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23. Skin Integrity and Wound Care

June 21, 2024

SKIN INTEGRITY AND WOUND CARE

Maintaining skin integrity is an important aspect of nursing care. Impaired skin integrity, such as wounds, may occur as a result of trauma or surgery. The potential for skin breakdown and eventual pressure ulcer formation also exists whenever factors such as prolonged pressure, constant irritation of the skin, and immobility are present. Nurses, through constant and timely observations and interventions, can prevent or minimize skin breakdown.

WOUNDS

The skin is the body’s largest organ and is the primary defense against infection. A disruption in the integrity of body tissue is called a wound.

Physiology of Wound Healing When an injury is sustained, a complex set of responses is set into motion, and the body begins a three-phase process of wound healing. Understanding these physio– logical responses will assist the nurse in caring for clients with impaired skin integrity and promoting optimal wound healing.

Defensive (Inflammatory) Phase The defensive phase occurs immediately after injury and lasts about 3 to 4 days. The major events that occur in this phase are hemostasis and inflammation. Hemostasis, or cessation of bleeding, occurs by vasoconstriction of large blood vessels in the affected area.

Platelets, activated by the injury, aggregate to form a platelet plug and stop the bleeding. Activation of the clotting cascade results in the eventual formation of fibrin and a fibrinous meshwork, which further entraps platelets and other cells. The result is fibrin clot formation, which provides initial wound closure, prevents excessive loss of blood and body fluids, and inhibits contamination of the wound by microorganisms.

Inflammation is the body’s defensive adaptation to tissue injury and involves both vascular and cellular responses. During the vascular response, tissue injury and activation of plasma protein systems stimulate the release of various chemical mediators, such as histamine (from mast cells), serotonin (from platelets), complement, and kinins. These vasoactive substances cause blood vessels to dilate and become more permeable, resulting in increased blood flow and leakage of serous fluid into the surrounding tissues. The increased blood supply carries nutrients and oxygen, which are essential for wound healing, and transports leukocytes to the area to participate in phagocytosis, or the envelopment and disposal of microorganisms. The increased blood supply also removes the “debris of battle,” which includes dead cells, bacteria, and exudate, or material and cells discharged from blood vessels. The area is red, edematous, and warm to touch, and it has varying amounts of exudate as a result.

During the cellular response, leukocytes move out of the blood vessel into the interstitial space. Neutrophils are the first cells to arrive at the injured site and begin phagocytosis. They subsequently die and are replaced by macrophages, which arise from blood monocytes.

Macrophages perform the same function as neutrophils but remain for a longer time. In addition to being the primary phagocyte of debridement, macrophages are important cells in wound healing because they secrete several factors, including fibroblast activating factor (FAF) and angiogenesis factor (AGF). FAF attracts fibroblasts, which form collagen or collagen precursors.

AGF stimulates the formation of new blood vessels. The development of this new microcirculation supports and sustains the wound and the healing process.

Reconstructive (Proliferative) Phase The reconstructive phase begins on the third or fourth day after injury and lasts for 2 to 3 weeks. This phase contains the process of collagen deposition, angiogenesis, granulation tissue development, and wound contraction. Fibroblasts, normally found in connective tissue, migrate into the wound because of various cellular mediators. They are the most important cells in this phase because they synthesize and secrete collagen. Collagen is the most abundant protein in the body and is the material of tissue repair.

Initially, collagen is gel-like, but within several months it cross-links to form collagen fibrils and adds tensile strength to the wound. As the wound gains strength, the risk of wound separation or rupture is less likely. The wound can resist normal stress such as tension or twisting after 15 to 20 days. During this time, a raised “healing ridge” may be visible under the injury or suture line.

Angiogenesis (formation of new blood vessels) begins within hours after the injury. The endothelial cells in preexisting vessels begin to produce enzymes that break down the basement membrane. The membrane opens, and new endothelial cells build a new vessel. These capillaries grow across the wound, increasing blood flow, which increases the supply of nutrients and oxygeeeded for wound healing. Repair begins as granulation tissue, or new tissue, grows inward from surrounding healthy connective tissue.

Granulation tissue is filled with new capillaries that are fragile and bleed easily, thus giving the healing area a red, translucent, granular appearance. As granulation tissue is formed, epithelialization, or growth of epithelial tissue, begins.

Epithelial cells migrate into the wound from the wound margins. Eventually, the migrating cells contact similar cells that have migrated from the outer edges. Contact stops migration. The cells then begin to differentiate into the various cells that compose the different layers of epidermis.

