Skin Integrity Skin 15% body weight. Pain, temp, absorbs Vit D.

Epidermis- multiple layers, Stratum corneum- thin outermost, flattened dead cells, protects cells and skin from dehydration. Basal layer- where cells originate, cells divide, prilierfate, migrate. Replenishes dead cells. intact skin. Wants to resurface wound and restore barrier. Dermis layer- inner layer, connective tissue, collagen, fibroblasts. Restores structural integrity. Pressure Ulcers: Unrelieved, prolonged pressure. At risk if decrease mobility and decrease perception. Fecal and urine incontinence. Poor nutrition. Tissue receives O2 and nutrients, eliminate waste. Pressure interrupts blood flow. Decreased blood flow causes tissue ischemia- death. Ischemia O2 returns you see redness and vasodilatation. Hyperemia (redness)- press finger you get redness is blanching white. Blanching hyperemia is when you press on red skin and turns white- fighting ischemia. If the redness does not blanch damage is possible. Does not occur with black ppl. Pressure duration: two thoughts, low pressures over long time and high pressures over short time. Extended pressure causes cell death. Clinical implications: pressure duration, amount of pressure, and pt tolerance. Tissue tolerance: depends on skin integrity and Shear Friction Moisture Risk factors: Impaired sensory perception, not able to feel pain, pressure and will not know if ulcer is there. Impaired mobility, ulcers on bony prominences. Change in mental status, unable to protect themselves
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Shear- gravity and resistance, bed to stretcher. Skin adheres to bed and bones pull. Friction- bed linens. Affect epidermis. Moisture decreases skins resistance- need hygiene Classification of PU Stage I. intact skin, nonblancheable redness. Stage II: partial thickness skin loss involving epi and dermis. Ulcer is superficial and presents as abrasion/ blister. Stage III: Full thickness loss. Sub cu fat visible. Bone and tendon not. Slough may be present. May have undermining and tunneling. Undermining_- tissue destruction underneath intact skin at wound edge, wound edges not attached to skin base Tunneling- a narrow channel of tissue loss that can extend in any direction- can be down to muscle. Stage IV: Full thickness loss with exposed bone, tendon, muscle. Slough or eschar. Often has undermining and tunneling. Slough- yellow, tan, soft, stringy and need to remove for healing. Eschar- black and brown necrotic tissue. Need to remove to heal. Granulation tissue- red moist tissue composed of new blood vessels..good. Measurement of wound important. Assessment of tissue type: Amount %, type, and appearance( viable and non-viable). Measurment made by depth of a Q-tip. Wound Exudate- describes amount, color, consistency, and odor of wound drainage. Part of assessment. Excessive amounts = infection. Lastly look at skin around wound, edema, maceration, warm, read= wound deterioration. Wound classification: A wound is the disruption of the integrity and function of tissue on body. All wounds are not created equally. Etiolgy of wound. Wound classification describes
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Skin intergrity Cause of wound Severity or extent of damage Cleanliness of wound or descriptive qualities. Identifies risks and needs for healing. Process of healing: Tissue layers involved. Two types of wounds: those with tissue loss and those without. Clean surgical incisions, a wound with little tissue loss will heal by primary intention. Skin edges approximated closed. Infection risk low and healing quick. Little scar as long as infection does not form. Secondary: edges not approximated, healing done by granulation tissue, tissue loss, burn, pressure ulcer, severe lac, wound is open until filled with scar tissue. Repair: partial thickness wound 3 parts: inflammatory response(first 24 hours), epithelial proliferation, establishment of epilthelial layer. (if wound left open to air 6-7 days, if kept moist 4 days). Full thickness and dry/pink. Full thickness repair: 3 parts: Inflammatory response- (lasts 3 days) redness, swelling. Hemostasis- injured blood vessels constrict and platelets gather to stop bleeding. Clots form with fibrin. Damaged tissue secrete histamine from mast cells. Throbbing, do not cool. Neutrophils and macrophages marginate. Collegen appears on second day. This stage controls bleeding and provides clean wound bed. Epithelial proliferation- 3- 24 days. Filling of wound with granulation, contraction of wound, and resurfacing (epitheliazation). Collagen gives strength. Area filled with tissue. Age, anemia, low zinc affects this stage. Establishment of epidermal layer
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Remodeling- can take more that yr. scar tissue and collagen fiber remodel. Complication of wound healing: Hemorrhage: bleeding from wound. Normal post trauma. Hemostasis occurs within minutes. Hemorrghage after hemostasis means problem. Can occur internally and externally. Look for distention and swelling. High risk (24-48) hours. Infection: Second most common health care assoc. (nosocomial) wound infected if there is drainage. Sample from drainage. All chronic dermal wounds are considered contaminated. High amount of bacteria makes infected. Some show signs 2-3 days. Surgical wound give 4-5 days to show infection. Fever tenderness, drainage, pain, increase WBC, inflamed, odor. Purulent- yellow, green, or brown. Dehiscence: partial or total separation of wound layers. When wound fails to heal correctly. Layers of skin tissue separate. 3-11 days post injury. Pt at risk for poor wound healing (obese, poor nutrition, infection) is at risk for dehiscence. Obese adipose tissue less vascularized. Cough increase in pressure (given way) increase in serosangounous drainage- splint. Evisceration- total separation of wound layers. See organs. Needs surgical repair. Place sterile soaked towels over to prevent drying and bacteria. Blood supply issue. Make NPO for surgery. Fistulas-abnormal passage between two organs or between organ and outside. Occurs as result of poor wound healing. (chrons disease) Trauma infection radiation cancer decreases tissue layers. Fistula tract to form. Increase risk of infection, fluid and electrolyte imbalance.

