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Skin integrity


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Skin integrity

  1. 1. Skin integrity – wound care
  2. 2. objectives By the end of this presentation students should be able to: Describe factors affecting skin integrity Explain etiology of pressure ulcer Identify clients at risk of pressure ulcers Describe the four stages of pressure ulcer development Differentiate primary and secondary wound healing Describe the three phases of wound healing Describe prevention and management of pressure ulcer
  3. 3. Skin: structure and function Skin is the largest organ in the body Protects deeper tissues from: Mechanical damage ( bumps & cuts) Chemical damage (acids & bases) Bacterial damage Thermal damage (heat & cold) Ultraviolet radiation (sunlight)
  4. 4. SKIN INTEGRITY Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds The appearance of skin and skin integrity are influenced by internal factors such as age, genetics and underlying health of the individual as well as external factors such as activity. Many chronic illnesses and their treatments affect skin integrity Eg.DM, cancer medicine may cause photo sensitivity (sensitive to sunrays) People with impaired peripheral arterial circulation may have skin on the legs that damages so easily Poor nutrition also alter skin integrity
  5. 5. Definition A wound can be defined as: “A cut or break in the continuity of any tissue, caused by injury or operation” (Baillière’ s 23rd Ed)
  6. 6. Body wounds are Intentional: operations, venipunctures Unintentional : Accidental Wounds may be classified According to contamination Clean: closed wounds Clean contaminated: surgical wounds Contaminated: Accidental wounds Dirty or infected wounds: wounds with dead tissue,infection
  7. 7. Wound Types and Characteristics CLOSED Contusion ( Bruise) – Tissue injury without breaking of skin. Hematoma – Tissue injury that disrupts a blood vessels; pooling of blood under the unbroken skin
  8. 8. Sprain – Wrenching or twisting of a joint with partial rupture of its ligaments; causes swelling OPEN Wounds are described according to how they acquired Incision- Surgically made separation of tissues with clean, smooth edges
  9. 9. Laceration – Traumatic separation of tissues with clean, smooth edges Abrasion- Traumatic scraping away of surface layers of skin
  10. 10. Puncture – Wound made by sharp, pointed object through skin or mucous membranes and underlying tissue. Penetrating- Variable – size open wound through skin and underlying tissues made by a bullet or metal or wood fragment; may extend deeply into body.
  11. 11. Avulsion – Tearing away of a structure or a part, such as a fingertip, accidentally or surgically Ulceration – Excavation of skin and/or underlying tissue from injury or necrosis
  12. 12. Wounds can be classified according to their nature: •
  13. 13. 2. According to depth Superficial Involves only the epidermis Injury is usually the result of friction, shearing (cut) or burn. Partial Thickness Involves the epidermis and the dermis Wounds heal more quickly Full Thickness Involves the epidermis, dermis, fat, fascia and exposes bone In order to heal, all dead tissue must be removed so that granulation tissue can gradually fill in the defect.
  14. 14. Pressure ulcer Definition: Pressure ulcer or Decubitus ulcer or bed sore is any lesion caused by unrelieved pressure that damage underlying tissue. A Pressure ulcer is an area of skin that breaks down when constant pressure is placed against the skin or when pressure applied to the skin over time is greater than normal capillary closure pressure, which is about 32mmHg. Critically ill patients have a lower capillary closure pressure and a greater risk of pressure ulcers.
  15. 15. Etiology Bed sores are accepted to be caused by 3 different tissue forces.  RE P SHE ARI FOR NG CE RE SU S FRICTION
  16. 16. 1.Pressure - The compression of tissues. In most cases, this compression is caused by the force of bone against a surface, as when a patient remains in a single position for a lengthy period. After an extended amount of time with decreased tissue perfusion, ischemia occurs and can lead to tissue necrosis if left untreated.
  17. 17. 2.Shearing force force created when a skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis . - A Eg: fowlers position
  18. 18. Sliding down word(shearing) Friction
  19. 19. 3.Friction - Aforce resisting the shearing of skin. - This may cause excess shedding through layers of epidermis.
  20. 20. Risk factors  Old age  Being unable to move certain parts of the body without help such as after a brain or spine injury.  Having chronic conditions such as DM, vascular diseases, etc.  Altered skin moisture, excessively dry or moist.  Urinary incontinence or bowel incontinence.  Malnourishment , anemia, vitamin deficiency  Use of casts, traction and restraints.  Mental disabilities.