Wound contraction is the final step of the reconstructive phase of wound healing. Contraction is noticeable 6 to 12 days after injury and is necessary for closure of all wounds. The edges of the wound are drawn together by the action of myofibroblasts, specialized cells that contain bundles of parallel fibers in their cytoplasm. These myofibroblasts bridge across a wound and then contract to pull the wound closed.

Maturation Phase

Maturation, the final stage of healing, begins about the twenty-first day and may continue for up to 2 years or more, depending on the depth and extent of the wound. During this phase, the scar tissue is remodeled (reshaped or reconstructed by collagen deposition and lysis and debridement of wound edges). Although the scar tissue continues to gain strength, it remains weaker than the tissue it replaces.

Capillaries eventually disappear, leaving an avascular scar (a scar that is white because it lacks a blood supply).

Types of Healing

Tissue may heal by one of three methods, which are characterized by the degree of tissue loss. Primary intention healing occurs in wounds that have minimal tissue loss and edges that are well approximated (closed). If there are no complications, such as infection, necrosis, or abnormal scar formation, wound healing occurs with minimal granulation tissue and scarring. Secondary intention healing is seen in wounds with extensive tissue loss and wounds in which the edges cannot be approximated. The wound is left open, and granulation tissue gradually fills in the deficit. Repair time is longer, tissue replacement and scarring are greater, and the susceptibility to infection is increased because of the lack of an epidermal barrier to microorganisms.

Tertiary intention healing, also known as delayed or secondary closure, is indicated when primary closure of a wound is undesirable. Conditions in which healing by tertiary intention may occur include poor circulation or infection. Suturing of the wound is delayed until the problems resolve and more-favorable conditions exist for wound healing.

Kinds of Wound Drainage

Chemical mediators released during the inflammatory response cause vascular changes and exudation of fluid and cells from blood vessels into tissues. Exudates may vary in composition but all have similar functions. These functions include:

1. Dilution of toxins produced by bacteria and dying cells

2. Transport of leukocytes and plasma proteins, including antibodies, to the site

3. Transport of bacterial toxins, dead cells, debris, and other products of inflammation away from the site

The nature and amount of exudate vary depending on the tissue involved, the intensity and duration of the inflammation, and the presence of microorganisms.

Serous exudate is composed primarily of serum (the clear portion of blood), is watery in appearance, and has a low protein count. This type of exudate is seen with mild inflammation resulting in minimal capillary permeability changes and minimal protein molecule escape (e.g., seen in blister formation after a burn).

Purulent exudate is also called pus. It generally occurs with severe inflammation accompanied by infection. Purulent exudate is thicker than serous exudates because of the presence of leukocytes (particularly neutrophils), liquefied dead tissue debris, and dead and living bacteria. The process of pus formation is called suppuration, and bacteria that produce pus are referred to as pyogenic bacteria. Purulent exudates may vary in color (e.g., yellow, green, brown) depending on the causative organism.

Hemorrhagic exudate has a large component of red blood cells (RBCs) due to capillary damage, which allows RBCs to escape. This type of exudate is usually present with severe inflammation. The color of the exudate (bright red versus dark red) reflects whether the bleeding is fresh or old.

Mixed types of exudates may also be seen, depending on the type of wound. For example, a serosanguineous exudate is clear with some blood tinge and is seen with surgical incisions.

FACTORS AFFECTING WOUND HEALING

Wound healing is dependent on multiple influences, both intrinsic and extrinsic. Wounds may fail to heal or may require a longer healing period when unfavorableconditions exist. Factors that may negatively influence healing include age, nutrition, oxygenation, smoking, drug therapy, and diseases such as diabetes. Such factors reduce local blood supply and, therefore, impair wound healing. Nutrition and diet can also have an impact on the healing process. See Tables 35-1 and 35-2 for a summary of factors that affect wound healing (these tables are compiled from information found in Cooper, 1990; Hottler, 1990; Jones & Millman, 1990; Levenson & Seifter, 1977; Schumann, 1979; and Sieggreen, 1987)

Hemorrhage

Some bleeding from a wound is normal during and immediately after initial trauma and surgery, but hemostasis usually occurs within a few minutes. Hemorrhage (persistent bleeding) is abnormal and may indicate a slipped surgical suture, a dislodged clot, or erosion of a blood vessel. Swelling in the area around the wound or affected body part and the presence of sanguineous drainage from the surgical drain may indicate internal bleeding. Other evidence of bleeding may include the signs and symptoms seen in hypovolemic shock (decreased blood pressure, rapid thready pulse, increased respiratory rate, diaphoresis, restlessness, and cool clammy skin). A hematoma (localized collection of blood underneath the tissues) may also be seen and appear as a reddish blue swelling or mass. External hemorrhaging is detected when the surgical dressing becomes saturated with sanguineous drainage. It is also important to assess the linen under the client’s wound site because it is possible for the blood to seep out from under the sides of the dressing and pool under the client. The risk for hemorrhage is greatest during the first 24 to 48 hours after surgery.

