foreign chapter 48 skin integrity and wound care the skin is the largest organ in the body it is a protective barrier against disease-causing organisms and a sensory organ for pain temperature and touch and the skin synthesizes vitamin D the most important responsibilities of the nurse include assessing and monitoring skin integrity identifying patient risks for skin problems identifying actual problems planning implementing and evaluating interventions to maintain its skin integrity when caring for an older adult there are various skin related issues to consider when assessing the skin and the risk for skin breakdown age-related changes cause reduced elasticity decreased collagen and thinning of underlying muscle and tissues this will cause the skin to be easily torn in response to shearing forces or mechanical trauma the attachment between the epidermis and the dermis becomes flattened in older adults allowing the skin to be easily torn in response to Mechanical trauma or tape removal existing medical conditions and polypharmacy are factors that can interview interfere with wound healing aging causes a diminished inflammatory response resulting in slow epithelialization and wound healing pressure injury pressure ulcer decubitus ulcer and bed sore these are all terms that'll that are used simultaneously that help describe impaired skin integrity related to unrelieved prolonged pressure injury is a localized damage to the skin and underlying soft tissue routinely over a bony prominence or can be related to a medical device or another type of device the injury can present as intact skin a blister or an open ulcer and it may be painful pressure is the major cause of injury tissue receives oxygen nutrients and eliminates metabolic waste through the blood system pressure or other factors that interfere with blood flow interfere also with cellular metabolism and the functioning or life of the cells the prolonged intense pressure affects the cellular metabolism by decreasing or obliterating the blood flow this causes tissue ischemia and ultimately tissue death low pressure over a prolonged period and high intensity pressure over a short period our two concerns related to the duration of pressure both types of pressure cause tissue damage the ability of tissue to endure pressure depends on the Integrity of the tissue and the supporting structures the extrinsic factors of Shear friction and moisture affect the ability of the skin to tolerate pressure the greater the degree of factors that are present the more susceptible the skin will be to damage from the pressure the second factor that is related to tissue intolerance is the ability of the underlying skin structures which are blood vessels and collagen to help redistribute that pressure systemic factors like poor nutrition hydration status low blood pressure and aging affect the tolerance of the tissue to externally applied pressure what type of mobility issues would you anticipate for this patient what are some risk factors that the patient may have for pressure ulcer development patients that have altered sensory perception for pain and pressure are more at risk for impaired skin integrity patients that are unable to independently change positions are also at risk for pressure injury patients who are comatose confuse oriented those who have expressive Aphasia or the inability to verbalize and those patients with changing levels of consciousness are unable to protect themselves from pressure injuries shearing force is the sliding movement of the skin and the subcutaneous tissue while the underlying muscle and bone are stationary the force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface like a bed linen is called friction the present presence and duration of moisture on the skin will also increase the risk of a pressure injury a stage one pressure injury this is non-blanchable erythema of re of intact skin the intact skin has a localized area of non-blanchable erythema and it may appear differently in dark pigmented skin the presence of blanchable erythema or changes in sensation temperature or firmness May precede any visual changes color changes do not include purple or maroon discolorations these May indicate to a nurse of deep tissue pressure injury a stage 2 pressure injury is a partial thickness skin loss with exposed dermis the partial thickness loss of skin with exposed dermis has a wound bed that is viable pink or red in color and moist and it may also be an intact or a ruptured serum fluid filled blister adipose tissue is not visible and deeper tissues are not visible the stage 3 pressure injury is a full thickness of skin loss the full thickness skin loss and this is when adipose tissue is visible in ulceration and granulation tissue as well as upable or rolled wound edges often are presented sloth or eschar may be visible the depth of tissue damage varies by anatomical location areas of significant adiposity these can develop in deep wounds undermining and tunneling may occur at this stage a stage 4 pressure injury is a full thickness skin and tissue loss the full thickness skin and tissue loss with exposed or directly palpable fascia muscle tendon ligament cartilage or bone in the ulcer sloth and or eschar may be visible Epi bowl or the rolled edges undermining and or tunneling may occur the depth will vary by the anatomical location a is an example of a stage one pressure injury B is a stage two C is a stage three D is a stage four e is a deep tissue injury and F is an unstageable pressure injury deep tissue pressure injuries this is a persistent non-blanchable deep red more maroon or purple discoloration intact or non-intact skin with localized area of persistent non-blanchable deep red maroon or purple or epidermal separation revealing a dark wound bed or blood-filled blister this injury results from Intense or prolonged pressure and Shear forces at the bone muscle interface the wound May evolve rapidly to reveal the actual extent of the tissue injury or may resolve without tissue loss an unstageable pressure injury is a full thickness skin and tissue loss to the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by sloth or eschar if the sloth or eschar is removed the stage 3 or stage 4 pressure injure pressure injury will be revealed stable Escher is dry adherent intact without erythema or flatuit flatulence on a heel or in it or an ischemic limb should not be softened or removed a wound is a disruption of the integrity