mgccc nursings

• protection (from infection)
• temp regulation
• pschosocial
• sensation
• vitamin d production
• immunological
• absorption
• elimination

*diabetics must be very careful w/skin integrity

• -healthy skin is the first line of defense against harmful agents
• -resistance to injury varies among people. (age, illness, etc.)
• -nourished and hydrated cells are more resistant to injury
• -adequate circulation is necesary to maintain cell life

You get skin infections from scratching.

can irritate skin

• -lifestyle variables
• -body piercing
• -changes in health state/illness
• -diagnostic measures (ex: colonoscopy-diarrhea)
• -theraputic measures

• -less than 2 y.o. skin is thinner/weaker
• -infants skin is easily injured
• -children become increasingly resistant to injury w/age
• -the structure of the skin changes as a person ages

• -very thin/very obese more susceptible to irritation & injury
• -dehydration reduces the fluid volume
• -excessive perspiration predisposes the skin to breakdown.
• -jaundice pts more likely to scratch, leading to potential for infection
• -diseases of the skin req. special care

• a break or disruption in the integrity of the skin
• -wounds can be mechanical (surgical incisions) or physical (burns)

intentional

unintentional

surgical

• -planned/unplanned event
• -healing proceeds in an orderly and timely fashion
• examples: surgical, abrasion/laceration

• -open or closed
• acute (heals faster)
• chronic (longer to heal)

all or a portion of the dermis is intact

• exists 2 weeks or longer
• does nt proceed thru normal healing process
• ex: pressure ulcers & diabetic/neuropathic ulcers

entire dermis, sweat glands, and hair follicles are severed

the dermis and underlying subcutneous fat tissue are damaged or destroyed.

post-operative dehisced wound

• -primary intention-well approximated; minimal tissue loss
• -secondary intention-not well approximated; require more tissue replacement; often contaminated
• -tertiary intention-left open for several das to allow edema or inf. to resolve, then closed

• -nerve damage
• -lack of circulation

• mechanical: pressure, friction, shear, epidermal stripping
• chemical: incontinence, drainage, harsh solutions, improper use of products
• vascular: arterial, venous, diabetic
• neuropathic:
• Infectious: candidaiasis, impetigo, herpes
• allergic

• -elastic
• -lubricated
• -acid mantle: pH 4.5-5.5
• -largest organ of the body
• -weighs 6-8 pounds
• -varied thickness

• -epidermal-dermal junction
• -basement membrane: separates epidermis from dermis
• -top layer

provides support and nutrition to the top of the epidermis

• -loss of subcutaneous fat
• -loss of elastin
• -dermal thinning
• -loss of collagen-sagging
• -altered epidermal-dermal junction
• -atherosclerosis of cutaneous vessels

• -less resistant to trauma
• -less resistant to temp changes 2degree decrease in sebaceous glands
• -decrease in immune response
• -changes in thermoregulation
• -unable to withstand stress/friction/shear

• -dry, cracked
• -wrinkled
• -thin
• -increased number of lesions
• -changes in hair color/distribution
• -nail hypertrophy

• -focus on prevention
• -early identification of at-risk pt
• -appropriate skin care (especially in the elderly and high risk pt)
• -use of devices for turning/positioning

partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

• where wound completely separates with protrusion of viscera thru the incisional area
• this is the most serious comlication of dehiscence

• *obese pts, malnourised pts, smokers are all at greater risk for this happening
• * pt on anticoagulants are at risk
• *pt who has infection
• * pt who coughs alot

normally occurs 4-14 days after surgery

• -fluid in wound between post op day 4-5
• -pt may feel like something has suddenly given way (ex:if they feel like stitches came loose)

• -place pt in a low fowlers position (this position will cause least pressure on the wound)
• -cover wound w/towels that are moistened w/sterile saline
• -call the doctor (this is a medical emergency)

*if another nurse is around-have them call doctor when you go get the normal saline & towels

• -focus on prevention
• -early identification of the at risk pt
• -appropriate skin care (esp. for the elderly & high risk pt)
• -use of devices for turning/positioning

• -immobility
• -nutrition and hydration
• -moisture
• -mental status
• -age

• 3
• -middle of 1st bed to edge of bed
• -edge of 1st bed to edge of 2nd bed
• -edge of 2nd bed to middle of 2nd bed.

• -assess on a daily basis, paying close attn to bony prominences
• -cleanse routinely and whenever soiling occurs
• -maintain high humidity and use moisturizers for dry skin
• -avoid massage over bony prominences
• -protect from moisture assoc. with incontinence or wound drainage
• -minimize friction/shearing
• -nutritional intervention
• -improve mobility/activity (ROM)
• -document pressure ulcers and the results.

