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Slide 2		Epidermis-Outermost layer, avascular. It actually has five layers. Outermost layer is stratum corneum. This is the layer that is thin and sloughs off (desquamation) when we wash our hands, shower, scratch, etc. The corneal layer allows for perspiration and absorption of topical medications. The lucidum is the thicker layer just below the corneum. It is found on tough areas like the soles of the feet and palms of the hand. BMZ-separates the epidermis from the dermis Dermis-the thickest layer of skin-made up of collagen and elastin. The papillary dermis supplies proteins and oxygen to the epidermis. The reticular dermis is made up of thicker strands of collagen and has most of the blood vessels in the dermis. Collagen is the major structural protein. Collagen gives the skin its tensile strength. Elastin is a protein that allows for skin recoil. Another words, it allows it to go back into shape when disturbed. Otherwise, our skin would be moldable like clay. Hypodermis-also known as the superficial fascia. It is a layer of fat (like yellow material in chickens). Its most important function is to hold everything together. This is the temperature insulator.
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Slide 4		pp. 1572-1575
Slide 5		Primary intention-these are wounds without loss of vital tissue. These are usually surgical wounds who have good wound approximation (wound edges are close together and evenly distributed). These wounds are not as likely to get infected. Healing occurs quickly and drainage usually stops by the third day, it is usually epithelialized by day 4, inflammation is resolving by day 5 and healing usually occurs by 9-10 days. Inflammatory phase-starts almost immediately after wounding. This phase lasts about three days. As the wound begins to heal, it forms epithelial cells, forms clotting mechanisms to control bleeding. Histamine reaction causes swelling and redness. The body forms exudate and the wound swells. This is a good thing. It is our body’s way of protecting itself. Exudate is just dead neutrophils that promote healing. Macrophages eat the dead cells and bacteria and help in preventing a wound infection. The fibroblasts form. These are the cells that produce collagen and collagen helps form scar tissue. When too much inflammation occurs (like in patients with compromised immunity or diabetes), healing will be slowed. Proliferative phase (regeneration)-this phase is responsible for continuing the wound healing. It can take anywhere from a few days to a month. It fills in the gaps of tissue with connective or granulation tissue and closes the top of the wound with epithelial tissue. As healing progresses the tissue has better tensile strength and becomes less likely to rupture. Maturation (remodeling)-This is the final stage of healing-can take up to one year. Scar tissue usually contains less pigmentation than original tissue and that is what gives it its appearance. Scars are more noticeable in darker skinned individuals. Remember: it will never be exactly the same as the original tissue. Secondary intention: This occurs when tissue loss is present or extensive. The healing process take much longer. The wound usually drains significantly more exudate. These wounds form granulation tissue that is usually fragile. It is not as strong as collagen and has a better chance for re-injury or becoming a potentially chronic wound. When the connective tissue and epithelial tissue cannot close the wound, the wound actually starts contracting and creates a larger scar than primary intention. The edges are usually irregularly shaped and can be a chronic skin irritation problem. The skin does not have as much blood or nutrient supply and often will create chronic irritation to the individual.
