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Chapter 31

Skin Integrity and Wound Care

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Functions of the Skin

• Protection
• Body temperature regulation
• Psychosocial
• Sensation
• Vitamin D production
• Immunologic
• Absorption
• Elimination

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Cross-Section of Normal Skin

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Factors Affecting the Skin • Unbroken and healthy skin and mucous membranes defend against harmful agents. Copyright © 2015 Wolters Kluwer • All Rights Reserved . • Resistance to injury is affected by age. • Adequately nourished and hydrated body cells are resistant to injury. • Adequate circulation is necessary to maintain cell life. amount of underlying tissues. and illness.

the maturation of epidermal cells is prolonged. leading to thin. • Circulation and collagen formation are impaired. • An infant’s skin and mucous membranes are easily injured and subject to infection. the skin is thinner and weaker than it is in adults. leading to decreased elasticity and increased risk for tissue damage from pressure.Developmental Considerations • In children younger than 2 years. Copyright © 2015 Wolters Kluwer • All Rights Reserved . • The structure of the skin changes as a person ages. easily damaged skin. a child’s skin becomes increasingly resistant to injury and infection.

• Excessive perspiration during illness predisposes skin to breakdown.Causes of Skin Alterations • Very thin and very obese people are more susceptible to skin injury. – Fluid loss during illness causes dehydration. Copyright © 2015 Wolters Kluwer • All Rights Reserved . such as eczema and psoriasis. • Jaundice causes yellowish. may cause lesions that require special care. itchy skin. • Diseases of the skin. – Skin appears loose and flabby.

full thickness.Types of Wounds • Intentional or unintentional • Open or closed • Acute or chronic • Partial thickness. complex Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Principles of Wound Healing • Intact skin is the first line of defense against microorganisms. • Normal healing is promoted when the wound is free of foreign material. Copyright © 2015 Wolters Kluwer • All Rights Reserved . • Response to wound is more effective if proper nutrition is maintained. • The extent of damage and the person’s state of health affect wound healing. • Careful hand hygiene is used in caring for a wound. • The body responds systematically to trauma of any of its parts. • An adequate blood supply is essential for normal body response to injury.

Phases of Wound Healing > • Hemostasis – Clotting and blood vessel constriction • Inflammatory – Fluid release. scar tissue formation Copyright © 2015 Wolters Kluwer • All Rights Reserved . WBCs move to wound • Proliferation – Regeneration of tissue • Maturation – New tissue.

Local Factors Affecting Wound Healing • Desiccation (dehydration) • Maceration (overhydration) • Trauma • Edema • Infection • Excessive bleeding • Necrosis (death of tissue) • Presence of biofilm (thick grouping of microorganisms) Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Systemic Factors Affecting Wound Healing • Age: children and healthy adults heal more rapidly • Circulation and oxygenation: adequate blood flow is essential • Nutritional status: healing requires adequate nutrition • Wound condition: specific condition of the wound affects healing • Health status: corticosteroid drugs and postoperative radiation therapy delay healing • Immunosuppression • Medication use Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Wound Complications • Infection • Hemorrhage • Dehiscence and evisceration • Fistula formation Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Factors Affecting Pressure Ulcer Development • Aging skin • Chronic illnesses • Immobility • Malnutrition • Fecal and urinary incontinence • Altered level of consciousness • Spinal cord and brain injuries • Neuromuscular disorders Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Mechanisms in Pressure Ulcer Development • External pressure compressing blood vessels • Friction or shearing forces tearing or injuring blood vessels Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Pressure Ulcer Assessment • Risk assessment • Mobility • Nutritional status • Moisture and incontinence • Appearance of existing pressure ulcer • Pain assessment Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Stages of Pressure Ulcers • Stage I: nonblanchable erythema of intact skin • Stage II: partial-thickness skin loss • Stage III: full-thickness skin loss. not involving underlying fascia • Stage IV: full-thickness skin loss with extensive destruction • Unstageable: base of ulcer covered by slough and/or eschar in wound bed Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Measurement of a Pressure Ulcer • Size of wound • Depth of wound • Presence of undermining. or sinus tract Copyright © 2015 Wolters Kluwer • All Rights Reserved . tunneling.

