (what is the pt's current pain level?
- Saturated vs. dry. Give saturation diameter of dressings some kind of relatable quantity.
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Assessing wound drainage
- Serous: clear
- Sanguineous: bloody
- Serosanguineous: combo
- Purulent: yellow(ish) discharge, likely with odor. Due to nfxn.
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Assessing wound bed
- Wound dimensions
- Tunnelling/undermining?
- Bed texture: moist/dry
- Wound odor
- Margins and surrounding skin
- Pain level
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Documentation of wound
- Wound/ulcer location
- Odor
- Ulcer category, stage, classification, depth
- Necrotic tissue
- Dimension and drainage
- Pain
- Induration (hardness of surrounding tissue)
- Color of wound bed
- Tunneling
- Undermining
- Redness
- Edges
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A few NANDA diagnoses
- Impaired Tissue Integrity
- Risk for Infection
- Pain
- Disturbed Body Image
- Deficient Knowledge (wound care)
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Desired outcomes examples
- Intact skin over ….. By (date)
- Pt will show no S & S of Infection by (date)
- Wound will decrease in size (named) by (date)
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Nursing intervensions
- Basic Wound Care
- Irrigation
- Surgical wound management
- Closed wound drain management
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Wet to dry dressings
Indicated for mechanical debridement only
- Causes injury to new tissue
- is painful
- predisposes wound to nfxn
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Intervensions: Dressings
- Dressing a wound
- Gauze
- Transparent film
- Hydrocolloids
- Hydrogels
- Alginate (most absorbent).
- Foam
- Secure with tape or Montgomery Straps (used to secure dressings that will require frequent changes. Has ties and an adhesive and nonadesive portion of the strap.)
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Supplies for basic wound care
- Allergies
- Overbed table
- Trash bag
- Wound measuring device
- Gloves
- Syringe for irrigation (if applicable)
- Cleaning solution (normal saline)
- Chux pads
- Sterile 4” X 4” gauze dressings
- Topical dressings
- Hypoallergenic tape to elastic netting
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How to debride a wound
- Goal: Remove dead tissue and debris, which impedes healing
- What to use: Normal saline or commercial noncytoxic solution
- Never use: Perioxide, Betadine or Dakin’s solution
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Irrigation/cleansing fundamentals
- May use irrigation syringe or gentle pouring of saline into wound.
- Position pt. so that irrigant will flow by gravity into a basin/pad
- Cleanse wound from inner to outer aspect: center of wound to sides
- Discard used cleansing materials after each stroke
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Irrigating facts
- USE APPROPRIATE PRESSURE
- * Gentle pressure 4-5 psi --60 ml catheter tipped syringe
- If needed may use 30ml syringe and 18-20 needle; (know 19 gauge for test) pressurized irrigation solution=8 psi
- Whirlpool: form of debridement that uses a whirlpool jets to wash away large amounts of nonviable tissue.
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Intervensions: dressings
- Dressing a wound
- Gauze
- Transparent film
- Hydrocolloids
- Hydrogels
- Alginate
- Foam
Secure with tape or Montgomery Straps
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Debridement intervensions
- Débriding a wound
- Sharp: removed with sharp instrument
- Mechanical: Wet-to-dry (not really used anymore), hydrotherapy
- Chemical:
- Enzymatic: breaks down only nonviable, however apply only to dead tissue because it can cause irritation.
- Autolysis: mode of choice in otherwise healthy individuals because it is tolerated best.
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Nursing Interventions: draining management
- Caring for a drainage device
- Jackson-Pratt; Hemovac
- Assess
- Ensure suction
- Check tubing
- Keep below wound level
- Empty unit
- Complete I&O’s
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Wound Evaluation
- Achievement or Maintenance of Skin Integrity
- Wound healing
- Progressive healing of ulcer aeb:
- Decreased depth and diameter
- Pale pink wound margins
- Presence of granulation tissue filling in cavity
- Prevention of infection
- Client education
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Hot or cold therapies
- Will need to monitor temp with either therapy. Pt. may not be able to self monitor if has periferal neuropathy.
- Heat--vasodilation
- cold-vasoconstriction, has mild anesthetic effect .
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