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Slide 9		pp.1599-1611
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Slide 11		Hemorrhage-Although hemorrhaging is not extremely common-it can happen. If it happens, it is usually directly after injury before hemostasis occurs. Hemostasis usually occurs within a few minutes unless a client has a bleeding or clotting problem. Late onset hemorrhage occurs during the following problems: Slipped or broken sutures early after surgery, a dislodged clot, infection or erosion. Sometimes hemorrhage is not visible on the outside of the body. It may bleed inside. The client will exhibit signs of hypovolemic shock and may have an unusual amount of swelling at the injury site. Sometimes it is obvious because the bleeding will occur into the dressing (it will saturate the dressing with frank blood). Be careful to check behind the site for blood that may have drained underneath the client (example-thyroid surgery). Infection-Wound infections are the second most common nosocomial infections. According to the CDC, a wound is infected if it has purulent drainage, even if the culture shows a negative result. The reason CDC feels this way is because wound cultures are not always done correctly or the patient may already be on antibiotics. Adversely, positive cultures may not indicate infection due to poor culturing techniques. Some wounds that are colonized have a lot of resident bacteria. The distinction between a contaminated wound and an infected wound is the amount of bacteria present. Infection are more likely to occur if: there is a lot of dead or necrotic tissue, a foreign body is invading the wound or the blood supply is poor to the area. Traumatic wounds show signs of infection quickly, whereas a surgical wound may not shows signs of infection for up to a week. The signs and symptoms of a wound infection are: fever, pain, redness, tenderness and purulent drainage (yellow, green or brown and cloudy). Dehiscence-A partial or total separation of skin layers. Usually occurs 3-11 days after injury. It occurs when wounds fail to heal properly. It occurs before collagen has a chance to form. Pts. Who are obese, nutritionally compromised or immunosuppressed are most at risk. Nurses should watch for increased serosanguinous drainage without signs of infection as an early indicator of dehiscence. Evisceration-total separation of wound layers with protrusion of visceral organs through the wound opening. Dangerous!!!! Medical emergency!!!! The nurse must place a saline embedded sterile towel over area immediately to reduce the risk of bacteria invasion and organ drying. Blood supply can be severely compromised and cause gangrene to set in. The client will need to go to immediate surgery. The nurse should place the client on NPO status and prep for surgery. Fistulas-it is an abnormal passage between two organs or an organ and the outside of the body. Surgeons can create fistulas on purpose (such as inserting a a feeding tube). However, most fistulas are due to poor healing or diseases that prevent healing (Crohn’s Disease clients are at risk for fistulas). The complications are: infection, electrolyte imbalance, skin or organ erosion and fluid loss. Delayed wound closure-this is sometimes referred to third-intention wound healing. Often physicians will intentionally not close a wound that is in need of drainage. It allows for effective drainage and when swelling decreases and fluid loss decreases, the wound will be surgically closed via first intention.
Slide 12		Pressure ulcers are the current term for impaired skin integrity. Previous terms were bed sores or decubitus ulcers. The NPUAP (National Pressure Ulcer Advisory Panel) and the pressure ulcer guidelines panel of the AHCPR (Agency for Health Care Policy and Research) set the overall guidelines for pressure ulcer education, terms, treatment and prevention. Pressure ulcers occur as a result of time-pressure relationships.
Slide 13		The skin has less tensile strength and the layers become weaker and more susceptible to injury as we age. The skin also loses elasticity and the ability to hold temperature as we age Decreased mobility causes us to stay in one place longer, thus increasing risk of pressure ulcers Impaired neurological impairment-immobility and failure to self-protect Decreased sensory-unable to feel when injury occurs Decreased circulation-lack of oxygen and blood to area increases risk of injury Devices-some devices can burrow into skin if not properly padded or applied
Slide 14		Shearing force can cause severe and lasting effects. It can cause deep tissue damage. Keeping the bed elevated 30 degrees can be helpful in preventing shearing Moisture-urine, stool and body fluids are caustic to skin; but perspiration can also cause problems Nutrition-the body needs proteins, iron and trace minerals in order to heal. Serum Albumin is used as an indicator of current nutritional status. Anything below a 3g/100 places the patient at risk for pressure ulcer development. Total protein levels are also looked at. Levels below 5.4 g/100 is considered at risk. Review Pages 1564 and 1565-Tables 47-6 and 47-7.
