SKIN INTEGRITY WOUND CARE - web2.aabu.edu.joweb2.aabu.edu.jo/tool/course_file/lec_notes/1001111_SKIN...
Transcript of SKIN INTEGRITY WOUND CARE - web2.aabu.edu.joweb2.aabu.edu.jo/tool/course_file/lec_notes/1001111_SKIN...
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SKIN
INTEGRITY
&
WOUND
CARE
Chapter 34 1Raeda Almashaqba
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skin integrity: intact
skin refers to the
presence of normal skin
layer uninterrupted by
wound
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WOUNDS
• DISRUPTION IN THE INTEGRITY OF BODY TISSUE
• CLASSIFIED AS:
1. OPEN or CLOSED
2. ACUTE or CHRONIC
3. ACCORDING TO SEVERITY (superficial / deep)
4. ACCORDING TO RISK OF INFECTION (clean / contaminated / infected)
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PHASES OF WOUND
HEALING
INFLAMMATORY PHASEOccurs immediately after injury and last 3-4
days.
1. Hemostasis: Cessation of bleeding - clotting cascade, vasoconstriction / vasodilation
2. Edema: Body’s defensive adaptation to tissue injury – histamine, leukocytes .
Skin is red, edematous & warm to touch.
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5Raeda Almashaqba
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6Raeda Almashaqba
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3-4TH day post injury and lasts for 2-3 weeks.
• Collagen (protein) adds strength to wound (less
chance of separation or rupture). Raised
healing ridge may be visible.
• Other cells help to compose different epidermal
layers (granulation & re-epithelization
continues).
PHASES OF WOUND HEALING
REGENERATION OR
PROLIFERATIVE PHASE
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8Raeda Almashaqba
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MATURATION OR REMODELING
PHASE
• 21st day to 2 years post injury.
• Scar tissue is remodeled or reshaped.
• Scar tissue is still weaker than the tissue it replaces (usually never greater than 80% of pre-injury strength).
• Scar appears large initially, but will decrease with time.
PHASES OF WOUND HEALING
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WOUND
CHARACTERISTICS
• SURGICAL WOUNDS – intentional, clean, made by sharp instrument, sutures / staples / steri-strips.
• TRAUMA WOUNDS – lacerations or punctures, considered dirty or contaminated, scarring more likely.
• CHRONIC WOUNDS – heals slowly, may recur, pressure ulcers / venous stasis ulcers.
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12Raeda Almashaqba
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TYPES OF WOUND HEALING
PRIMARY INTENTION• Wound edges “approximated”
• Granulation tissue fills in wound
• Occurs in first 14 days post surgery
• risk of infection
• Minimal scarring – predictable movement through phases of healing
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TYPES OF WOUND HEALING
SECONDARY INTENTION• Prolonged healing (extensive tissue loss)
• Edges cannot be approximated
• Granulation tissue must fill wound
• Risk of infection
• May be intentionally left open
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TERTIARY INTENTION
DELAYED / SECONDARY CLOSURE• Primary closure is undesirable
• Might be poor circulation or infection
• Suturing delayed until problems resolve
TYPES OF WOUND HEALING
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PRESSURE ULCERS
Patients at Increased Risk DEACREAS ACTIVITY LEVEL(Immobility)
INCONTINENCE (fecal and urinary incontinence )
ALTERED Level of consciousness
DIMIMSHED SENSATION
IMPAIRED CIRCULATION
POOR NUTRITION STATUS
EXCESEIVE BODY HEAT : increase the metabolic
rate which increase the need for oxygen
ADVANCED AGE. 16Raeda Almashaqba
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• Localized areas of tissue necrosis
• Tend to develop when soft tissue compressed between bony prominence & an external surface
• Due to ischemia
• Reduction of blood flow causes blanching
• Other contributors= shearing & friction
PRESSURE ULCERS
Characteristics
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STAGES
I : Nonblanchable erythema
II: Partial – thickness loss
III: Full – thickness loss
Extends into subcutaneous tissue
IV: Full-thickness loss
Extends into muscle / bone
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20Raeda Almashaqba
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Classification of Pressure Ulcers
• Stage I: persistent red, blue, or purple
tones; no open skin areas
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Classification of Pressure Ulcers
• Stage II: partial-thickness skin loss;
presents as an abrasion or blister
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Classification of Pressure Ulcers
• Stage III: full-thickness skin loss with
damage or necrosis of subcutaneous
tissue; presents as a deep crater
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Classification of Pressure Ulcers
• Stage IV: full-thickness skin loss with
extensive destruction, necrosis, or
damage to muscle, bone, other
structures
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PROBLEMS OF WOUND HEALING
INFECTION
• Most common 36-48hrs postop; common cause of altered wound healing
• Symptomatic 5 – 7 days
• Must monitor clients adequately
• Wound can become contaminated preop; intraop; or postop
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HEMORRHAGE
• Persistent bleeding is abnormal
• Some bleeding normal after initial trauma &
surgery
• Hemostasis within a few minutes
• Swelling around the wound & presence of
sanguinous drainage from a drain may indicate
hemorrhage
• HYPOVOLEMIC SHOCK: ↓ B/P, rapid thready
pulse, diaphoresis, restlessness, cool clammy skin
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DEHISCENCE
• PARTIAL OR TOTAL SEPARATION OF
WOUND EDGES (most likely to occur 4 – 5
days postoperatively)
EVISCERATION
• PROTRUSION OF AN INTERNAL ORGAN
THROUGH THE INCISION
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SKIN INTEGRITY FACTORS
• PERSONAL HYGIENE
• NUTRITIONAL STATUS
• SMOKING
• SUBSTANCE ABUSE
• ACTIVITY
• AGE
• INCONTINENCE
• HYPOXEMIA
• DIABETES
• MEDICATIONS
• INFECTION31Raeda Almashaqba
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ASSESSMENT-ASSESSMENT
• THOROUGH SKIN ASSESSMENT !!