• -not every pressure ulcer is preventable, but many are
• -if it was not documented on admission, by legal standards, it wasnt there; therefore it happened at your facility or under your supervision of care.

-documentation of skin integrity, altered or otherwise, is very important; however, documentation of interventions provided is equally important, especially in the at-risk pt.

• -money
• -morbidity
• -mortality
• -malpractice
• -pain/suffering

• -risk assessment
• -goal: indentify at-risk individuals needing prevention and the specific factors placing them at risk.

• -perform risk assessment (needs screening) Braden scale-p. 1205
• -assess and document skin condition on admission and at regular intervals

• -inspection
• -bathing
• -moisturize
• -no massage
• -positioning and turning
• -reduce friction
• -rehabilitate
• -monitor and document

goal: to maintain and improve tissue tolerance to pressure in order to prevent injury.

• -assess and treat incontinence
• -prevent or moisturize try skin
• -no vigorous massage
• -nutritional assessment

• -dietition consult
• -nutritional support
• -fluid management
• -vitamin and mineral supplementation

• -incorporate physical/occupational therapy as soon as possible
• -use devices that will assist the pt in turning/repositioning/mobility, ie, overhead trapeze, Hoyer lift, walker, cane, etc.

• -any lesion:
• -caused by unrelieved pressure
• -resulted in damage to underlying tissue
• -located over bony prominences
• -staged by depth

-epidermis intact with changes in skin temp, tissue consistency, sensation. The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whearas in darker skin tones, the ulcer may appear as a defined area of persistant red, blue, or purple hues.

partial thickness skin loss involving epidermis and/or dermis. Ulcer is superficial and presents an abraision, blister, or superficial crater.

-full thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of an adjacent tissue.

-full thicness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structurs (e.g. tendon, joint capsule, etc)

-An unstageable ulcer is covered with eschar or slough which prohibits complete assessment of the wound.

• -size of the wound
• -depth of the wound
• -wound tunneling
• -RYB Wound Classification
• r-red=protect
• y-yellow=cleanse
• b-black=debride

-an unsatgeable ulcer is covered with eschar or slough which prohibits complete assessment of the wound

necrotic tissue, usually black...can be brown or tan...does require deridement

• -shallow
• -involves epidermis, dermis
• -moist
• -painful
• -pink-red color

• -extends to subcutaneous layer or deeper
• -may include necrotic tissue or infection
• -often extensive tissue damage

• -"leave it open to air"
• -"the more often you change the dressing the better"
• -"if the wound is draining, its infected"
• -"swab cultures are adequate diagnostic tools for infections"

• -pressure
• -dessication (aka dehydration)
• -maceration (aka overhydration)
• -trauma
• -edema
• -infection (redness, drainage, swelling)
• -necrosis (tissue death)

-tissue load: pressure, friction, shear

goal: protect against adverse effects of external mechanical forces: pressure, friction, shear

• -turning schedules (every 2 hrs)
• -reduction/relief surfaces
• -use of pillows/splits for heel pressure relief

• -pressure relief: device which consistently reduces pressure less than capillary closure.
• -pressure reduction: device which does not consistently reduce pressure to less than capillary closure, but does provide pressure readings less than a standard mattress or chair.

they add pressure to certain areas

• -use pillows/wedges to separate bony prominences
• -totally relieve heel pressures "float"
• -no donuts

• capillary constriction:
• -decreased blood flow
• -reduced phagocytic activity
• -altered cellular mitosis

• the process of preparing the wound bed to promote optimal healing
• -removal of slough and necrotic tisssue,
• -reduction of bacterial burden
• -removing local barriers to healing

• -cleaning a linear wound
• -cleaning an open wound

• -protecting covering placed over a wound
• -debridement=removing dead or necrotic tissue (usually done by a dr, if not must be specifically trained & have dr order)l
• -dry gauze dressings
• -wet-to-dry dressings

• -fast
• -selective
• -access to tissue/bone cultures

• -specialized training
• -analgesia/anesthesia
• -requires sterile instruments

• -methods:
• -scalpel
• -scissors
• -curettes
• -laser
• -recommended for removal of thick, adheret eschar and devitalized tissue in large ulcers.

• methods:
• -hydrotherapy
• -irrigation
• -wet-to-dry dressings

• use in large full thickness wounds
• -agressive

• -may be painful
• -frequent dressings

• -wound charachteristics-size and location, degree of hydration, amt of exudate, signs and symptoms of infection
• -degree of selectivity desired to avoid damage to healthy tissue
• -skill of clinician
• -care setting
• -time avalible for debridement