INFECTION

Bacterial wound contamination is one of the most common causes of altered wound healing. A wound can become infected with microorganisms preoperatively, intraoperatively, or postoperatively. During the preoperative period, the wound may become exposed to pathogens because of the manner in which the wound was inflicted, such as in traumatic injuries. Nicks or abrasions created during preoperative shaving may also be a source of pathogens. The risk for intraoperative exposure to pathogens increases when the respiratory, gastrointestinal, genitourinary, and oropharyngeal tracts are opened. If the amount of bacteria in the wound is sufficient or the client’s immune defenses are compromised, clinical infection may result and become apparent 2 to 11 days postoperatively. Infection slows healing by prolonging the inflammatory phase of healing, competing for nutrients, and producing chemicals and enzymes that are damaging to the tissues.

Dehiscence and Evisceration

Wound healing may be disrupted by dehiscence, the partial or complete separation of the wound edges and the layers below the skin. Evisceration occurs when the client’s viscera protrude through the disrupted wound. Factors that may predispose a wound to dehiscence include obesity, poor nutrition, problems with suturing, excessive coughing, vomiting, straining, and infection. Wound dehiscence is most likely to occur 4 to 5 days postoperatively, before extensive collagen is deposited in the wound. It may be preceded by sudden straining, such as that associated with coughing, sneezing, or sitting up in bed. Signs of impending dehiscence may include the sensation of “something giving way” and an increased flow of serosanguineous drainage on the wound dressing.

Wound Classification

A variety of terms are used to describe and classify wounds. Wounds are usually described based on their etiology since the treatment for the wound varies depending on the underlying disease process. Wound classification systems describe the cause of the wound, the status of skin integrity, the extent of tissue damage, cleanliness of wounds, or descriptive qualities of the wound such as color. The following are commonly used classification systems.

Cause of Wound

• Intentional wounds occur during treatment or therapy. These wounds are usually made under aseptic conditions. Examples include surgical incisions and venipunctures.

• Unintentional wounds are unanticipated and are often the result of trauma or an accident. These wounds are created in an unsterile environment and therefore pose a greater risk of infection.

Cleanliness of Wound

This classification system ranks the wound according to its contamination by bacteria and risk for infection (Sussman & Bates-Jensen, 1998).

• Clean wounds are intentional wounds that were created under conditions in which no inflammation was encountered and the respiratory, alimentary, genitourinary, and oropharyngeal tracts were not entered.

• Clean-contaminated wounds are intentional wounds that were created by entry into the alimentary, respiratory, genitourinary, or oropharyngeal tract under controlled conditions.

• Contaminated wounds are open, traumatic wounds or intentional wounds in which there was a major break in aseptic technique, spillage from the gastrointestinal tract, or incision into infected urinary or biliary tracts. These wounds have acute nonpurulent inflammation present.

• Dirty and infected wounds are traumatic wounds with retained dead tissue or intentional wounds created in situations where purulent drainage was present.

Examples of classification systems that describe wound severity for different wound etiology are the National Pressure Ulcer Advisory Panel (NPUAP), discussed later in this chapter, the Wagner staging system, the partialthickness and full-thickness skin loss criteria, and Marion Laboratories red/yellow/black (RYB) color system.

Wagner Ulcer Grade Classification

The Wagner staging system measures the depth and infection in a wound, mainly a dysvascular foot. It is the primary assessment tool used to evaluate diabetic foot ulcers. The classification ranges from 0 to 5, with 0 identifying the predisposing factors that may lead to grades 1 to 3 (superficial ulcer, deep ulcer, abscess osteitis). Grade 4 and 5, respectively, describe gangrene of the forefoot and gangrene of the whole foot.

Classification by Thickness of Skin Loss

The thickness classification system is based on the depth of the wound (Figure 35-1) and is used for wounds whose etiology is other than pressure wounds such as skin tears, donor sites, vascular ulcers, surgical wounds, or burns.

Superficial epidermal (first degree) are confined to the epidermis layer, which comprises the four outermost layers of skin. Partial-thickness (first to second degree) involves the epidermis and upper dermis, which is the layer of skin beneath the epidermis. Deep (second degree) involves the epidermis and deep dermis. Fullthickness (third degree) refers to skin loss that extends through the epidermis and the dermis, and into subcutaneous fat and deeper structures. Fourth degree are deeper than full-thickness loss, extending into the muscle and bone.

Types of wounds are described and illustrated in Figure 35-2, and burns are shown in Figure 35-3.

