Wku Nursing_ Skin Integrity[1].txt

• author "Leslie"
• tags ""
• description ""
• fileName "Wku Nursing: Skin Integrity"
• freezingBlueDBID -1.0
• What is the largest organ in the body?
• Skin

• First line of defense against microorganism
• Regulation of Body temperature
• Transmits sensations
• Vitamin D synthesis
• Absorption
• Elimination

Break or disruption in nomal integrity of the skin or tissues

Intentional-surgical

Unintentional-cut, pressure sore

Impaired skin integrity related to unrelieved, prolonged pressure. Localized to skin and underlying tissue usually above bony prominance

• Pressure sores
• Decubitus ulcer
• Bedsore

Obstructed blood flow to tissues causing tissue death

Dilation of superficial capillaries causing redness of skin

An area that appears red and warm will turn a lighter color with palpation. Usually resolves if pressure is reduced or relieves.

Redness that persists after palpation, indicting tissue damage. (Pigmented people-darker skin, purplish/blue hue)

• Shear
• Friction
• Moisture-reduces skin's resistance
• Poor nutrition-causes tissue to become susceptible to breakdown
• Infection
• Impaired sensory perception
• Alteration in level of consciousness
• Age
• Incontinence
• Low blood pressure-perfusion drops=less tolerance

Force exerted against the skin

Results from two surfaces rubbing against each other

• 1) Caused by pressure exerted against skin surfaces
• 2) Skin breakdown occurs when capillary pressure increases above normal
• 3) High pressure for short time/Low pressure for long time

Scab or dry crust that results from death of the skin. Thick hard and leathery

Shedding of dead tissue. Moist yellow or grey-ideal place for bacteria to grow

Removal of necrotic tissue so that healthy tissue can regenerate.

Newly formed tissue with small capillaries and connective tissue. Grows after debridment should be red, shiny, bumpy

Granulation tissue

Course or pathway that can extend in any direction from the wound.

Tissue destruciton underlying intact skin along wound margins

Drainage pathway from a deep focus of acute infection through tissue or bone to an opening on the surface

Suspected deep tissue injury

Stage 1

• Keep pressure off area by turning frequently
• Wash with mild soap and water, rinse, and gently pat dry
• Include protein, calories, vitamins A and C, iron, zinc, and water in diet
• Have protective transparent dressing
• Mangage incontinence

Stage 2 pressure ulcer

• Transparent dressing
• Hydrocoloid dressing
• Saline dampened gauze
• Assess for infection
• (Dressings that retain moisture)

• Keep hydrated
• Nutritional support
• Manage incontinence
• Turn and keep off area

Stage 3 pressure ulcer

Stage 4 pressure ulcer

Surgery: direct closure, skin grafting, skin flaps

Rate of recurrence of surgically closed pressure ulcers is high (often stage 4 ulcers heal over a long time with local wound care)

Unstagable pressure ulcer

Primary and secondary intention

Primary intention: skin edges close with little to no tissue loss. No infection. Reepithelization. Sunburns, surgical wounds. Heal in 4-14 days with minimum scaring. Risk for infection slight.

Secondary intention: healing occurs gradually, skin edges do not close, granulation occurs. Pressure ulcers, severe laceration. Wound closes with a scar

Partial: wound repair only if needed, shallow with loss of epidermis possibly into dermis. Repair of clean surgical wound.

Full: is needed because of loss of epidermis and dermis. May involve subcutanous tissue and burns. Pressure ulcers, burns

Reduction in amount/control of movement

• Mobility smoking
• Inadequate nutrition immunosuppression
• Fecal/urinary incontinence radiation
• Diminished sensation wound stress
• Decreased mental status
• Excessive body heat
• Infection
• Chronic medical conditions/ tissue perfusion
• Age

Tissue softened by prolonged wetting or soaking. Makes epidermis more suceptible to injury due to epidermis more easily erroded.

Area of loss of the superficial layers of skin. Digestive enzymes in fecal and gastric drainage and urine contribute.

• Diabetes mellitus
• Cardiovascular disease

• Hemorrhage (Internal, External, Hematoma)
• Infection (prevents healing, increases tissue damage)
• Fistula

Abnormal opening between two organs or between an organ and skin

Guidelines for Prevention and Management of Pressure Ulcers (2003)

Bradden Scale

Has six subscales used to identify patients at risk for pressure ulcers. 23 low risk. 6 high risk. 18 is onset of pressure ulcers. Most used scale in USA.

• Risk assessment
• Skin care/Early treatment
• Support surfaces/Pressure reduction
• Nutrition
• Education

Surface area: centimeter ruler *width, length, depth* size, and location determining stage and condition of wound, bed. Presence of tunneling, undermining, skin surrounding. Signs/sympotoms of infection

Exudate: èstimate portion of ulcer bed covered by drainage

Appearance: estimate portion of ulcer for each tissue type (epithelial, granulation, slough, necrotic)

Color

Odor: strong, foul, pudent, fecal, musty, or sweet

Quantity

• Serous
• Purulent
• Sanguineous
• Serosanguineous

• Serous: clear and watery consists of serum
• Purulent: thick, foul odor, pus (protein rich with WBC, protein debris. Can be green or blue tinged)

Sanguineous: characterized by bloody drainage that can be bright (fresh) or dark (older). Indicates damage to capillaries

Serosanguineous: mixture of serum and RBC. Bloody and serous most commonly seen in new wounds.