and the functioning of tissues within the body wounds heal by various types of intention primary intention is a wound that is closed think of a surgical incision a wound that is sutured or stapled this healing occurs by epithelialization and heals quickly with minimal scar formation for a secondary intention the wound edges are not approximated surgical wounds that have tissue loss or contamination would be an example the wound heals by granulation tissue formation wound contraction and epithelialization tertiary intention this is a wound that is left open for several days then the wound edges are approximated wounds that are contaminated and require observations for signs of inflammation are these types of tertiary intention the closure of the wound is delayed until the risk of infection is resolved a is a black wound B is a yellow wound C is a red wound and D is a mixed color wound partial thickness wound repair this is tissue trauma that causes the inflammatory response of redness and swelling with moderate amount of serious extrudate for the first 24 hours the epithelial cells begin to regenerate and provide new cells to replace the Lost cells the epithelial proliferation and migration start at both the wound edges and the epithelial cells lining the epidermal appendages allowing for quick resurfacing the epithelial cells will begin to migrate across the wound bed soon after the wound occurs a wound that is kept moist can resurface in four days a wound that is left open to air can resurface within six to seven days the difference in the healing rate is related to the fact that the epidermal cells only migrate across a moist surface new epithelium is only a few cells thick and must undergo re-establishment of the epidermal layers the cells slowly re-establish normal thickness and appear as dry pink tissue for full thickness wound repair there are four phases that are involved hemostasis inflammatory proliferative and maturation hemostasis is a series of physiological events that are designed to control blood loss establish bacterial control seal the deficit foreign the injured blood vessels will constrict the platelets gather to stop the bleeding the clots form a fibrin matrix that later will provide a framework for cellular repair in the inflammatory phase the damaged tissue and mass cells secrete histamine cause vasodilation of capillaries and movement or migration of serum and white blood cells this results in localized redness edema warmth and throbbing this can be beneficial and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment like a spinal cord injury an ankle or the neck the leukocytes will reach the wound within hours the primary acting white blood cell is the neutrophil this begins to ingest bacteria in small degree and small debris the second is the monocyte this will transform into a macrophage macrophages are garbage cells that clean a wound of bacteria dead cells and debris by phagocytosis macrophages will continue to clear debris and release growth factors that attract fibroblasts which are cells that synthesize collagen or they're also known as connective tissue collagen actually appears on the second day and is the main component of scar tissue in a clean wound the inflammatory phase re-establishes the clean wound bed the proliferative phase is the appearance of new blood vessels as the Reconstruction progresses the prolifer the proliferative phase begins and lasts anywhere from 3 to 24 days the main activities of this phase are filling of the wound with granulation tissue wound contraction and wound resurfacing by epithelialization fibroblasts the cells that synthesize collagen are present to provide the Matrix for granulation to support the re-epithelialization the collagen will provide strength and structural integrity contracts to reduce the area that requires healing the epithelial cells will migrate from the wound edges to resurface the maturation phase may actually take more than one year depending on the depth and the extent of the wound the collagen scar continues to reorganize and grain gain strength for several months the healed wound does not have tensile strength of of the tissue that it replaces the collagen fibers need to undergo remodeling or reorganization before assuming normal appearance the scar tissue contains fewer pigmented cells or melanocytes and lighter color than normal skin Hemorrhage or bleeding from a wound site is normal during and immediately after initial trauma a wound infection is the second most common health care Associated infection dehiscence is when an incision will fail to heal properly and the layers of the skin and the tissue will separate this will occur before the collagen formation routinely three to eleven days after the injury dehiscence is partial or total separation of the wound layers evisceration is the protrusion of visceral organs through a wound opening this is a condition that is an emergency and requires surgical repair when evisceration occurs Place sterile gauze soaked in sterile saline over the extruding tissues to reduce the chance of bacterial Invasion and drying of the tissues if the organs protrude through the wound the blood supply blood supply to the tissues may be compromised preventing pressure injuries is a priority and is not limited to patients that have restrictions in Mobility impaired skin integrity Integrity usually is not a problem in healthy individuals but it is as serious and potentially devastating problem in ill or debilitated patients normal wound healing requires appropriate and proper nutrition oxygen fuels fuels cellular functions that are essential to the healing process the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing the wound infection will prolong the inflammatory process it delays the collagen synthesis prevents epithelialization and increases the production of pro-inflammatory cytokines which can lead to additional tissue destruction physiological changes associated with aging affect all phases of wound healing a decrease in the functioning of the macrophages leads to delayed inflammatory response delayed collagen synthesis and slower epithelialization the knowledge of normal musculoskeletal physiology the pathogenesis of pressure injuries the pressure injury stages the normal wound healing process and the pathophysiology of underlying diseases enables the scientific basis for care for these patients a are the bony prominences that most frequently are underlying