Maintaining Skin Integrity & Wound Care

Structure of Skin
• Skin Layers – Epidermis – Dermis – Subcutaneous Tissue- Fat and connective tissues • Skin appendages – nails, hair, sweat gland and sebaceous glands

Structure of Skin
• Skin Layers
– Epidermis – Dermis – Subcutaneous Tissue- Fat and connective tissues

Structure of Skin • Skin Layers – Epidermis .

Epidermis .

Dermis . – Supports and nourishes the epidermis.Structure of Skin • Skin Layers – Dermis is the thickest skin layer composed of connective tissue.

Layers of the Dermis Stratum corneum (SC) .dead and dying cells push their way to the skin surface (desquamation) .

Layers of the Dermis Stratum granulosa (SGR) – keratinocytes lipids .

Layers of the Dermis Stratum spinonum (SS) – separates stratum germination and stratum granulosa .

Layers of the Dermis Stratum germinaton (SG) .

• Skin Layers Structure of Skin – Subcutaneous Tissue • Fat and connective tissues Subcutaneous Tissue (hypodermis) .

Structure of Skin • Skin appendages – nails. hair. sweat gland and sebaceous glands .

from physical and chemical injury.ultraviolet rays from sun synthesizes Vitamin D.communicates through expressions and other non-verbal messages. • Metabolism . itch. heat/cold.Regulate body temperature.skin contains nerves that are sensitive to pain. vibration. • Communication . .FUNCTION OF THE SKIN • Protection . • Sensation . • Thermoregulation .

– The greater accumulation of melanin. the darker the skin tone. .CHARACTERISTICS OF THE SKIN • Color – Vary in races.

allergies 2. sensitivity to sunlight. Genetics / heredity • Skin color. . Age • Young & old skin are fragile • Healing is rapid in infant & children 3.Factors affecting skin integrity 1. Health • Illnesses & their treatment affects skin integrity • Cortecosteroids cause thinning of the skin causing harm.

Activity . chemotherapy drugs for cancer & psychotherapeutic drugs affects skin integrity • Poor nutrition 4.• Antibiotics.

CHARACTERISTICS OF THE SKIN (cont. • Odor .smooth with good elasticity.) • Temperature .Usually free from odor.normally dry.usually warm. . • Moisture . but moisture can accumulate in skin folds. • Texture and Thickness .

LIFESPAN CONSIDERATIONS • Newborn and Infant – Thinner and mores sensitive – Susceptible to blistering. chafing and rashes from irritation – Can develop “heat” .

LIFESPAN CONSIDERATIONS • Toddler and Preschooler– More prone to accidents and burns – Use sunscreen .

LIFESPAN CONSIDERATIONS • School-Age and Adolescent – Many childhood diseases – Adolescents develop pubic. . axillary and other body hair. • May develop acne.

. – Skin tags. – May have benign growths.LIFESPAN CONSIDERATIONS • Adults and Older adults – Becomes thinner and less elastic and develops wrinkles. – Moles get larger.

– Arteries and veins must be patent. – Heart must be able to pump adequately.FACTORS AFFECTING INTEGUMENTARY FUNCTION • Circulation – skin needs good blood flow. – Capillary pressure must be adequate. . – Volume of blood must be sufficient.

• Circulation problems lead to – Leg Ulceration - .

• Circulation problems lead to – Pressure Ulcers (decubitus) .result wh blood flow to skin is impeded usually by pressure • Increased pressure • Mental Status • Moisture • Nutrition and Metabolism .

) • Nutrition –well balance diet • Lifestyle and Habits .FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.hygiene • Condition of the Epidermis – free from breaks .

) • Allergy • Infections • Abnormal Growth Rate .FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.

) • Systemic Diseases • Trauma .accidental or surgical wounds • Excessive Exposure .FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.

intense pain.itching is usually allergy or inflammatory.MANIFESTATIONS OF ALTERED INTEGUMENTARY FUNCTION • Pain . . • Pruritis .stimulation of nerves in the skin due to alteration of the skin. – Highly sensitive. sharp.