Prediction and prevention of PU: Nursing care- maintenance of skin integrity, be consistent. Breakdown- impaired skin integrity, prolonged pressure, irritation, immobility= PU Risk: Are they at risk for PU? 5 factors: Physical condition, mental condition, activity, mobility, incontinence. Norton and Braden scale for PU risk. Prevention: if ill or debilitated. Can be healthy. PU develop within two weeks of hospital stay. Factors that effect PU formation and healing. Pressure ulcer and skin integrity- shear force, friction, moisture, nutrition, tissue perfusion, infection, age, and wound healing.

Nutrition therapy: 1500 cal a day promotes cellular healing. Malnutrition= delay in healing. Need protein, vitamins, zinc, copper. Collegen from amino acids- fibroblasts are from protein. Collegen is a protein formed from amino acids acquired by fibroblasts from protein ingested foods. Vitamin C helps with collagen Vitamin A steroids inhibit Pretein is needed- serum proteins are markers of mal nutrition (albumin, transferin, prealbumin) Tissue perfusion: oxygen fuels healing and cellular functions. Diabetes is a peripheral vascular disease causes Shock and decrease in perfusion. Bad perfusion due to bad circulation. Infection: Prolongs inflammatory process. Cytpkines cause tissue destruction.
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Age: decrease function. Macrophage- with old age delayed inflammatory response. Psychosocial impact of wounds: body image changes- stressful, scars, and drains.

Process: Assessment: Baseline and continual care. Check CSMs

Skin- visual and tactile inspection. Check for PU (bony areas). When have hyperemia note location, size and color. Reassess every hour. Palpate reddened area. Pressure areas: ASSESS RISK 1. mobility- baseline date. ROM, pressure sites 2. nutrition- initial assessment 3. presence of body fluids- incontinence and increases skin breakdown, purulent wound with exudate. 4. comfort level/ pain- if manage pain increase in mobility and decrease risk for PU. Wounds: Assess wounds two times. Once at time of injury, before treatment and second after therapy- relatively stable. Emergency setting: size of wound and tetanus shot. Stable setting: if wound is already covered by dressing do not inspect unless suspect serious complication or infection. Painanalgestic- 30 min before. Wound appearance: Crust from exudate, look for dehiscence and evisceration. Outer edges usually inflamed 2-3 days. 7-10 days heals. Bruise- lst blood collecting, bluish purpleclotted blood breaks down yellow, brown.
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Wound drainage: ACOD Amount, color, odor, drainage. Amount depends on location and extent of wound. Large abscess drains for 1-2 days. Appendectomy little drainage. Weigh saturated dressing = 1g = 1 ml. Record freq and amt of wound drainage. Types of drainage: Serous- clear, watery plasma Sanguineous-bright red; active bleeding Serosanguineous- pale, red, watery, mixture of clear and red fluid Purulent- thick, yellow, green, tan or brown. Example of accurate recording: abd incision is 5cm in width in RLQ edges well approximated w/o inflammation or exudate. 1.2cm diameter circle of serous drainage present on one 4 by 4 gauze changed every 8 hrs. Drains: If large amount some sutured in place. Penros drain lies underneath dressing, pin placed. Assess number of drains, drain placement, character of drainage, collecting equip, and volume. Decrease drainage may mean blockage. Suction sucking? Hemovac, j-pratt,= low pressure self suction if fluid accumulates with in tissue, wound healing will not happen. Increase risk of infection. Wound closures: Staples, sutures (stainless steal). Staple best. Intact? Infection? Irritation? Edematous- cont. swelling= staples too tight, wound dehiscence. Dermabond: facilitates normal healing of small and large wounds. Palpitation: Tenderness, drainage, infection

