Chapter 34 Foundations of Nursing

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Chapter 34Foundations of Nursing

• Skin and Wound Care
• Developed by
• Marcia A. Miller Cutler, EdDc, MSN, RN

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Skin-Largest Organ

• What is the role of the skin?
• Protection
• Prevention of Infection
• Temperature Regulation
• Sensation
• Secreting and Excreting

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Pressure Ulcers

• What is a pressure ulcer?
• Who is at risk?
• Tissue ischemia
• Reactive blanching hyperemia
• Nonblanching reactive hyperemia

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Pressure Ulcers(Contributing Factors)

• Shear
• Friction
• Moisture
• Nutrition
• Infection
• Age
• Immobility
• THESE FACTORS ALSO IMPAIR WOUND HEALING !!!! (Box
  34-1)

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Staging of Pressure Ulcers

• Stage I-alteration in skin that, when compared
  with adjacent or opposite areas shows change in
  temperature, color, consistency or sensation
• Stage II-superficial (partial-thickness) skin
  loss involving epidermis, dermis or both

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Staging of Pressure Ulcers

• Stage III-Full thickness loss involving damage or
  necrosis of subcutaneous tissue that may or may
  not extend to underlying fascia
• Stage IV-Full-thickness loss with extensive
  tissue destruction that can go to muscle, bone or
  supportng structures

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Remember..

• You CANNOT stage a wound that is covered in
  eschar (necrotic tissue)!!!

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Wound Healing Process

• Primary Intention
• Secondary Intention
• Delayed Primary Closure

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Stages of Wound Healing

• Partial-thickness Repair
• Inflammatory phase
• Epidermal repair
• Differentiation
• Full-thickness Repair
• Inflammation phase
• Proliferative phase
• Remodeling phase

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Complications

• Hemorrhage
• Infection
• Dehiscence
• Evisceration
• Fistulas

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How do we predict and prevent?
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Braden Scale for Pressure Ulcer Risk

• Review Table 34-1, page 849

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Common Pressure Ulcer Sites

• Figure 34-6, page 855

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How do we assess a wound?

• We gather data on.
• Size
• Drainage color, amount, type, odor
• Condition of surrounding skin
• Appearance of wound and the color of the wound
  bed

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Questions???

• What is an abrasion?
• What is a laceration?
• How do we know if a wound is infected?
• Culture
• Increased drainage, odor or pain
• Fever

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Wound Irrigation

• Box 34-6, page 857

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Treatment Options

• Topical Skin Care
• Lubricants
• Moisturizers
• Barrier creams
• Pouches
• Pads and briefs
• Positioning
• Regular schedule for turning and pressure relief

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Treatment Options.

• Support Surfaces
• Overlays
• Special mattresses
• Devices

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Treatment Options

• Dressings
• Gauze-wet to dry or dry sterile dressings
• Transparent film dressings
• Hydrocolloid dressings
• Hydrogel dressings
• Alginates
• Wound Vacuum Assisted Closure (VAC)

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Hot/Cold Therapy

• Issues that Influence Tolerance
• Duration of application
• Body part
• Body surface
• Prior skin temperature
• Body surface area
• Age and physical condition

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Effects of heat and cold

• Heat
• Vasodilation-blood flow increased to body part
• Can causes burning and blistering
• Cold
• Vasoconstriction-blood flow decreased to injured
  site prevents edema formation
• Skin mottling, numbness, burning
• Damage to skin from prolonged cold

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Types of Hot/Cold Applications

• Warm/Cold Moist Compresses
• Warm/Cold Soaks
• Sitz Bath
• Aquathermia Pads
• Commercial Hot/Cold Packs
• Hot water Bottles
• Electric Heating Pads
• Ice Pack/Collar

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Questions ???