Wound Care PPT 1

What is the largest organ system in the body?

Skin

Skin: Structures & Function

• Epidermis

• Dermis

• Subcutaneous

• Muscle & bone

Skin: Functions

• Protection

• Temperature Regulation

• Sweating/Shivering

• Touch & Feeling

• Vitamin D Conversion

Healthy Skin

Skin Changes Throughout Life

• Younger people heal faster

  As you get older the skin is:

• Thinner

• Wrinkles

• Tears/bruises easily

• Dryer

• Prolonged healing time

• Easier to develop pressure ulcers

Healthy Skin Maintenance

Bathing

• Use pH neutral soap

• Individualize Frequency

  • Elderly do not need daily bath, removes natural flora and dries skin

• Gently bathe - no vigorous rubbing needed

• Use of baby oil in bath water treats dry skin (fall risk)

• Apply moisturizer after bath/cleansing

  • Within 3 minutes of drying

Principles of Wound Healing

• Moist Wound Healing

  • If a wound is dry = add moisture

  • If a wound is wet = absorb moisture

  • Keep the wound moist

If a wound is not perfused, it will NOT heal

Classification of Wounds: Superficial

Superficial

• Skin tears

• Abrasions

• Lacerations

• Moisture Associated Skin Damage

Classification of Wounds: Partial Thickness

Partial Thickness

• Surgical

• Venous stasis

• Skin tears

• Trauma - abrasion, laceration

• Arterial ulcer

• Stage 2 Pressure Ulcer

Classification of Wounds: Full Thickness

Full Thickness

• Surgical

• Arterial Ulcer

• Trauma, Abrasion, Laceration

• Venous Stasis

• Skin Tears - Thin Fragile Skin

• Stage 3 & 4 Pressure Ulcer

Classification of Wounds: Other Pressure Ulcer Stages

• SDTI (Suspected Deep Tissue Injury)

• Unstageable

• Stage 1 Pressure Ulcer

Where do pressure injuries occur?

occur over a bony prominence (“pressure point”)

• Its vital to assess the client’s pressure points regularly because there are the hot spots where pressure injury is most likely to develop

• Medical devices can cause pressure injuries - e.g., oxygen tubing, syringe cap left in bed (pressing against skin)

Pressure Injuries

• Are the result of the bone compressing the blood vessels

• Decreased blood flow causes ischemia to the surrounding tissue

• End result = cell death

• Tissue Damage can be shallow or deep

What causes pressure injuries?

Pressure causes pressure injuries

• A little pressure for a long time or

• A lot of pressure for a short time

• Turn the patient!

How often should a patient be turned?

• Patients should be turned AT LEAST every two hours

• Depending on the patient’s situation, you may need to turn some patients even more frequently. 

Braden Scale

• Sensory Perception

• Moisture

• Activity

• Mobility

• Nutrition

• Friction and Shear

• Total Score: 23 = No Impairment

• Score: 18-23 = Low risk for PU

• Score: 17 & Below = High risk for PU

Patients At Risk For Pressure Injuries

• Patients with mobility issues who have difficulty or cannot move themselves

• Patients with nutritional deficits

• Patients with dependent edema

• Patients who are incontinent

• Patients with neuropathy

When treating a patient with a wound, what should you look at?

LOOK AT EVERYTHING not just the wound (look at nutritonal status)

• Labs

  • Albumin

  • Prealbumin

• Are supplements needed

  • MVI

  • Vitamin C

  • Zinc

  • Clinical dietitian consult

Who is the prevention of breakdown the responsibility of?

prevention of breakdown is the responsibility of all healthcare providers

• Assessment and Documentation are important

  • Litigation is on the rise

• Illness/Co-morbidities impact skin breakdown risk (e.g., heart failure that causes edema in legs)

What are the most common hot spots for pressure ulcers?

Sacrum & Heels

Most common when patient is on their back!

What are the only injuries that you stage?