Wound cultures: Purulent- sample. Never collect old drainage. Clean wound with saline and remove normal flora. Know pts expectations, pt has goals.

Nursing Diagnosis:
Assessment leads to if pt at risk for impaired skin integrity. Example: purulent drainage, tenderness due to impaired skin integrity related to contaminated wound. After completing assessment of pts wounds identify diagnoses that will direct supportive and preventive care. If pt has previous hx of impaired healing a additional diagnosis may be impaired nutrition or ineffective tissue perfusion. Support of wound repair, pain, impaired mobility = recovery

Planning:
Identify diagnoses now plan care for pt with actual or at risk of impaired skin integrity. Planning involves interventions that improve skin integrity/wound healing. Consult with care pros- nutritionist, wound care spec Involve pt fam Place goals and expected outcomes and from goals plan interventions according to risk of PU, possible complications, infection, PVD, immunosuppressant. Expect wound improvement in 2 wks, increase in tissue granulation, zero breakdown of skin, increase cal intake. Priorities: Stable or emergent? Incorporate goals and assessment. Acute wound? Vs. chronic stable? Hygiene a priority. When pt at risk for PU, skin education important. Promotion of wound healing improvement. Type of wound care depends on size, type, and location.
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Implementation:
most effective intervention is prevention. ID high risk of pt. immobile- OU assess risk factors for PU. 3 steps: Skin care- hygiene skin care Mechanical loading- supportive, proper positioning, therapist. Education Skin care- times one day Assessment and skin hygiene prevents skin breakdown. When cleaning around avoid soaps and hot H2O. Nonionic surfactants and dry completely- moisturizer. Control, contain, and correct incontinence, perspiration, wound drainage. Moisture barrier (barrier cream) protects skin from excess moisture, bacteria. Urinary incontinence behavioral. Bladder training, ?habit training- timed voiding, use absorbent pads. Positioning Decrease pressure and shearing force. Elevating head 30 degrees or less to decrease PU. Change the position based on activity level. Perceptual ability and daily routines. 1.5-2 may not always prevent PU but atleaset every 2 hours. Lateral position. If sitting in chair less than 2 hours. Try to encourage pt to shift weight 15min, use pad. After repositioning reassess skin. Look for normal reactive hyperemia and blanching. Dont message area. Support surfaces- therapeutic beds and mattresses. Acute care of PU- treatment depends on location of wound. Supportive measures: nutrients, redistribution of pressure, reassess, location, size, stage, tissue type, amount, exudate?, condition, every 8 hours. Dressing change once a day
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Wound management: Manage wound environment. 1. Prevent and manage infection 2. Cleanse wound 3. Remove non-viable tissue 4. Manage exudate 5. Maintain wound in moist envron 6. Protect wound Wound will not heal if infected. Prevention of infection if from wound cleansing and removal of non-viable tissue. Clean PU with noncytoxic- with normal saline ( wont effect fibrin) 1. Irrigate 2. debridement- removal of nonviable tissue, necrotic (mey be source of infection) 3. have a clean base except for heals- black stays (transparent film used to autolytically debride. (excessive drainage will need high abosrbancy dressing) CAN can report changes of wound, pain, fever, drainage, contamination. Types of Debridement: 1. Mechanicala. wet to dry dressing. Place moistened gauze and allow wound to seep, eat H2O. Nonselective, could take viable tissue when remove. DO NOT put on granulated tissue. b. Wound irrigation- whirlpool treatment 2. Autolytic debridementa. Synthetic dressing. Allow eschar to be self digested by actions of enzymes in wound fluid. If wound base is dry use moisture, if there is exudate use dressing that absorbs but leaves moisture at wound bed. Examples are transparent film and hyrocolloid dressing. Moisture assists epithelial movement and wound closure.