The RYB Wound Classification System

In 1988, the RYB classification system was introduced for use in conjunction with the other classification systems to assist the nurse in assessing the wound surface color. The three-color system is a tool to direct treatment of open wounds, with each color corresponding to specific therapy needs.

Red wounds are the color of normal granulation tissue and are in the proliferative phase of wound repair.

These wounds need to be protected and kept moist and clean. Yellow wounds have either fibrinous slough or purulent exudate from bacteria. These wounds need to be cleansed of the purulent exudate, and nonviable slough needs to be removed. Black wounds contain necrotic tissue (eschar). Eschar may be either black, gray, brown, or tan. These wounds need debridement, which is the removal of nonviable necrotic tissue.

Mixed color wounds often occur. The rule for treatment is to treat the worst color first. For example, a red and black wound would be debrided first. Then moisture and protection would be provided for the red portion.

ASSESSMENT

When it comes to wound care, the nurse is confronted with wounds that are extremely diverse. The wound may have occurred traumatically just before the client presents to the emergency room, or the wound may be a slow-healing chronic ulcer. Despite all this diversity, the nurse should approach assessment of the wound in a systematic manner, evaluating the wound’s stage in the healing process. The nurse also needs to show sensitivity to the client’s pain and tolerance levels during assessment and must always follow Standard Precautions to prevent transfer of pathogens. Following are some basic criteria for wound assessment.

Assessment

A personal and social history and a functional ability assessment is done to determine the client’s ability to provide self-care and to identify support systems present in the home. A risk assessment tool, such as the Braden or Norton scale to assess the risk for pressure ulcers, is a part of the history.

Physical Examination

Although the focus of the assessment will be to accurately describe and/or stage the wound, the physical effects of any existing concurrent condition are evaluated. Stotts and Cavanaugh (1999) identify the defining physical areas to be assessed for three common types of ulcers:

Vascular ulcers—Evaluate the skin, nails, hair, color,capillary refill, temperature, pulses, edema of the extremity, and hemosiderin (an iron pigment that is a product of red blood cell hemolysis) in the periulcer area

Arterial ulcers—Weak or absent pulses, thin skin, and lack of hair on the affected extremity Neuropathic ulcers—Use of the Wagner scale previously discussed to evaluate diabetic ulcers

Wound Assessment

The following discussion will describe how to assess a wound, documenting location and size, noting length, width, and depth in centimeters. The appearance of the wound bed and surrounding skin are assessed for sinus tracts, undermining, tunneling, exudate, drainage, necrotic tissue, and signs of infection. Some agencies may require a photograph of the wound on admission and documentation of the client’s response to therapy.

Location

Assessment begins with a description of the anatomical location of the wound; for example, “5-inch suture line on the right lower quadrant of the abdomen.” This task often becomes difficult if the client has multiple wounds close to each other, as is common in burn or multiple trauma victims. Use of a skin documentation form that incorporates drawings of the body (Figure 35-4) allows the nurse to draw circles and write numbers to depict the location of the various wounds.

Size

The length (head to toe), width (side to side), and depth of a wound are measured in centimeters. Single use measurement guides (tape measures) often come with dressing supplies. To determine the depth of a wound, insert a sterile cotton swab into the deepest point of the wound and mark it at the skin surface level.

Then the swab can be measured and the wound depth in centimeters can be documented. Tunneling, also called undermining, can be measured by using a cotton swab to gently probe the wound margins. If tunneling is noted, the location and depth are documented.

For clarity in describing the location of the tunneling, refer to the tunnel location, using the hands of the clock as a guide, with 12 o’clock pointing at the client’s head.

Example: “Tunneling occurs at 1 o’clock and its depth is 2 cm.” For extremely irregularly shaped wounds, the wound edges can be traced on a plastic surface. A plastic bag or piece of plastic sheeting folded in half is placed on the wound, and the wound margins are traced. The side of the plastic that has been placed against the skin is cut off and discarded. The rest of the plastic can be placed in the chart.

General Appearance and Drainage

A general description of the color of the wound and surrounding area helps to determine the wound’s present phase of healing. Gently palpate the edges of the wound for swelling. Document the amount, color, location, odor, and consistency of any drainage. Nurses who care for the client in the home must demonstrate the need for skilled nursing services by accurately describing all wounds (see the accompanying display). For example, for Medicare to reimburse nurse reflect a plan of care appropriate for the client’s diagnoses, prognosis, and rehabilitative potential (Baranoski, 1999).