Only-stage Pressure Injuries

• Identifying non-pressure related wounds as:

  • Partial thickness

  • Full thickness

• Do not stage

  • Chemical irritation from diarrhea

  • Road rash

  • Venous leg ulcer

  • Skin tears

  • Arterial ulcers

  • Diabetic ulcers

  • Surgical wounds

What is a blanchable erythema/hyperemia?

• There is a red area on the skin and when you press it, it turns white and when you let off it goes back to red

• This is the EARLY STAGE of a pressure ulcer

• This is GOOD it represents the blood flow and the body is trying to compensate

• REMOVE THE PRESSURE is the priority (don’t add no pillow, instead float a heel)

Blanchable Erythema/Hyperemia

• Pressure applied to skin from support surface to bony prominence

• Reactive hyperemia occurs when capillaries dilate when pressure is releives

Implication for Nursing Management:

• Remove pressure

• Moisturize skin

Reactive Hyperemia

• Once pressure to an area has been relieved, reactive hyperemia is the reddened skin color.

• It is blanchable and will resolve in approximately 1/2 to 3/4 the amount of time that the area was exposed to pressure.

Blanchable Erythema

• Reddened area that turns pale under applied light pressure

• Blanchable Erythema is NOT a Stage 1 Pressure Ulcer

Non Blanchable Erythema

The ulcer appears as a defined area of redness that does not blanch (become pale) under applied light pressure

• THIS IS CONCERNING

Non Blanchable Erythema

• Prolonged pressure caused damage to capillary bed over bony prominence

• If tissue appears purple/dark red: damage to deep muscle/bone interface occurred:

  • Deep Tissue Injury (DTI)

• Implication for Nursing Management:

  • Relieve pressure, protect and moisturize

  • Consult WOCN with suspected DTI

Can you put a pillow on the area to relieve pressure?

NO

• Putting the area on a pillow does NOT relieve the pressure

• You need to “float” the heel (keep the heel completely off the bed or surface by using a pillow or device under the lower leg)

Deep Tissue Injury

• Damage to the subcutaneous/muscle tissue from pressure.

• Presents initially as a bruise, but this may only be the “tip of the iceberg” of the actual injury.

• Damage below the level of the skin is not visible but may be extensive-like an iceberg!!

Partial Thickness Injury

• Loss of epidermal and dermal layers.

• Multiple causes: pressure, shear, trauma, venous disease (venous ulcers), incontinence

• Presents as shallow crater, usually painful as nerve endings are exposed

• Implication for Nursing Management:

  • Keep clean, keep moist, protect from further damage (turn!)

Nursing Plan of Care: Partial Thickness Injury

• Cleanse ulcer with dermal wound cleanser prior to dressing changes.

• Select and apply one of the following:

  • Hydrocolloid/Foam - low to moderate amounts of exudate. Change every 3 days and as needed.

  • Antifungal/Zinc cream - three times a day and after incontinent episodes.

Full Thickness Injury

• Full thickness skin loss involving damage to subcutaneous tissue that may extend down to or through underlying fascia.

• The injury presents clinically as a deep crater with or without undermining of adjacent tissue.

Full Thickness Injury

• Loss of tissue through the muscle tissue

• Undermining along wound edges

Nursing Plan of Care: Full Thickness Injury

• Assess area and document findings at each dressing change.

• Cleanse ulcer with dermal wound cleanser prior to dressing changes.

• Apply skin sealant to periwound skin.

• Select and apply one of the following:

  • If ulcer has minimal drainage, apply wound gel to wound bed, fluff gauze, lightly fill wound cavity and any tunneled areas with gauze, cover and secure with medipore tape. Change daily and as needed.

  • If ulcer has moderate to heavy amount of drainage, lightly fill wound cavity with calcium alginate, cover with dry gauze and secure with medipore tape. Change daily and as needed for drainage

Unstageable Pressure Injury

• Wound is covered with eschar or slough.

• The true base of the wound cannot be seen.