Student Version Skin Wounds 1119 9 11 13

Chapter 32 Skin Integrity and Wound Care
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Functions of the Skin

Protection Body temperature regulation Psychosocial Sensation Vitamin D production Immunological Absorption Elimination
Cross-Section of Normal Skin
Factors Affecting the Skin

Unbroken and healthy skin and mucous membranes defend against harmful agents. Resistance to injury is affected by age, amount of underlying tissues, and illness. Adequately nourished and hydrated body cells are resistant to injury. Adequate circulation is necessary to maintain cell life.
Developmental Considerations
Infants skin and mucous membranes are easily injured and subject to infection. A childs skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages. The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.
Aging Skin: Hands
Causes of Skin Alterations

Very thin and very obese people are more susceptible to skin injury. Fluid loss during illness causes dehydration.
Skin appears loose and flabby.

Excessive perspiration during illness predisposes skin to breakdown. Jaundice causes yellowish, itchy skin. Diseases of the skin cause lesions that require care.
Anatomic Distribution of Common Skin Disorders Scabies Herpes Zoster
Chronic, noncontagious, proliferative skin disorder Signs and symptoms include red papules covered with silvery, yellow-white scales that the client constantly sheds. The main objective of treatment: reduce scaling and itching
Psoriasis
Therapeutic baths, wet dressings, or lubricating ointments may be helpful, followed by application of emollient creams to soften the scaling.
UV light treatment or sun exposure may be useful but requires careful supervision.
Severe Psoriasis of the Knees
Nursing Process: The Care of the Patient with PsoriasisPlanning

Major goals may include: Increased understanding of psoriasis and the treatment regimen
Achievement of smoother skin with control of lesions

Development of self-acceptance Absence of complications
Infections Warts
Small, flesh-colored, brown or yellow papules caused by human papillomavirus (HPV)
May grow anywhere on the skin

Filiform warts are slender, soft, thin, finger-like growths seen primarily on the face and neck. Plantar or palmar warts are firm, elevated, or flat lesions occurring on the soles or palms. Treated using electrodessication, curettage, cryosurgery, locally applied laser therapy, or keratolytic agents
Medications that Affect the Integumentary System

Dermatologic agents Medications applied to the skin to treat localized skin conditions
Examples
Soothing agents Antiseptics
Anesthetics
Corticosteroids
Medications that Affect the Integumentary System

Antifungals Pediculicides (medications used to kill lice)
Transdermal medication
Topical agents designed to be absorbed through the skin systemic effects.
Selected Dermatologic Agents

Care of Patients with Skin Conditions

Objectives of therapy are to prevent additional damage, prevent secondary infection, reverse inflammatory processes, and relieve symptoms. Nursing care includes administration of topical and systemic medications, wound care and dressings, and providing for patient hygiene. Nursing care also needs to address the educational, emotional, and psychosocial needs of the patient.
Infectious Diseases of the Skin

Viral infections Herpes zoster Herpes simplex: orolabial, genital
Rubella (German Measles)

After 34 days, a rash begins with red spots, first appearing behind the ears and at the forehead, spreading down the neck, arms, trunk, and finally the legs. The red spots can merge together on the face.
Pinkish-red maculopapular rash
Rubeola
A typical case of measles begins with mild to moderate fever, cough, runny nose, red eyes, and sore throat. Two or three days after symptoms begin, tiny white spots (Kopliks spots) may appear inside the mouth.
Three to five days after the start of symptoms, a red or reddish-brown rash appears. The rash usually begins on a persons face at the hairline and spreads downward to the neck, trunk, arms, legs, and feet. When the rash appears, a persons fever may spike to more than 104 degrees Fahrenheit.
Fifth Disease
Human Parvovirus Erythema Maculopapular red spots appear symmetrically distributed on upper and lower extremities
Patient Teaching: Viral Infections

