this is foundations of nursing topic number four skin integrity and wound care skin the largest organ in the body is a protective barrier against disease-causing organisms and a sensory organ for pain temperature and touch it also synthesizes vitamin D injury to the skin poses risks to an individual's safety wound healing is a complex cellular and biochemical process and it is affected by systemic and local factors such as underlying disease processes the cause of the wound and the condition of the wound your clinical judgment must integrate scientific and nursing knowledge to thoroughly assess and monitor skin integrity and to identify client risks for or with actual impaired skin integrity a critical thinking approach to this process will yield clinical decisions for how to plan Implement and evaluate interventions to maintain Skin Integrity or improve wound healing the skin has two layers the epidermis and the dermis the epidermis or the top layer has several layers the stratum corneum is the thin outermost layer of the epidermis it consists of flattened dead keratinized cells the constant movement of the layers of the epidermis ensures replacement of surface cells left off during normal desquamation or shedding the thin stratum corneum protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents the stratum corneum allows evaporation of water from the skin and permits absorption of certain topical medicines the dermis the inner layer of the skin provides tensile strength mechanical support and protection for the underlying muscles bones and organs it differs from the epidermis in that it contains mostly connective tissue and few skin cells when the skin is injured the epidermis functions to resurface the wound and restore the barrier against invading organisms and the dermis responds to restore the structural integrity and the physical properties of the skin the normal aging process Alters skin characteristics and makes skin more vulnerable to damage pressure injury pressure ulcer decubitus ulcer and bedsore are terms used to describe impaired skin integrity related to unrelieved prolonged pressure the most current terminology is pressure injury a pressure injury is localized damage to the skin and underlying soft tissue usually developing over a bony prominence or related to pressure from a medical device or other device the injury can present as intact skin a blister or an open ulcer and may be painful the injury occurs because of intense and or prolonged pressure or pressure in combination with shear the tolerance of soft tissue for pressure and Shear may also be affected by microclimate such as the temperature humidity and airflow next to the skin nutrition perfusion comorbidities and the condition of the soft tissue any client experiencing decreased Mobility decreased sensory perception fecal or urinary incontinence and or poor nutrition is at risk for pressure injury development pressure is the major element in the cause of pressure injuries tissue receives oxygen and nutrients and eliminates metabolic waste via the blood pressure or other factors that interfere with blood flow in turn interfere with cellular metabolism and the function or life of the cells prolonged intense pressure affects cellular metabolism by decreasing or obliterating blood flow resulting in tissue ischemia and ultimately tissue death current theory suggests that skin and soft tissue damage can begin at the surface and progress inward or begin at the muscle and progress outward depending on causation top-down damage superficial is thought to be caused by superficial Shear or friction presenting as red skin a stage one pressure injury bottom up or deep damage is believed to be caused by several pressure related factors pressure intensity pressure duration and tissue tolerance the goal in preventing the development of pressure injuries is early identification of an at-risk client and the implementation of prevention strategies a variety of factors predispose a client to pressure injury formation these factors may be related to a disease such as reduced peripheral circulation from diabetes mellitus or they may be secondary to an illness such as decreased sensation following a cerebral vascular accident or stroke clients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity they are unable to feel when a part of their body undergoes increased prolonged pressure or pain clients who are unable to independently change positions are at risk for pressure injury for example a client who is seriously ill will be weakened and less likely to turn independently clients who are comatose confused or disoriented those who have expressive Aphasia or the inability to verbalize and those with changing levels of consciousness are unable to protect themselves from pressure injury also clients who are confused or disoriented may be able to feel pressure but are not always able to understand how to relieve it or communicate their discomfort here's our case study for this lesson Mr Omar Ahmed a 76 year old accountant has come to the hospital again this time for pneumonia before admission he was unable to eat and lost more than 20 pounds over the last two months three years ago he had coronary artery bypass surgery as a precaution he is placed on Telemetry monitoring he also has hypertension and type 2 diabetes mellitus his Mobility is limited because of weakness what Mobility concerns do you anticipate for Mr Ahmed Mr Ahmed is retired he lives in a one family home with his wife Natalie their children and grandchildren live nearby and visit often he complains that his bottom hurts from lying in bed Linda is the nursing student assigned to the medical nursing unit this is her first hospital-based clinical practice what risk factors does Mr Ahmed have for pressure injury development Shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary Shear Force occurs when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed and as an example is shown in this figure where the shear is exerted in the sacral area it also occurs when transferring a client from the bed to stretcher when a client's skin is pulled across the bed this can be avoided using friction relief devices during safe client handling when Shear is present the skin and subcutaneous layers adhere to the surface of the bed and the layers of muscle and the bones slide in the direction of body movement the damage that Shear causes occurs at the deeper fascial level of the tissues over the bony prominence the force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens is called friction unlike Shear injuries friction injuries affect the epidermis or top layer of the skin also known as superficial skin loss the denuded skin appears red and painful and is sometimes referred to as a sheet burn a friction injury occurs in clients who are restless in those who have uncontrollable movements such as [ __ ] conditions and in those whose skin is dragged rather than lifted from the bed surface during position changes or transfer to a structure the presence and duration of moisture on the skin increases the risk of pressure injury moisture reduces the resistance of the skin to other physical factors such as pressure friction or