Pain

Document and notify the physician of any pain or tenderness at the wound site. Pain may indicate infection or bleeding. It is normal to experience pain at the incision site of a surgical wound for approximately 3 days. If there is any sudden increase in pain accompanied by changes in the appearance of the wo nd, be sure to notify the physician immediately. See Chapter 33 for more information on assessing pain.

Laboratory Data

Cultures of the wound drainage are used to determine the presence of infection and to identify the causative organism. The sensitivity results list the antibiotics that will effectively treat the infection. An elevated WBC count is indicative of an infectious process. A decreased leukocyte count may indicate that the client is at increased risk for developing an infection related to decreased defense mechanisms. Albumin is a measure of the client’s protein reserves; if decreased, there are decreased resources of protein for wound healing. Procedure 35-1 outlines the correct techniques for culturing a wound.

NURSING DIAGNOSES

Nursing diagnoses for clients with wounds focus on prevention of complications and promotion of the healing process through proper wound care and client teaching. Following are NANDA(2001)-approved nursing diagnoses with a partial list of related factors:

1. Impaired Tissue Integrity related to surgical incision,pressure, shearing forces, decreased blood flow, immobility, mechanical irritants, mechanical (pressure, shear, friction), radiation, nutritional deficit or excess, thermal, irritants, including body excretions, secretions, and medications.

2. Risk for Infection related to malnutrition, decreased defense mechanisms

3. Pain related to inflammation, infection

4. Disturbed Body Image related to changes in body appearance secondary to scars, drains, removal of body parts

5. Deficient Knowledge (wound care) related to lack of exposure to information, misinterpretation, lack of interest in learning.

Outcome Identification and Planning

After identifying the nursing diagnoses, the nurse establishes targeted outcomes for wound healing. When formulating outcomes, keep in mind that they should be based on the client’s identified needs and should be individualized on the basis of the client’s condition. Changes in the health care delivery system have brought about early discharge from the hospital, so clients are often sent home with wounds that need continued care. The goals for clients with wounds generally focus on promoting wound healing, preventing infection, and educating the client. An example of a goal for debilitated clients would be demonstrating no signs of infection and preventing pressure to certain skin areas for extended periods of time.

IMPLEMENTATION

Nursing interventions to promote wound healing and prevent infection include emergency measures to maintain homeostasis (state of internal constancy of the body), and cleansing and dressing of the wound.

Initiate Emergency Measures

The nurse assesses the type and extent of injury that the client has sustained. If hemorrhage is detected, sterile dressings and pressure should be applied to stop the bleeding. Standard Precautions are always implemented. The client’s vital signs should be monitored frequently and the physiciaotified immediately.

When dehiscence or evisceration occurs, the client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings, such as ABD pads soaked with sterile normal saline, should be used to cover the wound and abdominal con tents. This will reduce the risk of bacterial contamination and drying of the viscera. The surgeon should be notified immediately and the client prepared for surgical repair of the area.

Cleanse the Wound

The goal of cleansing the wound is to remove debris and bacteria from the wound bed with as little trauma to the healthy granulation tissue as possible. Choice of cleansing agent depends on the physician’s prescription as well as agency protocol. It is recommended that isotonic solutions such as normal saline or lactated Ringers be used to preserve healthy tissue. Much research has been conducted on the proper use of antiseptic solutions in open wounds. The results remain debatable, and continued research is needed to investigate the effects of antiseptic agents on leukocytes and fibroblasts. Many of the studies do show that commonly used agents such as povidone-iodine 10%, hydrogen peroxide 3%, sodium hypochlorite (Dakin’s solution), and acetic acid are effective in destroying bacteria but at the same time destroy fibroblasts and healthy granulation tissue (Lineaweaver, Howard, & Saucy, 1985). Studies suggest that some of these antiseptic solutions at dilute concentrations remain bactericidal yet not cytotoxic to healthy fibroblasts (Doughty, 1994).

The major principles to keep in mind when cleansing a wound are:

1. Use Standard Precautions at all times.

2. When using a swab or gauze to cleanse a wound, work from the clean area out toward the dirtier area. (Example: When cleaning a surgical incision, start over the incision line, and swab downward from top to bottom. Change the swab and proceed again on either side of the incision, using a new swab each time (Figure 35-8).

3. When irrigating a wound, warm the solution to room temperature, preferably to body temperature, to prevent lowering of the tissue temperature. Be sure to allow the irrigant to flow from the cleanest area to the contaminated area to avoid spreading pathogens (Procedure 35-2).

