Skin Integrity,Etc
Name implications for older adults for skin integrity:
- Decreased Barrier Function
-Decreased Epidermal turnover
-Decreased Subcutaneous tissue
-Decreased Subcutaneous padding
-Adhesive dressing removal
Stage I :
-Intact skin with nonblanchable redness
Partial-thickness wounds:
shallow in depth, moist, and painful, and the wound base generally appears red
Full-thickness wound REPAIR:
Hydrocolloid dressing
Hydrocolloid dressings are dressings with complex formulations of colloids and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment
Risk factors for pressure ulcer development
-Impaired sensory perception
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
Stage II:
Partial-thickness skin loss involving epidermis, dermis, or both.
extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location
complications of wound healing
hemorrhage, hematoma, infection, dehiscence, evisceration
Wound management:
-debridement
-protection
-education
-nutritional status
Dehiscence
is the partial or total separation of wound layers. A patient who is at risk for poor wound healing (e.g., poor nutritional status, infection, or underlying diseases such as diabetes mellitus or peripheral vascular disease
Stage III:
Full thickness tissue loss with visible fat
Primary Intention:
The skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly, with minimal scar formation.
*Wound that is closed*
-Nutrition
-Tissue Perfusion
-Infection
-Age
-Psychosocial impact of wounds
Types of dressings:
1. Gauze:
2.Transparent Film
3.Hydrocolloid
4.Hydrogel
5.Foam
6.Composite
Evisceration
With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) occurs. The condition is an emergency that requires surgical repair.
Stage IV:
Full-thickness tissue loss with exposed bone, muscle, or tendon
Secondary Intention:
The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention; therefore the chance of infection is greater. If scarring from secondary intention is severe, loss of tissue function is often permanent (see Fig. 48.7B).
*Wound edges not closed or approximated*
Assessment for pressure ulcers:
-Predictive measures
-Mobility
-Nutritional Status
-Body fluids
-Pain
Hydrogel dressings
Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. This type of dressing hydrates wounds and absorbs small amounts of exudate. Hydrogel dressings are indicated for use in partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin.
Foam dressings
Protective and prevents wound dehydration; also absorbs moderate to large amounts of drainage.
Safety guidelines for nursing skills:
When changing a dressing, follow proper aseptic technique:
-Keep a plastic bag within reach to discard dressings and prevent cross-contamination.
-Keep extra gloves within reach to allow a change of gloves if the gloves become soiled.
-If irrigating a wound, use appropriate PPE
-When applying an elastic bandage, check the extremity for temperature or sensation changes
Partial-thickness wound REPAIR:
inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
Wound assessment:
-Wound appearance
-character of wound drainage
-drains
-wound closures
-wound cultures
Gauze dressing
Gauze—Apply as moist dressing, a dry cover dressing when using enzymes or topical antibiotics, or a means to deliver solution to wound.
-Gauze delivers moisture to wound and is absorptive.