shear prolonged moisture softens skin making it more susceptible to damage there are various sources of moisture including wound drainage urine or stool perspiration wound exudate mucus or saliva risk factors for pressure injury development include the inability to perceive pressure incontinence or moisture decreased activity level the inability to reposition poor nutritional intake and friction and shear a staging system exists for classifying pressure injuries accurate staging requires knowledge of the skin layers A major drawback of a staging system is that you cannot stage an injury when it is covered with necrotic tissue because the necrotic tissue is covering the depth of the injury in serious wounds with necrotic tissue the wound must be debrided or removed if appropriate to the overall treatment plan to expose the wound base to allow for assessment pressure injury staging describes the pressure injury depth at the time of assessment once you stage the pressure injury the stage endures even as it heals in a stage one pressure injury the skin is intact with a localized area of non-blanchable erythema top row picture on the left changes in sensation temperature or firmness May precede visual changes color changes do not include purple or maroon discoloration these May indicate deep tissue pressure injury in a stage 2 pressure injury there is a partial thickness skin loss with exposed dermis top row picture on the right the wound bed is viable pink or red and moist and may also present as an intact or ruptured serum filled blister adipose or fat tissue is not visible and deeper tissues are not visible granulation tissue sluff and escar are not present these injuries commonly result from adverse microclimate and Shear in the skin over the pelvis and Shear in the heel in the stage 3 pressure injury there is a full thickness loss of skin in which adipose or fat tissue is visible in the ulcer and granulation tissue and epibally or rolled wound edges are often present bottom row picture Slough and or escar may be visible the depth of tissue damage varies by anatomical location undermining and tunneling may occur fascia muscle tendon ligament cartilage and or bone are not exposed if sluff or escar obscures the extent of tissue loss this is classified as an unstageable pressure injury in a stage 4 pressure injury the full thickness of the skin and tissue loss with exposed or directly palpable fascia muscle tendon ligament cartilage or bone in the ulcer is seen picture on the top row on the left sloth and or escar may be visible a pivoli rolled edges undermining and or tunneling often occurs depth varies by anatomical location if sluff or escar obscures the extent of tissue loss this is classified as an unstageable pressure injury an unstageable pressure injury has a full thickness skin and tissue loss but the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by Slough or escar picture on the top row on the right if sluff or escar is removed a stage three or stage 4 pressure injury will be revealed a deep tissue pressure injury presents with intact or non-intact skin with a localized area of persistent non-blanchable deep red maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister the picture on the bottom row pain and temperature change often precedes skin color changes discoloration may appear differently in Darkly pigmented skin this injury results from intense and or prolonged pressure and Shear forces at the bone muscle interface the wound May evolve rapidly to reveal the actual extent of tissue injury or may result without tissue loss if necrotic tissue subcutaneous tissue granulation tissue fascia muscle or other underlying structures are visible this indicates a full thickness pressure injury and should be classified as an unstageable stage 3 or stage 4 pressure injury here is what the skin and underlying tissues look like in each stage of a pressure injury shown as figure 48.4 from the textbook a is a stage 1 pressure injury B is a stage 2 pressure injury C is a stage 3 pressure injury D is a stage four pressure injury e is a deep tissue injury and F is an unstageable pressure injury Linda reviews the nursing assessment and finds that Mr Ahmed was admitted with a pressure injury the injury is a stage 2 1 by 2 inch and 1 8 inch deep partial thickness wound over his sacral area no necrotic tissue is present and the wound bed has red moist tissue when Linda prepares to conduct a skin assessment she recalls information about the pathogenesis of pressure injuries and guidelines for skin assessment for patients with Darkly pigmented skin can you recall the descriptions of the ulcer stages so that you know why Mr ahmed's ulcer is a stage two three components are involved in the healing process of a partial thickness wound inflammatory response epithelial proliferation and migration and re-establishment of the epidermal layers Linda observed care of a stage four pressure injury during an experience in an extended care facility from that experience she increased her knowledge about the debilitating effects of pressure injuries in addition she was able to practice skin assessment techniques during her clinical experience in the Extended Care Facility the review of previous clinical experiences is often helpful in preparing to care for your patients a medical device related pressure injury occurs when the skin or underlying tissues are subjected to sustain pressure or Shear from medical devices or equipment the resultant pressure injury generally conforms to the pattern or shape of the device and are most commonly seen at the face and head region and the ears specifically critically ill patients and neonates are particularly vulnerable to these types of pressure injuries table 48.1 in the textbook describes strategies to prevent medical device related pressure injuries tape and other medical adhesives such as those used to secure ostomy devices can cause skin injury medical adhesive related skin injury is An Occurrence in which erythema and or other manifestation of cutaneous abnormalities such as Skin tears persists 30 minutes or more after removal of a device or adhesive securing the device a wound is a disruption of the integrity and function of tissues in the body a wound may result from trauma to the skin causing laceration or puncture or from surgical intervention the two major types of wounds are open and closed in a closed wound the surface of the skin remains intact but the underlying tissues may be damaged examples of closed wounds are contusions hematomas or stage one pressure injuries with open wounds the skin is split incised or cracked and the underlying tissues are exposed to the outside environment open wounds create a significant risk for infection to develop there are many ways to classify Surgical and traumatic wounds wound classification systems describe onset and duration of healing process such as the status of Skin Integrity the cause of the wound or the severity or extent of tissue injury or damage table 48.2 in the textbook describes various types of wounds their causes and implications for healing wounds can also be classified by the extent of tissue loss partial thickness wounds that involve only a partial