Dressing the Wound

The three purposes of a wound dressing are to:

1. Keep the wound moist and therefore enhance epithelialization

2. Clean the wound or keep it clean

3. Protect the wound from physical trauma or bacterial invasion

Keeping these three purposes in mind, the nurse and physician are confronted with the daunting task of determining the appropriate dressing for the client’s wound. There are literally thousands of different wound care products on the market, which fall into eight basic categories. In order to make an appropriate dressing choice, the nurse needs to be familiar with the proper use and indications for each of these categories and to select the one that meets the client’s wound healing needs (Table 35-3). In addition, it is important to remember that the dressing plans must be modified as the wound changes. An excellent guide to help the nurse in the decision-making process is the RYB color code. Procedures 35-3 and 35-4 explain the proper technique for dry sterile dressing and wet to dry dressing changes.

Monitor Drainage of Wounds

During the inflammatory response, exudates develop within a wound. When excessive drainage accumulates in the wound bed, tissue healing is delayed. If the outer surface is allowed to heal while the drainage remains entrapped within the wound, infection and abscess formation may occur. To facilitate drainage of any excess fluid, the physician may insert a tube or drain.

When the drain is inserted by the surgeon at the time of surgery, one end of the drain is placed in the operative site and the other end is usually passed through a separate small stab wound near the main incision.

Various types of drains exist on the market. Some flexible drains such as Penrose drains function by gravity and have an open end that drains onto dressings.

Closed suction drainage systems commonly have a reservoir that is capable of creating negative pressure or a vacuum. The gentle suction that is created draws exudate from the wound into the reservoir. As fluid enters the reservoir, suction is lost; therefore, the nurse must empty the reservoir when it is half full. Hemovac and Jackson-Pratt drains are examples of closed suction drainage systems (Figure 35-9).

Nurses are responsible for maintaining the patency of the system and for assessing the amount, type, and color of the drainage. It is important for the nurse to be cautious when changing wound dressings to prevent accidental removal or dislodgement of drains.

Provide Suture Care

Sutures are a surgical means of closing a wound by sewing, wiring, or stapling the edges of the wound together. When placed deep within the tissue layers, sutures made of absorbable material are used so that the sutures will not need to be removed but rather can dissolve into the tissue. For surface closures, steel staples or sutures made of wire, nylon, cotton, or other materials are used; these need to be removed as the wound heals.

Nurses are often responsible for removing sutures and should therefore be familiar with different suturing methods (Figure 35-12). Continuous sutures are made with one thread, tied at the beginning and end of the suture line. Intermittent sutures are each tied individually. In blanket continuous sutures, the single thread is grounded again in the last suture exit.

Checking Bandages, Binders, and Slings

Bandages and binders are applied over wound dressing sites: to secure, immobilize, or support a body part; to hold a dressing in place; or to prevent or minimize swelling of a body part. Bandages are long rolls of material, such as gauze, webbing, or muslin, designed to be wrapped around body parts. Figure 35-13 illustrates several different methods of bandaging.

Binders are bandages made for specific body parts, usually the abdomen, perineal area, or arm (sling) (Figure 35-14). Abdominal binders support the abdomen and are used following abdominal surgery or childbirth. Perineal binders, called T binders, are used to hold pads or dressings in the perineal area. Because of urination and defecatioeeds of clients, T bindersmust be changed regularly. A sling is a cloth support for an injured arm that wraps around the back of the neck to maintain the arm in a set position.

PRESSURE ULCERS

Pressure ulcers, also known as bedsores or decubitus ulcers, are localized areas of tissue necrosis that tend to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time (National Pressure Ulcer Advisory Panel, 1989). Pressure ulcers are due to ischemia, or decreased blood supply, and commonly occur in areas subject to high pressure from body weight on bony prominences.

Physiology of Pressure Ulcers

The reduction of blood flow causes blanching (white color) of the skin when pressure is applied. When pressure is relieved, the skin takes on a brighter color (reactive hyperemia) due to vasodilation, the body’s normal compensatory response to the absence of blood flow. If this area blanches with fingertip pressure or if the redness disappears within an hour, no tissue damage is anticipated. If, however, the redness persists and no blanching occurs, then tissue damage is present.

Other forces acting in conjunction with pressure contribute to pressure ulcer formation. Shearing is the force exerted against the skin when a client is moved or repositioned in bed by being pulled or allowed to slide down in bed. The skin and subcutaneous tissue tend to adhere to the bed surface and remain stationary while deeper underlying tissues pull away and slide in the direction of movement. This action results in stretching and tearing of blood vessels, reduced blood flow, and necrosis. Shearing forces account for the high incidence of sacral ulcers.

Friction is the force of two surfaces moving across one another. When a client moves or is pulled up in bed, rubbing of the skin against the sheets creates friction. Friction can remove the superficial layers of the skin, making it more prone to breakdown.