  21. 21.  Occiput  Ear  Scapula  Elbow  Sacrum  Ischial tuberosities  Greater trochanter  Medial condyle of tibia  Fibular head  Medial malleolus  Lateral malleolus  Heel
  22. 22. Pressure sore
  23. 23. Pressure ulcer classification Stage I Characterized by erythema .skin intact Stage II Partial thickness involving epidermis and dermis Full thickness involves to subcutaneous tissue and fascia Full thickness involves muscle and bone Stage iii Stage IV
  24. 24. Wound healing (Regeneration) All wounds heal following a specific sequence of phases which may overlap The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption The phases are: Inflammatory phase Proliferative phase Remodeling or maturation phase
  25. 25. PHASES OF WOUND HEALING 1. INFLAMMATORY PHASE -starts immediately after injury and lasts 3-6 days . 2 major processes occur during this phase … HEMOSTASIS AND PHAGOCYTOSIS Haemostasis - Tissue and capillaries are destroyed, plasma and blood leaks. Area blood vessels constrict, platelets aggregates and bleeding stops, scabs ( rough protective crust) forms, preventing entry of infectious organisms.
  26. 26. INFLAMMATORY PHASE Phagocytosis The macrophages engulf microorganisms and cellular debris by a process known as Phagocytosis
  27. 27. Phagocytosis
  28. 28.  Inflammation Characterized by edema, erythema, pain, temperature increase blood flow, to wound resulting localized redness and edema, attracts WBC and wound growth factors.  WBC arrive-clear debris from wound.
  29. 29. injury Exposure of plasma to injured site Release of Histamine Activation of Hageman Factor Capillary Permeability Vasodilation Kinin Prostaglandin Edema Inc bld Flow Clotting Dolor ( Pain) Tumor ( Swelling) Rubor (Redness) Calor ( Heat)
  30. 30. PROLIFERATIVE PHASE -extends from day 3 to about day 21 post injury. Macrophages continue to clear the wound debris, Stimulates Fibroblast to synthesize collagen .( For tissue scaring) New capillary networks are formed. 2.
  31. 31. REMODELLING OR MATURATION PHASE -final healing stage begins about 21 day may continue for I year or more. 3. Re modelling of scar tissue to provide wound strength.
  32. 32. Wound Healing Phases
  33. 33. TYPES OF WOUND HEALING  FIRST INTENTION HEALING-partial thickness wounds. - a clean incision is made with primary closure, minimal scarring. -expected when the edges of clean surgical incisions are sutured together, tissue loss is minimal or absent if the wound is not contaminated with microorganism. -e.g.-abrasion or skin tear.
  34. 34.  SECOND INTENTION HEALING -granulation -accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count. -go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect. -e.g.-contaminated surgical wound, pressure ulcer. Delayed primary healing If there is high infection risk – patient is given antibiotics and closure is delayed for a few days e.g. bites
  35. 35. Factors affecting healing Immune status Blood glucose levels (impaired white cell function) • Hydration (slows metabolism) Age: children and adults quick healing than elderly Lifestyle- enhances blood circulation Nutrition: Protein, carbohydrate, lipids, vit A, C, zinc, iron, copper require for healing. Malnourishment delay healing Blood albumin levels (‘building blocks’ for repair, colloid osmotic pressure - oedema) Life style: Activity increase Oxygen and vascular supply Medication- Corticosteroids, Aspirin(depress immune function)
  36. 36. TYPES OF WOUND DRAINAGE  Exudate :is fluid and cell material Escaped from blood vessels  Serous -clean, watery  Purulent - thick, yellow, green, tan or brown. (Pus)process of pus formation called suppuration  Sanguineous - bright red, indicative of active bleeding.  Sero sanguineous -pale, red, watery mixture of serous and sanguineous.