MANIFESTATIONS OF ALTERED INTEGUMENTARY FUNCTION • Rash . communicable disease or stress.involves loss of structure or function of normal tissue. • Lesions . allergy . .caused by excessive heat. – Vary is size.

no break but soft tissue injury .TYPES OF WOUNDS • Broad Categories – Accidental unintentional Injury – Surgical .ragged tear – Contusion .closed with bleeding into underlying tissues • Skin Integrity – Open .penetrating wound – Laceration .break in Skin – Closed .friction of the skin – Puncture .planned therapy • Description – Abrasion .

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Types of wound
1. Intentional trauma – occurs during therapy. E.g. operations or venipunctures 2. Unintentional wounds – are accidental e.g. fracture in the arm

DEGREE OF WOUND CONTAMINATION

• Clean

– Closed surgical wound that did not enter GI, respiratory, or GU systems

DEGREE OF WOUND CONTAMINATION

• Clean Contaminated
– Wound entering GI, respiratory or GU systems.

. traumatic wound. surgical wound with break in asepsis.DEGREE OF WOUND CONTAMINATION • Contaminated – Open.

DEGREE OF WOUND CONTAMINATION • Infected – Wound site with pathogens present. .

subcutaneous tissue & possibly muscle and bone. require connective tissue repair.involving the dermis.confined to the skin. & heal by regeneration • Full thickness. epidermis. . dermis. epidermis.Classifying wound by DEPTH • Partial thickness.

.WOUND HEALING • Wounded skin is repaired by regeneration or damaged tissues with connective repair. • Partial and full thickness wounds are healed by 4 phases.

WOUND HEALING PHASE 1 – Inflammatory phase Lasts 3-5 days. Two major Processes: hemostasis and phagocytosis .

. = deposition of fibrin and the formation of blood clots in the area.• Hemostasis= which is the cessation of bleeding = results from vasoconstriction of the larger blood vessels in the affected area.

• Blood clots form from blood platelets. Provide a matrix of fibrin that becomes the framework for cell repair. Scab form on the surface of the wound .

• In phagocytosis there is attraction of leukocytes to the wound bed and engulfing of microorganisms and cellular debris by macrophages .

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3) Wound healing and tissue repair . 2) The formation of a physical barrier to the spread of the tissue damage or infection.The functions of the inflammatory response include: 1) The delivery of effector molecules and cells to the sites of infection.

3.Edema Emigration of cells Chemotaxis Shashi-Mar 2000 . 5.WOUND HEALING Inflammation-13 Inflammation . 2.Mechanism 1. Vasoconstriction Vasodilatation Exudation . 4.

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Proliferative Phase of Wound Healing • From post injury day 3 or 4 until day 21post injury • Collagen synthesis Collagen whitish protein substance that adds tensile strength to the wound. • Granulation tissue formation • Eschar dried plasma protein & dead cells .

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Maturation Phase of Wound Healing (remodeling) • From day 21 until 1 or 2 years post injury • Collagen organization • Remodeling or contraction • Scar stronger .

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TYPES OF WOUND HEALING • Primary intention • Secondary intention • Tertiary intention .

– Granulation is not visible and scarring is minimal.TYPES OF WOUND HEALING (cont. .) • Primary intention – Edges of wound approximated.

it is characterized by the formation of minimal granulation tissue and scarring.Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. .g. e. closed surgical incision Primary intention healing is healing of a wound where the wound edges heal directly touching each other. It is also called primary union or first intention healing.

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– Wound gradually fills with soft tissue buds. . – Epithelial cells grow over this to form skin.) • Secondary intention – Extensive tissue loss.TYPES OF WOUND HEALING (cont.

e.g. and in which the edges cannot or should not be approximated. Secondary intention healing differs from primary intention healing in three ways:1.Susceptibility to infection is greater .It is extensive and involves considerable tissue loss.The repair time is longer 2..Scarring is greater 3. pressure ulcer.

) • Tertiary intention – Delay ensues between injury and approximation – Also known as delayed primary intention .TYPES OF WOUND HEALING (cont.

Hand abrasion Approximate days since injury 0 2 17 30 .

