Skin integrity and wound care (test 3)

Function of skin

Protects tissue from trauma and bacteria

Prevents loss of water and electrolytes

Allows temperature, pain and touch sensation

Regulates body temperature

Synthesis of Vit D

Promotes wound repair

Risk for impaired skin integrity

Age

Mobility status

Nutrition/hydration

Sensation level

Impaired circulation

Medication

Moisture

Infection

Lifestyle

Age related to skin integrity

Thin skin

low elasticity

lower subcutaneous

reduce collage

Mobility status related to skin integrity

Sedentary

Use draw sheet so won't shear

"Turn Q2H"

If person is be ridden you have to move them up causing friction

Pad bony prominences

Nutrition/hydration related to skin integrity

Protein and calories help repair wounds

Sensation level related to skin integrity

Diabetes or neuropathy can affect

Edema (shiny/waxy/tight) decreased sensation

Impaired circulation related to skin integrity

Post op after a couple hours

ambulate asap

Medication related to skin integrity

Allergic reaction cause Fluid filled blisters

Moisture related to skin integrity

Diaphoretic or sweaty skin

change lines and gown because will impaired skin integrity

Infection related to skin integrity

Puts them at risk for other infections

Can lead to candida (natural flora) infections

Lifestyle related to skin integrity

Tattoos (tattoo parlor may be unclean)

tanning

leaves more at risk

Assessment

Healthy history

Pass surgery/illness (neuropathy) skin cancer

Physical assessment

Color (pink,pale)

Texture and turgor

Moisture (dry?)

Temperature (dorsal)

Lesions (any scars?, surgery)

Braden scale

Within 24 hours of admission for risk of pressure injuries

braden scale

A tool for predicting pressure ulcer risk

Braden scale factors

Sensory perception (1-4)

Moisture (1-4)

Activity (1-4)

Mobility (1-4)

Nutrition (1-4)

Friction and shear (1-3)

Braden Scale rankings and risks

Severe risk 1-9

High risk 10-12

Moderate risk 13-14

Mild risk 15-18

No risk 19-23

consideration with braden scale

Make sure within 24 hours because hospital can be blamed for any previous ulcers

Severe risk (braden scale)

1-9

High risk (braden scale)

10-12

Moderate risk (braden scale)

13-14

mild risk (braden scale)

15-18

No risk (braden scale)

19-23

Pressure injury (pressure ulcer, pressure sore, decubitus ulcer, or bed sore) factors

Pressure intensity

Tissue ischemia

Blanching (nonblanchable)

Pressure duration

Tissue tolerance

Hospital acquired pressure ulcers

Pressure intensity

Elbows rubbing, knees rubbing, put something between legs so no rubbing

Tissue ischemia

Bad oxygenation to area, blood flow, causing layer for high risk pressure injury

Blanching (nonblanchable)

Area turns white

Wounds you can press in a dont turn white its a CONCERN stage one

Pressure duration

More at risk longer on

Bony prominences (tail bone, coccyx, knees, heels) turn pt and provide padding

Hospital acquired pressure ulcers

Negligent care (no reason for injury)

Come in with none and get stage 3-4 medicare will not pay for it.

If documents it protects you

Stage one pressure ulcer

Intact skin with non-blanchable redness of a localized area

Stage Two pressure ulcer

Partial thickness skin loss involving epidermis dermis or both

Stage three pressure ulcer

Full thickness tissue loss with visible fat

Stage four pressure ulcer

Full thickness loss with exposed bone muscle or tendon

eschar may be present

unstageable

wound bed covered in sufficient slough/eschar to preclude staging

deep tissue

localized area of intact skin that is purple or maroon or blood filled blister that occurs when underlying tissue is damaged from friction or shearing

Eschar

black on ulcer, requires surgical removal, cut tissue and underneath is tunnels/tissue, we want it to be red underneath

Debridement

(removal of nonviable necrotic tissue)

Mechanical Debridement

Wet to dry dressing changes (remove old dressing)(may pull off tissue)(use syringe to clean out)(pre intervention for dressing change-medicate)

autolytic debridement

Synthetic dressing that helps "digest" eschar and enzymes

Chemical debridement

Enzyme that goes on topically and breaks down necrotic tissues and breaks down bacteria decreasing risk for infection

Surgical debridement

Remove eschar and we want healthy tissue underneath (red/pink)(good o2)(it is granulation tissue)

Education wound care

6-8 weeks to heal so give proper education

Nutritional status for wound care

Need protein and calories to repair tissues

Protein status measurements

albumin!

Hemoglobin

Look at oxygenation of tissues

Women 12-16 g/dL

Men 14-18 g/dL

Prevent ischemia

wound cultures

wound cultures (culture before give antibiotics)

Assessment of wound

-abrasion-superficial scratch

-laceration-tear with jagged edges

-Serous-clear

-sanguineous(sangria)-red

-purulent-green/yellow foul

-turn patient, padding, pain level, give meds as needed, chart where it is on body, reassess after pain scale,

planning and implementation for wound care

Specific individualized goals for patients needs

Goals are based on NDX and must be timed measurable and realistic

Include patient Promote health

Incontinence

Moisture is a risk

Topical skin care and incontinence management

Protect bony prominences and skin barriers for incontinence

Position turn Q1-2H

Support surfaces

Shearing force

Primary

Primary

Surgical incision

Sutures and staples hold together

Little scaring

Secondary

Leave open

Longer to heal

More scarring

Purpose of dressings

Protect wound from microorganism

Aid in hemostasis (blood clots and healing)

Promote healing by absorbing drainage and derbinding wound

Mechanical debridement

Support or splint wound site

Protect patients from seeing the wound

Promote thermal insulation of the wound surface

Type of dressing

Dry or moist gauze

film dressing

hydrocolloid (protects the wound from surface contamination)

hydrogel (maintains a moist surface to support healing)

wound vacuum assisted closure (VAC, uses negative pressure to support healing)

Packing a wound

assess size, depth, shape, saturate gauze w ordered solution, wring out, unfold and lightly pack into wound, pack the wound only until the packing material reaches the surface, cover with a dry dressing

when They have tunneling

Cotton applicator and press in wound, take out wound dressing, repack and cover

Vacuum assisted closure

Risk for not healing well For obese or surgeon preferred

Machine exert pressure on wound continuously and creates suction

Jackson pratt and hemovac drains

Closed Systems drains that decreases dead space by collecting drainage via the utilization of suction

Implanted by the surgeon, then take the cap off and measure, document, squeeze and recap.

Complications of wounds

dehiscence

evisceration

hemorrhage

infection

fistula

dehiscence

primary closure opens, stand up and hear pop, NO ORGAN HANGS OUT, reinforce it

Infection

purulent drainage, temperature and fever, will be foul smelling and green

Hemorrhage

excessive bleeding, check behind them because blood pools

Fistula

abnormal passage from surgery or injury from two body parts or organs, EX: rectum and vaginal

Evisceration

organs poke out of body (surgical emergency), organ cannot live on outside of body, put moist wet dressing on it