loss of skin layers which are the epidermis and superficial dermal layers and full thickness wounds that involve total loss of the skin layers the epidermis and dermis wound healing involves integrated physiological processes the tissue layers involved in their capacity for regeneration determine the mechanism for repair for any wound a partial thickness wound heals by regeneration and a full thickness wound heals by forming new tissue a process that can take longer than the healing of a partial thickness wound shown as figure 48.6 from the textbook wounds classified by color assessment a is a black wound B is a yellow wound C is a red wound and D is a mixed color wound 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 healing occurs quickly with minimal scar formation if infection and secondary breakdown are prevented in contrast a wound involving the loss of tissue such as a burn stage two pressure injury or severe laceration heals by secondary intention the wound is left open until it becomes filled by Scar Tissue it takes longer for a wound to heal by secondary intention therefore the chance of infection is greater if scarring from secondary intention is severe loss of tissue function is often permanent not shown in this figure are wounds healing by tertiary intention these wounds are left open for several days and then the wound edges are approximated this is seen with wounds that are contaminated and require observation for signs of inflammation before closing them the best environment for wound healing is moist and free of necrotic tissue and infection no specific studies demonstrate the benefit of using one cleaner over another for pressure injuries in most cases water or saline is sufficient for cleansing a clean wound when any wound is contaminated with debris necrotic tissue or heavy drainage use a cleaner that is non-cytotoxic to healthy tissue the wound repair process differs depending on whether a wound is partial or full thickness partial thickness wounds are shallow involving the loss of epidermis and possible loss of dermis full thickness wounds extend into the dermis and heal by scar formation because deeper structures do not regenerate hemostasis involves a series of physiological events designed to control blood loss established bacterial control and seal the defect that occurs when there is an injury during hemostasis injured blood vessels constrict and platelets gather to stop bleeding clots form a fibrin matrix that later provides a framework for cellular repair hemostasis is impaired when clients are on anticoagulants or have specific diseases that affect platelet production or blood clotting in the inflammatory phase damaged tissue and mast cells secrete histamine resulting in vasodilation of surrounding capillaries and movement or migration of serum and white blood cells into the damaged tissues this results in localized redness edema warmth and throbbing with the appearance of new blood vessels as reconstruction progresses the proliferative and new tissue formation phase begins three to four days after injury and can last as long as two weeks during this period a wound contracts to reduce the area that requires healing Remodeling and maturation the Final Phase of wound healing begins several weeks after injury and continues for more than a year depending on the depth and the extent of the wound the collagen scar continues to reorganize and gain strength for several months usually Scar Tissue contains fewer pigmented cells or melanocytes and has a lighter color than normal skin in individuals with Darkly pigmented skin the scar tissue may be more highly pigmented than the surrounding skin there are several complications that can be seen as the wound heals Hemorrhage or bleeding from a wound site is normal during and immediately after initial trauma however hemostasis occurs within several minutes unless large blood vessels are involved or a patient has poor clotting function Hemorrhage occurring after hemostasis indicates a dislodged surgical suture a clot infection or erosion of a blood vessel by a foreign object such as a surgical drain shown in the top picture on this slide Hemorrhage may occur externally or internally you detect internal hemorrhaging by looking for distension or swelling of the affected body part A change in the type and amount of drainage from a surgical drain or signs of hypovolemic shock external hemorrhaging is obvious you examine dressings covering a wound for bloody drainage and You observe for blood underneath the body if bleeding is extensive the dressing soon becomes saturated and frequently blood drains from under the dressing and pools beneath the patient observe all wounds closely particularly surgical wounds in which the risk of hemorrhage is great during the first 24 to 48 hours after surgery or injury Moon infection is one of the most common health care Associated infections in acute care settings surgical site infections are a significant problem microorganisms infect a surgical wound through various forms of contact such as from the touch of a contaminated health care provider or surgical instrument through the air or through contact on or in a person's body and then spread into the wound all wounds have some level of bacterial burden however few wounds become infected wound infection develops when microorganisms invade the wound tissues the local clinical signs of wound infection include erythema increased amount of wound drainage change in the appearance of a wound drainage including increased thickness color change presence of odor and peri-wound warmth pain or edema a client may have a fever and an increase in their white blood cell count laboratory tests such as a wound culture or tissue biopsy assist in determining the presence of wound infection and the causative microorganism table 48.3 in the textbook describes the various types of wound drainage in the second picture on the slide notice the redness on the left hand side which is a clinical sign of a wound infection when a surgical incision fails to heal properly the layers of skin and tissue separate this is most commonly occurs before collagen formation approximately 3 to 11 days after injury dehiscence is the partial or total separation of wound layers a client who is at risk for poor wound healing due to poor nutritional status infection or underlying diseases such as diabetes mellitus or peripheral vascular disease is at risk for dehiscence it can occur five to twelve days after suturing at a time when wound repair is at its peak clients often report feeling as though something has given way when there is an increase in serosanguinous drainage from a wound in the first few days after surgery be alert for the potential for dehiscence with total separation of wound layers evisceration or the protrusion of visceral organs through a wound opening occurs this condition is an emergency that requires surgical repair when evisceration occurs Place sterile gauze soaked in sterile saline over the extruding tissues to reduce chances of bacterial Invasion and drying of the tissues if the organs protrude through the wound blood supply to the tissues can be compromised then contact the surgical team do not allow the