Risk Factors for Pressure Ulcers

Pressure ulcers can be prevented if at-risk individuals and the specific factors placing them at risk can be identified. Many risk factors have been associated with pressure ulcer formation, including immobility and inactivity, incontinence, malnutrition, decreased mental status, diminished sensation, and age-related changes. Individuals should be assessed for pressure ulcer risk on admission to acute care hospitals, nursing homes, and other health care facilities (USDHHS, 1992). Validated risk assessment tools such as the Braden Scale (Braden, 1989) or the Norton Scale (Norton, 1989) can be used to predict who will or will not develop pressure ulcers (Tables 35-6 and 35-7).

Assessment

Pressure ulcers are staged to classify the degree of tissue damage (Figure 35-16). The revised National Pressure Ulcer Advisory Panel (USDHHS, 1998) recommends the following staging system:

• Stage I. Nonblanchable erythema of intact skin; the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.

• Stage II. Partial thickness skin loss involving epidermis or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

• Stage III. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

• Stage IV. Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with Stage IV pressure ulcers.

Nursing Diagnoses

Nursing diagnoses for clients with pressure ulcers will be similar to those for clients with wounds, because the type of injury and its consequences are similar. The emphasis is on gentle client care and client teaching to promote healing of the ulcer and to prevent its recurrence. Identifying the client’s psychological needs as well, in terms of diagnoses such as Disturbed Body Image and Anxiety, will ensure that the client’s symptoms are addressed holistically.

Outcome Identification and Planning

As with nursing diagnoses, the outcome identification and planning phase of the nursing process for relieving pressure ulcers is similar to that for clients with wounds.

Individualized outcomes based on the client’s overall physical condition, the stage of the wound, and the client’s risk factors will help in identifying priority interventions. Client teaching should be included as an integral part of the planning process; if the client desires, family and support persons should be brought into the learning circle as well.

Implementation

Pressure ulcers can be prevented through a variety of measures. Early identification of high-risk individuals and contributing risk factors and an ongoing assessment of risk factors and skin integrity should be done to decrease the possibility of pressure ulcer formation. Other areas to focus on in the prevention of pressure ulcers include hygiene and skin care, positioning, and the use of support surface therapy. The following interventions may be used as guidelines by the nurse in caring for adult clients at risk for pressure ulcer development. They are based on recommendations developed by the Agency for Health Care Policy and Research (USDHHS, 1992).

Ensure Proper Hygiene and Skin Care

Proper skin care is essential to preventing skin breakdown. To maintain and improve tissue tolerance to pressure, the nurse should perform the following interventions:

• Assess the skin at least once a day, paying particular attention to bony prominences.

• Cleanse the skin at routine intervals and at time of soiling. Keep the client’s skin clean, dry, and free of irritation and maceration by urine, feces, and sweat. A moisture barrier cream can also be applied to the perineal area to protect the skin from moisture and toxins from urine and stool.

• Use warm water and mild cleansing agents so as not to irritate and dry the skin. Avoid the use of soaps and alcohol-based lotions, which may cause drying and leave an alkaline residue that discourages normal skin bacteria, leading to growth of opportunistic bacteria. Minimize the force and friction applied to the skin during cleansing so as not to disrupt the “natural barrier” to the skin.

• If the skin is dry, use moisturizing lotions and minimize exposure to cold and low humidity, which canProvide Proper Positioning Positioning interventions prevent the adverse effects of pressure, friction, and shear. For most clients, maintaining current activity levels, mobility, and range of motion is sufficient to prevent pressure ulcers. For the immobilized client, the following interventions may help prevent the development of pressure ulcers:

• Turn and reposition client at least every 2 hours so that ischemic areas can recover. If a reddened area does not blanch when you press it, turn the client more often.

• When positioning, pay attention to body alignment. The position shown in Figure 35-17 relieves pressure on the sacrum and trochanters. There should be a 30° angle between the client’s trochanters and the surface of the bed. The hips and knees should be flexed. To maintain this position, support the client’s back with a pillow or foam wedge, and put a pillow between the knees.

• When turning the client, remove the pillows and wedges, lower the head of the bed, and use a draw cause dryness of the skin.

• Avoid massage over bony prominences. Current evidence suggests that massage may be harmful and cause deep tissue trauma (Maklebust, 1991; USDHHS, 1992). sheet to lift, not drag, the client to a new position. Maintain the head of the bed at 30° or less to prevent shearing.

• If the client is supine, make sure the heels are not resting on the mattress. Suspend them by placing a pillow or foam pad lengthwise under the lower legs.

• Place at-risk clients on pressure-reducing surfaces.

• Have clients who are able to sit up shift their weight every 15 minutes; those who caot do so need to be repositioned at least every hour.

