22Skin Integrity and Wound Healing

Skin Integrity and Wound Healing. Heat and Cold Therapy.

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 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 pre-existing 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 exudates (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 haemorrhaging 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.

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 apart 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,

A. Superficial epidermal (first degree burn):

Injury to the epidermis; skin is red, dry, and painful.

B. Deep (second degree burn): Injury to the epidermis and upper layers of the dermis, skin is red, moist or dry blisters, and extremely painful; exudate and swelling usually occur.

C. Full-thickness (third degree burn): Injury is to the epidermis, dermis, and subcutaneous tissue; skin is dry, pearly white to charred, inelastic, and leathery 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 multipletrauma 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

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 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.

Laboratory Data

Cultures of the wound drainage are used to determine the presence of infection and to identify the causative. The sensitivity results list the antibiotics that

will effectively treat the infection. An elevated WBCcount 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.

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, 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 15°C (60°F); at temperatures below 15°C, the vessels begin to dilate. Prolonged exposure to cold results in a reflex vasodilation. Initially the skin is reddened, but later it takes on a bluish purple mottled appearance with numbness and pain because of impaired circulation and tissue ischemia. Vasodilation and vasoconstriction of the blood vessels in the skin result primarily from increased sensitivity of the vessels to nerve stimulation but also from a protective reflex response that passes to the spinal cord and then back to the vessels. The therapeutic effects of heat and cold applications are outlined in Table 35-4.

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 thataffect 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.

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.

Heat application is used to promote vasodilatation, increase capillary permeability, decrease blood viscosity, increase tissue metabolism, and reduce muscle

tension. Moist heat can be in the form of immersion of a body part in a warmed solution or water. It can also be accomplished by wrapping body parts in dressings that are saturated with warmed solution.

ASSESSMENT

1. Assess the area to receive heat treatment for circulation. Heat increases circulation; adequate vasculature must be present to be effective.

2. Assess the skin sensation and integrity around the area to be treated. Heat treatment cannot be used over areas of blisters, burns, or redness indicative

of burning.

3. Assess for open wounds that may be affected by the treatment. Moist heat provides an ideal climate for the growth of microorganisms. Moist

heat should be applied to open wounds only with orders from a physician or qualified practitioner.

DIAGNOSIS

1.4.1.1 Altered Tissue Perfusion

9.1.1 Pain

1.6.2.1.2.2 Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. If heat treatment is being used to decrease muscle tension or alleviate pain, then the client will experience a decrease in pain and tension.

2. If heat treatment is being used to increase circulation, then circulation will improve as demonstrated by color or assessment for blanching.

3. If heat treatment is being used to decrease edema, then the client will experience a decrease in swelling in the area being treated.

Equipment Needed (see Figure 3-5-2):

• Aqua heat pad

• Commercial heat pack

• Solution for heat treatment

• 434 Gauze and waterproof pads

• Examination gloves

• Sterile glove if open wounds

• Towel

CLIENT EDUCATION NEEDED:

1. Teach client that overuse of heat can cause tissue damage and burn the skin.

2. Applying heat longer than the prescribed time can cause reflex vascular constriction.

3. Moist heat can cause damage faster than dry heat.

4. Do not use moist heat over scarred or exposed tissue unless treatment is specifically for those areas.

5. If electric heating systems are used, avoid high settings. Teach the caregiver to watch so that the client at home doesn’t fall asleep with the unit in place.Warn the client to stay awake when a heating unit is in place.

6. Teach the client not to use the wrong heat source—placing lower legs on a space heater for warmth, for example

EVALUATION

• Evaluate post-treatment for decreased swelling, decreased edema, decreased muscle tension, and improved circulation depending on the purpose of the

treatment.

• Evaluate skin post-treatment for any heat damage such as excess redness, swelling, or blistering.

DOCUMENTATION

Nurses’Notes

• Document the treatment and the results of treatment.

• Document the condition of the skin.

• Document the purpose and type of moist heat application.

• Record the results of the treatment and the client’s tolerance.

• Document client teaching.

CRITICAL THINKING SKILL

Introduction

Remind outpatient or home care clients to monitor water temperature carefully.

Possible Scenario

A diabetic client being seen in the diabetic clinic reports that he soaks his feet in hot water to decrease swelling. The nurse notes this in her record. She also notes that

this client has peripheral vascular disease and peripheral neuropathy.

Possible Outcome

The nurse does not connect the two related pieces of information. She recalls it as she is performing a dressing change on this client, who could not sense the temperature of the water on his feet and suffered second-degree burns when his water heater malfunctioned.