  37. 37. Wound Specimens WOUND SPECIMEN Tissue Wound fluid (purulent exudates) Superficial swabs Basic principle of specimen collection: Only wounds with clinical signs of infection, deteriorating, or fail to heal should be sampled for Gram’s stain and culture
  39. 39. Assessment History and physical examination Skin disease,Skin condition, lesions, skin turgor,edema, pressure areas. Assess wounds : Untreated wounds(immediate after an injury) Treated wounds(sutured wounds)
  40. 40. Assessing untreated wounds Location, tissue damage, measure length width and depth. Inspect for bleeding, foreign bodies( soil, broken glass cloth etc) Injuries like fractures, internal bleeding, spinal cord injury , head injury Determine Tetanus toxoid injection
  41. 41. Assessment of Pressure ulcer  Assess total skin condition of the patient once in every shift.  Inspect each pressure site for erythema.  Palpate the skin for increased warmth.  Inspect for dry skin, moist skin, and breaks in skin.  Note the drainage and color.  Evaluate level of motility.  Evaluate circulatory status.  Assess neurovascular status.  Determine presence of incontinence.
  42. 42. Norton’s pressure area assessment form General physical condition Mental state Good 4 Alert Fair 3 Apathetic 3 Poor 2 Very bad 1 Activity 4 Confused 2 Stuporous 1 Mobility Ambulatory 4 Full Incontinence 4 Absent 4 Walks with help 3 Slightly limited Occasional 3 3 Chair bound 2 Very limited Usually 2 urinary 2 Bed fast 1 Immobile Double 1 1
  43. 43. Nursing diagnosis Risk for impaired Skin integrity Impaired skin integrity Impaired tissue integrity Risk for infection Pain
  45. 45. Prevention of pressure sores  Look for reddened areas ,blisters,sores,or craters.  Change position at least every 2 hours to relieve pressure  Use items that can help to reduce pressure like pillows, foam padding, etc.  Eat well balanced meals that contain enough calories.  Drink plenty of water(8-10 glasses of water per day)  Exercise daily including range of motion exercises.  Keep the skin clean and dry.
  46. 46. Wound assessment Signs of infection Odour or exudate Lab tests: Etiology Size, depth & location WOUND ASSESSMENT Wound bed: • necrosis Wound edge Surrounding skin: colour, moisture, • granulation
  47. 47. Clinical appearance Describes the type of material present In the base of the wound: Granulating tissue (red) Slough (yellow) Necrotic tissue (black) RED YELLOW BLACK (RYB CODE) Infected tissue (green) Epithelializing (pink)
  48. 48. Granulating wound • Aims: support granulation, protect new tissue, keep moist Assess depth and exudate levels Moist wound surface – non-adherent dressing Treat over-granulation Hydrocolloids, foams, alginates
  49. 49. Sloughy wound • Aim: to liquefy slough and aid its removal • Dead cells accumulated in exudate • Prepare wound bed for granulation • Assess wound depth and exudate levels • Hydrogels, hydrocolloids, alginates and hydrofibre dressings
  50. 50. Necrotic wound • Aims: to debride and remove eschar Provide the right environment for autolysis • Assess wound depth and exudate levels • Hydrogels, hydrocolloid dressings
  51. 51. Infected wound • Aims: reduce exudate, odour and promote healing Clinical signs of infection Swab wound – systemic antibiotics Treat symptomatically: exudate and odour control Change dressings daily
  52. 52. Epithelialising wound • Aims: to provide suitable conditions for re-surfacing , films, hydrocolloids Disturb as little as possible
  53. 53. COMPLICATIONS OF WOUND HEALING  1. HEMORRRHAGE -risk of hemorrhage is greatest during the 1st 48 hours after surgery. -emergency -- should apply pressure dressing to the wound and monitor vital signs.  2. INFECTION -surgical infection is apparently 2-11 days post operatively.
  54. 54. - watched for presence of changed in wound color, pain or drainage-culturing of the wound.  3. DEHISCENCE WITH POSSIBLE EVISCERATION -may occur 4-5 days postoperatively. -involves an abdominal wound in which the layers below the skin separates. - an increase in flow of serosanguinous drainage into the dressing can indicate
  55. 55. impending dehiscence. - If occurs should be quickly supported by sterile dressing soaked in sterile normal saline. position? Client in bed with knees bent… why? To decrease pull on the incision. and? Notify physician……
  56. 56. Infected wound dehiscence
  57. 57. Wound evisceration from sstab wound
  58. 58. Wound dehiscence
  59. 59. WOUND MANAGEMENT  1. DRESSINGS - material applied to wound with or without medication, to give protection and assist in healing. -what are the purposes? To protect the wound from mechanical injury Splint or immobilized the wound. Absorbs dressing Prevent contamination from bloody discharges
  60. 60.  Promote homeostasis, (pressure dressing)  Debride the wound  to kill or inhibit microorganism  provide a physiologic environment conducive to healing  provide mental and physical comfort for the patient.