patient anything by mouth in other words keep them NPO and observe for signs and symptoms of shock and prepare the patient for emergency surgery let's do a practice question 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 a are approximated B migrate across the incision C appear slightly pink D slightly overlap each other the correct 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 identify the support surface that would be appropriate to decrease pressure on Mr ahmed's Skin Mr Ahmed cannot tolerate Physicians that might relieve or reduce pressure to his skin inspect and palpate the wound the wound is a one by two inch full thickness skin loss pressure injury over the sacral area with a red moist base redened Perry wound skin conduct a calorie count Mr Ahmed is eating fewer than 1600 calories daily What nursing diagnosis do you think is appropriate one nursing diagnosis is impaired skin integrity that is related to pressure over bony prominences in the sacral region the goal is that the pressure will be reduced to the sacral area and the wound will show movement toward healing in one week we expect to see that the wound will decrease in diameter in seven days and no evidence of further wound formation will be noted in three days it is important to set achievable goals and expected outcomes for the patient does this goal meet the smart requirements preventing pressure injuries is a priority and is not limited to patients with restrictions in Mobility impaired skin integrity usually is not a problem in healthy individuals but is a serious and potentially devastating problem in ill or debilitated clients your clinical judgment in planning consistent skin care interventions is critical to preventing pressure injuries risk assessment varies according to client status several assessment tools are available for assessing patients who are at risk for developing a pressure injury by identifying at-risk clients you can put preventive interventions into place and also spare low-risk clients unnecessary and sometimes costly preventative treatments table 48.4 in the textbook provides a chart that describes the guidelines for pressure injury risk assessment the Braden scale shown in table 48.5 is a reliable and valid tool for pressure injury risk assessment the scale was developed based on risk factors in a nursing home population and is widely used on General client care units in hospitals and long-term care the Braden scale contains six sub-scales sensory perception moisture activity Mobility nutrition and friction and Shear the total score ranges from 6 to 23. a lower total score indicates a higher risk for pressure injury development pressure injuries are a continual problem in acute and restorative care settings especially in patients age 65 years and older when a pressure injury occurs the length of stay in a healthcare agency and the overall cost of Health Care increase these injuries are also costly to clients in terms of disability pain and suffering the centers for Medicare and Medicaid services no longer reimburses hospitals for care related to stage 3 and stage 4 pressure injuries that occur during a hospitalization this photo shows the braid and risk assessment scale remember that the lower the number the higher the risk for skin impairment in addition to previously discussed risk factors of impaired sensation impaired mobility Shear friction and moisture a client's nutrition tissue perfusion infection or age may increase the risk for pressure injury and poor wound healing normal wound healing requires proper nutrition deficiencies in any of the nutrients result in impaired or delayed healing physiological processes of wound healing depend on the availability of protein vitamins especially a and c and the trace minerals zinc and copper table 48.6 discusses the role of selected nutrients in wound healing calories provide the energy source needed to support the cellular activity of wound healing protein needs especially are increased and are essential for tissue repair and growth oxygen fuels the cellular functions essential to the healing process therefore the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing a major goal of wound management is prevention of infection wound infection prolongs the inflammatory phase the physiological changes associated with aging affect all phases of wound healing the psychosocial impact of wounds on the physiological process of healing is unknown however the psychosocial impact can be significant body image changes resulting from a wound often impose a great stress on clients adaptive mechanisms they also influence self-concept and sexuality the care of any patient with an existing wound or who is at risk for developing a wound can be complex successful critical thinking requires a synthesis of knowledge experience environmental factors critical thinking attitudes and intellectual and Professional Standards sound clinical judgments require you to anticipate information analyze the data and make clinical decisions regarding your clients care during assessment consider all critical thinking elements that will enable you to make the clinical decisions necessary for identifying appropriate nursing diagnoses shown as figure 48.8 from the textbook this is the critical thinking model for skin integrity and wound care assessment the knowledge of normal physiology of the integumentary and musculoskeletal systems the pathogenesis of pressure injuries the pressure injury stages normal wound healing and the pathophysiology of underlying diseases provides a scientific basis for how you approach an assessment of a specific client for example you will assess a client who has a history of diabetes mellitus differently than a client who has been lying in bed with skeletal traction of the leg during the assessment process use critical thinking when making clinical judgments that are necessary to thoroughly assess a patient's skin integrity and determine that assessment data are accurate and complete if the knowledge you have about a client suggests the client is at risk for a pressure injury be sure to focus on the specific factors that create risk for pressure injuries such as a client's level of sensation the presence of medical devices or medical adhesives independent or assisted movement and nutritional incontinence status box 48.3 has a series of questions that you can use when assessing the client because a client and family need to be involved with Wound Care Management it is important to know a client's expectations does the client expect to have Home Care is there the expectation that the client's wound will heal to allow a quick return to work a client who has a realistic expectations and is informed about the length of time for wound healing is more likely to adhere to the specific therapies designed to promote healing and prevent further skin breakdown be aware of environmental factors in the health care setting that have the potential to affect your ability to assess a client's Skin Integrity often clients require frequent turning or assistance with position changes clients with complicated non-healing wounds have complex dressing changes assess when visitors or other health health care