Functions of the Skin
-Protection
-Body temperature regulation
-sensation
-excretion
-maintenance of water and electrolyte balance
-vit D production and absorption
Pressure Ulcers
Localized injury to skin usually over boney promidence due to pressure, sheering, friction and moisture
Sheer Force
sliding movement of skin while underlying muscle and tissue stays stationary (sliding down bed)
-this increases pressure, circulation problems(vessel encution) and decrease curculation to that area (breakdown of skin)
Pressure Intensity
-pressure exceeds normal capillary pressure
-vessels occlude and dissue ischemia develops
-tissue may be damaged or tissue death may result
Pressure Duration
Low pressure over prolonged period of time &/or High pressure over a short period of time
-pressures occur quickly (1-2hrs)
Tissue Tolerance
ability of tussue to endure pressure depends on integrity of the tissue and supporting factors
-Extrinsic Factors = shear, friction, moisture
-Condition of underlying skin structures= blood vessels, collagen
-Systemic factors= nutrition, ageing and low bl
Signs of Pressure Ulcer
-redness, erythroema
-warm to touch
-edema
-pain
Factors contributing to Pressure Ulcer Development
-PRESSURE!
-immobility
-decreased sensory perception
-fecal and/or urinary incontinence/moisture
-poor nutrition
-aging skin
-chronic illnesses
-altered level of conciousness
-spinal cord or brain injuries
-neuromuscular disorders
Most at Risk
-diabetes
-stroke patients
-cognitive development
-COPD
-PVD
-hemodynamic
-dehydration
-obesity
-edemitis
Shear
Force exerted parallel to the skin resulting from gravity pushing down on the body and resistance (friction) between the client and a surface
Friction
Force of two surfaces moving across one another
Moisture
Pressure and moisture on the skin increases the risk of ulcer formation
Classification of Pressure Ulcers
Stage I
Stage II
Stage III
StageIV
Unstageable
Stage I Pressure Ulcer
-intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II Pressure Ulcer
-Partial-thickness skin loss involveing epidermis, dermis or both
-ulcers look like blisters and bliseters not open
-can see underlying skin
-can tell the skin is not intact
-presents a shallow open ulcer with a red pink wound bed without slough
-abrasion
Stage III Pressure Ulcer
-Full-thickness skin loss with visible fat
-damage or necrosis of subcutaneious dissue
-bone, tendon and muscle are NOT exposed
-slough may be present but does not obscure the depth of the tissue loss
- maybe undermining and tunneling
Stage IV Pressure Ulcer
-Full-thickness skin loss with exposed bone, muscle or tendon
- Slough or eschar may be present on some parts of wound bed
-oftne includes undermining and tunneling
Unstageable Pressure Ulcer
-full thickness tussue loss
- base of ulcer is covered by slough and eschar
-cant determine depth becasue of slough and eschar
-once slough and eschar removed, to expose the base of wound bed that true depth is determined
Assessment of Pressure Ulcers
-location of ulcer
-uncer dimensions: length, width, depth
-presence of undermining, tunneling or sinus tract
-exudate: amount, color, oder, consistancy
-tissue type of ulcer
-skin surrounding the ulcer: redness, hardness, warmth, maceration
-clinical sig
Granulation
red, moist tissue = progressing toward healing
-new blood vessels
Slough
stringy tissue attached to wound bed which is tissue that must be removed before healing can proceed
Eschar
Black or brown necrotic tisse that must be removed before healing can proceed
Dressing Recommendations
-clean wound at each dressing change
-use a dressing that will continuously proved a moist environment
-perform wound care using topical dressings as determined by a thorough assessment
-choose a dressing that keeps the surrounding intact skin dry while k
Wound
disruption of the integrity and function of tissues in the body
Wound Classifications
-status of skin integrity= open/closed; acute/chronic
-casue: intention or unintentional
-depth: partial or full thickness
-severity: superficial, penetrating or perforating
-cleanliness: clean, clean-contaminated, contaminated, infected, colonized
-descr
Types of Wounds
Intentional: surgical wound
Unintentional: injury
Abrasion: superficial wound, considered partial thickness
Laceration
Puncture Wound
Types of wound drainage
Serous- clear, watery
Purulent- yellow, green, tan or brown & odor
Serosanguineous- pale, red, watery: mixture of clear red fluid (pink)-thin
Sanguineous- active bleeding - bright red (active process)
Presence of infection
-Wound is swollen
-wound or edges are deep red in color
-feels hot on palpation
-drainage is increased and possibly purulent
-foul odor may be noted
-wouldn edges may be separated with dehiscence present
Abnormal findings with Primary wounds
-incision line poorly approximated
-drainage present for more tahn 3 days after closure
-inflammation increased in first 3-5days after injury
-no epithelialization of wound edges by day 4
-no healing ridge by day 9
Abnormal findings with Secondary wounds
-pale or fragile granulation tissue, granulation tissue bed excessively dry or moist
-purulent exudate present
-necrotic or slough tissue present in wound base
-epithelialization not continuous
-fruity, earthy or putrid ordor present
-presence of fistula,
Drains and Drainage Devices
-provide an exit for blood and fluids that accumulate during the inflammatory process
-may be active or passive drains
Penrose & Jackson Pratt
Hemovac type drain
Wound Closures
-sutures and staples hold edges of a surgical wound together until wound can heal
-silver wire clips also somtimes used
-large retention sutures may be used
-steri-strips can be used if the wound is small
-dermabond is a synthetic, noninvasive glue
Open Wound Classifications
