Skin
-protective barrier and a sensory organ for pain, temperature, and touch; and it synthesizes vitamin D
-2 layers: epidermis and the dermis separated by a membrane called the
dermal-epidermal junction
-if injured, the epidermis fans to resurface the wound
Epidermis
-top layer; has several layer with the stratum corneum as the thin, outermost layer
-consists of flattened, dead, keratinized cells originating from the innermost epidermal layer (basal layer)
-cells in the basal layer divide, proliferate, and migrate tow
Dermis
-inner layer; provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs
-differs from epidermis bc is contains mostly CT and few skin cells; Collagen, BVs, and nerves are found here; Fibroblast (collagen fo
Pressure Ulcers
-pressure ulcer, pressure sore, decubitus ulcer, and bedsore describe impaired skin integrity related to prolonged pressure
-
pressure ulcer:
localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure
At Risk Patients for Pressure Ulcers
-patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition
Factors Contributing to Pressure Ulcer Formation
-pressure is major cause
-any factor that interferes with blood flow in turn interferes with cellular metabolism and fan or life of cells resulting in tissue ischemia and tissue death
Pathogenesis of Pressure Ulcers
(Pressure Intensity)
-
tissue ischemia
occurs if pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged period of time
-
blanching
(turns lighter in color) occurs when normal red tones of light skinned patient are absent
Pathogenesis of Pressure Ulcers
(Pressure Duration)
-extended pressure occludes blood flow and nutrients and contributes to cell death
-evaluate amount of pressure (checking skin for reactive hyperemia) and determine time patient tolerates pressure (checking to be sure after relieving pressure that affecte
Pathogenesis of Pressure Ulcers
(Tissue Tolerance)
-ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures
-extrinsic factors of shear, friction, and moisture affect ability of skin to tolerate pressure
-systemic factors such as poor nutrition, increased agin
Risk Factors for Pressure Ulcer Development
-Impaired Sensory Perception
-Impaired mobility
-Alteration in level of consciousness
-Shear: sliding movement of skin and subQ tissue while muscle and bone are stationary
-Friction
-Moisture
Stage I
-
Nonblanching Redness of Intact Skin
-intact skin presents with nonblanchable erythema
-discoloration, warmth, edema, hardness, or pain
Stage II
-
Partial-thickness skin loss or blistering
-shiny or dry shallow ulcer without slough or bruising
Stage III
-
Full-thickness Skin Loss (Fat Visible)
-tendon, muscle, or bone NOT EXPOSED
Stage IV
-
Full-thickness Tissue Loss (Muscle/Bone Visible)
-slough or eschar may be present
Unstageable/Unclassified
-
Full-thickness Skin or Tissue Loss--Depth Unknown
Suspected Deep-Tissue Injury
-Depth Unknown
Slough/Eschar/Exudate
Slough: stringy substance attached to wound bed (must be removed before wound can heal)
Eschar: black or brown necrotic tissue (must be removed before wound can heal)
Exudate: describes amount, color, consistency, and order of wound drainage
Wound Classification
-
wound:
disruption of the integrity and function of tissues in the body
-classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive qualities o
Wound Healing
2 types of wounds:
those with loss of tissue and those without
primary intention
: how surgical incision heals; skin edges are approximated (closed) with low risk of infection. heals quickly with minimal scar formation
secondary intention
: how wound invo
Partial-Thickness Wound Repair
includes inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of epidermal layers
Full-Thickness Wound Repair
Hemostasis: control of blood loss, bacterial control, and seal the defect occurs when there is an injury; during this phase injured BVs constrict and platelets gather to stop bleeding (clots form fibrin matrix providing framework for cellular repair)
Infl
Complications of Healing: Hemorrhage
-hemorrhage: (bleeding from wound site) normal during and immediately after initial trauma
-hemorrhage occurring after hemostasis indicates a slipped surgical suture, dislodged clot, infection, or erosion of a BC by foreign object
-
hematoma:
localized co
Complications of Healing: Infection
-
2nd most common health care associated infection
(nosocomial)
-a wound is infected if purulent material drains from it, even if culture is not taken or has negative results
-if drainage is present, it is odorous and purulent (causing yellow, free, or br
Complication of Healing: Dehiscence
-when wound fails to heal properly, the layers of skin and tissue separate
-
dehiscence:
partial or total separation of wound layers
Complication of Healing: Evisceration
-total separation of wound layers
-
evisceration
: protrusion of visceral organs through a wound opening
-EMERGENCY that requires surgical repair
Types of Wound Drainage
Serous: clear, watery plasma
Purulent: thick, yellow, green, tan, or brown
Serosangineous: pale, pink, watery; mixture of plasma and RBCs
Sanguineous: bright red; indicates active bleeding
Risk Assessment
-
Braden Scale:
a valid tool to use for pressure ulcer risk assessment; 6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear (ranging from 6-23=lower indicates higher risk for ulcer development)
-
Prevention:
econom
Factors Influencing Pressure Ulcer Formation and Wound Healing
-Nutrition:
table 48-4
-Tissue Perfusion
-Infection
-Age
-Psychosocial Impact of wounds
Assessment
-skin
-pressure (predictive measure, mobility, nutritional status, body fluids, pain)
-wounds (emergency setting, stable setting, wound appearance, character of wound drainage, drains, wound closure, palpation of wound, wound cultures)
Abrasion/Laceration/Puncture
Abrasion: superficial with little bleeding and is considered a partial-thickness wound
Laceration: bleeds more profusely, depending on the depth and location of wound
Puncture: wound bled in relation to the depth and size of the wound
Drains
Penrose drain: lies under dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into wound
Hemovac or Jackson-Pratt: evacuator unit that exerts a constant low pressure as long as the suction devis
Nursing Diagnosis
-risk for infection
-imbalanced nutrition: less the required
-acute or chronic pain
-impaired physical mobility
-impaired skin integrity
-risk for impaired skin integrity
-ineffective peripheral tissue perfusion
-impaired tissue integrity
Health Promotion: Prevention
-immobile patients are at major risk for developing pressure ulcers
-topical skin care and incontinence management
-positioning
-support surfaces (therapeutic beds and mattresses) Table 48-7
Positioning
-interventions reduce pressure and shearing force to the skin
-elevate head of bed to <30 degrees decreases chance of ulcer development from shearing forces
-reposition
every 1-2 hours
and protect bony processes
-
30-degree lateral position is recommended