Slide 15		Tissue Ischemia-absence of blood flow or a major reduction in blood flow. This, in turn causes blanching. Blanching-This is seen as the absence of red and pink tones in the skin (for light/fair skin patients). Dark pigmentation does not show blanching. See Box 47-2 for dark skinned pts. (it has other ways to identify this change). When the pressure exerted is high enough, the capillaries close and blood and oxygen are closed off. In light tones pts., they can undergo one of two hyperemic changes: a. Normal Reactive Hyperemia-the area turns red, it blanches with finger touch. It returns to normal within one hour after the insult is removed. Abnormal Reactive Hyperemia-area turns red, blanching occurs, excessive vasodilation, local edema occurs and you have induration. This can last for more than one hour up to several weeks after the removal of the insult. REMEMBER: the longer the pressure is exerted on bony prominences, the greater the risk for skin breakdown.
Slide 16		NPUAP Staging System (National Pressure Ulcer Advisory Panel) is seen below. There is another system known as the AHCPR (Agency for Healthcare Policy and Research) guidelines; but NPUAP is most widely used. Stage I-Non blanchable erythema: it is an observable pressure-related alteration in intact skin, whose indicators, as compared with an adjacent or opposite area of the body has changes> These changes can be: Temperature (hot or cold), Tissue consistency (very firm or beefy feeling), Change in sensation (Pain, itching). When you relieve the pressure, the problem is reversable. REMEMBER: In light skinned patients, it may be red-in darker skinned patients, it could be blue, red or slightly darker than the rest of their skin. Stage II-Partial thickness skin loss involving the epidermis and/or dermis. It is superficial and usually presents 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, the underlying fascia. It usually presents as a deeper crater and may or may not have undermining (undermining is where you will find a ridge extending under the wound edges. Stage IV-Full-thickness skin loss with extensive tissue destruction, tissue necrosis (dead tissue) or damage to bone, muscle or adjacent structures (tendons, ligaments, joint capsules) Wound classifications by color A) Black wound-this is a wound that has black necrotic eschar. A wound that is covered by eschar cannot be staged!!!!! These wounds have to be debrided in order to allow for healing. They will not heal without debridement! It is the wound color type that causes the most concern. B) Yellow wound-this is between the black and the red wound. It usually drains a lot of exudate. These wounds also need to be debrided to expose a red wound. This will allow for healing. C) Red wound-although these wounds look painful, they are more healthy than the black or yellow wound. When edges are debrided, the wounds heal better. D)Mixed –color wounds. These may have several color. The goal is to debride the wound to expose healthy red tissue. When wounds have undermining (a shelf underneath the wound edge) or tunneling (an actual tunnel under the skin), they must be filled. You can fill the tunnels and undermining with imbedded gauze products, calcium alginates (a form of seaweed that swells when it comes in contact with moisture, fiber fillings or various other products currently on the market. For really large wounds with deep craters there is a new system can the VAC. It has a large impregnated sponge that fills the crater and then is vacuumed to the wound to draw out the moisture and exudate and promote healing (very cool!). For general wound classifications, have the students view pages 1552-3. This table is a very thorough breakdown of the classifications.
Slide 17		Pg. 1588
Slide 18		Norton Scale-It scores five areas of risk: physical condition, mental condition, activity, mobility and incontinence. The total score ranges from 5-20. The lower the score, the higher the risk. Second mostly widely used scale. Gosnell-this is actually based on Norton’s Scale. Nutrition replaced the physical condition factor and incontinence was renamed continence. The total score ranges from 5-20. The higher the score, the higher the risk (opposite of Norton). Braden Scale-most used-based first on risk factors in nursing home. It has six categories: sensory perception, moisture, activity, mobility, nutrition, friction and shear. Scoring is from 6-23. The lower the score, the higher the risk-just like Norton.
Slide 19		Prevalence-number of cases present in a population at one point in time Incidence-new cases in a specified population over a defined period of time
Slide 20		Enterostomal Therapy Nurses will review the steps to take in assessing a patient’s risk for Pressure Ulcer Development on October 16^th. They will also talk about wound appearance, the character of wound drainage, drains, wound closures, palpation of the wound, wound cultures and how to conduct properly. They will discuss the variety of dressing types and treatment currently out there. They will discuss support surfaces and the PSST Tool.
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