Skin Integrity and Wound Care

Transcription

1 Skin Integrity and Wound Care By Dr. Amer Hasanien & Dr. Ali Saleh Skin Integrity and Wound Care Skin integrity: the presence of normal Skin & Uninterrupted skin layers by wounds. Factors affecting appearance of the skin and skin integrity: Genetics and heredity Age Chronic illnesses Some medications Poor nutrition 1

2 Types of wounds Intentional v.s unintentional Closed v.s open Types of wounds Types of wounds according to degree of wound contamination: Clean wounds (closed) Clean-Contaminated wounds: surgical wounds w no evidence of infection Contaminated wounds: open, fresh, accidental and surgical wounds w major break in sterile technique. It showed evidence of inflammation. Dirty or infected wounds: wounds containing dead tissues w evidence of clinical infection (purulent discharge) 2

3 Types of wounds According to onset of occurrence: acute, chronic, or postoperative. Types of wounds according to how they acquired (iatrogenesis) (table 36-1) 3

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5 Pressure ulcers Previously called decubitus (lying down) ulcers, pressure sores, or bed sores. Is localized injury to the skin and/or underlying tissues usually over bony prominences, as a result of pressure, or pressure in combination with shear. Etiology of pressure ulcers Ischemia: compression greater than 32 mm Hg O2 and nutrients to the cells and waste products accumulate in the cells tissue dies. Reactive hyperemia: when pressure relieved, skin becomes bright and flush due to vasodilation. 5

6 Risk factors Immobility and inactivity Inadequate nutrition: weight, muscle atrophy, and loss of subcutaneous tissue padding between the skin and bones. Fecal and urinary incontinence: Decreased mental status (less able to respond to pain) Diminished sensation Excessive body heat: metabolism need for O2 Risk factors Advanced age Chronic medical condition: e.g. DM Friction and shearing Friction: force acting parallel to skin surface. Shearing force: friction with pressure (e.g. Fowlers position) Other factors: poor lifting and transferring techniques, incorrect positioning, hard support surfaces, incorrect application of pressure relieving devices. 6

7 Stages of Pressure Ulcers Stage I: Nonblanchable Erythema of Intact Skin Blanching/Blanchable - An erythematous lesion that loses all redness when pressed 7

8 Characterized as a defined area of redness that does not blanche (become pale) under applied light pressure. This finding is consistent with a Stage 1 pressure ulcer. Stage II: Partial Thickness Skin Loss Involving Epidermis and / or Dermis 8

9 Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue 9

10 stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as tendon 10

11 Risk Assessment Tools Norton Scale Waterlow scale Braden Scale 11

12 Wound Healing Healing: is a quality of living tissue, is also referred to as regeneration (renewal) of tissue. Types of healing 1. Primary Intention Healing (e.g. closed surgical incision) Tissue surfaces approximated (closed) Minimal or no tissue loss Formulation of minimal granulation and scarring is the healing of a clean wound without tissue loss granulation tissue is not visible and scar formation is minimal. Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process 12

13 Wound Healing 2. Secondary Intention Healing (e.g. pressure ulcer) Considerable tissue loss Edges cannot be approximated Repair time longer Scarring greater Susceptibility to infection greater A wound that is extensive and involves considerable tissue loss, and in which the edges cannot be brought together heals in this manner. also known as delayed and is indicated where there is a reason to delay suturing or closing a wound some other way, for example when there is poor circulation to the injured area. 13

14 Wound Healing 3. Tertiary Intention Healing (Delayed Primary Intention) Initially left open (3-5 days) Edema, infection, or exudate resolves Then closed Phases of wound healing Inflammatory Phase of Wound Healing Immediately after injury; lasts 3 to 6 days Hemostasis Phagocytosis Proliferative Phase of Wound Healing From post injury day 3 or 4 until day 21 Collagen synthesis Granulation tissue formation 14

15 Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process Phases of wound healing Maturation Phase of Wound Healing From day 21 until 1 or 2 years post injury Collagen organization Remodeling or contraction Scar stronger 15

16 Types of wound exudate Material such as fluid and cells that have escaped from blood vessels during inflammatory process Deposited in tissue or on tissue surface major types Serous (transparent, and of a benign nature) Purulent (pus; white-yellow, yellow, or yellow-brown) Sanguineous (hemorrhagic) mixed 16

17 Types of wound exudate Serous Exudate Mostly serum (clear portion of the blood) Watery, few of cells E.g., fluid in a blister of burn Purulent Exudate Thicker Presence of pus Color varies with organisms Types of wound exudate Sanguineous Exudate Hemorrhagic Large number of RBCs Indicates severe damage to capillaries Mixed Exudate Serosanguineous Clear and blood-tinged drainage Purosanguineous Pus and blood 17

18 Complications of Wound Healing Hemorrhage Infection Dehiscence with possible Evisceration Dehiscence :(فتاق) wound ruptures along surgical suture. Evisceration :(فتاق) ejection of viscera (e.g., as a defensive action by an animal). 18

19 Factors Affecting Wound Healing Developmental consideration Nutrition Lifestyle: e.g. exercise and smoking Medications: e.g. anti-inflammatory and anti-neoplastic drugs interfere with healing. Resistant organisms and antibiotics Assessing skin integrity Nursing History and physical assessment Wound assessment - untreated wounds - treated wounds 19

20 Assessing skin integrity Untreated wounds Location Extent of tissue damage Wound length, width, and depth Bleeding Foreign bodies Associated injuries Last tetanus toxoid injection 20

21 Untreated wounds Control severe bleeding Prevent infection: (second layer of dressing if first layer become saturated) Control swelling and pain (ice) Assess for shock (bleeding): e.g. pulse BP, pallor, cold skin. Wound assessment Treated wounds Appearance Size Drainage Presence of swelling Pain Status of drains or tubes 21

22 Surgical drain Assessment of Pressure Ulcers Location of the ulcer related to a bony prominence Size of ulcer in centimeters including length (head to toe), width (side to side), and depth Presence of undermining or sinus tracts Stage of the ulcer Color of the wound bed Location of necrosis Condition of the wound margins Integrity of surrounding skin Clinical signs of infection 22

23 Presence of undermining or sinus tracts Supporting Wound Healing Moist wound healing Nutrition and fluids ml. fluids/ day adequate vitamins (A, C, B1, B5) and zinc sufficient proteins Preventing infection Positioning 23

24 Preventing and Treating Pressure Ulcers Maintaining skin hygiene Mild cleansing agents Avoid hot water Moisturizing lotions/skin protection, NO use of baby powder Reduce irritants, No massage over bony prominences Avoiding skin trauma Smooth, firm, and wrinkle free surfaces Clients must positioned, transferred, and turned correctly Head of the bed no more than 30 degrees (Semi- Fowler s position) Preventing Pressure Ulcers Risk Assessment Skin assessment and skin care Providing nutrition Repositioning 24

25 Treating Pressure Ulcers Assessement Dressing Cleaning Medication 25