Personnel are at the client's bedside or room you need to plan to perform wound assessments and dressing changes when there are no extra people in the room or at the bedside this maintains client privacy but also controls for transmission of infection to the wound from others shown his figure 48.9 from the textbook this diagram highlights bony prominences that are most frequently underlying pressure injury it also highlights common pressure injury sites when you identify the presence of a skin wound or pressure injury closer assessment is required assess the type of tissue in the wound base and the factors influencing the client's risks for poor healing so you can plan appropriate interventions the assessment includes the amount or percentage and appearance color of viable and non-viable tissue granulation tissue is red moist tissue composed of new blood vessels the presence of which indicates progression toward healing soft yellow or white tissue is characteristic of sluff a stringy substance attached to the wound bed and it must eventually be removed by a qualified health care provider or by means of an appropriate wound dressing before the wound is able to heal black brown tan or necrotic tissue is escar which also needs to be removed before healing can occur measurement of the wound size provides information on overall changes in Dimensions which is an indicator for wound healing progress this includes measuring the length and width of a wound as well as determining its depth assessment of wound exudate should describe the amount color consistency and odor of wound drainage normally a closed surgical wound has minimal serosanguinous dressing immediately after surgery excessive exudate indicates the presence of infection wound pain including the location distribution type quality and intensity and any aggravating or relieving Factor should also be assessed examine the skin around a wound the Perry wound for redness warmth and signs of maceration and palpate the area for signs of pain let's do a practice question a post-operative patient arrives at an Ambulatory Care Center and States I am not feeling good upon assessment you note an elevated temperature an indication that the wound is infected would be a it has no odor b a culture is negative C the edges reveal the presence of fluid D it shows prevalent drainage coming from the incision site the answer is D purulent drainage coming from the incision site is a sign of infection on admission to Acute Care Rehabilitation hospitals nursing homes home care and other health care agencies clients are assessed for risk of pressure injury development assessment for pressure injury risk includes using an appropriate predictive measure and assessing a client's Mobility nutrition presence of body fluids and comfort level assessment includes noting the Baseline level of mobility and the potential effects of impaired mobility on skin integrity an assessment of a client's nutritional status is an integral part of the initial assessment data for any client especially one at risk for impaired skin integrity it is important to prevent and reduce a client's exposure to body fluids when exposure occurs provide meticulous hygiene and Skin Care continual exposure of the skin to moisture increases a client's risk for skin breakdown and pressure injury formation the routine assessment of pain in surgical clients is critical to selecting appropriate pain management therapies and to determine a client's ability to progress toward recovery maintaining adequate pain control and client Comfort increases the client's willingness and ability to increase Mobility which in turn reduces pressure injury risk for surgical and traumatic wounds assess the wounds at the time of injury or post-operatively during wound care when a client's overall condition changes and on a regularly scheduled basis inspect traumatic wounds for foreign bodies or contaminant material when a client's condition is stabilized after surgery or treatment assess the wound to determine progress toward healing if the wound is covered by addressing and the health care provider has not ordered it changed do not inspect it directly unless you suspect serious complications such as a large volume of bright red bleeding excessive odor or severe pain under the dressing a surgical incision healing by primary intention should have clean well-approximated edges there may be some redness at the edges of the incision that can be present for the first few days after surgery crusts often form along wound edges from exudate if a wound is open the edges are separated and you inspect the condition of tissue at the wound base the outer edges of a wound normally appear in flame for the first two to three days but this slowly disappears within seven to ten days a normally healing wound resurfaces with epithelial cells and the edges close table 48.7 lists assessment characteristics for abnormal wound healing in primary and secondary intention wounds note the amount color odor and consistency of wound drainage when inspecting a wound observe for swelling or separation of wound edges while wearing clean gloves lightly press the wound edges detecting localized areas of tenderness or drainage collection drains provide a mean for fluid or blood that accumulates within a wound bed to drain out of the body a surgeon inserts a drain into or near a surgical wound if there is a large amount of drainage assess the number and type of drains drain placement and character of drainage determine if the drainage is within expected guidelines for volume or color and condition of collecting equipment surgical wounds are closed with staples sutures or wound adhesives look for irritation with redness around staple or suture sites and note whether closures are intact if you detect purulent or suspicious looking drainage report to the health care provider because a specimen of the drainage may need to be obtained for culture finally assess how a wound is influencing a client's self-perception and socialization ask the client to describe how the wound affects the view of self your review of data will reveal clusters of data to support a problem-focused or negative diagnosis such as impaired skin integrity or a risk diagnosis of risk for impaired skin integrity in addition review your assessment data to identify information about any related factors for example a post-operative client has purulent drainage from a surgical wound and reports tenderness around the area of the wound these data support a nursing diagnosis of impaired skin integrity related to infection once the nursing diagnoses have been identified use clinical judgment to develop a plan of care to promote wound healing and prevent complications of any existing wounds clients who have large chronic wounds or infected wounds have multiple nursing care needs nursing care is based on a client's identified nursing diagnoses and collaborative problems identify expected outcomes for each diagnosis and plan individualized interventions according to the risk for pressure injuries or the type and severity of an existing wound as you select interventions consider the presence of any complications such as infection poor nutrition peripheral