• Report any drainage or necrotic tissue. Copyright © 2015 Wolters Kluwer • All Rights Reserved . gentle motions to minimize trauma. • Use careful. • Use 0.9% normal saline solution to irrigate and clean the ulcer.Cleaning a Pressure Ulcer • Clean with each dressing change.

Psychological Effects of Wounds • Pain • Anxiety • Fear • Impact on activities of daily living • Change in body image Copyright © 2015 Wolters Kluwer • All Rights Reserved .

and pain – Serous drainage.serum and blood – Sanguineous drainage. drainage. and manifestation of complications Copyright © 2015 Wolters Kluwer • All Rights Reserved . drains or tubes.Wound Assessment • Inspection for sight and smell • Palpation for appearance.Infected • Sutures.bloody drainage – Purulent drainage.clear serum – Serosanguineous drainage.

and aesthetic comfort • Remove necrotic tissue • Prevent.Purposes of Wound Dressings • Provide physical. or control infection • Absorb drainage • Maintain a moist wound environment • Protect wound from further injury • Protect skin surrounding wound Copyright © 2015 Wolters Kluwer • All Rights Reserved . eliminate. psychological.

• Wound feels hot on palpation. • Drainage is increased and possibly purulent. • Wound is deep red in color. Copyright © 2015 Wolters Kluwer • All Rights Reserved .Presence of Infection • Wound is swollen. with dehiscence present. • Foul odor may be noted. • Wound edges may be separated.

Types of Wound Dressings • Dry or moist gauze • Iodoform gauze.autolytic debridement (duoderm) • Enzymatic. vaseline gauze • Telfa • Gauze dressings • Transparent dressings • Hydrocolloidals.Aquacel • Mechanical debridement • Surgical debridement • Hyperbaric treatment Copyright © 2015 Wolters Kluwer • All Rights Reserved .Accuzyme • Alginates.

Application of Bandages • Roller bandages • Circular turn • Spiral turn • Figure-of-eight turn • Recurrent-stump bandage Copyright © 2015 Wolters Kluwer • All Rights Reserved .

and groin area • Sling: used to support an arm Copyright © 2015 Wolters Kluwer • All Rights Reserved . perineum.Types of Binders • Straight: used for chest and abdomen • T-binder: used for rectum.

Type of Drainage Systems • Open systems – Penrose drain • Closed systems – Jackson-Pratt drain – Hemovac drain Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Color Classification of Open Wounds • R = red—protect • Y = yellow—cleanse • B = black—débride • Mixed wound—contains components of RY&B wounds Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Topics for Home Health Care Teaching • Supplies • Infection prevention • Wound healing • Appearance of the skin/recent changes • Activity/mobility • Nutrition • Pain • Elimination Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Factors Affecting the Response to Hot and Cold Treatments • Method and duration of application • Degree of heat and cold applied • Patient’s age and physical condition • Amount of body surface covered by the application Copyright © 2015 Wolters Kluwer • All Rights Reserved .

moist compresses – Sitz baths – Warm soaks Copyright © 2015 Wolters Kluwer • All Rights Reserved .Effects of Applying Heat • Dilates peripheral blood vessels • Increases tissue metabolism • Reduces blood viscosity and increases capillary permeability • Reduces muscle tension • Helps relieve pain • Methods of heat application: – Hot water bags or bottles – Electric heating pads – Aquathermia pads – Hot packs – Warm.

Effects of Applying Cold • Constructs peripheral blood vessels • Reduces muscle spasms • Promotes comfort • Methods of cold application: – Ice bags – Cold packs – Hypothermia blankets – Cold compresses to apply moist cold Copyright © 2015 Wolters Kluwer • All Rights Reserved .