Prevention

Burns can occur readily in clients with poor circulation and are extremely difficult to heal. The client isn’t able to gauge the water temperature and should, therefore

either use the back of his hand or have someone else check the water temperature. If a household thermometer is available, have the client check the temperature with the thermometer.Make sure the client is not visually impaired and can read the thermometer correctly.

t VARIATIONS

Geriatric Variations:

• Elderly clients have thin skin and decreased sensation and can be burned easily.

• Teach elderly clients not to use the “high” setting on their heating pad. Use a more moderate setting, even if it takes a little longer to achieve the desired warmth.

Pediatric Variations:

• Children have increased sensitivity to heat.

• Age-appropriate activities can be provided to distract and entertain the child during the treatment.

• Go over types of feedback children will give to tell you how comfortable they are with the heat treatment. “Cold, warm, hot, red hot” or “green, yellow, red” are ways to receive feedback from children.

Home Care Variations:

• If pain continues and no relief is achieved from home heat treatment, further assessment of the cause of the pain should be performed. Make sure the client knows who to contact.

• Make sure cords and electrical outlets are in good condition when assessing home heat therapies

that use electric heating pads or other electric heat sources.

• Microwavable forms of heat are commonly available for home use. Make sure the client does not overheat items in the microwave. Liquid packets can explode and cause burns.

Long-Term Care Variations:

Reusable sources of heat will wear out when used periodically over time. Check and replace as needed.

> NURSING TIPS

• Do not use heat treatment more than 20–30 minutes.

• If a large area of the body is exposed to heat treatment, the client’s systemic temperature may be affected. Dizziness or hypotension may occur from vasodilatation.

• Assess client’s fluid status if large parts of the body are immersed in heat, and take vital signs before and after treatment.

Warm Soaks and Sitz Baths

OVERVIEW OF THE SKILL

The application of warm soaks encourages increased circulation and helps distribute the body’s healing elements to a specific area. In addition to encouraging healing, warm soaks also provide nonpharmacological pain relief and help to localize infection. Sitz baths are a method used to apply warm soaks to the perineum.

ASSESSMENT

1. Assess the client for conditions such as circulatory problems, decreased sensation, age, or diagnosis that may require alteration to the treatment plan.

2. Assess the ability of the client to participate in treatment. For example, ascertain whether a client will be able to maintain a position for 15–20 minutes to determine whether any alterations to the procedure are necessary.

3. Assess the area of injury for drainage, edema, or redness. The injured area should not have increasing edema at the time of heat application. Determines the appropriateness of the procedure.

4. Assess the availability of appropriate equipment and clean hot water to determine whether changes to the procedure will be necessary.

5. Warm soaks are used frequently in many people’s homes. Assess each client’s experience of using warm soaks before teaching to determine the type and amount of client teaching needed.

DIAGNOSIS

9.1.1 Pain Edema and/or Muscle Spasm

1.6.2.1.2.2 Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. Client will experience decrease in pain.

2. Affected area will heal.

Equipment Needed:

Sitz Bath: Portable

• Portable sitz bath (see Figure 3-6-2)

• Towels

• Peri-care equipment

CLIENT EDUCATION NEEDED:

1. Do not begin using warm soaks until the initial injury phase is over, usually the first 12–24 hoursfollowing the injury. Some injuries may require up to 72 hours to stabilize.Warm soaks will add to post-trauma swelling in the first hours after injury, which could lead to more damage.

2. If there is no thermometer to measure the water temperature, water should be as warm as can be comfortably tolerated. Also, the client may become used to the temperature quickly, creating the feeling that the soak is not hot enough.Warn the client that this does not signal the need to increase the temperature.

3. Soak about 15–20 minutes (or as directed by health care provider). After this much time, the vessels may “rebound” and constrict, creating a situation opposite of the desired effect.

4. Following the soak, elevate the affected area.

5. A sitz bath can be a time for a new mother to have a few minutes to herself. Ensure that the baby is cared for by others during this time. Encourage the mother to rest either flat or with hips elevated for 15–20 minutes (or longer if possible) after a sitz bath. This will help prevent unnecessary swelling or pressure. Sitz baths may

be taken two to four times per day. Also, women should be encouraged to use a peri-bottle with warm or cool water to cleanse the perineal area after each void or defecation for the first week after childbirth.

6. If the client is to perform warm soaks at home, encourage the client or the client’s caregiver to participate in setting up and carrying out the procedure as they are able.