vascular diseases or immunosuppression that can affect wound healing an outcome allows you to Target specific interventions some examples of outcomes associated with preventing or reducing risk for pressure injuries and wound healing could include increase in the percentage of granulation tissue in the wound base no wound erythema or tenderness to palpation or increase in caloric intake of 10 percent established nursing care priorities in wound care based on the nursing diagnoses identified and the outcomes of care these priorities also depend on whether the client's condition is stable or emergent collaborate with the client when possible with regard to when to perform wound care other client factors to consider when establishing priorities include client preferences planning around daily activities and family caregiver factors if a family caregiver is required when a client is discharged home education of the family caregiver will be essential clients with wounds or pressure injuries will often benefit from the expertise of a skin care specialist or wound care team when available a client with a high risk for pressure injury development will also benefit from these resources these clinicians help you plan specific interventions to manage poorly healing wounds and pressure injuries and to identify strategies for reducing the risk for pressure injuries the major health promotion activities regarding Skin Integrity are prevention of pressure injuries and promotion of normal wound healing clients with any type of wound require nutritional support proper positioning and Skin Care clients with existing wounds or those at risk for pressure injury will need extra protein calories and nutrients nursing interventions for clients who are immobile or have other risk factors for pressure injuries focus on prevention prevention minimizes the impact that risk factors or contributing factors have on pressure injury development three major areas of nursing interventions for prevention of pressure injuries are one skin care and management of incontinence two mechanical loading and support devices which include proper positioning and the use of therapeutic surfaces and three education table 48.8 in the textbook provides a quick guide to pressure injury prevention when you clean the skin avoid soap and hot water as they increase skin dryness use cleaners with non-ionic surfactants that are gentle to the skin after you clean the skin make sure that it is completely dry and apply moisturizer to keep the epidermis well lubricated but not over saturated make an effort to control contain or correct incontinence perspiration or wound drainage when clients have an incontinent episode gently clean the area dry and apply a thick layer of moisture barrier to the exposed areas a moisture barrier protects the skin from excessive moisture and from bacteria found in the urine or stool repositioning or turning clients is a consistent element of evidence-based pressure injury prevention the two-fold aim of repositioning should be to reduce or relieve pressure at the interface between a bony prominence and support surface such as the bed or chair and to limit the amount of time for which the tissue is exposed to pressure shown on this slide is figure 48.15 from the textbook 30 degree lateral position at which pressure points are avoided repositioning intervals must be based on the client assessment a standard turning interval of one and a half to two hours does not always prevent pressure injury development some clients may need more frequent position changes whereas other clients can tolerate every two hour position changes without tissue injury support surfaces are specialized devices such as mattress overlays mattress Replacements integrated bed systems seat cushions or seat cushion overlays that redistribute pressure and are designed for management of tissue loads microclimate shear and or other therapeutic functions now that you have completed your assessment and taken the cues from the assessments to form a nursing diagnosis as well as develop a plan for the client based on their nursing diagnosis you need to decide what you the nurse will do to help the client meet the plan this is the implementation part of the nursing process when a client suffers a traumatic wound first aid interventions include stabilizing cardiopulmonary function promoting hemostasis cleaning the wound and protecting it from further injury after assessing the type and extent of the wound control bleeding by applying direct pressure on it with a sterile or clean dressing after bleeding subsides an adhesive bandage or gauze dressing taped over the laceration allows skin edges to close and a blood clot to form serious lacerations need to be sutured by a healthcare provider pressure dressings used during the first 24 to 48 hours after trauma help maintain hemostasis the process of cleaning a wound involves selecting an appropriate cleaning solution and using a mechanical means of delivering that solution without causing injury to the healing wound tissue normal saline is the preferred cleaning agent for wounds it is physiologically neutral and does not harm tissue gentle cleaning with normal saline and the application of moist saline dressings are often used in healing wounds regardless of whether bleeding has stopped protect a wound from further injury by applying sterile or clean dressings and immobilizing the body part a light dressing applied over minor wounds prevents entrance of microorganisms a variety of dressing materials are commercially available the correct dressing selection facilitates wound healing the dressing type depends on the assessment of the wound and the phase of wound healing for surgical wounds that heal by primary intention it is common to remove dressings as soon as drainage stops in contrast when dressing a wound healing by secondary intention the dressing material becomes a means for providing moisture to the wound or assisting in debridement listed are interventions and their rationales for Mr Ahmed note that the first two actions address pressure management the next two address wound care and the final intervention addresses Nutrition management education of the client and caregivers is an important nursing function a variety of Educational Tools including videotapes and written materials are available for you to use when teaching clients and caregivers or family to prevent and treat pressure ulcers and care for wounds nutritional assessment in support of the patient with a wound is based on the appreciation that nutrition is fundamental to normal cellular integrity and tissue repair early intervention is necessary to correct inadequate nutrition and to support healing The Joint Commission recommends a nutritional assessment within 24 hours of admission reassessments reflect changes in status and effects of interventions clients with pressure injuries who are underweight or losing weight need enhanced caloric and protein supplementation a client can lose as much as 50 grams of protein per day from an open weeping pressure ulcer although the recommended intake of protein for adults is 0.8 grams per kilogram per day a higher intake of protein up to 1.8 grams per