Maintaining Skin Integrity & Wound Care

Structure of SkinStructure of Skin

• Skin LayersSkin Layers– Epidermis– Dermis – Subcutaneous Tissue- Fat and

connective tissues

• Skin appendagesSkin appendages – nails, hair, sweat gland and sebaceous glands

Structure of SkinStructure of Skin

• Skin LayersSkin Layers– Epidermis– Dermis – Subcutaneous Tissue- Fat and connective tissues

Structure of SkinStructure of Skin• Skin LayersSkin Layers

– EpidermisEpidermis

Epidermis

Structure of SkinStructure of Skin• Skin LayersSkin Layers

– DermisDermis is the thickest skin layer composed of connective tissue.

– Supports and nourishes the epidermis.

Dermis

Layers of the DermisLayers of the Dermis

Stratum corneum Stratum corneum (SC) - dead and (SC) - dead and dying cells push dying cells push their way to the their way to the

skin surface skin surface (desquamation)(desquamation)

Layers of the DermisLayers of the Dermis

Stratum Stratum granulosa granulosa (SGR) – (SGR) –

keratinocytes keratinocytes lipidslipids

Layers of the DermisLayers of the Dermis

Stratum spinonum Stratum spinonum (SS) – separates (SS) – separates

stratum stratum germination and germination and

stratum granulosastratum granulosa

Layers of the DermisLayers of the Dermis

Stratum Stratum germinatongerminaton (SG) (SG)

Structure of SkinStructure of Skin• Skin LayersSkin Layers

– Subcutaneous TissueSubcutaneous Tissue• Fat and connective tissues

Subcutaneous Subcutaneous Tissue Tissue

(hypodermis(hypodermis))

Structure of Skin• Skin appendagesSkin appendages – nails, hair, sweat gland

and sebaceous glands

FUNCTION OF THE SKINFUNCTION OF THE SKIN

• ProtectionProtection - from physical and chemical injury.

• ThermoregulationThermoregulation - Regulate body temperature. • SensationSensation - skin contains nerves that are sensitive to

pain, itch, vibration, heat/cold.

• MetabolismMetabolism - ultraviolet rays from sun synthesizes Vitamin D.

• CommunicationCommunication - communicates through expressions and other non-verbal messages.

CHARACTERISTICS OF THE SKINCHARACTERISTICS OF THE SKIN• ColorColor

– Vary in races.– The greater accumulation of melanin, the

darker the skin tone.

Factors affecting skin integrity

1. Genetics / heredity• Skin color, sensitivity to sunlight, allergies

2. Age • Young & old skin are fragile• Healing is rapid in infant & children

3. Health• Illnesses & their treatment affects skin integrity• Cortecosteroids cause thinning of the skin causing

harm.

• Antibiotics, chemotherapy drugs for cancer & psychotherapeutic drugs affects skin integrity

• Poor nutrition

4. Activity

CHARACTERISTICS OF THE SKIN (cont.)CHARACTERISTICS OF THE SKIN (cont.)

• TemperatureTemperature - usually warm.

• MoistureMoisture - normally dry, but moisture can accumulate in skin folds.

• Texture and ThicknessTexture and Thickness - smooth with good elasticity.

• OdorOdor - Usually free from odor.

LIFESPAN CONSIDERATIONSLIFESPAN CONSIDERATIONS• Newborn and InfantNewborn and Infant

– Thinner and mores sensitive– Susceptible to blistering, chafing and

rashes from irritation– Can develop “heat”

LIFESPAN CONSIDERATIONSLIFESPAN CONSIDERATIONS

• Toddler and Preschooler- – More prone to accidents and burns– Use sunscreen

LIFESPAN CONSIDERATIONSLIFESPAN CONSIDERATIONS

• School-Age and Adolescent– Many childhood diseases– Adolescents develop pubic, axillary and other

body hair. • May develop acne.

LIFESPAN CONSIDERATIONSLIFESPAN CONSIDERATIONS

• Adults and Older adultsAdults and Older adults– Becomes thinner and

less elastic and develops wrinkles.

– May have benign growths.

– Moles get larger.– Skin tags.

FACTORS AFFECTING INTEGUMENTARY FACTORS AFFECTING INTEGUMENTARY FUNCTIONFUNCTION

• CirculationCirculation – skin needs good blood flow.

– Heart must be able to pump adequately.

– Volume of blood must be sufficient.

– Arteries and veins must be patent.

– Capillary pressure must be adequate.

• Circulation problems lead toCirculation problems lead to– Leg UlcerationLeg Ulceration -

• Circulation problems lead toCirculation problems lead to– Pressure Ulcers (decubitusPressure Ulcers (decubitus)) - result

when blood flow to skin is impeded usually by pressure• Increased pressure• Mental Status• Moisture• Nutrition and Metabolism

• NutritionNutrition –well balance diet

• Lifestyle and Habits - hygiene

• Condition of the EpidermisCondition of the Epidermis – free from breaks

FACTORS AFFECTING FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.)INTEGUMENTARY FUNCTION (cont.)

• AllergyAllergy• InfectionsInfections• Abnormal Growth RateAbnormal Growth Rate

FACTORS AFFECTING FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.)INTEGUMENTARY FUNCTION (cont.)

• Systemic DiseasesSystemic Diseases

• TraumaTrauma - accidental or surgical wounds

• Excessive ExposureExcessive Exposure

FACTORS AFFECTING FACTORS AFFECTING INTEGUMENTARY FUNCTION INTEGUMENTARY FUNCTION

(cont.)(cont.)