• HEALTH HISTORY (client interview)
• DIAGNOSTIC TESTS….
• WBC (infection)
• ALBUMIN LEVELS
• Skin: color, temperature, turgor, integrity
• Risk for pressure ulcers
• Nutritional status
• Exposure of skin to body fluids
• Pain 32Raeda Almashaqba
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Nursing Diagnoses
• Risk for infection
• Imbalanced nutrition: less than body requirements
• Pain
• Impaired skin integrity
• Impaired tissue integrity
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Planning
• Goals and outcomes
– Wound improvement within 2 weeks
– No further skin breakdown
– Increase in caloric intake by 10%
• Setting priorities
• Continuity of care
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Implementation• Prevention of pressure ulcers
– Skin care, Positioning, Use of support surfaces
• Prevent and manage infection
• Cleanse the wound
• Remove nonviable tissue
• Manage exudate
• Protect the wound
• Client education
• Nutritional support35Raeda Almashaqba
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First Aid for Wounds
• Control of bleeding
• Cleansing
• Application of topical growth factors
• Protection
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Wound Care
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NSG DX: IMPAIRED SKIN
INTEGRITY
• WHAT DO YOU DOCUMENT ??
1. LOCATION
2. SIZE (in centimeters cm)
3. COLOR
4. SURROUNDING SKIN
5. DRAINAGE
6. TEMPERATURE
7. PAIN
8. WOUND CLOSURES
9. ODOR38Raeda Almashaqba
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WHAT ARE THE RELATED
FACTORS?
• MECHANICAL FORCES (RESTRAINTS – PRESSURE)
• CIRCULATION
• IMMOBILIZATION
• ALTERED SENSATION
• NUTRITIONAL STATE
• SKIN TURGOR
• SURGERY
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SOME DESIRED OUTCOMES
(GOALS) MAY BE:
1. MAINTAINS ADEQUATE
NUTRITIONAL & FLUID INTAKE
2. CLIENT CAN PERFORM WOUND
CARE
3. CLIENT CAN STATE SIGNS OF
INFECTION
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KNOW THE RIGHT
INTERVENTIONS!!
• MONITOR CLIENT (ASSESSMENT / ASSESSMENT)
• SKIN CLEANSING
• NUTRITION (MULTIDISCIPLINARY EFFORT)
• POSITIONING
• TEACHING
• WOUND CARE / SKIN PROTOCOL
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WOUND CLEANSING
•IRRIGATION DEVICES
•VARIOUS SOLUTIONS
NORMAL SALINE
GENERALLY..WOUND ITSELF CLEANER THAN SURROUNDING SKIN
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43Raeda Almashaqba
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DRAINS
• PLACED IN WOUNDS BEFORE SURGICAL INCISION CLOSED
• PREVENTS FLUID FROM COLLECTING BETWEEN WOUND SURFACES
• USUALLY LEFT IN PLACE 3 TO 7 DAYS
PENROSE
HEMOVAC
JACKSON-PRATT
RUBBER BAND
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45Raeda Almashaqba
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IMPLEMENTATION
• Ensure proper hygiene & skin care
• Proper positioning
• Consults as needed
• Apply complementary therapies
• Precautions if necessary
• Specialty beds
• HANDWASHING – staff & patient
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EVALUATION
• If goals not met – examine interventions
& revise plan of care appropriately
• Review techniques & procedures of staff
• Review techniques of client & family
• Focus on CLIENT TEACHING !!
47Raeda Almashaqba