Herpes zoster: instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene Herpes simplex: instruction regarding prescribed antiviral medications and prophylactic medication use, instruction regarding spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpes
Herpes Simplex
HSV I, usually like the common cold sore Outbreaks Usually occur in the same spot each time May be found on genitalia due to oral sex HSV II Outbreak or Dormancy Usually found on genitalia, but can be transmitted to mouth due to oral sex
Nursing Process: The Care of the Patient with Blistering DiseasesAssessment

Appearance of the skin Monitor VS frequently and assess for signs and symptoms of infection
Pain, pruritis, and discomfort

Coping of the patient with condition Note impact of the disease on patient activities and interactions
Nursing Process: The Care of the Patient with Blistering DiseasesPlanning

Major goals may include: Relief of pain and discomfort for lesion Skin healing Reduced anxiety Improved coping Absence of complications
Interventions
Meticulous oral hygiene Avoid commercial mouthwashes Keep lips moist with lip balm, petroleum, or lanolin Cool mist humidified air Cool wet dressing or baths, hygiene measures Apply powder liberally to keep skin from adhering to sheets Monitor for and prevent hypothermia Skin care may be similar to that of the patient with extensive burns Measures to prevent secondary infections Encourage adequate fluid and nutritional intake
Psoriasis
A chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate. Affects about 2% of the population, primary those of European ancestry Improves and recurs; a life-long condition. May be aggravated by stress, trauma, seasonal and hormonal changes. Treatment: baths to remove scales and medications.
Nursing Process: The Care of the Patient with PsoriasisAssessment

Appearance of the skin (Plaque psoriasis is raised, roughened, and covered with white or silver scale with underlying erythema) Coping of the patient with condition Note impact of the disease on patient activities and interactions
Nursing Process: The Care of the Patient with PsoriasisPlanning

Major goals may include: Increased understanding of psoriasis and the treatment regimen
Achievement of smoother skin with control of lesions

Development of self-acceptance Absence of complications
Interventions
Patient teaching regarding the disease, skin care, and treatment regimen Measures to prevent skin injury: avoid picking or scratching Measures to prevent skin dryness: use of emollients, avoid excessive washing, and use warm (not hot) water, pat dry
Use of the therapeutic relationship for support and to aid coping
Anatomic Distribution of Common Skin DisordersContact Dermatitis
Medical Management of Skin Disorders

Topical: Ointments, Lotions, silver sulfides, creams Transdermal medication Topical agents designed to be absorbed through the skin systemic effects. Selected Dermatologic Agents Mechanical Whirlpool UV light
Tip
If wound is wet you dry it and protect it If wound is dry, you wet it
By S.D.,RN
WOUNDS AND WOUND CARE
Types of Wounds
Intentional or unintentional Open or closed Acute or chronic Partial thickness, full thickness, complex
Principles of Wound Healing

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 (cont.)

The extent of damage and the persons state of health affect wound healing. Response to wound is more effective if proper nutrition is maintained.
Phases of Wound Healing

Hemostasis Inflammatory Proliferation Maturation
Question
In which one of the following phases of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory phase C. Proliferation phase D. Maturation phase
Answer
Answer: C. Proliferation phase Rationale: In the proliferation phase, granulation tissue is formed to fill the wound. In hemostasis, involved blood vessels constrict and blood clotting begins. In the inflammatory phase, white blood cells move to the wound. In the maturation phase, collagen is remodeled forming a scar.
Inflammatory Phase
Begins at time of injury Prepares wound for healing Hemostasis (blood clotting) occurs Vascular and cellular phase of inflammation
Hemostasis
Occurs immediately after initial injury Involved blood vessels constrict and blood clotting begins Exudate is formed causing swelling and pain Increased perfusion results in heat and redness Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Inflammatory Phase
Follows hemostasis and lasts about 4 to 6 days. WBCs move to the wound. Macrophages enter wound area and remain for extended period. They ingest debris and release growth factors that attract fibroblasts to fill in wound. Patient has generalized body response.
Proliferation Phase
Phase begins within 2 to 3 days of injury and may last up to 2 to 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 development.
Maturation 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.
Factors Affecting Wound Healing

Agechildren and healthy adults heal more rapidly Circulation and oxygenationadequate blood flow is essential
Nutritional statushealing requires adequate nutrition