a pressure injury B are the pressure injury sites when pressure injuries or chronic wounds develop the course of treatments may be lengthy and costly because the patient and family need to be involved with Wound Care Management it is important to know the patient's expectations the nurse should perform a skin assessment of a patient whenever they initiate care and then a minimum of once a shift when identifying the presence of skin wound or pressure injury a closer assessment is necessary the nurse should assess the type of the tissue in the wound base to plan appropriate interventions the assessment will include the amount or percentage the appearance or color of the viable and non-viable tissue granulation tissue is red moist tissue that is composed of new blood vessels and indicates a progression toward healing sloth is yellow soft white tissue that is stringy substance it is attached to a wound bed and must be removed before the wound May heal properly eschar is black brown tan or necrotic tissue that needs to be removed before healing can occur wound drainage serous drainage is clear watery light pink in color it is plasma purulent is thick yellow green tan or brown and it will indicate an infection serosanguinous is pale pink watery it's a mixture of the clear plasma and blood or the red fluid sanguinous is bright red and this indicates active bleeding think about the description of a stage 2 pressure ulcer remembering and reviewing previous clinical experiences is helpful in preparing to care for a patient inappropriate nursing diagnosis for this patient may be impaired skin integrity related to pressure over bony prominences in the sacral region the nursing assessment will reveal clusters of data to indicate whether a problem focused or a negative diagnosis of impaired skin integrity or a risk diagnosis of risk for impaired skin integrity exists patients that have large chronic wound s or infected wounds have multiple nursing care needs the nurse needs to establish goals and expected outcomes plan interventions according to the risk for pressure injuries or the type and the severity of the wound and the presence of any complications like infection poor nutrition peripheral vascular diseases or immunosuppressant that may affect wound healing remember that it is important to set achievable goals and expected outcomes with the patient the nursing assistant asks you the difference between a wound that heals by primary or secondary intention you will reply that a wound heals by primary intention when the skin edges are approximated migrate across the incision appear slightly pink slightly overlap each other the answer is a are approximated a clean surgical incision is an example of a wound with little tissue loss the surgical incision heals by primary intention the skin edges are approximated or closed and the risk of infection is low the Cleveland Clinic recommends these daily nutrients to help improve and promote wound healing individuals need protein five to eight servings daily yeah they should eat the protein portion of the meal first in case the individual becomes too full they need five servings of whole grains for higher protein content they need two servings per day of vegetables three servings per day of fruit choosing fruit for dessert is a great idea they need three servings per day of dairy an individual may substitute milk for water in recipes add powdered milk or yogurt to shakes smoothies and cooked cereals and top soups with cheese or Greek yogurt the repositioning or turning of patients is a consistent element of evidence-based pressure injury prevention the treatment of patients with pressure injuries requires a holistic approach that uses interprofessional expertise before treating a pressure injury reassess the wound for the location stage size the tissue type and the amount of extrudite and the surrounding skin condition to maintain a healthy wound environment the nurse will need to address the following objectives prevent and manage infection clean the wound remove non-viable tissue maintain the wound in a moist environment eliminate any dead space control odor eliminate or minimize pain and protect the wound and the Perry wound skin irrigation is one common method of delivering a wound cleansing solution to the wound wound irrigation cleans and debreeds necrotic tissue with pressure that can remove the debris from the wound bed without damaging the healthy tissue debridement is the removal of non-viable necrotic tissue the removal of necrotic tissue is necessary to rid the wound of a source of infection enable visualization of the wound bed and provide a clean base that is needed for for healing a moist environment will support the movement of epithelial cells and will facilitate the wound closure a wound that has excessive extrudite or drainage provides an environment that supports bacterial growth macerates the Perry wound skin and slows the healing process protecting the wound from further injury is a priority a strategy to prevent surgical wound dehiscence is to place a folded thin blanket or a pillow over an abdominal wound so that a patient can splint the area during coughing the nutritional support of a patient with a wound is based on the idea that nutrition is fundamental to normal cellular integrity and tissue repair please note that the first two actions or interventions address pressure management number three and four address wound care and the last intervention addresses nutritional management a is a dehist wound before the wound vac and B is a dehist wound after wound VAC therapy a wound dressing serves many purposes it will protect the wound from microorganism contamination it will Aid in hemostasis it will promote healing by absorbing drainage and debriding a wound support or splint the wound site it will promote thermal insulation of the wound surface and it will provide a moist environment there are various considerations when thinking about wound dressings the wound should be clean and the peri-wound area at each dressing change to minimize the trauma to the wound a dressing should be used that continually provides a moist environment the wound care should be performed using topical dressings as determined by a thorough assessment a dressing should be chosen that keeps the Perry wound skin dry while keeping the injury bed moist a dressing should be chosen that controls the exudate but that does not desiccate the injury bed the dressing may change