7. Encourage clients to plan how this procedure will be carried out in their home.

8. Warm soaks are used frequently in many people’s homes. Assess each client’s experience of using warm soaks before teaching.

EVALUATION

1. Client experienced decrease in pain.

2. Affected area is healing as indicated by improved appearance of the injured area.

3. Client does not report a negative reaction to the procedure.

DOCUMENTATION

Follow the guidelines for documentation in your institution.

Nurses’Notes

• Record the date and time of each warm soak.

• Document any variation from expected, individual needs and preferences.

• Document improvement or decline in the client’s condition

NURSING TIPS

• Ensure that your client is comfortable and able to cooperate with the treatment.

• If it is appropriate to leave your clients during treatment, check on them periodically and ensure they have the call bell in reach.

• If a portable sitz bath is not available, disinfect the tub and wrap a towel in a horseshoe shape. The client sits on the round side of the horseshoe-shaped towel with the knees bent to keep the perineum off the tub floor. Do not use inflatable donuts for the sitz bath because these may prevent the warm water from giving the most benefit and cause undue pressure on the perineal area, preventing increased circulation. Fill the tub to about the top of the hip. This allows a regional vasodilation instead of a generalized increase in blood flow.

• A sitz bath can be a time for a new mother to have a few minutes to herself. Ensure that the baby is cared for by others during this time.

• Encourage the mother to rest either flat or with hips elevated for 15 to 20 minutes (or longer if possible) after a sitz bath. This will help prevent unnecessary swelling or pressure.

• Sitz baths may be taken two to four times per day.

• If the client is to perform warm soaks at home, encourage the client or the client’s caregiver to participate in setting up and carrying out the procedure.

• Encourage clients to plan how this procedure will be carried out in their home.

Applying Dry Heat

OVERVIEW OF THE SKILL

Dry heat can be used to enhance circulation, promote healing, reduce swelling and inflammation, reduce pain, reduce muscle spasms, and increase systemic temperature. Different types of equipment are used to apply dry heat to body surfaces, specific areas, and the entire body. These can be divided into the following

categories:

1. Body surfaces. Equipment used to apply heat to any body surface includes disposable instant hot packs, gel-filled hot packs, aquathermia pads, electric heating pads, and hot water bags or bottles. Aquathermia pads are waterflow rubber heating pads with tubing and a reservoir control unit, sometimes called aqua pads, k-pads, t-pump, or hydrocalculator. Hot water bags or bottles should be used only by clients at home because bags and bottles cannot be cleaned properly to meet universal standards.

2. Specific areas. Equipment used to apply heat to specific areas includes heat lamps or infrared lamps (generally for the abdomen, perineum, or the chest), heat cradles (generally for the lower extremities), and diathermy (generally for deep heat treatment, which utilizes electrical energy that is changed to heat).

3. Entire body. Equipment used to heat the entire body to treat cases such as hypothermia includes thermal blankets and infant radiant warmers, which are discussed in Skill 3-8. The principlesand precautions are similar in most types of heat application

ASSESSMENT

1. Assess the skin integrity in the area where heat is to be applied. If the client has preexisting skin breakdown, redness, or scar tissue, carefully evaluate before applying heat. Assess the level of pain or swelling in the area where heat is to be applied. Heat treatment cannot be used over areas of blisters, burns, or redness indicative of burning.

2. Assess the client’s tolerance of heat. If there is scar tissue or any decreased sensitivity in the area of treatment, the client will not be able to feel the sensation of burning. Assess the client’s ability to perceive and report pain and sensation of burning. If sedated, confused, or agitated, the client should not be left alone with heat treatment in place. Ensures client safety.

3. Assess the client’s vascular status. Dry heat should be used only with a physician’s or qualified practitioner’s orders and then cautiously in clients with diabetes or vascular disease. Because heat increases circulation, adequate vasculature must be present to be effective and not cause further tissue and vessel damage.

4. Assess the client’s preexisting illness. Heat should not be used over areas of malignancy.

5. Assess the skin for the presence of any lotion or ointments. Heat can be retained with the presence of these products and lead to increased risk of heat intolerance and burning.

DIAGNOSIS

1.4.1.1 Altered Tissue Perfusion

9.1.1 Pain

1.2.2.4 Ineffective Thermoregulation

1.6.1 Risk for Injury

PLANNING

Expected Outcomes:

1. The patient will derive the benefits of the heat treatment such as increased circulation and healing; decreased swelling, inflammation, pain, or muscle spasms; or thermoregulation.