kilogram per day is necessary for healing increase protein intake helps rebuild epidermal tissue increased caloric intake helps replace subcutaneous tissue vitamin C promotes collagen synthesis capillary wall Integrity fibroblast function and immunological function in preparation for her husband's discharge Mrs Ahmed is interested in learning how to change Mr ahmed's pressure ulcer dressing Linda develops a teaching plan to include Mrs Ahmed with the outcome goal that at the end of the teaching session Mrs Ahmed will perform an acceptable return demonstration of the dressing application what teaching strategies would it be appropriate here plan time that Mrs Ahmed is present and be prepared to spend 30 minutes in two separate teaching sessions avoid using words that Mrs Ahmed will not understand provide a brief description of what will be taught to both patient and spouse include the patient and all the teaching even though he is unable to see the wound bring an extra dressing to the bedside to show Mrs Ahmed what the dressing looks like and how to apply it use a pictorial guide of a pressure ulcer to help Mrs Ahmed understand what the wound looks like and how it will progress if it shows signs of healing plan one session and wishes Mrs Ahmed will watch a demonstration of the womb being cleaned and the dressing applied plan a second session where she will do a return demonstration at the end of each session ask Mrs Ahmed how she felt doing the dressing and include Mr Ahmed in this evaluation evaluation strategies that would be appropriate include asking Mrs Ahmed questions as she does the procedure to evaluate her understanding of each step asking Mrs Ahmed what she will evaluate at each dressing change and observing Mrs Ahmed changing the dressing and cleaning the wound also observing any body language that indicates how she is feeling while doing the procedure when treating a pressure injury reassess the wound for location stage size tissue type and amount exudate and surrounding skin condition acute wounds require close monitoring many times every eight hours sometimes chronic wound assessment occurs less frequently depending on the topical management system evaluate the wound with every dressing change usually not more than one time per day maintenance of a physiological local wound environment is the goal of effective wound management to maintain a healthy wound environment you need to address the following principles prevent and manage infection clean the wound remove non-viable tissue manage exudate maintain the wound in a moist environment and protect the wound a wound does not move through the phases of healing if it is infected preventing wound infection includes cleaning and removing non-viable tissue clean pressure ulcers only with non-cytotoxic wound cleaners such as normal saline or commercial wound cleaners non-cytotoxic cleaners do not damage or kill fibroblasts and healing tissue irrigation as shown in the picture on this slide is a common method of delivering a wound cleaning solution to the wound debridement is the removal of non-viable necrotic tissue 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 necessary for healing a moist environment supports the movement of epithelial cells and facilitates wound closure a wound that has excessive exudate provides an environment that supports bacterial growth macerates the periwound skin and slows the healing process in choosing a dressing for a pressure injury there are many choices depending on the stage and the status of the wound table 48.8 in the textbook describes various dressings by pressure injury stage to prepare for changing a dressing you need to know the type of dressing the presence of underlying drains or tubings and the type of supplies you need for wound care poor preparation can cause a break in aseptic technique or accidental dislodging of a dream sometimes such as with chronic non-surgical wounds the nurse uses a clean technique versus an aseptic technique for dressing change the healthcare provider's order for changing the dressing will indicate the dressing type the frequency of changing and any solutions or ointments to be applied to the wound the first step in packing a wound is to assess its size depth and shape these characteristics are important in determining the size and type of dressing used to pack a wound the dressing needs to be flexible and in contact with the entire wound surface it is important to remember not to pack the wound too tightly over packing causes pressure on the tissue in the wound bed pack the wound only until the packing material reaches the surface of the wound there should never be so much packing material that it extends higher than the wound surface packing that overlaps onto the wound edges causes maceration of the tissue surrounding the wound a treatment modality for wounds is negative pressure wound therapy or vacuum assisted closure negative pressure wound therapy is used for treating acute and chronic wounds the vacuum assisted closure is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together the first picture on the slide shows a dehist wound before the use of a wound vacuum assisted closure or wound VAC therapy and the second picture is after the wound back therapy use tape ties or a secondary dressing and cloth binders to secure a dressing over a wound site the choice of anchoring depends on the wound size and location the presence of drainage the frequency of dressing changes and the patient's level of activity most often strips of tape are used to secure dressings if the client is not allergic to it non-allergenic paper and plastic tapes are available that minimize skin reactions a wound is often painful depending on the extent of tissue injury use several techniques to minimize discomfort during wound care carefully removing tape gently cleaning wound edges and carefully manipulating dressings and drains minimizes stress on sensitive tissues careful turning and positioning also reduces strain on a wound although a moderate amount of wound exudate promotes epithelial cell growth some healthcare providers Order cleaning a wound or drain sight if a dressing does not absorb drainage properly or if an open drain deposits drainage onto the skin wound cleaning requires good hand hygiene and aseptic techniques clean surgical or traumatic wounds by applying non-cytotoxic Solutions with sterile gauze or by irrigation the following three principles are important when cleaning an incision or the area surrounding a drain one clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin two use gentle friction when applying Solutions locally to the skin three when irrigating allow the solution to flow from the least to most contaminated area after applying a solution to sterile gauze clean away from the wound never use the same piece of gauze to clean across an incision or wound twice drain sites are a source of contamination because moist drainage Harbors microorganisms if a wound has a dry incisional area and a moist drain sight cleaning moves from the incisional area toward the drain use two separate swabs or gauze pads one to clean from the top of the incision toward the drain and one to clean from the bottom of