Exudate • Material such as fluid and cells that have escaped from blood vessels during inflammatory process • Deposited in tissue or on tissue surface • 3 major types – Serous – Purulent – Sanguineous (hemorrhagic) .

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

Purulent Exudate • Thicker • Presence of pus • Color varies with organisms .

Sanguineous Exudate • Hemorrhagic • Large number of RBCs • Indicates severe damage to capillaries .

Mixed Exudate • Serosanguineous – Clear and blood-tinged drainage • Purosanguineous – Pus and blood .

Medications. Obesity. and Stress • Local Factors – Nature of the Injury – Presence of Infection – Local Wound Environment .FACTORS AFFECTING HEALING • Systemic Factors – Nutrition nutritional deficiencies retard healing.  Circulation and Oxygenation Hemoglobin levels – Immune Cellular Function Immunosuppre ssive Drugs • Individual Factors – Age. Smoking.

. • Evisceration . • Dehiscence . • Infection – Local and Systemic • Indicated by yellow/black coloration of wound itself.Abnormal passageway that forms between two organs.total or partial disruption in wound edges.localized collection of blood. • Other S&S.COMPLICATIONS OF WOUND HEALING • Hemorrhage and Interstitial Fluid Loss • Hematomas . • Fistula .protrusion of viscera through abdominal wound opening.

DEHISCENCE & EVISCERATION • Dehiscence: edges of wound fail to join may lead to. . • Most likely during 6-7 days post-op. • May lead to peritonitis & septic shock. • Evisceration: portion of the viscera (usually bowel loop) protrudes thru incision.

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. • Call physician ASAP.S. • Take V. • Place waterproof sterile drape over area. • Moisten every hr with NS. • Use sterile towel/dressing saturated with NS & place them over viscera. • Tell client to stay in bed. • Have someone stay with client.IMPLEMENTATION for Dehisence or Evisceration • Provide reassurance & support.

use strict sterile technique.PREVENTION for Dehisence or Evisceration • Client with poor healing should be given adequate supply of protein. • Assess wound during dressing change. • Monitor dietary deficiencies. . • Do not bandage wound to tightly. & calories. treat infection early. vitamins.

Nursing Process: Assessment • Nursing history – – – – – – Review of systems Skin diseases Previous bruising General skin condition Skin lesions Usual healing of sores .

Assessment Data • Inspection and palpation – – – – – Skin color distribution Skin turgor Presence of edema Characteristics of any skin lesions Particular attention paid to areas that are most likely to break down .

width.Assessment Data • Untreated wounds – – – – – – – Location Extent of tissue damage Wound length. and depth Bleeding Foreign bodies Associated injuries Last tetanus toxoid injection .

Assessment Data • Treated wounds – – – – – – Appearance Size Drainage Presence of swelling Pain Status of drains or tubes .

Risk Factors for Pressure Ulcers • Advanced age • Chronic mental conditions • Poor lifting and transferring techniques • Incorrect positioning • Hard support surfaces • Incorrect application of pressurerelieving devices .

Assessment of Pressure Ulcers • Location of the ulcer related to a bony prominence • Size of ulcer in centimeters including length (head to toe). and depth • Presence of undermining or sinus tracts • Stage of the ulcer • Color of the wound bed • Location of necrosis or eschar • Condition of the wound margins • Integrity of surrounding skin • Clinical signs of infection . width (side to side).

Assessment of Pressure Sites • Inspect pressure areas for discoloration and capillary refill or blanche response • Inspect pressure areas for abrasions and excoriations • Palpate the surface temperature over the pressure area sites • Palpate bony prominences and dependent body areas for the presence of edema .

Assessment of Laboratory Data • • • • Leukocyte count Hemoglobin level Blood coagulation studies Serum protein analysis – Albumin level • Results of wound culture and sensitivities .

Nursing Diagnoses – Risk for Impaired Skin Integrity – Impaired Skin Integrity: – Impaired Tissue Integrity – Risk for Infection – Pain .

Goals in Planning Client Care • Risk for Impaired Skin Integrity – Maintain skin integrity – Avoid or reduce risk factors • Impaired Skin Integrity – Progressive wound healing – Regain intact skin • Client and family education – Assess and treat existing wound – Prevention of pressure ulcers .

