Chapter 48 Skin Integrity and Wound Care

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

Scientific Knowledge Base: Skin

 Dermal-epidermal junction  Separates dermis and epidermis  Epidermis  Top layer of skin  Dermis  Inner layer of the skin Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Pressure Ulcers

 Pressure ulcer  Pressure sore, decubitus ulcer, or bed sore  Pathogenesis  Pressure intensity  Blanching  Pressure duration  Tissue tolerance Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Risk Factors for Pressure Ulcer Development

Impaired sensory perception Alterations in LOC Impaired mobility Shear Friction Moisture Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Classification of Pressure Ulcers

Stage I Intact skin with nonblanchable redness Stage II Partial-thickness skin loss involving epidermis, dermis, or both Stage III Full-thickness tissue loss with visible fat Stage IV Full-thickness tissue loss with exposed bone, muscle, or tendon Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 5

 Classification  Wound healing  Repair  Complications

Wounds

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Nursing Knowledge Base

 Prediction and prevention of pressure ulcers  Norton Scale • Physical and mental condition, activity, mobility, and continence  Braden Scale • Sensory perception, moisture, activity, mobility, nutrition, and friction and shear Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Factors Influencing Pressure Ulcer Formation and Wound Healing

 Nutrition  Tissue perfusion  Infection  Age  Psychosocial impact of wounds Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Assessment

 Skin  Presence of ulcers  Mobility  Nutrition and fluid status  Pain  Existing wounds, appearance, character  Wound culture Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Nursing Diagnosis and Planning

  The assessment will reveal important information regarding the client’s status.

Use NANDA-I –approved diagnoses.  Write client goals and outcomes specific to the client’s needs.

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Implementation

 Health promotion  Topical skin care • Protect bony prominences, skin barriers for incontinence.

 Positioning • Turn every 1 to 2 hours as indicated.

 Support surfaces • Decrease the amount of pressure exerted over bony prominences.

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Acute Care

 Wound management  Debridement • Mechanical, autolytical, chemical, or surgical/sharp  Nutrition  Client education Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Dressings

 Dry or moist  Gauze  Hydrocolloid  Protects the wound from surface contamination  Hydrogel  Maintains a moist surface to support healing  Wound V.A.C.

 Uses negative pressure to support healing Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Dressings



Changing

 Know type of dressing, placement of drains, and equipment needed.



Securing

 Tape, ties, or binders 

Comfort measures

 Carefully remove tape.

 Gently cleanse the wound.

 Administer analgesics before dressing change.

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Wound Cleansing

Cleansing Apply noncytotoxic solution.

Irrigation Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle Suture Care Consult health care facility policy.

Drainage Evacuation Portable units that exert a safe, constant, low-pressure vacuum to remove and collect drainage Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Bandages and Binders

 Bandages  Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin  Binder application  Breast, abdominal, sling Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Heat and Cold Therapy

 Assessment for temperature tolerance  Bodily responses to heat and cold  Factors influencing heat and cold tolerance  Education Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Evaluation

 Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals.

Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 18