P&P Chapter 48: Skin Integrity and Wound Care

P&P Chapter 48: Skin Integrity and Wound Care

1. • Discuss the risk factors that contribute to pressure ulcer formation.

   • Any patient that experiences a decrease in mobility, decrease sensory perception, fecal or urinary incontinence, and/or poor nutrition are at risk for pressure ulcer development
   • Patients who are at risk are; older adults, that have experienced trauma, spinal cord injuries, sustained a fractured hip, long-term homes or community care, the acute ill, individuals with diabetes, patients in critical care settings.

2. • Describe the pressure ulcer staging system.

   • STAGE I: Nonblanchable Redness of Intact Skin: Intact skin with nonblanchable erythema of a localized area (usually over a bony prominence). skin discoloration, warmth, edema, hardness, or pain a(dark pigmented skin "at-risk" may not have visible blanching, difficult to detect), area may be painful, firm, soft, warmer, or cooler than adjacent tissue.
     • STAGE II: Partial-thickness Skin Loss or Blister: partial-thickness loss of dermis, shiny or dry shallow open ulcer with red-pink wound bed without slough or bruising. may present as an intact or open/ruptured serum-filled or serosangineous filled blister,this stage shouldn't be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation
       • STAGE III: Full-thickness Skin Loss (Fat Visible): subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. some slough may be present. may include undermining and tunneling, depth of a stage III pressure ulcer varies by anatomical location. (bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and stage III ulcers can be shallow). areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable
         • STAGE IV: Full-thickness Tissue Loss (Muscle/Bone Visible): exposed bone, tendon, or muscle. slough/eschar may be present; often includes undermining and tunneling. depth of a stage IV pressure ulcer varies by anatomical location. (bridge of nose, ear, occiput, and malleolus don't have (adipose) subcutaneous tissue; and these ulcers can be shallow). can extend into muscle and/or supporting structures (fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. exposed bone/muscle is visible or directly palpable
           • UNSTAGEABLE/UNCLASSIFIED: Full-thickness Skin or Tissue Loss—Depth Unknown: base of the wound cannot be visualized. loss in which actual depth of ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in wound bed. until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but is either a stage III or IV. Stable eschar (dry, adherent, intact without erythema or fluctuance) on heels serves as "the natural (biological) cover of the body" and should not be removed.
             • SUSPECTED DEEP-TISSUE INJURY —Depth Unknown: purple/maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear area may be preceded by tissue that's painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue. difficult to detect in individuals with dark skin tones. --evolution may include a thin blister over a dark wound bed. may further evolve and become covered by thin eschar. --evolution may be rapid, exposing additional layers of tissue even with treatment.

3. • Discuss the normal process of wound healing.

   • PARTIAL-THICKNESS WOUNDS: shallow wounds involving loss of the epidermis and possibly partial loss of dermis. Heal by epidermis regeneration (surgical wound or an abrasion)
     • 1) INFLAMMATORY RESPONSE: causes redness and swelling with moderate amount of serous exudate. Generally limited to the first 24 hours after wounding.
       • 2) EPITHELIAL PROLIFERATION (reproduction) and MIGRATION: epithelial cells regenerate, providing new cells to replace lost cells. Start at both the wound edges and epidermal cells lining epidermal appendages, allowing for quick resurfacing. Epithelial cells migrate across wound bed soon after a wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. The difference in healing rate is related to the fact that epidermal cells only migrate across a moist surface. (in a dry wound the cells migrate down into a moist level before migration can occur)
         • 3) REESTABLISHMENT of EPIDERMAL LAYERS: new epithelium is only a few cells thick and must undergo reestablishment of epidermal layers. cells slowly reestablish normal thickness and appear as dry, pink tissue.
   • FULL THICKNESS WOUNDS: extend into dermis (involving both layers of tissue). heal by scar formation, because deeper structures don't regenerate (pressure ulcers)
     • 1) HEMOSTASIS: injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that provides a framework for cellular repair
       • 2) INFLAMMATORY RESPONSE: damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and WBCs into damaged tissues. Localized redness, edema, warmth, and throbbing. Leukocytes (WBCs) reach wound within a few hours. Neutrophil (primary-acting WBC): ingest bacteria and small debris. Monocyte (transforms to macrophages): the "garbage cells" that clean a wound of bacteria, dead cells, and debris by phagocytosis. Macrophages continue clearing wound debris and release growth factors that attract fibroblasts (cells that synthesize collagen). collagen (appears as early as second day): connective tissue main component of scar tissue.
         • 3) PROLIFERATIVE PHASE: lasts from 3-24 days, filling the wound with granulation tissue, contraction of the wound, and resurfacing of wound by epithelialization. fibroblasts synthesize collagen, providing matrix for granulation. collagen: mixes with granulation tissue (supports reepithelialization), provides strength and structural integrity to a wound. wound contracts to reduce area that requires healing, finally epithelial cells migrate from wound edges to resurface. In a clean wound: vascular bed is reestablished (granulation tissue), area is filled with replacement tissue (collagen, contraction, and granulation tissue), and surface is repaired (epithelialization)
           • 4) REMODELING: maturation takes place for more than a year, depending on the depth and extent of the wound. collagen scar continues to reorganize and gain strength for several months. (however, a healed wound usually doesn't have tensile strength of the tissue it replaces). collagen fibers undergo remodeling/reorganization before assuming their normal appearance. scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. in dark-skinned individuals scar tissue may be more highly pigmented than surrounding skin.

4. • Describe the differences in wound healing by primary and secondary intention.

   • PRIMARY INTENTION: wounds without loss of tissue, clean surgical incision, wound sutured or stapled (skin edges are approximated, or closed, and the risk of infection is low), healing occurs quickly, by epithelialization, with minimal scar formation, as long as infection and secondary breakdown are prevented
   • SECONDARY INTENTION: wounds involving loss of tissue, burn, pressure ulcer, or severe laceration. heals by granulation tissue formation, wound contraction, and epithelialization, wound is left open until it becomes filled by scar tissue. takes longer to heal, thus chance of infection is greater. if scarring from secondary intention is severe, loss of tissue function is often permanent

5. • Describe complications of wound healing.

   • 1) HEMORRHAGE --bleeding from a wound site (normal during and immediately after initial trauma) --occurs after hemostasis: a slipped surgical suture, dislodged clot, infection, or erosion of a blood vessel by a foreign object (a drain). --occurs externally or internally --hematoma (internal): localized collection of blood underneath tissues. It appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration. (hematoma near a major artery/vein is dangerous because pressure from the expanding hematoma obstructs blood flow)
     • 2) INFECTION --infected if purulent material drains from it, even if a culture is not taken or has negative results --wounds with more than 100,000 (105) organisms per gram of tissue are infected --chances of wound infection are greater when: wound contains necrotic tissue, there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced. --bacterial wound infection inhibits wound healing
       • 3) DEHISCENCE --wound fails to heal properly, the layers of skin and tissue separate (commonly occurs before collagen formation 3-11 days after injury). --partial or total separation of wound layers. --patients who's at risk for poor wound healing (poor nutritional status, infection, or obesity) is at risk --obese patients have a higher risk: constant strain placed on their wounds and poor healing qualities of fat tissue --involves abdominal surgical wounds and occurs after a sudden strain (coughing, vomiting, or sitting up in bed) --increase serosanguineous drainage: potential dehiscence
         • 4) EVISCERATION --total separation of wound layers (protrusion of visceral organs through a wound opening) occurs. --emergency condition that requires surgical repair. --place sterile towels soaked in sterile saline over extruding tissues to reduce chances of bacterial invasion and drying of tissues. --if organs protrude through wound, blood supply to tissues is compromised. --immediately contact surgical team, don't allow patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare for emergency surgery.

6. • Explain the factors that impede or promote wound healing.

   • IMPEDE HEALING --when there's too little inflammation occurs during inflammatory phase (cancer or after administration of steroids) --when there's too much inflammation, because arriving cells compete for available nutrients. (wound infection in which increased metabolic energy requirements compete for available calorie intake) --systemic factors: age, anemia, hypoproteinemia, and zinc deficiency. --poor nutritional status, infection, or obesity --dry wound left open to air can resurface within 6 to 7 days; cells will migrate down into a moist level before migration can occur
   • PROMOTE HEALING --wound that's kept moist can resurface in 4 days, because epidermal cells only migrate across a moist surface. --Calories: fuel for cell energy "protein protection" --Protein: fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function --Vitamin C: collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant --Vitamin A: reduces the negative effects of steroids on wound healing, epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation --Zinc (trace element): epithelialization, collagen synthesis, protein synthesis, cell membrane and host defenses --Copper: collagen fiber linking --Fluid: essential fluid environment for all cell function --Oxygen

7. • Describe the differences between nursing care of acute and chronic wounds.

   • ACUTE WOUNDS --wound heals promptly and without complications; easily cleaned and repaired; wound edges are clean and intact. --needs immediate intervention; require close monitoring (every 8 hours) --skill of applying dry and moist dressings to the new acute wound can't be delegated to nursing assistive personnel (NAP) --Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity --trauma, a surgical incision
   • CHRONIC WOUNDS --course of treatment is lengthy and costly --patient's hygiene is more important --assessment occurs less frequently (usually not more than 1 time per day) --stable, but difficult to heal --uses clean technique --wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity --vascular compromise, chronic inflammation, or repetitive insults to tissue --continued exposure to insult impedes wound healing

8. • Complete an assessment for a patient with impaired skin integrity.

   • Table 48-4 page 1194 and Box 48-4 page 1196.

9. • List nursing diagnoses associated with impaired skin integrity.

   • Box 48-6 page 1200

10. • Develop a nursing care plan for a patient with impaired skin integrity.

    • Example page 1201 -1202

11. • List appropriate nursing interventions for a patient with impaired skin integrity.

    • Pressure Management: --reposition every 90 minutes. --offer pain medication as needed. --when patient transfers from bed to chair, remind them not to slide over sheets but to pick up pelvis and relocate from one position to another. --be careful not to slide patient on sheets. --elevate head of bed no more than 30 degrees.
    • Pressure Ulcer Care: --keep skin dry and clean; avoid rubbing area. --use moisture barrier ointment over ulcer at least 3 times a day to decrease friction and provide moisture to open tissue.
    • Surgical Wound Care: --irrigate wound with saline solution twice per day per wound care provider's order. --apply dressing (gauze moistened with antibiotic solution twice a day after irrigation) according to wound care provider's order. --at frequent intervals, evaluate patient's pain level and offer pain medication as indicated by assessment.

12. • State evaluation criteria for a patient with impaired skin integrity.

    • measure the effectiveness of interventions, important to include the patient and caregiver in the evaluation process. determine what they know about the formation of impaired skin integrity, determine how the patient and caregiver feel about the presence of the wound and the need for wound care, and develop a plan of care to provide education and support. Individualize nursing interventions. determining the patient's response to nursing therapies and whether he or she achieved each goal, evaluate the need for additional referrals to other experts in wound care and pressure ulcers.