Measures to Prevent Pressure Ulcers • • • • Providing nutrition Maintaining skin hygiene Avoiding skin trauma Providing supportive devices .

zinc Dietary consult Weight/lab data monitoring .Providing Nutrition • • • • Fluid intake Protein. vitamins.

Maintaining Skin Hygiene • • • • Mild cleansing agents Avoid hot water Moisturizing lotions/skin protection Reduce irritants .

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

Risk Assessment Tools • Braden Scale for Predicting Pressure Sore Risk • Norton’s Pressure Area Risk Assessment Form Scale .

1988) • Sensory Perception: 1-4 Score ____ – Completely limited to No Impairment • Mobility: 1-4 Score_____ – Completely Immobile to No Impairment • Nutrition: 1-4 Score _____ – Very poor to Excellent • Activity: 1-4 Score_____ – Bedfast to Walks frequently • Friction/Shear :1-4 Score _____ – Problem.Nursing Assessment: Braden Scale Risk to Develop Pressure Ulcers (Braden. 12 or below=High Risk . 13-14=Moderate Risk. potential or none – Total Score: determines Risk Above 16=Minimal risk – 15-16=Low Risk. B.

. C. lateral position.Figure 36-3 Body pressure areas in A. B. Fowler’s position. prone position. D. supine position.

Figure 36-3 (continued) Body pressure areas in A. supine position. D. Fowler’s position. . C. lateral position. prone position. B.

prone position. supine position. C. B.Figure 36-3 (continued) Body pressure areas in A. Fowler’s position. . D. lateral position.

. prone position. B. supine position. C. lateral position. D. Fowler’s position.Figure 36-3 (continued) Body pressure areas in A.

Four Stages of Pressure Ulcer Formation A B C D .

STAGES OF PRESSURE ULCERS (DECUBITUS)
•Non blanching erythema

STAGES OF PRESSURE ULCERS (DECUBITUS)
•Partial-thickness skin loss. •Involving the epidermis and possibly the dermis. •Examples: Abrasion, blister, or shallow crater.

STAGES OF PRESSURE ULCERS (DECUBITUS)
•Full-thickness skin loss •Involving damage or necrosis of SQ tissue that may extend down to, but not through, underlying fascia. •A deep crater.

STAGES OF PRESSURE ULCERS (DECUBITUS)
•Full-thickness skin loss with tissue necrosis or damage.

•Involves damage to muscle, bone or supporting structures, such as a tendon or joint capsule.
•Sinus tracts may be present.

Providing Supportive Devices
• • • • Mattresses Beds Wedges, pillows Miscellaneous devices

if infected Teach the client Provide ROM exercise .Treating Pressure Ulcers • • • • • • • • 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.

RYB Color Guide for Wound Care • Red (protect) • Yellow (cleanse) • Black (debride) .

. or transparent film. cover with protective barrier such as duoderm.• Red: protect by gentle cleansing. hydrogel.

irrigating the wound. alginate dressings and topical antimicrobial .• Yellow: cleanse to remove nonviable tissue by applying moist to moist normal saline dressings.

mechanical. Debridement is mostly done by PT .• Black: debridement can be done by sharp. maggots. chemical. or autolytic.

Debridement may be achieved in four different ways: 1. . 2. Sharp debridement. a scalpel or scissors is used to separate and remove dead tissue. Mechanical debridement through scrubbing force or mist to moist dressings.

such as hydrocolloid and clear absorbent dressings. 4.3. dressing that contain wound moisture. Chemical debridement collagenase enzyme agents such as papain – urea. A utolytic debridement . .

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and zinc intake Dietary consult Nutritional supplements Monitor weight/lab values . vitamin.Promoting Wound Healing • • • • • Fluid intake Protein.

• apply moisturizing lotions while the skin is moist after bathing. . exposure to cold and low humidity.Maintaining Skin Hygiene • Use mild cleansing agents that do not disrupt the skin’s “natural barriers.”_ • avoid using hot water.