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Exudate supports bacterial growth, slows healing process. 3. Chemical debridment- either will digest or dissolve tissue. a. Topical enzyme prepb. Dakins solution- breaks down and loosens dead tissue. Apply to gauze and pack c. Sterile maggots 4. Surgicala. Removal of tissue with scapal. b. For cellulitis or sepsis A necrotic wound use transparent film and autolytically debride. Once necrotic tissue gone use new dressing. Nurse teaches use of topical growth factors, medication, wound care, prevention of wound breakdown and reoccurrence . Education: dressing changes and PU prevention Nutrition: Early intervention needed. Can give supplements 24 hours prior. Ex: serum albumin less than 3.5, lyphocytic count less then 1800, body weight decreases 15%, positive nitrogen balance >>30-35g protein. Protein- pts with potential risk or actual low serum albumin, poor protein need calcium. Pt w/ PU can loose 50g protein a day. Reccomeneded 0.8 increase to 1.8. If increase protein can rebuild epidermal tissue. Vit C collagen synthesis- gives way to capillary wall integrity, fibroblasts, immune funct. Hemostasis: Direct pressure and dressing. Edges close and blood clots form. Elevate, give pressure and dressing. Do not remove penetrating object. Cleansing removes bacteria use normal saline. Wet to dry for debriding wounds with out granulated tissue. Dressing Type of dressing depends on type and stage. Infection management vs. removal of non-viable tissue.
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Primary intention- remove dressing as soon as drainage stops. Secondary intention- dressing debridement. Purpose of dressing Protect Aid hemostasis Absorb drainage, debriding wound Moist environment Supports site Thermal regulation PRIMARY function to absorb drainage of dressing sticking to wound- moisten. Treatment depends on goal of treatment plan Example: goal- maintain moist environment for clean granulated wound. Therefore important to not let moist gauze dry. If you want to debride- remove non-viable use wet to dry. If draining wound do often-freq to prevent bacterial growth, skin breakdown. Want clean, dry. Secondary intention- dressing support, moist promotes epithelial movement. Wet to dry debridement, not moisten when removal. Dry- moist, can wet to lift off and not remove viable tissue. Telfa- does not stick to skin Transparent film: Traps moisture, gives moist environment, promotion of epithelial movement. Can be used on small wounds, secondary dressing and for autolysis. Can remove without damaging tissue underneath. Hydracolloid: Adhesive and forms a gel when in contact with skin as fluid is absorbed. Can use on clean granulated skin, autolytic debirdment. 3-5 days. Use for shallow mod deep PU but not with heavy drainage.
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Hydrogel:has water and glycerin base. Partial and full thickness wounds. With exudate, absorb, painful, debrides with necrosis. Foam: absorb Calcium alginate: forms a soft gelwhen in contact with wound fluid. from seaweed. Use only with infected wounds with exudate. Changing: risk for sepsis. Use apesis. Look for signs of infection. Pain meds, explain procedure, supplies, Montgomery ties. Skin cleansing- practice good hand hygiene. Aspetic technique. Sutures can dissolve or be removed. (7 day removal) Drainage evacuations: drainage interferes with healing. Portable Abd binders for support. If bleeding or inflamed no heat- cardiac No coldness of edema, decreases circulation and not for neuropathy. Heat can be therapeutic and increase blood flow (heat pack for vein poping) Cold can dimish swelling, decrease pain, use on bruise, sprain. If on too long can cause blue then molting. Can warm soak to decrease edema.

Evaluation: (1339)
Outcome examples: Prevent injury to skin and tissue. Reduce, restore skin integrity. Wound first aid: control of bleeding, cleansing, protecting . Each pt will have different risk factors for impaired skin integrity. For evaluation: Reassess skin for S&S with skin integrity and wound healing
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 Obtain pts perception of SI and intervention Ask if expectation are met. Assess mobility health and education.

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