• Risk for infection
• Impaired tissue integrity
• Acute pain
• Imbalanced nutrition: less than body requirements
• Ineffective peripheral tissue perfusion
• Risk for and paired skin integrity
• Impaired skin integrity
• Impaired physical mobility

• Maintain skin integrity
• Avoid potential risks
• Know sites of body pressure areas
• Set priorities- address acute needs first
• Reasonable, achievable outcomes

• Adequate nutrition.
• Training schedule.
• Skin protective devices.
• Wound care.
• Plan for discharge on admission.
• Collaborate with other disciplines for care.

Red, yellow, black. Goals of wound care based on color of an open wound:

Protect red with cover-granulation tissue. Protect by gently cleaning with wound cleaner. Apply without pressure. Filling dead space with hydrogel or calcium alginate and cover with appropriate dressing.

Cleanse yellow-slough, purulent drainage. Previously infected, cleanse to remove nonviable tissue. Moist-moist normal saline dressing. Irrigating wound using absorpten dressing material.(hydrogel/alginate) topical antimicrobial to minimize growth

Debrid black-eschar covers. Removal of necrotic tissue before wound can be staged or healed. Sharp, mechanical, autolytic, chemical debridement.

• Cover wound
• Fill in wound cavity
• Moisten dry wounds( moist is good if on wound bed. Too much causes macerations though)
• Control excessive moisture

• Cover the wound.
• Influence wound healing.
• Provide moist environment to promote normal epidermal cell migration.
• Absorb drainage to prevent pooling exudate.

• Gauze (dry or moist)
• Transparent film
• Hydrocolloid
• Hydrogel
• Alginates
• Negative pressure wound therapy

• Tegaderm
• Opsite

They are semipermeable occlusive dressings for stage 1 or 2 wounds without debris. Allow gaseous exchange/water vapor transfer from the skin, prevent peri-wound maceration. Adhesive side will not stick to wound because of moisture but with trap moisture over the wound bed providing a moist environment. Can see wound without removing. Stimulates granulation tissue.

Not bulky used as primary dressing. Wounds with minimum tissue lost and little drainage. Requires less frequent changes. Wounds with eschar to promote autolytic debridement. Change when seal is broken. Used for stage one or stage 2 wounds.

If wound is exudative or patient is diaphoretic

For moist and draining wounds. Facilitates debridement by softening dead tissue. Used to fill the wound. Contain high percentage of water and for wounds that require moisture (wound with granulation, high percentage of necrotic tissue, maintaining moist wound environment for healing.

Facilitates debridement by softening the dead tissue. When you clean the gel out it takes out some debridement.

Easy to apply and less painful to remove. It turns to gel but comes in tube and sheets. Change dressing according to amount of dressing. (From daily to every 3 days) Lightly pack into wound, secondary dressing applied over the hydrogel.

They fill the wound and moisten it by interacting with wound exudate forming a gel. It keeps wound surface moist and enhances healing while protecting wound from secondary infection. Help minimize shear.

Duoderm

Shallow stage 3 sacral ulcers

• Wound location
• Dimensions
• Type of tissue RYB
• Amount of exude
• Condition of skin around wound (maceration, induration, erythema)
• Conditions that can imped healing (incontinence, immobility)
• Use of barrier cream
• Type of treatment performed

• Wound filled with sterile foam. Covered with occlusive drape and attach to negative pressure pump.
• Removes exudate from wound.
• Promotes granulation and wound contraction
• Changed 3 times per week
• Reduces exposure to contamination and pain
• Expensive
• Can be used at home with insurance approval. Not covered at home by Medicaid

Multi-disciplinary team

• Has the physical condition changed
• Were appropriate devices used?
• Were risk factors indentified?
• Was turning done?
• Was nutritional intake adequate?
• Were measures taken to control incontinence?
• Was appropriate wound care done?

• Blood circulation in oxygen delivery to wound, clotting, and phagocytes impaired.
• Cell growth and diffferentiation are slower
• Scar tissue never regains tensile strength increasing risk for altered body function
• Deline in number of WBC
• Risk for infection greater

• Surgery, severe wounds, serious infections, and preoperative nutritional deficits increase nutritional requirements.
• Nutrients provide raw materials needed for cellular activities that contribute to wound healing.

Prolons the inflammatory phas, delays collagen synthesis, prevents epithelialization.

Less abundant supply of blood vessels in fatty tissue impairs delivery of nutrients and cellular elements needed for healing.

Chronic tissue hypoxia is assoicated with impaired collagen synthesis and reduced