• Use a pressure-reducing device such as a foam overlay on the seating surface to reduce pressure on the ischial tuberosities by redistributing weight over a much larger surface area. Do not use donut-shaped cushions, which reduce blood supply to the affected area, leading to even more ischemia.

Employ Support Surfaces

A variety of support surfaces are available to support the entire body and evenly distribute pressure. These devices can be used as adjunct therapy to help reduce pressure and prevent ulcers, but they are no substitute for frequent positioning and there is no scientific evidence that any one support surface works consistently better than any other (USDHHS, 1992).

In addition to pressure reduction or relief, many support surfaces reduce shear and friction and control moisture. Pressure-reducing support surfaces include overlays filled with foam, gel, or water (e.g., eggcrate mattresses, alternating air-filled mattresses) and replacement mattresses (replace standard mattresses).

Pressure-relieving devices include specialty beds that replace hospital beds. Examples are low-air-loss (LAL) beds (e.g., Flexicair), air-fluidized beds (e.g., Clinitron), and beds that provide kinetic therapy. Kinetic beds (e.g., Rotorest) provide continuous passive motion or oscillation to counteract the effects of immobility. See Table 35-8 for a list of selected support devices.

Complementary Therapies

Nature is rich in plants that promote healing of cuts, burns, and wounds. Herbalist recognize that skin problems may reflect a variety of internal conditions; therefore herbs used to treat wounds are selected based on their internal and external actions (Hoffmann, 1998).

Herbs that create the following actions are particularly useful for wound healing: vulneraries (promote healing of wounds and ulcers), alteratives (restore proper bodily function), diaphoretics (promote sweating and capillary dilation), antimicrobial (resist pathogenic microorganisms, usually by strengthening the immune system), and nervines (act on the nervous system as either tonics, relaxants, or stimulants). Some of the vulnerary herbs discussed below also work as an astringent (bind to skin and mucous tissue, reduce irritation and inflammation, protect against infections) to arrest bleeding and to condense tissue.

Chickweed, a common garden weed, is a vulnerary and anti-microbial. It may be applied directly to an insect bite to relieve itching and irritation or used as an ointment in combination with marshmallow for cuts and wounds (Tierra, 1998).

Comfrey contains a chemical, allantoin, that stimulates cell proliferation and promotes wound healing both inside and out. Although it can be used internally to treat gastric and duodenal ulcers, comfrey is often used externally as a compress or poultice to speed healing of wounds and fractures and reduce scarring.

Caution is given when using comfrey to treat deep wounds since it can lead to tissue forming over the wound before the wound heals from within, creating a risk for an abscess to form (Goldberg, 1999). The anticancer action of this herb has been reputed and it should be used with caution in anyone with a family history of cancer. Aloe vera is a common household plant. The juice from the plant is used externally to treat minor cuts and burns, sunburn, and insect bites. It has been used effectively to decrease the scarring from acne. Aloe is primarily a vulnerary herb that promotes wound healing and has an antimicrobial action. Internally this herb is used as a cathartic and emmenagogue (normalize and tone the female reproductive system) and should be used with caution during pregnancy and should be avoided during breastfeeding since it is excreted in the mother’s milk. Caution is given when taking dieter’s teas containing aloe and other substances; they act as laxatives when consumed in large quantities, can disrupt potassium levels and contribute to cardiac arrhythmias (Fontaine, 2000).

Woundwort is a vulnerary, antiseptic, antispasmodic, and astringent used primarily as a wound healer. It is equivalent to comfrey as a wound healer and may be used directly on the wound or as a ointment or compress (Hoffmann, 1998).

Other herbs that may be used to promote wound healing and relieve irritation and pain associated with an ulcer or wound are tea tree oil, lavender oil, colloid silver, echinacea, golden seal (refer to Chapter 31 for a complete discussion of their antimicrobial action), slippery elm, knitbone, and self-heal.

Although most wounds heal with a well-balanced diet, special attention should be given to the diet when wounds are at risk for infection. Avoid stressor foods such as refined sugars, excess caffeine, and alcoholic beverages because they may decrease the body’s immune function and healing (Goldberg, 1999). The

diet should be rich in essential fatty acids, vitamin A, zinc, and vitamin C to promote the skin’s healing. Foods rich in these essential elements are: green and yellow vegetables, eggs, cold water fish, raw seeds and nuts, oysters.

Evaluation

Evaluation of the plan of care for a client with a pressure ulcer will consider the physical signs of healing and the status of the pressure ulcer, as well as the client’s adaptation to the altered skin integrity. Each intervention should be evaluated for its effectiveness, and the plan of care revised to reflect those actions that have proven the most beneficial in realizing the expected outcomes of care.

Applying a Dry Dressing