Chapter 36 - Skin And Wounds

Front 1

Types of Wounds

Back 1

Intentional wounds - occur during therapy ex. venipuncture, surgery

Unintentional wounds - occur from an accident. Trauma under the skin is a closed wound. If skin is broken, open wound.

Wounds are classified by depth, that is, the tissue layers involved in the wound or how they are acquired.

Front 2

Clean Wounds

Back 2

uninfected wounds in which minimal inflammation is encountered and the respiratory, alimentary, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds.

Front 3

Clean-contaminated Wounds

Back 3

surgical wounds in which Age influences skin integrity in that the skin of both the very the respiratory, alimentary, genital, or urinary tract has been entered. Such wounds show no evidence of infection

Front 4

Contaminated wounds

Back 4

include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Contaminated wounds show evidence of inflammation

Front 5

Incision

Back 5

sharp instrument; open wound; deep or shallow; ex. scalpel, knife

Front 6

Contusion

Back 6

blow from a blunt instrument; closed wound, skin appears ecchymatic because of damaged blood vessels.

Front 7

Abrasion

Back 7

surface scrape; can be intentional or unintentional; open wound involving the skin. Ex. scraped knee or dermal abrasion)

Front 8

Puncture

Back 8

Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional/unintentional; open wound

Front 9

Laceration

Back 9

tissues torn apart, often from accidents; open wound; edges are often jagged; ex with machinery

Front 10

Penetrating Wound

Back 10

Penetration of the skin and the underlying tissues, usually unintentional; open wound; ex from a bullet or metal fragment

Front 11

Dirty or infected wounds

Back 11

include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.

Front 12

Wound Healing Process

Back 12

3 phases:
Inflammatory Phase
Proliferative Phase
Maturation Phase

Front 13

Inflammatory Phase of Wound Healing

Back 13

• Immediately after injury; lasts 3 to 6 days
• Hemostasis
• Phagocytosis

Front 14

Proliferative Phase of Wound Healing

Back 14

• From post injury day 3 or 4 until day 21
• Collagen synthesis
• Granulation tissue formation – if it doesn’t form then there might be an infection

Front 15

Maturation Phase of Wound Healing

Back 15

• From day 21 until 1 or 2 years post injury
• Collagen organization
• Remodeling or contraction
• Scar stronger

Front 16

Primary Intention Healing

Back 16

• Tissue surfaces closed
• Minimal or no tissue loss
• Formulation of minimal granulation and scarring
ex. closed surgical incision

Front 17

Secondary Intention Healing

Back 17

• Extensive tissue loss
• Edges cannot be closed
• Repair time longer
• Scarring greater
• Susceptibility to infection greater
Ex. burns and pressure ulcers

Front 18

Tertiary Intention Healing

Back 18

(Delayed Primary Intention)
• Initially left open
• Edema, infection, or exudate resolves
• Then closed

Front 19

Wound Drainage (Exudate)

Back 19

• Material such as fluid and cells that have escaped from blood vessels during inflammatory process (edema)
4 Types Serous, Purulent, Sanguineous, Mixed

Front 20

Serous Exudate

Back 20

• Mostly serum
• Watery, clear of cells
• E.g., fluid in a blister

Front 21

Purulent Exudate

Back 21

• Thicker
• Presence of pus
• Color varies with organisms

Front 22

Sanguineous Exudate

Back 22

• Hemorrhagic
• Large number of RBCs
• Indicates severe damage to capillaries

Front 23

Mixed Exudate

Back 23

• Serosanguineous - Clear and blood-tinged drainage
• Purosanguineous - Pus and blood

Front 24

Complications of wound healing

Back 24

• Hemorrhage – can be internal or external
• Infection
• Dehiscence - partial or total rupturing of a sutured wound
• Evisceration – protrusion of the internal viscera thru an incision.

Front 25

Factors Affecting Wound Healing

Back 25

age, nutritional status, lifestyle, medications, health status

Front 26

Pressure Ulcer Development

Back 26

-Immobility and inactivity
-inadequate nutrition
-fecal and urinary incontinence
-decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-chronic medical conditions- Diabetes, cardiovascular disease
-Friction-removes superficial layers making it prone to breakdown
-shearing - sliding downward in bed

Front 27

Pressure Ulcer Staging

Back 27

• Stage I: nonblanchable erythema signaling potential ulceration
• Stage II: partial-thickness skin loss involving epidermis and possibly dermis
• Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue
• Stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting
structures

Front 28

Skin Risk Assessment Tools

Back 28

• Provide the nurse with systematic means of identifying clients at high risk for pressure ulcer developmnet
• Braden Scale for Predicting Pressure Sore Risk
• Norton’s Pressure Area Risk Assessment Form Scale

Front 29

Nursing process: Assessing

Back 29

Nursing History and Physical assessment - skin diseases, previous bruising, general skin condition, skin lesions, usual healing of sores

Front 30

Assessing (con't)

Back 30

Inspection and Palpation - skin color distribution, skin turgor, edema, characteristic of any skin lesions; pay attention to areas that are most likely to break down such as folds, bony prominences, perineum

