Skin Integrity n Wound Care
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Transcript of Skin Integrity n Wound Care
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Skin Integrity and Wound
CareTeresa V. Hurley, MSN, RN
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Skin Integrity
Largest organ in the body Functions
First line of defense against microorganisms Regulation of body temperature
Transmits sensations of pain, temperature,touch and pressure
--Vitamin D production and absorption--secretes sebum
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Wounds
What are wounds ? Break in skin or mucous membranes
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Wound Classification
Superficial
Deep (blood vessels, nerves, muscle,tendons, ligaments, bones) Open Wound
Superficial or deep break in skin (abrasion,puncture, laceration)
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Wound Classification Closed: blunt force; twisting, turning, straining,
bone fracture, visceral organ tear Acute: trauma sharp object or blow
Surgical incision, gun shot, venipuncture Chronic: pressure ulcers Causality
Intentional: surgical incision Unintentional: traumatic
Knife Burn
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Pressure Wounds
Damage to tissues due to pressure Factors
Immobility Elderly Skin moisture Malnutrition (protein)
Shearing Forces Friction Risk Factors as outlined on Braden Scale
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Pressure Ulcer Stages
Stage I: No Skin Break Skin temperature, consistency (firm),
sensation (pain or itching) Persistent redness in light skin tones Persistent red, blue or purple hue in darker
skin tones
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Pressure Ulcer Stages
Stage II: Superficial Partial-thickness skin loss (epidermis and/or
dermis
Abrasion, blister or shallow crater
Stage III Full-thickness skin loss (subcutaneous damage
or necrosis and may extend down to but notthrough fascia
Deep crater
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Pressure Ulcer Stages Stage IV: full thickness skin loss and destruction,
necrosis of the tissue, damage to muscle, bone,tendons and joint capsules and sinus tract
Types of Dressings Transparent film (Tegraderm, Bioclusive) Hydrocolloid (Duoderm, Comfeel) Hydrogel Gauze Roll (Kerlix)
Provide moist environment Loosen slough and necrotic tissue Wick drainage from wound
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Pressure Ulcer Assessment
Tissue Type Granulation Tissue: red and moist Slough: yellow stringy tissue attached to
wound bed; removal essential for healing Eschar: necrotic tissue which is brown or
black appearance must be debrided
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Pressure Ulcer Assessment
Wound Dimensions (L, W, D) Wound Deterioration
Skin surrounding ulcer Redness, warmth, edema
Exudate Amount, color, consistency, odor
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Wound Healing
Primary Intention skin edges are approximated (closed) as in a surgical
wound
Inflammation subsides within 24 hours (redness,warmth, edema) Resurfaces within 4 to 7 days
Secondary Intention: tissue loss Burn, pressure ulcer, severe lasceration Wound left open Scar tissue forms
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Wound Healing Inflammatory Response
Serum and RBCs form fibrin network Increases blood flow with scab forming in 3 to 5 days
Proliferative Phase: 3-24 days Granulation tissue fills wound Resurfacing by epithelialization
Remodeling: more than 1 year collagen scar reorganizes and increases in strength Fewer melanocytes (pigment), lighter color
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Some Factors Influencing WoundHealing
Age Nutrition: protein and Vitamin C intake Obesity decreased blood flow and increased risk for
infection
Tissue contamination: pathogens compete with cells for oxygen and nutrition Hemorrhage Infection: purulent discharge Dehiscence: skin and tissue separate Evisceration: protrusion of visceral organs Fistula: abnormal passage through two organs or to
outside of body
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Therapeutic Modalities Contingent on location, size, wound type,
exudate, infection, dressed or undressed
Assessment Inspect and palpate surrounding area Wound edge approximation (healing ridge noted) Presence and characteristics of drainage
Serous
Sanguineous Serosanguineous Purulent Consistency, odor and amount
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Wound Assessment
Wound Closure Staples Sutures Steri-strips
Drains Penrose Hemovac or Jackson Pratt exert low pressure
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Some Dressing Types and Assistive Devices
Dry Dressings Wet-to-Dry Dressings Packing
Wound Vacuum Assisted Closure: apply localnegative pressure to draw wound edgestogether; healing acclerated with the formationof granulation, collagen etc. to close wound or prepare for skin grafting
Electrical Stimulation Abdominal Binders Montgomery Straps
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Heat and Cold Therapies
Heat Vasodilation
Increases blood flow Nutrient delivery Removal of waste Decreases venous congestion
Blood Viscosity Decreased leuokocytes
antibiotics
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Heat and Cold Applications
Heat Muscle relaxation with decrease in pain from
spasm and stiffness Tissue Metabolism increased with increased
warmth and blood flow Increased capillary permeability promotes
nutrient delivery and waste removal
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Cold Applications
Vasoconstriction Reduce blood flow preventing edema
formation and decreases inflammation
Local anesthesia Cell metabolism decreased with o2 demands
decreased Increased blood viscosity promotes
coagulation Pain relief with decrease in muscle tension Direct Trauma; superficial lacerations, arthritis
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Complications
Heat application leads to reflexvasoconstriction within 1 hour Complications
Epithelial cells damaged Redness, tenderness, blistering
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Complications
Cold Reflex vasodilation
Tissue ischemia Skin redness Bluish purple mottling Numbness Burning pain Tissues may freeze
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Modalities MD order: body site, type, frequency and
duration of application Moist or dry
Warm/Cold Compresses Warm Soaks (relaxation, debride wounds) Sitz Baths (rectal or vaginal surgery,
hemorrhoids, episiotomy) Aquathermia pads (muscle sprains,
inflammation or edema) Commerical Hot and Cold Packs
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Contraindications
Heat Site with active bleeding Acute localized pain (appendicitis) leads to
rupture Cardiovascular (vasodilation to large areas
leads to decrease blood supply to vital organs
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Contraindications
Cold Site pre-existing edema prevents absorption
of intersitial fluid Neuropathy (unable to sense) Shivering will intensify with acute elevations in
temperature
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Critical Thinking
What other factors need to be assessedbefore application of heat and coldtherapies?
Circulatory? LOC? Sensory?