Skin
Integrity and Wound Healing
COMPETENCIES
1. Describe the normal process of tissue healing.
2. Differentiate between primary, secondary, and tertiary
wound healing.
3. Discuss factors that may impair or promote wound
healing.
4. Discuss common complications of wound healing.
5. Discuss the risk factors and pathogenesis of pressure
ulcers.
6.
Identify preventive
and early treatment measures in clients at risk for pressure ulcer development.
7. Utilize the nursing process for a client with impaired
skin integrity by:
a.
Identifying
appropriate assessment data
b.
Formulating relevant
nursing diagnoses
c.
Developing a plan of
care and identifying outcome criteria
d.
Implementing
appropriate nursing interventions
e.
Evaluating a plan of
care according to outcome criteria
8. Describe the principles of wound assessment and care.
9. Outline dressing products used to treat wounds.
10. Discuss the therapeutic uses of heat and cold therapy
and their methods of application.
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 physiological 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 con-
tains 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 oxygen
needed 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 exudate 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 unfavorable conditions 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, 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.
Health History The health history is conducted to elicit
information regarding medical conditions or disease processes that are often
associated with delayed or disrupted healing such as cardiovascular disease,
diabetes, renal failure, immunosuppression, gastrointestinal disorders,
collagen disorders, malignancy, septic shock, trauma, infection, liver disease,
pulmonary disease, musculoskeletal disease, and depression/psychosis. It is
important to obtain the data in chronological order: when and how the wound
occurred, the initial location and size, and all associated symptoms such as
pain and itching. The history should include aggravating and alleviating
factors, such as radiation at the site of the wound, which can influence the
healing process. The nurse should document allergies to tape, latex,
medications, or other substances. 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. Singleuse 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
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 nursing care, the care must be
reasonable, necessary, and 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 wound, 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 physician notified 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 contents. 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 defecation needs of clients, T binders must 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.
ADMINISTER HEAT AND COLD THERAPY Cells in the hypothalamus act as a
thermostat to regulate body temperature. When the hypothalamic thermostat
detects that the body temperature is either too high or too low, it responds
systemically by instituting appropriate temperature-decreasing (vasodilation,
sweating) or temperature-increasing (vasoconstriction, shivering) mechanisms to
restore body temperature to the normal level. Local responses to heat and cold
occur through stimulation of temperature-sensitive receptors in the skin.
Impulses travel from the periphery to the hypothalamus and the cerebral cortex.
The hypothalamus then initiates heat-producing or heat-reducing reactions of
the body. The conscious sensations of temperature are aroused in the cerebral
cortex. Heat and cold receptors adapt to changes in temperature. On initial
exposure, receptors are strongly stimulated by extremes in temperature, but,
within a short time, this response declines as the receptors adapt to the new
temperature variations. This adaptive ability of the body to temperature
variations can be dangerous to clients insensitive to heat and cold extremes
and may predispose them to serious injury. Nurses and clients need to
understand this adaptive response when applying heat and cold. Heat is one of
the oldest nursing measures used to reduce pain and promote healing. Heat
causes vasodilation and increases blood flow to the affected area,
producing skin redness and warmth. Heat produces maximum vasodilation in 20 to
30 minutes; after this period, reflex vasoconstriction occurs along with tissue
congestion. Periodic removal and reapplication of heat will restore
vasodilation. Prolonged exposure to heat damages epithelial cells and results
in redness, tenderness, and even blister formation. The application of cold
lowers the temperature of the skin and underlying tissues and causes vasoconstriction.
Vasoconstriction reduces blood flow to the affected area and produces skin
pallor or a bluish discoloration and coolness. Maximum vasoconstriction is achieved
at
The body’s response to the application of
heat and cold is influenced by a number of factors. See the accompanying
display for a discussion of the factors that affect tolerance to heat and cold.
The following conditions necessitate precautions in the use of heat and cold
applications: • Neurosensory impairment: Clients with
reduced perception of sensory or painful stimuli (e.g., spinal cord injuries)
are at an increased risk for tissue injury. • Impaired
mental status: Clients who are confused or unconscious need to be monitored and
assessed frequently to ensure safety. • Impaired
circulation: Clients with cardiovascular and peripheral vascular problems or
diabetes may not have the ability to dissipate heat through dilation of blood
vessels and are at an increased risk for tissue injury. • Skin and tissue integrity (open wounds, broken skin,
scar formation, edema): Subcutaneous tissues are more sensitive to temperature
variations than are superficial tissues (e.g., cold can decrease blood flow to
an open wound, thereby inhibiting healing). Heat and cold can be applied in dry
and moist forms (Figure 35-15).
The type of wound or injury, location, and
presence of drainage or inflammation are considered when selecting moist or dry
applications. See Table 35-5
for a discussion on the various forms of
dry and moist heat and cold, their therapeutic effects, and general guidelines
for their application.
Evaluation The nurse needs to evaluate the client’s achievement
of the goals established during the planning phase to achieve or maintain skin
integrity. Goals for clients with wounds generally focus on wound healing,
prevention of infection, and client education. If the goals are not achieved,
the nurse will need to examine the nursing interventions and strategies that
were employed and revise the nursing care plan accordingly. Reviewing
techniques and procedures, especially those performed by the client or other
caregivers in the client’s support system, is especially important.
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 can 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).
Provide 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 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 can not 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 Chapter 34 for a complete discussion of beds used 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, knit
bone, 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.
K E Y C ONCEPTS
• A wound is a disruption in the integrity of the body
tissue that puts an individual at risk for infection.
• Wounds go through a three-step healing process that
includes a defensive (inflammatory) phase, a reconstructive (proliferative)
phase, and a maturation phase.
• The type of exudate from a wound can help determine
the pathology of the infectious process.
• Wounds are often classified by their cause, level of
cleanliness, depth, or color.
• Nursing diagnoses for clients with wounds and pressure
ulcers focus on both the physical (pain, infection, impaired tissue integrity)
and the psychosocial (anxiety, deficient knowledge, disturbed body image)
aspects.
• A significant nursing intervention in all cases of
impaired skin integrity is client education on wound care and promotion of
healing; the client’s support people are often included in this teaching.
• Heat and cold applications help the body’s own systems
respond to and therefore relieve the pain that accompanies wounds.
• Pressure ulcers, or bedsores, are a common problem in
acute and chronic care settings, resulting in longer stays for clients and
increased costs of health care.
• Pressure ulcers are classified into four stages,
depending on the depth of tissue damage.
• Proper positioning is the most effective preventive
measure for pressure ulcers.
C R I T I C A L T H I N K I N G AC T I V
I T I E S
1. Describe the similarities and differences between
wounds and pressure ulcers in terms of their formation, physiology, and care.
2. Define each of the three phases of wound healing, and
outline the process that each represents.
3. Differentiate among primary, secondary, and tertiary
intention healing.
4. What are the different types of exudates, and what
does each indicate?
5. Describe measures the nurse and client can take to
promote wound healing and to prevent complications that often hinder the
wound-healing process.
6. Explain to a colleague the process of hot and cold
therapeutic applications and the mechanics of how and why they work.
7. What steps should a nurse take to ensure that a
comatose client will not develop pressure ulcers?
WEB RESOURCES
American Diabetes Association http://www.diabetes.org
Podiatry Today Journal
http://www.podiatrytoday.com
The Nursing Institute
http://www.springnet.com/ce.htm
Wound Care Information Network
http://www.medicaledu.com/wndguide.htm