#1 - Skin
Fundamental Definitions in Skin Integrity
Pressure injury: Defined as damage to the skin or underlying soft tissue, typically occurring over a bony prominence or related to a medical or other device. It results from intense and/or prolonged pressure or pressure in combination with shear.
Debridement: The clinical process of removing dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Friction: The mechanical force exerted when skin is dragged across a coarse surface such as bed linens. This rubbing can damage the epidermal layer.
Ischemia: A restriction in blood supply to tissues, causing a shortage of oxygen and glucose needed for cellular metabolism and to keep tissue alive.
Maceration: The softening and breaking down of skin resulting from prolonged exposure to moisture, which often appears white or pruned.
Necrosis: The death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply.
Pressure area: A specific region over a bony prominence (e.g., sacrum, heels, hips) that is at a high risk for developing skin breakdown.
Reactive hyperemia: The transient increase in organ blood flow that occurs following a brief period of ischemia (e.g., the redness seen on the skin once pressure is relieved).
Shearing force: A combination of friction and pressure that occurs when the skin remains stationary against a surface while the underlying bone and muscle move in another direction.
Etiology and Staging of Pressure Injuries
Risk Factors for Pressure Injury Development: * Immobility: Inability to change positions independently to relieve pressure. * Poor nutrition: Lack of nutrients necessary for skin maintenance and repair. * Moisture: Prolonged skin contact with sweat, wound drainage, or urine/feces. * Incontinence: Increased risk of maceration and chemical irritation from waste. * Decreased sensation: Inability to feel discomfort or pain that would normally prompt a position change.
Staging of Pressure Injuries: * Deep tissue pressure injury: Persistent non-blanchable deep red, maroon, or purple discoloration. The skin may be intact or non-intact. * Stage I: Intact skin with localized area of non-blanchable erythema (redness). * Stage II: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. * Stage III: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. * Stage IV: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. * Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
Clinical Management and Prevention of Pressure Injuries
Assessment Parameters: * Measurement of wound size (length, width, and depth). * Assessment for drainage (amount and type). * Evaluation of odor. * Assessment of patient pain levels.
Nursing Interventions and Prevention Strategies: * Repositioning: Turning the patient at minimum every . * Offloading pressure: Ensuring bony prominences are not in direct contact with surfaces. * Skin Hygiene: Keeping the skin clean and dry to prevent maceration. * Nutritional Support: Providing adequate caloric and protein intake. * Support Surfaces: Utilizing specialized mattresses or chair pads designed to redistribute pressure.
Classification of Wounds and Debridement Methodologies
Types of Wounds: * Abrasion: A superficial scrape on the skin surface. * Contusion: A bruise caused by blunt force trauma that damages underlying capillaries while the skin remains intact. * Incision: A clean, straight surgical cut made by a sharp instrument. * Laceration: A torn or jagged wound, often caused by blunt trauma. * Puncture: A deep, narrow wound caused by a sharp object (e.g., a needle or nail).
Rationales for Debridement: Removing necrotic tissue is essential to promote healing, reduce the risk of infection, and allow for proper visualization of the wound bed.
Specific Debridement Methods: * Autolytic: Uses the body's own enzymes and moisture under semi-occlusive or occlusive dressings to liquefy necrotic tissue. * Surgical: Performed by a healthcare provider using a scalpel or scissors to remove dead tissue. * Mechanical: Physical removal of debris, such as the wet-to-dry dressing technique. * Chemical: Application of topical enzymatic agents that break down necrotic tissue.
Nursing Implications for Debridement: * Monitor for pain and provide analgesia as needed. * Observe for bleeding or signs of new infection. * Ensure a moist wound environment is maintained.
Wound Exudate Classification and Therapeutic Dressings
Types of Wound Exudate (Drainage): * Serous: Clear, watery plasma. * Sanguineous: Bright red, indicating active bleeding. * Serosanguineous: Pale, pink, watery; a mixture of clear and red fluid. * Purulent: Thick, yellow, green, tan, or brown; indicates infection (pus).
Clinical Dressing Selection: * Alginate: Highly absorbent; derived from seaweed; used for heavily draining wounds. * Gauze: Versatile; can be used for packing or as a protective cover. * Hydrocolloid: Forms a gel as it absorbs exudate; maintains a moist environment. * Hydrogel: High water content; used to hydrate dry wound beds and provide soothing comfort. * Non-adherent: Designed not to stick to the wound bed; protects fragile tissue. * Foam: Highly absorbent; cushions and protects the wound area. * Transparent film: Allows for visualization of the wound while protecting it from contaminants.