Apply skin protection (dimethicone-based creams or alcohol-free barrier films) if indicated.• keep skin clean. . feces. and dry skin completely after a bath. dry and free of irritation and maceration by urine._Avoid massaging over bony prominences since massage may lead to deep tissue trauma. sweat.

Types of Wound Dressings • • • • • • • Transparent film Impregnated nonadherent Hydrocolloids Clear absorbent acrylic Hydrogel Polyurethane foam Alginate .

to maintain a clean moist surface that facilitates cellular migration. . to provide insulation by preventing fluid evaporation.Transparent film • is used to provide protection against contamination and friction. and to facilitate wound assessment.

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soothe. . and protect partialand full-thickness wounds without exudate.Impregnated nonadherent dressings • are used to cover.

and urine or feces.Hydrocolloid dressings • are used to absorb exudate. and to prevent shearing. to protect the wound from bacterial contamination. foreign debris. to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin. .

and can be used with alginates to provide packing to deeper wound beds. . provide bacterial and shearing protection.Clear absorbent acrylic dressings • maintain a transparent membrane for easy wound bed assessment. maintain moist wound healing.

. and fill in dead space.Hydrogels • are used to liquefy necrotic tissue or slough. rehydrate the wound bed.

Polyurethane foams • absorb up to heavy amounts of exudate. . providing and maintaining moist wound healing.

to eliminate dead space or pack wounds. . and to support debridement. to absorb exudate.Alginates (exudate absorbers) • are used to provide a moist wound surface by interacting with exudate to form a gelatinous mass.

straight abdominal binder .Types of Bandages • Gauze – Retain dressings on wounds – Bandage hands and feet • Elasticized – Provide pressure to an area – Improve venous circulation in legs • Binders – Support large areas of body • Triangular arm sling.

. The tape should adhere to intact skin.Figure 36-10 The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing.

.Figure 36-11 Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

. Place the tape over a joint at a right angle to the direction the joint moves.Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client’s movement.

Place the tape over a joint at a right angle to the direction the joint moves.Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client’s movement. .

are used to secure large dressings that require frequent changing.Figure 36-12 Montgomery straps. . or tie tapes.

.Figure 36-13 Vacuum-assisted closure (VAC) system for wounds.

e.. . foreign materials.Cleaning wounds Wound cleaning involves the removal of debris ( i.Wound irrigation and packing . bacteria). necrotic tissue.

Bandages and binders serve various purposes: • Support a wound • Immobilizing a wound • Applying pressure • Securing a dressing • Retaining warmth .Supporting and immobilizing wounds Bandages: strip of cloth used to wrap some part of the body Binders : is a type of bandage designed for a specific body part.

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.Administer Heat and Cold Therapy • Heat and cold therapies require nursing care that assesses both the vasoconstriction and vasodilation of an individual.

.Local effect of heat • Sedative effect to relief pain and aches • Vasodilatation and increase blood flow to the affected area • Bringing oxygen and nutrients. antibodies. and leukocytes • Promote soft tissue healing • It is often used for clients with musculoskeletal problems such as arthritis.

Disadvantages: • Increase capillary permeability which cause edema .

which decrease the blood supply and nutrients to the affected area. • Decrease cellular metabolism • Decrease removal of wastes • Prolonged exposure to cold results impaired circulation. cell deprivation.Local effect of Cold • Vasoconstriction. and subsequent cell damage .

decrease inflammation • Local anesthetic effect .Advantages: • Slow bacterial growth.

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Shivering is the body response to cold. or large body area. especially for those with pulmonary and cardiac problems. increase in blood pressure.  Cold application cause vasoconstriction.Systemic effects of cold and heat  Heat applied to a localized body area. fainting. . it may cause excessive vasodilatation. drop in blood pressure.

the nurse need to follow these guidelines: • • • • • • • • Client’s ability to tolerate the therapy Contraindication of treatment such as bleeding Explain the application to client Assess skin area Ask the client to report any discomfort Return to the client after 15 minutes Remove the equipment at the designed time Examine the area and record the result .For all local applications of heat and cold.

• Conditions that necessitate precautions in the use of heat and cold applications: – Neurosensory impairment – Impaired mental status – Impaired circulation – Open wounds. broken skin. scar formation. edema .