8/14/2015
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Skin Integrity & Wound
Care
Denise Hudson
Pressure Ulcer data By Bonnie Felmister, MSN RN,
CWOCN, ANP, GNP-BC
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Discuss the processes involved in wound
healing.
Identify factors that affect wound healing.
Identify patients at risk for pressure ulcer
development.
Describe the method of staging of
pressure ulcers.
Accurately assess & document the
condition of wounds.
Objectives
Provide nursing interventions to prevent
pressure ulcers.
 Implement appropriate dressing changes
for different kinds of wounds.
 Provide information t patients &
caregivers for self-care of wounds at
home.
 Apply hot & cold therapy effectively &
safely.
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Objectives Cont.
Unbroken & healthy skin & mucous
membranes defend against harmful
agents.
 Resistance to injury is affected by age,
amount of underlying tissues, & illness
 Adequately nourished & hydrated body
cells are resistant to injury
 Adequate circulation is necessary to
maintain cell life
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Factors Affecting the Skin
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Protection
Body temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunological
Absorption
Elimination
Functions of the Skin
The structure of the skin changes as a
person ages
 The maturation of epidermal cells is
prolonged, leading to thin, easily
damaged skin
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Developmental Considerations
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Very thin & very obese people are more
susceptible to skin injury
◦ Fluid loss during illness causes dehydration
◦ Skin appears loose & flabby
Excessive perspiration during illness
predisposes skin to breakdown
 Jaundice causes yellowish, itchy skin
 Diseases of the skin cause lesions that
require care
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Causes of Skin Alterations
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Intact skin is the first line of defense
against microorganisms
Surgical asepsis is used in caring for a
wound
The body responds systematically to
trauma of any of its parts
An adequate blood supply is essential for
normal body response to injury
Normal healing is promoted when wound
is free of foreign material
Principles of Wound Healing
Hemostasis-immediately after the initial
injury
 Inflammatory –lasts about 4-6 days
 Proliferation-connective tissue phase
 Maturation- begins 3 wks after injury &
can continue up to years
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Phases of Wound Healing
Intentional or unintentional
Open or closed
 Acute or chronic
 Partial thickness, full thickness, complex
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Types of Wounds
The extent of damage & the person’s
state of health affect wound healing
 Response to wound is more effective if
proper nutrition is maintained
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Principles of Wound Healing
(cont.)
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Begins at time of injury
Prepares wound for healing
◦ Homostasis (blood clotting) occurs
◦ Vascular & cellular phase of inflammation
Inflammatory Phase
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Occurs immediately after initial injury
Involved blood vessels constrict & blood
clotting begins
 Exudate is formed causing swelling & pain
 Increased perfusion results in heat &
redness
 Platelets stimulate other cells to migrate
to the injury to participate in other phases
of healing
Follows hemostasis & lasts about 4-6 days
WBCs move to the wound
 Macrophages enter wound area & remain
for extended period
 The ingest debris & release growth factors
that attract fibroblasts to fill in wound
 Patient has generalized body response
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Hemostasis
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Phase begins within 2-3 days of injury &
may last up to 2-3 weeks
New tissue is built to fill wound space
through action of fibroblasts
Capillaries grow across wound
A thin layer of epithelial cells forms across
wound
Granulation tissue forms a foundation for
scar tissue
Proliferation Phase
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Age– children & healthy adults heal more
rapidly
Circulation & oxygenation– adequate blood
flow is essential
Nutritional status—healing requires adequate
nutrition
Wound condition– specific condition of wound
affects healing
Health status—corticosteroid drugs &
postoperative radiation therapy delay healing
Factors Affecting Wound Healing
Inflammatory Phase
Final stage of healing begins about 3
weeks to 6 months after injury
 Collagen is remodeled
 New collagen tissue is deposited
 Scar becomes a flat, thin, white line
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Maturation Phase
Infection
Hemorrhage
 Dehiscence & evisceration
 Fistula formation
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Wound Complications
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Pain
Anxiety
 Fear
 Change in body image
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 Localized
tissue destruction
caused by the COMPRESSION
of soft tissue over a bony
prominence & an external
surface for a prolonged
period of time.
Guidelines for Prevention & Management of Pressure Ulcers
WOCN 2003
Psychological Effects of Wounds
What is a Pressure Ulcer?
 This
Compression interferes
with blood supply leading to
vascular insufficiency &
ischemia.