2. The patient will not experience any injury to skin integrity.

Equipment Needed:

• Equipment determined by type of heat treatment: disposable gel-filled packs (see Figure 3-7-2), aquathermia pad, heating pad, hot water bottle (generally used only in home setting if at all), heat lamp or heat cradle, hot blankets (see Figure 3-7-3), or hot air patient warming system (see Figures 3-7-4 and 3-7-5)

• Protective cover to be used between heat source and patient

• Electrical source for pads

• Timer or clock

> CLIENT EDUCATION NEEDED:

1. Client understands the need to report any increase in pain or sensation of burning.

2. Client understands the purpose and desired outcome of the treatment.

3. Client understands that if heat source is over area of decreased sensitivity that this must be monitored closely.

4. Client understands that the temperature of the heating device should not be changed without the knowledge of the nurse or qualified practitioner.

5. Client understands that heat treatment must be discontinued if symptoms of heat intolerance are present.

6. Client understands that heat treatment should not be used beyond the recommended time, which is usually no longer than 20–30 minutes.

EVALUATION

• Evaluate the client’s response to the heat treatment such as was the level of pain or muscle spasms lessened, did the inflammation or swelling decrease, did the circulation increase, and so on. Also evaluate the client 15–20 minutes after heat treatment—redness is a natural response to heat and this redness should lessen after the heat is removed.

• Evaluate whether the client’s systemic temperature changed.

DOCUMENTATION

Nurses’Notes

• Document the time and date of the treatment.

• Document the procedure and the equipmentused.

• Record the client’s response to the procedure as determined in the evaluation.

• Document the length of time the heat treatment

was in place.

NURSING TIPS

• Check the client frequently to avoid adverse reactions; especially check in the first 5 minutes.

• Set time to avoid heat treatment beyond 30 minutes, especially if using electrical system.

• Tell the client to alert the nurse if there is increased pain or burning with the treatment

Using a Thermal Blanket and an Infant Radiant Heat Warmer

OVERVIEW OF THE SKILL

A thermal blanket is a fluid-filled blanket that can be used to heat or cool a client who is hypothermic or hyperthermic. For hyperthermia, the physician or qualified practitioner will order a cooling blanket. If a client is hypothermic, a warming blanket can be used to gradually raise the client’s core temperature to a normal range. Some thermal blankets have a rectal probe, which monitors the client’s core temperature and regulates the blanket temperature according to set parameters. Some types of warmers use warm air instead of warm water to increase the client’s core temperature. The Bair Hugger, a plastic convective warming blanket that inflates and uses circulating warm air to warm the client (see Figures 3-8-2 and 3-8-3).

Infants have specialized body-warming needs, and there are several types of appliances available to help infants maintain a healthy body temperature.

Isolette incubators keep infants warm by providing a heated pad for the infant to lie on. Overhead radiant warmers heat the infant with overhead lights (see Figure 3-8-4). These and other products can be used to help maintain optimal body temperature when the infant cannot selfregulate temperature.

ASSESSMENT

1. Assess the client’s temperature. Establishes a baseline measurement.

2. Assess the client’s skin condition and integrity. If skin integrity is disrupted, protection must be applied to that area. Applications of extreme cold to

already compromised vascular areas can cause injury. Heat or cold can injure areas of decreased sensitivity.

3. Assess client’s knowledge regarding treatment. Determines client teaching needed.

4. Assess the client’s mental status. Temperature extremes can cause confusion and agitation, and the client may not be able to cooperate with the treatment regime.

DIAGNOSIS

1.2.2.1 Risk for Altered Body Temperature

1.2.2.2 Hypothermia

1.2.2.3 Hyperthermia

1.6.2.1.2.2 Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. The client’s core temperature will be maintained within the desired range.

2. The client will not incur any skin or tissue damage as a result of the hypothermia/hyperthermia treatment.

3. The client will be as comfortable as possible during the treatment.

4. The client’s core temperature will not change rapidly enough to cause chilling or diaphoresis.

Equipment Needed:

• Warming/cooling blanket with machine and temperature probe (see Figures 3-8-5 and 3-8-6)

• Thermometer, if not provided with blanket, to do comparison checks

• Blanket or sheet to protect skin from direct contact with warming/cooling blanket if not provided with commercial setup

• Lubricating solution for rectal temperature probe

• If an infant warmer is to be used, radiant warmer with accompanying skin or rectal probe and bedding for warmer (see Figure 3-8-7)

CLIENT EDUCATION NEEDED:

1. Instruct clients to alert the nurse if they feel chilled or overheated.

2. Teach the purpose of the blanket.

3. Instruct clients to alert the nurse if the temperature probe comes out.

4. If an infant warmer is used, instruct the parents of the goal of the warmer and the need for the infant to remain in the isolette.