Phases and Mechanics of Wound Healing
The Four Phases of Healing: 1. Hemostasis: The immediate phase where blood vessels constrict and clotting begins to stop bleeding. 2. Inflammation: Characterized by the movement of white blood cells to the wound to clean the area and prevent infection. 3. Proliferation: New tissue (granulation tissue) is built to fill the wound space. 4. Maturation: The final phase where collagen is remodeled and the wound site strengthens.
Levels of Healing Intention: * Primary intention: Occurs in wounds with minimal tissue loss and well-approximated edges (e.g., a surgical incision closed with sutures). * Secondary intention: Occurs in wounds with extensive tissue loss and edges that cannot be approximated; the wound heals from the bottom up (e.g., a pressure injury). * Tertiary intention: Also known as delayed primary closure; occurs when a wound is left open intentionally for a period (often due to infection or edema) before being surgically closed.
Granulation tissue: Identifiable as red, moist, and bumpy tissue; it is a sign of healthy healing.
Factors Affecting Healing, Diagnostic Labs, and Nutrition
Factors Influencing Wound Repair: * Tissue perfusion and oxygenation. * Systemic or localized infection. * Advanced age. * Overall nutritional status. * Comorbidities (e.g., diabetes, vascular disease). * Smoking (causes vasoconstriction and reduces oxygen delivery).
Essential Laboratory Values: * Platelets: Normal range is (crucial for the hemostasis phase).
Critical Nutrients for Wound Healing: * Protein: Essential for tissue repair and collagen synthesis. * Vitamin C: Aids in collagen formation and capillary integrity. * Zinc: Supports cell proliferation. * Iron: Necessary for oxygen transport to tissues.
Nursing Diagnoses and Standards of Care
Common Nursing Diagnoses: * Impaired skin integrity. * Risk for impaired skin integrity. * Risk for infection.
Core Interventions: * Implementing a strict turning and repositioning schedule. * Performing meticulous wound care and dressing changes. * Providing optimal nutritional therapy. * Maintaining patient hygiene. * Strict adherence to aseptic technique.
Core Concepts in Infection and Inflammation
Medical Terminology: * Antibiotic/Antimicrobial/Antifungal/Antiviral: Agents used to treat or prevent infections caused by specific pathogens. * Erythema: Redness of the skin surface. * Exudate: Fluid, such as pus or serum, that has leaked out of blood vessels or organs, especially during inflammation. * Infection: The invasion and growth of germs (pathogens) in the body. * Inflammation: The body's natural response to injury or infection. * Leukocytosis: An increase in the number of white blood cells (WBCs) in the blood. * Phagocytosis: The process by which certain living cells (phagocytes) ingest or engulf other cells or particles. * Resistant strain: A colony of bacteria that has developed the ability to survive exposure to antibiotics. * Superinfection: A new infection that occurs during or after treatment for another infection, often due to the depletion of normal flora. * Vasodilation/Vasoconstriction: The widening or narrowing of blood vessels, respectively.
Biological Defenses and the Pathophysiology of Inflammation
Host Defense Systems: * Nonspecific Defenses: The body's first line of defense, including the skin, mucous membranes, and the inflammatory response. * Specific Defenses: Target specific pathogens using antibodies and T-cells.
Clinical Signs of Localized Inflammation: * Redness (Erythema). * Heat. * Swelling (Edema). * Pain.
Risk Factors for Infection: * Extremes of age (very young or elderly). * Chronic diseases. * Malnutrition. * Presence of invasive devices (e.g., catheters, IV lines).
Diagnostic Markers, Pharmacotherapy, and Antimicrobial Stewardship
Diagnostics: * White Blood Cell (WBC) Count: Normal range is . * Differential: Breaks down the types of WBCs present. * Cultures: Essential for identifying the specific pathogen to guide targeted antibiotic therapy.
Pharmacology Focus: Penicillin V: * Indications: Treatment of bacterial infections. * Side Effects (SE): Allergic reactions and gastrointestinal (GI) upset. * Nursing Implications (NI): Verify patient allergy history before administration and emphasize the importance of completing the full course.
Preventing Antibiotic Resistance: * Ensure the correct dosage is administered. * Ensure the patient finishes the full prescribed course. * Avoid the use of antibiotics for viral illnesses or unnecessary conditions.