Transcript Tissue integrity

Skin Integrity
and wound care
Tissue Integrity
Definition
Tissue integrity is the state of structurally
intact and physiologically functioning
epithelial tissues such as the integument
(including the skin and subcutaneous tissue)
and mucous membranes.
Categories of Impaired Skin Integrity
Epidermis
• SC: Cells are flattened &
dead
• Protects underlying cells
and tissues from
dehydration and prevents
entrance of certain
chemical agents. It allows
evaporation of water
from the skin and permits
absorption of certain
topical medications
Dermis
Inner Layer
• Provides tensile
strength, mechanical
support, and protection
to the underlying
muscles, bones and
organs.
• It contains mostly
connective tissue and
few skin cells
Pressure Ulcer
• A localized injury to the skin and other underlying
tissue, usually over a body prominence, as a result of
pressure or pressure in combination with shear
and/or friction.
Pathogenesis of Pressure Ulcers
• Pressure Intensity
– Tissue ischemia
– Blanching
• Pressure Duration
• Tissue Tolerance
Risk Factor for Pressure
Ulcer Development
• Prolong pressure
• Shearing
• Friction
Classification of Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
• Intact skin with nonblanchable redness
• Partial-thickness skin loss involving
epidermis, dermis, or both
• Full-thickness tissue loss with visible fat
• Full-thickness tissue loss with exposed bone,
muscle, or tendon
Classification of Pressure Ulcers
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Stage I: Nonblanchable Redness of Intact Skin
Stage II: Partial-thickness Skin Loss or Blister
Stage III: Full-thickness Skin Loss (Fat Visible)
Stage IV: Full-thickness Tissue Loss (Muscle/Bone
Visible)
• Unstageable/Unclassified: Full-thickness Skin or
Tissue Loss-Depth Unknown
• Deep-Tissue injury: Full-thickness Skin or Tissue
Loss-Depth Unknown
Wounds and Wound Care
Complications of Wound Healing
• Hemorrhage
– Initial trauma: normal during and immediately
after.
– After hemostasis:
• Slipped surgical suture
• Dislodged clot
• Infection
• Erosion of a blood vessel
Complications of Wound Healing
• May be internal or external
– Internal
• Distention or swelling of the affected body part
• Type and amount of drainage drain surgical drain
• Signs of hypovolemic shock
• Hematoma: localized collection of blood underneath the
tissue
– External
• Obvious!
• Risk of hemorrhage is great during first
24-48 hours after surgery or injury
Complications of Wound Healing
• Infection: wound infection is the second most
common health care-associated infection
– A wound is infected if purulent material drains from it
– Wound infection is greater when
• Wound contains death or necrotic tissue
• There are foreign bodies in or near the wound
• Blood supply and local tissue defense are reduced
– Bacterial wound infection inhibits wound healing
Complications of Wound Healing
– Signs and symptoms of wound infection
• Contaminated or traumatic wounds: 2-3 days
• Post op surgical wound: 4-5 days
• Fever, tenderness and pain at wound site
• Elevated WBC count
• Wound edges appear inflamed
• Drainage may be present: odorous and
purulent (yellow, green, or brown)
Infection
Serous
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Clear, watery plasma
Purulent
– Thick, yellow, green,
Tan, or brown
Serosanguineous
• Redness, warmth, pain,
and an elevated WBC
count
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Pale, pink, watery:
Mixture of clear and red
Fluid
Sanguineous
– Bright red: indicates
Active bleeding
Complications of Wound Healing
• Dehiscence: partial or
total separation of
wound layers
Complications of Wound Healing
• Evisceration: With total
separation of wound
the visceral organ
protrudes through the
wound opening
Wound Management
• Principles to maintain a healthy wound
environment:
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Prevent and manage infection
Clean the wound
Remove nonviable tissue
Manage exudate
Maintain the wound in a moist environment
Protect the wound
Prevent and Manage Infection
• Cleaning the wound
– Pressure ulcers: use noncytotoxic wound cleaners
– NS: preferred cleaning agent, does not harm tissue
– Commercial wound cleaners
– Other wounds: cytoxic wound cleaners
• Dakin’s solution
• Acetic acid
• Povidone-iodine
• Hydrogen peroxide
• Irrigation is a common method of delivering
wound-cleaning solution to the wound.
Debridement
• Debridement is the removal of nonviable, necrotic
tissue.
– Wet to dry dressings
– Autolytic debridement
– Chemical debridement
– Surgical debridement
Protection
• Protect the wound by applying a sterile or clean
dressing.
• For surgical wounds that heal by primary intention, it
is common to remove dressings as soon as drainage
stops.
• For wounds healing by secondary intention, the
dressing material becomes a means for providing
moisture to the wound or assisting in debridement.
Purposes of Dressings
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Protect a wound from microorganism contamination
Aid in hemostasis
Promote healing by absorbing drainage and
debriding a wound
Support or splint the wound site
Protect patients from seeing the wound (if perceived
as unpleasant)
Promote thermal insulation of the wound surface
Dressings
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Dry or moist
Gauze
Dressing
• Film dressing
Dressing
• Hydrocolloid—protects the wound from
surface from from surface contamination
Dressings
• Hydrogel—maintains a moist
surface to support healing
Dressings
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Wound vacuum assisted closure (V.A.C.)—
uses negative pressure to support healing
Dressings
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Changing
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Know type of dressing, placement of drains, and
equipment needed.
Prepare the patient for a dressing change
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Evaluate pain.
Describe procedure steps.
Gather supplies.
Recognize normal signs of healing.
Answer questions about the procedure or wound.
During a Dressing Change
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Assess the skin beneath the tape.
Perform thorough hand hygiene before and after
wound care.
Wear sterile gloves before directly touching an open
or fresh wound.
Remove or change dressings over closed wounds
when they become wet or if the patient has signs or
symptoms of infection, and as ordered.
Dressings
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Packing a wound
 Assess size, depth, and shape
Securing
 Tape, ties, or binders
Comfort measures
 Carefully remove tape.
 Gently clean the wound.
 Administer analgesics before dressing
change.
Cleaning Skin
1. Clean in a direction from the least contaminated
area such as from the wound or incision to the
surrounding skin or from an isolated drain site to
the surrounding skin.
2. Use gentle friction when applying solutions
locally to the skin.
3. When irrigating, allow the solution to flow from
the least to the most contaminated area.
PICC Line Dressing Changing Kit
Cleaning around the insertion site
Putting on the new dressing
Putting on the new dressing
Completed dressing change with date