EVALUATION

• The client’s core temperature is stable within the desired range.

• The client did not incur any skin or tissue damage as a result of the hypothermia/hyperthermia treatment.

• The client was as comfortable as possible during the treatment.

• The client’s core temperature did not change rapidly enough to cause chilling or diaphoresis.

DOCUMENTATION

Nurses’Notes

• Document the procedure and results of the procedure.

• Document the client’s temperature every 15 minutes, vital signs every 30 minutes, and the settings on the hypothermia/hyperthermia machine.

• Document any adverse outcomes such as chilling or tissue injury, and document any follow-up actions, such as notification of the physician or qualified practitioner, administration of medication to prevent shivering, and so on.

Vital Signs Flow Sheet

• Note the client’s core temperature according to the rectal probe, the core temperature according to the independent thermometer, and the client’s other vital signs.

NURSING TIPS

• Assess the client every 15 minutes after the cooling blanket is put in place.

• Be sure to check the functioning of the temperature probe by cross-checking with other systems.

• Protect clients from tissue injury.

• Protect any open wound areas and areas of decreased perfusion.

• Clean the rectal probe every 4 hours.

Applying Cold Treatment

OVERVIEW OF THE SKILL

Cold therapy is used to decrease blood flow to an area by promoting vasoconstriction and increased blood viscosity. These changes facilitate clotting and control

bleeding. Cold decreases tissue metabolism, reduces oxygen consumption, and decreases inflammation and edema formation. Cold therapy has a local anesthetic

effect by raising the threshold of pain receptors. It causes a decrease in muscle tension. Cold is used to reduce fever.

Sources of cold include ice packs, ice bags, cold collars, or commercial cold packs. If the client’s systemic temperature is elevated, cooling blankets or cooling tepid sponge baths can be used. Moist cold compresses or immersion of a body part can be used for large areas of acute inflammation or swelling. Cooling the extremity decreases blood flow and may also decrease pain and suppress inflammation

ASSESSMENT

1. Ascertain the client’s sensation of hot and cold changes at the site where cold therapy is to be administered. Certain areas of the skin have sensitivity

to temperature variations, while other areas may not be as sensitive; the perineal areas are very sensitive.

2. Assess if decreased circulation is present at the site where cold therapy will be applied such as areas with wounds and damaged tissue present because cold application may cause further tissue damage.

3. Check the client’s systemic temperature. If larger areas are exposed to cold, the total body temperature may be decreased. If the client is cooled too

rapidly with extreme cold, a reverse chilling effect may occur, increasing body metabolism and defeating the cooling effect.

4. Assess age. Tolerance to cold varies with individuals and is related to age, thinner layers of skin, or general sensitivity to cold.

DIAGNOSIS

1.4.1.1 Altered Tissue Perfusion, related to inflammation or edema

1.2.2.1 Risk for Altered Body Temperature

1.6.1 Risk for Injury

1.6.2.1.2.2 Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. The client will experience decreased bleeding.

2. The client will have decreased inflammation and/or edema.

3. The client will experience decreased pain or discomfort.

Equipment Needed:

(Select equipment depending on the treatment chosen and supplies available.)

• Pan for cold soak

• Ice or ice bag

• Gauze or towel

• Water bottles or reusable containers if used for one client only

• Compresses (if moist cold) consisting of gauze dressing, iced or chilled solution, and a container of the appropriate size for the body part

• Commercially prepared ice pack (see Figure 3-9-2)

• Disposable ice pack

• Tape, elastic wrap, or bandage (see Figure 3-9-3)

CLIENT EDUCATION NEEDED:

1. Report any pain or lack of sensation (if cold is being used as local anesthetic then decreased sensation is expected).

2. Report chilling from overexposure since this would increase general metabolism. This can especially happen if the client has a large area of the body exposed to cold; therefore, it may be necessary to add increased covers to the rest of the body.

3. Teach the client the basics of cold application, why it is used, and how long the treatment will remain in place (20–30 minutes).Modify the therapy for home use, and teach the client how to apply the treatment at home, if applicable.

4. Teach clients the reason for cold therapy vs. hot therapy