  61. 61. Pressure dressing
  62. 62. What are the types of dressings? a. DRY TO DRY DRESSINGS -used primarily for wounds closing by primary intention. -offers good protection, absorption & provide pressure -they adhere to the wound surface when drainage dries. - when remove can cause pain and disruption of granulation tissue.
  63. 63.  b. WET TO DRY DRESSINGS -used for untidy or infected wounds that must be debrided and closed by secondary intention. >how can it be done? -gauze saturated with sterile saline or antimicrobial sol’n. is packed into the wound, the wet dressing are then covered by dry dressings >when to changed? -when it becomes dry
  64. 64.  c. WET TO WET DRESSINGS -used on clean open wounds or on granulating surfaces. -provide a more physiologic environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort. -surrounding tissues can become ulcerated. high risk for infection.
  65. 65.  2. DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface. -what are the purposes? a) placed in the wounds only when abdominal fluid collections are present. b) placed near the incision site > wound drainage-drains placed within the wounds are attached to a portable suction with a collection container. e.g. hemovac, jackson-pratt, penrose drain.
  66. 66.  3. BINDERS AND BANDAGES -what are the purposes? Creates pressure over the body parts Immobilize body parts Reduce or prevent edema Secure a splints Secure dressing
  67. 67. Dressing A process of cleansing the wound using aseptic solution. ∆ To aid debridement The ideal dressing • A dressing that ∆ To remove excess exudate creates the optimum ∆ To control bleeding environment ∆ To protect a wound • Wound debridement ∆ To support healing • Wound cleansing • Alternative therapies
  68. 68. TYPES OF DRESSINGS Hydrogel Dressings Hydrogels are indicated for management of pressure ulcers, skin tears, surgical wounds, and burns, including radiation therapy burns. Because they contain up to 95% water, hydrogels cannot absorb much exudate and should be reserved for dry wounds or wounds with minimal to moderate drainage.
  69. 69. Hydrocolloid Dressings Because they are occlusive, hydrocolloid dressings do not allow water, oxygen, or bacteria into the wound. This may help facilitate angiogenesis and granulation. Hydrocolloids also cause the pH of the wound surface to drop; the acidic environment can inhibit bacteria growth. Because of their occlusive nature, hydrocolloids cannot be used if the wound or surrounding skin is infected.
  70. 70. Alginate Dressings Alginate dressings absorb moderate to high amounts of wound drainage. An alginate can be used in infected and noninfected wounds. Because an alginate is highly absorbent, it should not be used with dry wounds or wounds with minimal drainage; it could dehydrate the wound, delaying healing.
  71. 71. Composite dressings Made of three layers. The layers of the composite dressings combine to form an antimicrobial barrier for moderate to heavy exuding wounds. Some composite dressings also gradually release silver over time to promote healing. Composite dressings have multiple layers and can be used as primary or secondary dressings. They are appropriate for wounds with minimal to heavy exudate, healthy granulation tissue, necrotic tissue (slough or moist eschar), or a mixture of granulation and necrotic tissue composite dressings cautiously used if the patient is dehydrated or has fragile skin.
  72. 72. Transparent Films    Film dressings are flexible sheets of transparent polyurethane coated with an acrylic adhesive. They can be used as a primary or secondary dressing. These dressings are semipermeable, vary in size and thickness, and have an adhesive that holds the dressing on the skin. They conform easily to the patient's body but do not hold well in high-friction areas, such as the sacrum or buttocks. Because films are transparent, the wound can be easily monitored. Because films are semiocclusive and trap moisture, they allow autolytic debridement of necrotic wounds and create a moist healing environment for
  73. 73. Transparent film
  74. 74. Securing dressing Principles: Shouldn’t be too narrow &long & wide Should allow joint movement
  75. 75. Questions???
  76. 76. THAN Q