Front 31

Assessing (con't)

Back 31

Untreated wounds - location, extent of damage, wound length, width and depth, bleeding, foreign bodies, last tetanus
Treated Wounds- appearance, size, drainage, swelling, pain, status of drains/tubes

Front 32

Assessment of Pressure Ulcers

Back 32

-location
-stage
-color of wound bed - white/yellow=slough
red/beefy=granulation
-undermining or sinus tracts
-necrosis/eschar- black, brown or tan
-condition of wound margins
-integrity of surrounding skin
-signs of infection

Front 33

Assessment of Pressure sites

Back 33

Inspect for:
-discoloration and capillary refill/blanche response
-abrasions/excoriations
Palpate:
-surface temperature
-presence of edema
NO MASSAGING ON RED AREAS!!

Front 34

Assesment of Lab Data

Back 34

Leukocyte count
Hemoglobin level
Blood coagulation
Serum protein
Albumin level
Wound cultures

Front 35

Nursing Diagnoses

Back 35

Risk for Impaired Skin Integrity:
those at risk include Immuno-suppressed; immobile; unconscious, diabetic with impaired sensation; age, nutrition, incontinence

Front 36

Nursing Diagnoses (con't)

Back 36

- Impaired Skin Integrity: Stage 1 and 2 Pressure Ulcers
- Impaired Tissue Integrity: Stage 3 and 4
- Risk for Infection
- Pain

Front 37

Goals in Planning Client Care

Back 37

-maintain skin integrity ex. turning schedule
-progressive wound healing
-regain intact skin
-avoid or reduce risk factors
-Education:
assess and treat existing wounds; prevention

Front 38

Measures to Prevent Pressure Ulcers:
Nutrition

Back 38

• Fluid intake
• Protein, vitamins, zinc
• Dietary consult
• Weight/lab data monitoring

Front 39

Measures to Prevent Pressure Ulcers:
Maintaining Skin Hygiene

Back 39

• Mild cleansing agents
• Avoid hot water
• Moisturizing lotions/skin protection
• Reduce irritants

Front 40

Measures to Prevent Pressure Ulcers:
Avoiding Skin Trauma

Back 40

• Smooth, firm surfaces
• Semi-Fowler’s position
• Frequent weight shifts
• Exercise and ambulation
• Lifting devices
• Reposition q 2 hours
• Turning schedule

Front 41

Measures to Prevent Pressure Ulcers:
Providing Supportive Devices

Back 41

• Mattresses
• Beds
• Wedges, pillows

Front 42

Treating Pressure Ulcers

Back 42

• Minimize direct pressure
• Schedule and record position changes
• Provide devices to reduce pressure areas
• Clean and dress the ulcer using surgical asepsis
• Never use alcohol or hydrogen peroxide
• Obtain C&S, if infected (culture and sensitivity)
• Teach the client
• Provide ROM exercise

Front 43

RYB Color Guide for
Wound Care

Back 43

• Red (protect)
• Yellow (cleanse) – moist dressings, wet to dry dressings
• Black (debride) – scalpels, chemicals

Front 44

Promoting Wound Healing

Back 44

• Fluid intake
• Protein, vitamin, and zinc intake
• Dietary consult
• Nutritional supplements
• Monitor weight/lab values

Front 45

Cleaning wounds

Back 45

• use solutions or wound cleansers to clean or irrigate wounds
• warm solution to body temp
• if wound has debris, bacteria, slough or necrotic tissues, clean at every dressing change
• avoid re-cleaning clean wounds with healthy granulation tissue and little exudate
• use gauze squares instead of cotton
• retain wound moisture
• clean in outward direction

Front 46

Supporting and immobilizing wounds

Back 46

Bandages and binders serve to support and immobilize but also serve in:
• applying pressure
• securing a dressing
• retaining warmth
When used correctly they can promote healing, provide comfort and prevent injury

Front 47

Physiologic Effects of Heat

Back 47

• Vasdilation
• Increases capillary permeability
• Increases cellular metabolism
• Increases inflammation
• Produces sedative effect

Front 48

Indications for Heat

Back 48

• Muscle spasms
• Inflammation
• Pain
• Contracture
• Joint stiffness

Front 49

Physiologic Effects of Cold

Back 49

• Vasoconstriction
• Decreases capillary permeability
• Decreases cellular metabolism
• Slows bacterial growth
• Decreases inflammation
• Local anesthetic effect

Front 50

Indications for Cold

Back 50

• Muscle spasms
• Inflammation
• Pain
• Traumatic injury

Front 51

Methods for Applying
Dry and Moist Heat

Back 51

• Dry heat
Hot water bottle; aquathermia pad; disposable heat pack; electric pad
• Moist heat
Compress; hot pack; soak; sitz bath

Front 52

Methods for Applying Dry
and Moist Cold

Back 52

• Dry cold
Cold pack ;ice bag; ice glove; ice collar
• Moist cold
Compress; cooling sponge bath