over time as the pressure injury heals or deteriorates the wound needs to be monitored at every dressing change and regularly assess to determine whether modifications in dressings are needed foreign sponges are the oldest and most common form of dressings these are absorbent and are especially useful in wounds to Wick away wound exudate hydrocolloid dressings are dressings that have complex formulation of colloids and adhesive components they are both adhesive and occlusive the wound contact layer of this dressing forms a gel as the wound extrudate is absorbed and maintains a moist healing environment hydrocolloids support healing in clean granulating wounds this is showing a wound VAC system that uses negative pressure to remove fluid from the area surrounding the wound this helps reduce edema and improve circulation to the area to avoid the repeated removal of tape from sensitive skin dressings may be secured with pairs of reusable Montgomery ties each section consists of a long strip half contains an adhesive backing to apply to the skin and the other half folds back and contains cloth ties or a safety pin or rubber band in a combination that can be fastened across the dressing and untied at dressing changes to remove Staples insert the tips of the staple remover under each wire staple while slowly closing the ends of the staple remover together squeeze the center of the staple with the tips freeing it from the skin and gently lift up and out of the skin when drainage interferes with healing evacuation of the drainage is achieved by using either a drain or a drainage tube with continuous suction drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe constant low pressure vacuum to remove and collect the wound drainage binders are bandages that are made of large pieces of material routinely elastic or cotton or cotton to fit a specific body type the most common type is an abdominal binder this supports the large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs binders and bandages applied over or around dressing will provide Extra Protection and therapeutic benefits by the following creating pressure over a body part immobilizing a body part supporting a wound reducing or preventing edema securing a splint or securing dressings a post-operative patient arrives at an Ambulatory Care Center in States I'm not feeling good upon assessment you note an elevated temperature an indication that the wound is infected would be it has no odor a culture is negative the edges reveal the presence of fluid it shows purulent drainage coming from the incision site the answer is D the purulent drainage indicates wound infection itching strategies that would be appropriate for this patient are necessary the nurse should plan time that the patient is present and be prepared to spend 30 minutes in two separate teaching sessions the nurse should avoid using words that the patient will not understand the nurse should provide a brief description of what will be taught to both the patient and the family and include the patient in all of the teaching even though the patient may not see the wound the nurse should bring in extra dressing to the bedside to show the patient what the dressing looks like and how to apply it the use of a pictorial guide of pressure of a pressure ulcer will help the patient understand what the wound looks like and how it will progress if it shows signs of healing foreign should be planned where the patient will watch a demonstration of the wound being cleaned and the dressing being applied a second session should be planned where the patient will do a return demonstration and each teaching session session you should ask the patient how the patient felt doing the dressing change and include the family in the evaluation moist heat applications are beneficial in increasing muscle and ligament flexibility it will promote relaxation and healing and relieve spasm joint stiffness and pain dry heat is also used to reduce pain and increase healing by increasing the blood flow in the tissues and may be used at a low level for a longer period with little chance of tissue injury cold therapy is designed to treat the localized inflammatory response of an injured body part this will provide Improvement to Joint Mobility following the cold therapy and it is used to reduce pain and swelling inhibit muscle spasm and reduce muscle tension cold therapy is contraindicated if the injury is already edematous there's impaired circulation has a presence of neuropathy or the patient is shivering the effects of heat application is that heat are is quite therapeutic and improves the blood flow to the injured area if the heat is applied for one hour or more the body will reduce the blood flow by a reflex vasoconstriction to control the heat loss from the area periodic removal and reapplication of local heat will restore the vasodilation continuous exposure to heat can damage epithelial cells cause redness localized tenderness and even blistering the effects of cold application are the cold initially diminishes the swelling and the pain the prolonged exposure to cold will result in reflex vasodilation the inability of the cells to receive adequate blood flow and nutrients can result in tissue ischemia the skin initially takes on a reddened appearance followed by a bluish purple modeling and will include numbness and a burning sensation of pain skin tissues will freeze from an exposure to extreme cold considering evaluation what other type of evaluation could this nurse be using think about nutritional status and asking the patient about the food intake and reviewing the calorie count over the past week a surgical wound requires a hydrogel dressing the primary advantage of this type of dressing is that it provides an absorbent surface to collect wound drainage decreased incidence of skin maceration protection from the external environment the moisture needed for wound healing the answer for the hydrogel dressing is D the moisture that is necessary for wound healing the optimal outcomes are to prevent injury to the skin to reduce injury to the skin and underlying tissues and possible wound healing with restoration of skin integrity consider why it is important to teach family members to continue the health program for patients at discharge when providing wound care always use a septic technique assess skin each shift mix minimize the friction and potential for shear and understand any chronic disease processes