 Pressure
Pressure Ulcers
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Elbows
Sacrum
Ischial tuberosities
Greater trochanters
Heels
Lateral Malleoli
Pressure Ulcers Most Common
Locations
Cascade
Pressure
 Ischemia
 Edema & inflammation
 Small vessel thrombosis
 Cell death
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Pressure Cascade
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Develop pressure ulcers
◦ Skin folds
◦ Pressure from Tubes & Catheters
◦ Ill-fitting
 Chairs
 Wheelchairs
 Side rails
Obese Patients
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General medical
conditions: diabetes,
stroke, multiple sclerosis,
cognitive impairment,
cardiopulmonary disease,
malnutrition &
dehydration
Smoking history
Hx of a previous Pressure
ulcer
Increased Length of stay
in a facility
Undergoing surgery with
long operative procedures
Significant weight loss
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Emergency stays
Prolonged time on
stretchers
Medications: sedatives,
hypnotics, analgesics,
NSAIDS
Refusal of care
Critically ill patients in ICU
are 4 times more likely to
develop pressure ulcers
Moisture problems
Receiving norepinephrine
Anemia
Fecal incontinence
Evidence Based 100+ Risk Factors
Acute care—pressure ulcers usually
develop within the first 2 weeks of
hospitalization
 ICU patients have been shown to develop
pressure ulcers within 72 hours of
admission to the ICU
 Fifteen percent of elderly patients will
develop a pressure ulcer within the first
week of hospitalization
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Settings
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Acute Care: perform initial assessment on
admission & reassess at least every 24-48
hours or whenever the patient’s condition
changes or deteriorates
Home Health Care- perform initial
assessment at admission & reassess every
nurse visit
Long-term Care- perform initial assessment
at admission; reassess weekly for the first 4
wks, monthly to quarterly after that &
whenever the resident’s condition changes
Clinical Setting
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Physical condition
Activity
Immobility
Mental Condition/
Sensory Deficits
Continence
Poor Nutrition
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Prolonged
immobilization
< ( less than)
20 Nocturnal
Movements
Sensory deficit
Circulatory
Disturbances
Pressure Ulcer Risk Factors
Critically ill childern have been found to
develop pressure ulcers within the first
day of hospital admission
 Home health care- most ulcers developed
with in the first 4 weeks of admission to
the agency
 Long term care- patients usually develop
pressure ulcers within the first 4 weeks of
admission
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Settings Cont.
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Aging skin
Chronic illness
Immobility
Malnutrition
Fecal & urinary incontinence
Altered level of consciousness
Spinal cord & brain injuries
Neuromuscular disorders
Factors Affecting Pressure Ulcer
Development
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External pressure compressing blood
vessels
 Friction or shearing forces tearing or
injuring blood vessels
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Mechanisms in Pressure Ulcer
Development
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Method of Communication about the depth of
a pressure ulcer
◦ Visual inspection to determine depth
◦ Sometime palpation to determine depth
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Purposeful for care planning /quality of care
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Stage I—nonblanchable erythema of
intact skin
Stage II—partial-thickness skin loss
Stage III—full-thickness skin loss; not
involving underlying fascia
State IV—full-thickness skin loss with
extensive destruction
Unstageable—base of ulcer covered by
slough & or eschar in wound bed
Stages of Pressure Ulcers
Size of wound
Depth of wound
 Presence of undermining, tunneling, or
sinus tract
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Stage I may represent risk
Stage II healing may represent quality of care
Stage III will require more resources to heal
Stage IV will likely require antibiotics
Deep Tissue injury may represent venue risk
What is Staging
Clean with each dressing change
Use careful, gentle motions to minimize
trauma
 Use 0.9% normal saline solution to
irrigate & clean the ulcer
 Report any drainage or necrotic tissue
Measurement of a Pressure Ulcer
Determine the Cause
Remove the Cause
 Pressure Reduction or Relief
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Cleaning a Pressure Ulcer
◦ Devices
◦ Turn Schedules
Do Not elevate Head of Bed over 30
degrees
 Nutritional Support
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Prevention Interventions
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Inspect for sight & smell
Palpation for appearance, drainage, &
pain
 Sutures, drains or tube, & manifestation
of complications.
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Wound Assessment
Serous
Sanguineous
 Serosanguineous
 Purulent drainage
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Presence of Infection
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Assessment of Wound Drainage
Telfa
Gauze
 Transparent
Provide physical, psychological, &
aesthetic comfort
Remove necrotic tissue
Prevent, eliminate, or control infection
Absorb drainage
Maintain a moist wound environment
Protect wound from further injury protect
skin surrounding wound
Purposes of Wound Dressings
Adhesive
Paper
 Plastic
 Microfoam
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Types of Wound Dressings
Wound is swollen
Wound is deep red in color
Wound feels hot on palpation
Drainage is increased & possibly purulent
Foul odor may be noted
Wound edges may be separated with
dehiscence present
Types of Tape
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Roller bandages
Circular turn
 Spiral turn
 Figure-of-eight turn
 Recurrent-stump bandages
Straight—used for abdomen & chest
T-binder– used for rectum, perineum, &
groin area
 Sling—used to support an arm
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Techniques for Applying Bandages
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Types of Binders
Open systems
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◦ Penrose drain
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Closed systems
◦ Jackson-Pratt drain
◦ Hemovac drain
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Types of Drainage Systems
Important Nursing Responsibility
Clear & Accurate Documentation
 Precise documentation contributes to
continuity of care, accurate evaluation of
care, & appropriate changes in wound
care , if necessary.
 Use skin & wound assessment tools–
Braden Scale or Norton Scale
Additional Techniques to Promote
Wound Healing
Method & duration
Degree of heat & cold applied
 Patient’s age & physical condition
 Amount of body surface covered by the
application
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Documenting Wound Care
Fibrin Sealants
Negative-Pressure Wound Therapy
Growth Factors
Oxygen Therapy
Heat & Cold Therapy
Surgery
Factors Affecting the Response of
Hot & Cold Treatments
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Dilates peripheral
blood vessels
Increases tissue
metabolism
Reduces blood
viscosity &
increased capillary
permeability
Reduces muscle
tension
Helps relieve pain
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Constructs
peripheral blood
vessels
Reduces muscle
spasms
Promotes comfort
Aspects of Applying Heat & Cold
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Hot water bags or
bottles
Electric heating
pads
Aquathermia pads
Hot packs
Moist heat
Sitz baths
Warm soaks
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Ice bags
Cold packs
Hypothermia
blankets
Aquathermia pads
Devices to Apply Hot & Cold
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