the incision toward the drain to clean the area of an isolated drain site clean around the drain moving in circular rotations outward from a point closest to the drain in this situation the skin near the site is more contaminated than the site itself irrigation is a special way of cleaning wounds use an irrigating syringe to flush the area with a constant low pressure flow of solution the gentle washing action of the irrigation cleans a wound of exudate and debris sutures are threads or metal used to sew body tissues together while steel staples are a common type of outer skin closure that cause less trauma to tissues than sutures while providing extra strength policies vary with an institution as to who is able to remove sutures if it is appropriate that the nurse removed them a health care provider's order is required when drainage interferes with healing evacuation is achieved by using either a drain alone or a drainage tube with continuous suction you may apply special skin barriers including hydrocolloid dressing similar to those used with ostomes around drain sites the skin barriers are soft material applied to the skin with adhesive drainage flows on the barrier but not directly on the skin a simple gauze dressing is often not enough to immobilize or Provide support to a wound binders and bandages applied over or around dressings provide Extra Protection and therapeutic benefits these help create pressure or immobilize the body part support a wound prevent or reduce edema and secure dressings bandages are available in roles of various widths and materials including gauze elasticized knit elastic webbing flannel and muslin gauze bandages are lightweight and inexpensive mold easily around Contours of the body and permit air circulation to prevent skin maceration elastic bandages conform well to body parts but are also for exerting pressure binders are bandages that are made of large pieces of material to fit a specific body part most binders are made of elastic or cotton an abdominal binder and a breast binder are examples after applying a bandage the nurse assesses documents and immediately reports changes in circulation Skin Integrity Comfort level and body function such as ventilation or movement sling support arms with muscular sprains or fractures Health Care Providers commonly order heat and cold applications for traumatized areas before applying heat or cold therapies assess the client's physical condition for signs of potential intolerance to heat and cold first observe the area to be treated assess the skin looking for any open areas such as alterations in Skin Integrity including abrasions open wounds edema bruising bleeding or localized areas of inflammation that increase the client's risk of injury assessment includes identification of conditions that contraindicate heat or cold therapy do not cover an active area of bleeding with a warm application because bleeding will continue cold is contraindicated if the site of injury is already edematous it further slows circulation to the area and prevents absorption of the interstitial fluid if the patient has impaired circulation for example arteriosclerosis it further reduces blood supply to the affected area cold therapy is also contraindicated in the presence of neuropathy because the patient is unable to perceive temperature change and damage resulting from temperature extremes table 48.9 in the textbook describes conditions that increase the risk of injury from heat and cold application you can administer heat and cold applications in dry or moist forms the type of wound or injury the location of the body part and the presence of drainage or inflammation are factors to consider in selecting dry or moist applications warm moist compresses improve circulation relieve edema and promote consolidation of purulent drainage immersion of a body part in a warm solution promotes circulation lessens edema increases muscle relaxation and provides a means to apply medicated solution the client who has had Rectal Surgery and epipyotomy during childbirth painful hemorrhoids or vaginal inflammation benefits from a sitz bath a bath in which only the pelvic area is immersed in warm or sometimes cool fluid the client sits in a special tub or chair or a basin that fits on the toilet seat so the legs and feet remain out of the water as shown in the picture commercially prepared disposable hot packs apply warm dry heat to an injured area the chemicals mix and release heat when you strike knead or squeeze the pack the procedure for applying cold moist compresses is the same as that for warm compresses apply cold compresses for 20 minutes to relieve inflammation and swelling you can use clean or sterile compresses commercially prepared cold packs that are similar to the Disposable hot packs for dry applications are available they come in various shapes and sizes to fit different body parts the procedure for preparing cold soaks and immersing a body part is the same as for warm soaks the desired temperature for 20 minute cold soak is 15 degrees Celsius or 59 degrees Fahrenheit for a client who has a muscle sprain localized Hemorrhage or hematoma or who has undergone dental surgery an ice bag is ideal to prevent edema formation control bleeding and anesthetize the body part ensuring client safety is an essential role of the professional nurse to ensure client safety communicate clearly with the members of the healthcare team assess and incorporate the client's priorities of care and preferences and use the best evidence when making decisions about care Linda evaluates the outcomes for Mr Ahmed she observes the wound and measures it to be one by one inch with serous drainage and notes the red color validating improved tissue type and reduced wound size she palpates the underlying skin which remains intact showing no evidence of an advancing ulcer or tissue damage She also asked Mr Ahmed about his pain and he denies any New Sensations indicating no evidence of new tissue damage what other means of evaluation could Linda be using Linda could also evaluate nutritional status She asked Mr Ahmed about his food intake and reviews his calorie count over the past week he reports that his appetite is increasing and that he is eating most of his meals calorie count shows a steady increase in Daily consumption the outcome has been achieved as noted by improved nutritional intake Linda has completed her clinical experience with Mr Ahmed his pressure injury is still present but it is reduced in size and demonstrates progress toward healing no other sites of non-blanchible erythema were noted and the rest of his skin remains intact Linda taught Mrs Ahmed how to assess her husband's skin for signs of increased risk or further breakdown Linda with the help of her instructor devised a plan of care for the home and they are meeting with the home care nurse today when she visits Mr Ahmed at the hospital consider why teaching family members is a key in continued health for patients at discharge this information was referenced from Potter Perry stockert and Hall 2023 Fundamentals of Nursing if you have questions about any of the content presented in this video please contact your assigned course instructor thank you