Wound conditionspecific condition of wound affects healing Health statuscorticosteroid drugs and postoperative radiation therapy delay healing
Wound Complications
Infection Hemorrhage Dehiscence and evisceration Fistula formation
Question
Which one of the following wound complications is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration
Answer
Answer: D. Maceration Rationale: Maceration is caused by overhydration related to incontinence that causes impaired skin integrity. Necrosis is dead tissue present in the wound that delays healing. Edema is swelling at a wound site that interferes with blood supply to the area. Desiccation is the process in which the cells dehydrate and die.
Wound Dehiscence and Evisceration
Psychological Effects of Wounds

Pain Anxiety Fear Change in body image
Factors Affecting Pressure Ulcer Development

Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders
Mechanisms in Pressure Ulcer Development

External pressure compressing blood vessels Friction or shearing forces tearing or injuring blood vessels
Stages of Pressure Ulcers

Stage Inonblanchable erythema of intact skin Stage IIpartial-thickness skin loss Stage IIIfull-thickness skin loss; not involving underlying fascia Stage IVfull-thickness skin loss with extensive destruction Unstageablebase of ulcer covered by slough and or eschar in wound bed
Measurement of a Pressure Ulcer

Size of wound Depth of wound Presence of undermining, tunneling, or sinus tract
A Wound With Various Types of Wound Surface Tissue
Cleaning a Pressure Ulcer

Clean with each dressing change. Use careful, gentle motions to minimize trauma. Use 0.9% normal saline solution to irrigate and clean the ulcer. Report any drainage or necrotic tissue.
Wound Assessment
Inspection for sight and smell Palpation for appearance, drainage, and pain Sutures, drains or tube, and manifestation of complications
Presence of Infection
Wound is swollen. Wound is deep red in color. Wound feels hot on palpation. Drainage is increased and possibly purulent. Foul odor may be noted. Wound edges may be separated with dehiscence present.
Assessment of Wound Drainage

Serous Sanguineous Serosanguineous Purulent
Purposes of Wound Dressings

Provide physical, psychological, and 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.
Types of Wound Dressings

Telfa Gauze dressings Transparent dressings
Types of Bandages
Roller bandages Circular turn Spiral turn Figure-of-eight turn Recurrent-stump bandage
Topics for Home Care Teaching

Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination
BANDAGES AND BINDERS
Types of Binders
Straightused for chest and abdomen T-binderused for rectum, perineum, and groin area Slingused to support an arm
Type of Drainage Systems

Open systems Penrose drain Closed systems Jackson-Pratt drain Hemovac drain
Penrose Drain
Jackson-Pratt Drain
HEMOVAC DRAIN
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Chapter 32 Skin Integrity and Wound Care

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Functions of the Skin

Cross-Section of Normal Skin

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors Affecting the Skin

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Aging Skin: Hands

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Causes of Skin Alterations

Skin appears loose and flabby.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic Distribution of Common Skin Disorders Scabies Herpes Zoster

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Severe Psoriasis of the Knees

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with PsoriasisPlanning

Achievement of smoother skin with control of lesions

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

May grow anywhere on the skin

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medications that Affect the Integumentary System

Medications that Affect the Integumentary System

Selected Dermatologic Agents

Care of Patients with Skin Conditions

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Infectious Diseases of the Skin

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rubella (German Measles)

Pinkish-red maculopapular rash

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Patient Teaching: Viral Infections

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with Blistering DiseasesAssessment

Pain, pruritis, and discomfort

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with Blistering DiseasesPlanning

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with PsoriasisAssessment

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with PsoriasisPlanning

Achievement of smoother skin with control of lesions

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Use of the therapeutic relationship for support and to aid coping

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic Distribution of Common Skin DisordersContact Dermatitis

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medical Management of Skin Disorders

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

WOUNDS AND WOUND CARE

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Principles of Wound Healing

The body responds systematically to trauma of any of its parts.

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Principles of Wound Healing (cont.)

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phases of Wound Healing

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins