Skin Integrity And Wound Care

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Developmental considerations

Back 1

-less than 2 yrs: skin thinner & weaker

-infant- membranes easily injured & increase infection, over time becomes more resistant

- Aged adult- maturation of epidermal skins prolonged=thin, easy damaged skin, circulation and collagen formation impaired=decrease elasticity and increase tissue damage risk

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Types of Wounds

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*Intentional- therapy or treatment or surgery: sterile infection decreased, healing increased

*Unintentional- trauma, stabbing, burns, gunshot: infection increased, bleeding uncontrolled

*Open- trauma(intentional or unintentional): increase risk for infection delayed healing

*closed- blow force or strain (fall, assault) skin not broken-> ecchymosis and hematoma

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Acute

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Surgical incision, heal quickly, risk infection low

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Chronic

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healing process not normal, risk infection high, healing time delayed remain in inflammatory phase of healing:

- wound that doest heal in normal time: arterial or venous insufficiency

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Contusion

Back 5

caused by blunt instrument that may result in bruising or hematoma

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Abrasion

Back 6

rubbing or scraping of epidermal layers of skin

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laceration

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tearing of skin and tissue w/ blunt or irregular instrument

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Avulsion

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tearing of structure from normal anatomic position

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phases of wound healing

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hemostasis- involved blood vessels constrict and blood clotting begins

inflammatory- white blood cells move to wound

proliferation- granulation tissue is formed to fill the wound

maturation-collagen is remodeled forming scar

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hemostasis

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occurs as first response to injury

- blood vessels constrict=clotting

- Blood vessels dilate, increase permeability

- exudate= liquid that forms from plasma and blood components to leak out into the area=swelling and pain

-increased perfusion= heat and redness

-platelet stim other cells to migrate to injury to help in healing

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Inflammatory

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after hemostasis 4-6 days

- WBC leukocytes and macrophages go to wound

- ingest debris release growth factors attract fibroblast to fill wound

-mild temp and malaise

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Proliferation

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- begin 2-3 days within injury last 2-3 weeks

- new tissue built to fill wound from action of fibroblast( connective tissue cells secrete collagen induces blood vessel formation and endothelial cells--> which form across wound

-granulation tissue forms scar tissue

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Maturation Phase

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Final stage of healing

- 3 wks- 6 months after injury

- collagen remodeled, wound stronger

- scar is flat, thin white line

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Local factors affecting wound healing

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*pressure- blood supply disturbed delay healing

*desiccation (dehydration) delay heal

*WOUNDS KEPT MOIST NOT WET AND HYDRATED= enhanced epidermal cell migration, supporting epithelialization

*trauma- inability to heal or delay

*Edema- interfere with blood supply to area

* infection- increase stress on body

*excessive bleeding= large clots, increase amount of space needed to be filled for healing, decrease o2 diffusion to tissues ("o's to the toes")

*necrosis- death of tissue must remove ]

* biofilm- thick grouping of micro bacteria, decreased effectiveness of antibiotics, chromic wound inflammation, slimy barrier of sugars and proteins

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Systemic factors affecting wound healing

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*factors not related to wound location but can prolong healing

-Age- children and healthy adults heal quicker

-Circulation and Oxygenation- adequate blood flow needed

- nutritional status- adequate nutrition needed

- wound condition - specific condition of wound affects healing

- health status- steroid drugs and postoperative radiation delay heal

- Immunosuppression- AIDS, lupus

- Meds- chemo

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Wound complications

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- infection

-hemorrhage

- dehiscence- partial or total separation of wound layers: Evisceration- wound completely separates protrusion of viscera(obese, smokers , malnourished, straining

-fistula formation: abnormal passage from internal vessel to outside of body or to another organ

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Maceration

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caused by over hydration related to incontinence that causes impaired skin integrity

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Necrosis

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dead tissue in wound delays healing

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Edema

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swelling at wound interferes with blood supply to the area

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Desiccation

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process where cells dehydrate and die

Front 21

Factors affecting pressure ulcer

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wound w/ localized area of injury to skin or tissue

-aging skin

-chronic illness

-immobility

-malnutrition

-fecal and urinary incontinence

- altered level of consciousness

-spinal cord and brain injuries

-neuromuscular disorders

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Mechanisms in pressure ulcer development

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- external pressure compressing blood vessels: bony prominences

-Friction: 2 surfaces rub against each other

- shearing: one layer of skin slides over another layer( pt being pulled rather than lifted)

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Stages of pressure ulcers

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1- intact skin, blanching( pale and white 'ischemia)

2- partial thickness tissue and skin loss, shallow open ulcer

3- full thickness tissue loss, fat may be seen, NO bone tendon or muscle visible

4- full thickness loss, EXPOSED bone tendon or muscle

5- UNSTAGEABLE- covered by slough or eschar in wound bed must be removed to determine stage

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undermining

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erosion under wound edges

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tunneling

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destruction of fascial planes=narrow passageway

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sinus tract

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blind ended tract extends from skin surface to abscess cavity or area

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Assessment of wound drainage

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-serous- clear, watery

- sanguineous- large # of RBCs and looks like blood. Bright red=fresh blood, Dark=older blood

-serosanguineous- mix of serum and RBC, light pink

- Purulent- WBS liquefied dead tissue debris, thick must foul odor, vary color

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Wound Assessment

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-Inspect sight and smell

- palpation for appearance, drain, pain, different drainages

- sutures, drains or tubes, complications

- penrose- after abdominal surgery

- t-tube- bile drain

- hemovac- ortho, abdominal

- gauze

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types of wound dressings

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Telfa- nonadherent

Gauze

transparent dressings- op site

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Cleaning wounds- edges

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Approximated edges- work outward from incision

Unapproximated edges- clean in full or half circles, begin in center work toward outside clean 1 inch beyond

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types of bandages

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-roller

- circular-anchors bandage

-spiral-wrist,fingers, trunk

-figure of 8 turn-effective for around joints

- recurrent stump bandage- risidual limb, head fingers

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Types of binders

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- straight- chest and abdomen

- T-binder- rectum, perineum, groin

-Sling- arm

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Drainage systems

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open- penrose

closed- sutured in skin, low continuous suction: jackson prat- bulb, hemovac- round

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Color class of open wounds

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R- red- protect

Y- yellow- cleanse

B- black- debride

Mixed wound- has both RY &B wounds

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Effects applying heat

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-dilates blood vessels

- increase tissue metabolism

- reduce blood viscosity and increase capillary permeability

- reduce muscle tension and spasm

- relieve pain

- treat infections, surgical wounds, inflamed tissue, arthritis, joint, muscle pain, dysmenorrhea, chronic pain

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Applying Cold

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-constrict blood vessels

- reduce muscle spasm

- reduce blood flow and release of pain producing histamine, serotonin and bradykinin, reduce edema and inflammation

- after direct trauma, dental pain, sprains, chronic pain