Transcript Skin Integrity and Wound Care

Skin Integrity and Wound
Care
Teresa V. Hurley, MSN, RN
Skin Integrity
• Largest organ in the body
• Functions
– First line of defense against microorganisms
– Regulation of body temperature
– Transmits sensations of pain, temperature,
touch and pressure
--Vitamin D production and absorption
--secretes sebum
Wounds
• What are wounds ?
– Break in skin or mucous membranes
Wound Classification
• Superficial
• Deep (blood vessels, nerves, muscle,
tendons, ligaments, bones)
• Open Wound
– Superficial or deep break in skin (abrasion,
puncture, laceration)
Wound Classification
• Closed: blunt force; twisting, turning, straining,
bone fracture, visceral organ tear
• Acute: trauma sharp object or blow
– Surgical incision, gun shot, venipuncture
• Chronic: pressure ulcers
• Causality
– Intentional: surgical incision
– Unintentional: traumatic
• Knife
• Burn
Pressure Wounds
• Damage to tissues due to pressure
• Factors
– Immobility
– Elderly
– Skin moisture
– Malnutrition (protein)
– Shearing Forces
– Friction
– Risk Factors as outlined on Braden Scale
Pressure Ulcer Stages
• Stage I: No Skin Break
– Skin temperature, consistency (firm),
sensation (pain or itching)
– Persistent redness in light skin tones
– Persistent red, blue or purple hue in darker
skin tones
Pressure Ulcer Stages
• Stage II: Superficial
– Partial-thickness skin loss (epidermis and/or
dermis
– Abrasion, blister or shallow crater
• Stage III
– Full-thickness skin loss (subcutaneous damage
or necrosis and may extend down to but not
through fascia
– Deep crater
Pressure Ulcer Stages
• Stage IV: full thickness skin loss and destruction,
necrosis of the tissue, damage to muscle, bone,
tendons and joint capsules and sinus tract
• Types of Dressings
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Transparent film (Tegraderm, Bioclusive)
Hydrocolloid (Duoderm, Comfeel)
Hydrogel
Gauze Roll (Kerlix)
– Provide moist environment
– Loosen slough and necrotic tissue
– Wick drainage from wound
Pressure Ulcer Assessment
• Tissue Type
– Granulation Tissue: red and moist
– Slough: yellow stringy tissue attached to
wound bed; removal essential for healing
– Eschar: necrotic tissue which is brown or
black appearance must be debrided
Pressure Ulcer Assessment
• Wound Dimensions (L, W, D)
• Wound Deterioration
– Skin surrounding ulcer
• Redness, warmth, edema
• Exudate
– Amount, color, consistency, odor
Wound Healing
• Primary Intention
– skin edges are approximated (closed) as in a surgical
wound
– Inflammation subsides within 24 hours (redness,
warmth, edema)
– Resurfaces within 4 to 7 days
• Secondary Intention: tissue loss
– Burn, pressure ulcer, severe lasceration
– Wound left open
– Scar tissue forms
Wound Healing
• Inflammatory Response
– Serum and RBC’s form fibrin network
– Increases blood flow with scab forming in 3 to 5 days
• Proliferative Phase: 3-24 days
– Granulation tissue fills wound
– Resurfacing by epithelialization
• Remodeling: more than 1 year
– collagen scar reorganizes and increases in strength
– Fewer melanocytes (pigment), lighter color
Some Factors Influencing Wound
Healing
• Age
• Nutrition: protein and Vitamin C intake
• Obesity decreased blood flow and increased risk for
infection
• Tissue contamination: pathogens compete with cells for
oxygen and nutrition
• Hemorrhage
• Infection: purulent discharge
• Dehiscence: skin and tissue separate
• Evisceration: protrusion of visceral organs
• Fistula: abnormal passage through two organs or to
outside of body
Therapeutic Modalities
• Contingent on location, size, wound type,
exudate, infection, dressed or undressed
• Assessment
– Inspect and palpate surrounding area
– Wound edge approximation (healing ridge noted)
– Presence and characteristics of drainage
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Serous
Sanguineous
Serosanguineous
Purulent
Consistency, odor and amount
Wound Assessment
• Wound Closure
– Staples
– Sutures
– Steri-strips
• Drains
– Penrose
– Hemovac or Jackson Pratt exert low pressure
Some Dressing Types and
Assistive Devices
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Dry Dressings
Wet-to-Dry Dressings
Packing
Wound Vacuum Assisted Closure: apply local
negative pressure to draw wound edges
together; healing acclerated with the formation
of granulation, collagen etc. to close wound or
prepare for skin grafting
• Electrical Stimulation
• Abdominal Binders
• Montgomery Straps
Heat and Cold Therapies
• Heat
– Vasodilation
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Increases blood flow
Nutrient delivery
Removal of waste
Decreases venous congestion
– Blood Viscosity Decreased
• leuokocytes
• antibiotics
Heat and Cold Applications
• Heat
– Muscle relaxation with decrease in pain from
spasm and stiffness
– Tissue Metabolism increased with increased
warmth and blood flow
– Increased capillary permeability promotes
nutrient delivery and waste removal
Cold Applications
• Vasoconstriction
– Reduce blood flow preventing edema
formation and decreases inflammation
– Local anesthesia
– Cell metabolism decreased with o2 demands
decreased
– Increased blood viscosity promotes
coagulation
– Pain relief with decrease in muscle tension
– Direct Trauma; superficial lacerations, arthritis
Complications
• Heat application leads to reflex
vasoconstriction within 1 hour
– Complications
• Epithelial cells damaged
• Redness, tenderness, blistering
Complications
• Cold
– Reflex vasodilation
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Tissue ischemia
Skin redness
Bluish purple mottling
Numbness
Burning pain
Tissues may freeze
Modalities
• MD order: body site, type, frequency and
duration of application
• Moist or dry
• Warm/Cold Compresses
• Warm Soaks (relaxation, debride wounds)
• Sitz Baths (rectal or vaginal surgery,
hemorrhoids, episiotomy)
• Aquathermia pads (muscle sprains,
inflammation or edema)
• Commerical Hot and Cold Packs
Contraindications
• Heat
– Site with active bleeding
– Acute localized pain (appendicitis) leads to
rupture
– Cardiovascular (vasodilation to large areas
leads to decrease blood supply to vital organs
Contraindications
• Cold
– Site pre-existing edema prevents absorption
of intersitial fluid
– Neuropathy (unable to sense)
– Shivering will intensify with acute elevations in
temperature
Critical Thinking
• What other factors need to be assessed
before application of heat and cold
therapies?
• Circulatory?
• LOC?
• Sensory?