-Red wounds = clean and ready to heal-protective dressings hould be used
-Yellow wounds= have a layer of yellow fiborous debris and sloughing-need to be coninually cleansedand ahve an absorbent dressing
-Black wounds= need debridement of dead tissue, usua
Needle Aspiration Procedures
-clean skin with disinfectant solution and allow to dry
-use 10mL disposable syringe with a 22gauge needle pulling .5mL of air into the syringe
-insert needle through skin next to wound and withdrawl plunger and apply suction to 10mL mark
-move needle bac
Quantatative Swab Procedures
-clean wound surface with nonantiseptic solution
-use sterile swabs
-mosten swab with normal saline
-rotate swab in 1cm of clean tissue in open wound then apply pressure to the swab for tissue fluid. insert tip of swab into sterile container, lable and se
Principles of wound healing
-intact skin is the first line of defense against microorganisms
-surgical asepsis is used in caring for a wound
-body responds systemically to trauma of any of its parts
-adaquate blood supply is essential for normal body response to injury
-normal heali
Factors Influencing Wound Healing
-nutrition
-tissue perfusion
-infection
-age-increases all phase of wound healing
Calories
-fluid for cell energy
-30-40k/cal/kg/day or enough to maintain positive nitrogen
Protein
-fibroplasia, angiogenesis, collagen formation, and wound remodeling, immune function
-1-1.5g/kg/day or enough to maintain postitive nitrogen balanc
-poultry, fish, eggs, beef
Vitamin C (ascorbic acid)
-collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxident
-100-1000mg/day
-need long time to develop clinical scurvy from vit C deficiency
-low toxicity
-citrus fruits, tomatoes, potatoes, fortified furit juci
Vitamin A
-epithelialization, wouldn closure, inflammatory response, angiogenesis, collage formation
-can reverse steroid effects on skin and delayed healing
-1600-2000 retinol equivalents per day
-supplement if deficient
-20,000units x 10days
-green leafy vegetabl
Vitamin E
-no known role in wound healing, antioxident
-no recommendations
-fish, oysters, liver, dark meat, eggs, legumes
Zinc
-collagen formation, protein synthesis, cell membrane and host defenses
-15-30mg
-coorect deficiencies
-no improvment in wound healing with supplementation unless zinc deficient
-use with caution, large doses can be toxic
-may inhibit copper matabolism an
Fluid
-essential fluid environment for all cell function
-30-35mL/kg/day
-increase by another 10-15mL/kg if aptient is on an air fluidized bed
-use noncaffeine, non alcoholic fluides without suger
-water is best- 6-8glasses a day
Cleaning Skin
-clean in direction from the least contaminated area such as from wound or incision to the surrounding skin or from an isolated drain site to the surround skin
-use gentle friction when applying solutions locally to the skin
-when irrigating, allow the so
Dressings
-Gauze= oldest and most common and rolls
-Non-adherent gauze= does not stick but allows drainage to pass
-Transparent film= ideal for small, superficial wounds and protects and helps maintain a moist surface
-Hydrocolloid= adhesive and occlusive - absorbs
Why do we pack a wound?
to eliminate dead space
Wound VAC
- assists in wound closure by applying localized nagative pressure to draw the edges of the wound together
-pulls drainage out of wound
-pulls blood supply to the wound
Phases of Wound Healing
-inflammatory phase
-proliferation or reconstruction phase
-maturation or remodeling phase
Inflammation Phase of Wound Healing
-begins immediately and lasts 1-4 days
-swelling or edema at injured part
-erythema resulting from increased blood supply
-heath or increased temperature at site
-pain stemming from pressure on nerve receptors
-possible loss of function resulting from all
Proliferation Phase of Wound Healing
-begins on 3rd, 4th day - lasts 2-3 weeks
-macrophages continue to clear the wound of debris and stimulate fibroblasts which synthesize collagen
-new capillary networks formed to provide oxygen and nutrients to spport collagen and for further synthesis of
Maturation Phase of Wound Healing
-final phase begins about 3 weeks from injury
-may take up to 2 years
-collagen is lysed and resynthesized by macrophages, producing storng scar tissue
-scar maturation, or remodeling
-scar tissue slowly thins and becomes paler
Hemorrhage
internally or externally - hematoma is localized collection of blood underneath the tissues
-risk is greats in first 14-48hrs
Infection
second most common nonsocomial infection.
-CDC states a wound is infected if purulent drainage is present
-color of drainage is dependent on the organism
Dehiscence
Partial or total rupturing of wound layers
-risk factors = poor nutrition, infection, or obesity.
-help prevent by splintingth wound
Evisceration
Total seperation of wound layers
-portrusion of visceral organs through a wound opening
-EMERGENCY!!!
-sterile saline soaked towels, knees bent, NPO and observe for signs of shock
Fistula
-abnormal passage between two organs or between an organ and the outside of the body
-increases risk for infect and fluid and electrolyte imbalance
Effects of Cold Application
-initially diminishes swelling and pain
-prolonged exposure resluts in reflex vasodialation (reddened apperance, followed by purplish mottling with numbness and burning type pain)
Cold
-Vasoconstriction
-local anesthesia
-reduced cell matabolism
-increase blood viscosity
-decreased muscle tension
-used most often for sports injuries
Effects of Local Heat
-improves blood flow
->1hr causes reflex of vasoconstriction (ABNORMAL)
-continued exposure damages epitheilial cells, causes redness, localized tenderness, and blistering
-vasodilation (NORMAL)
-reduced blood viscosity
-reduced muscle tension
-increased
How long should a cold compress be applied for?
20 minutes at 50 degrees F