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 Epidermis Separates dermis and 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 Stage II Intact skin with nonblanchable redness Partial-thickness skin loss involving epidermis, dermis, or both Stage III Stage IV Full-thickness tissue loss with visible fat 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 Wounds Classification Wound healing Repair Complications 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 Hydrocolloid Protects the wound from surface contamination Hydrogel Gauze 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 Securing Know type of dressing, placement of drains, and equipment needed. 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 Irrigation Apply noncytotoxic solution. Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle Suture Care Drainage Evacuation Consult health care facility policy. 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