MANIFESTATIONS OF ALTERED MANIFESTATIONS OF ALTERED INTEGUMENTARY FUNCTIONINTEGUMENTARY FUNCTION

• PainPain - stimulation of nerves in the skin due to alteration of the skin.– Highly sensitive, sharp, intense pain.

• PruritisPruritis - itching is usually allergy or inflammatory.

MANIFESTATIONS OF ALTERED MANIFESTATIONS OF ALTERED INTEGUMENTARY FUNCTIONINTEGUMENTARY FUNCTION

• RashRash - caused by excessive heat, allergy , communicable disease or stress.

• LesionsLesions - involves loss of structure or function of normal tissue.

– Vary is size.

TYPES OF WOUNDSTYPES OF WOUNDS

• Broad CategoriesBroad Categories– Accidental -

unintentional Injury

– Surgical - planned therapy

• Skin IntegritySkin Integrity– Open - break in

Skin– Closed - no break

but soft tissue injury

• DescriptionDescription– Abrasion - friction of the

skin– Puncture - penetrating

wound– Laceration - ragged tear– Contusion - closed with

bleeding into underlying tissues

Types of wound

1. Intentional trauma – occurs during therapy. E.g. operations or venipunctures

2. Unintentional wounds – are accidentale.g. fracture in the arm

DEGREE OF WOUND CONTAMINATIONDEGREE OF WOUND CONTAMINATION

• CleanClean

– Closed surgical wound that did not enter GI, respiratory, or GU systems

DEGREE OF WOUND CONTAMINATIONDEGREE OF WOUND CONTAMINATION

• Clean ContaminatedClean Contaminated

– Wound entering GI, respiratory or GU systems.

DEGREE OF WOUND CONTAMINATIONDEGREE OF WOUND CONTAMINATION

• Contaminated

– Open, traumatic wound, surgical wound with break in asepsis.

DEGREE OF WOUND CONTAMINATIONDEGREE OF WOUND CONTAMINATION

• InfectedInfected

– Wound site with pathogens present.

Classifying wound by DEPTH

• Partial thickness- confined to the skin, dermis, epidermis, & heal by regeneration

• Full thickness- involving the dermis, epidermis, subcutaneous tissue & possibly muscle and bone; require connective tissue repair.

WOUND HEALINGWOUND HEALING

• Wounded skin is repaired by regeneration or damaged tissues with connective repair.

• Partial and full thickness wounds are healed by 4 phases.

WOUND HEALINGWOUND HEALING

PHASE 1 – Inflammatory phase PHASE 1 – Inflammatory phase

Lasts 3-5 days.

Two major Processes: hemostasis and phagocytosis

• Hemostasis= which is the cessation of bleeding

= results from vasoconstriction of the larger blood vessels in the affected area.

= deposition of fibrin and the formation of blood clots in the area.

• Blood clots form from blood platelets.

Provide a matrix of fibrin that becomes the framework for cell repair.

Scab form on the surface of the wound

• In phagocytosis there is attraction of leukocytes to the wound bed and engulfing of microorganisms and cellular debris by macrophages

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Inflammation-3

Introduction:

“Inflame” – to set fire.Inflammation is “dynamic response of vascularised tissue to injury.”Is a protective response.Serves to bring defense & healing mechanisms to the site of injury.

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Inflammation-14Mechanism of Inflammation:

The functions of the inflammatory response include:

1) The delivery of effector molecules and cells to the sites of infection. 2) The formation of a physical barrier to the spread of the tissue damage or infection. 3) Wound healing and tissue repair

WOUND HEALINGWOUND HEALING

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Inflammation-13

Inflammation - Mechanism

1. Vasoconstriction2. Vasodilatation3. Exudation - Edema4. Emigration of cells5. Chemotaxis

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Inflammation-19

Chemical Mediators:Chemical substances synthesised or released which mediate the changes in inflammation.Histamine by mast cells - vasodilatation.Prostaglandins – Cause pain & fever.Bradykinin - Causes pain.

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Inflammation-22

Inflammation Outcome

Acute Inflammation

Resolution

Chronic Inflammation

Abscess

SinusFistula

Fibrosis/Scar

Ulcer

Injury

FungusVirusCancersT.B. etc.

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Inflammation-33

Acute Vs ChronicFlush, Flare & WealAcute inflammatory cells - NeutrophilsVascular damageMore exudationLittle or no fibrosis

Little signs -Fibrosis, Chronic inflammatory cells – LymphocytesNeo-vascularisationNo/less exudationProminent fibrosis

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Inflammation-12

Heat Redness Swelling Pain Loss Of Func.

The 5 Cardinal Signs of

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Inflammation-11

Cardinal Signs of Inflammation

RuborRubor : : Redness – Hyperaemia.CalorCalor : : Warm – Hyperaemia.DolorDolor :: Pain – Nerve, Chemical med.TumorTumor:: Swelling – ExudationLossLoss ofof FunctionFunction: :

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Inflammation-5

Red, Warm & Swollen(Flare, Flush & Weal – Lewis)

Triple response

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Inflammation-4Lewis Triple Response:

FlushFlush:: capillary dilatation.FlareFlare:: arteriolar dilatation.WealWeal:: exudation, edema.

Proliferative Phase of Wound Healing

• From post injury day 3 or 4 until day 21post injury

• Collagen synthesisCollagen whitish protein substance that

adds tensile strength to the wound.• Granulation tissue formation• Eschar dried plasma protein & dead

cells

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Inflammation-37

Granulation tissue

Maturation Phase of Wound Healing (remodeling)

• From day 21 until 1 or 2 years post injury

• Collagen organization• Remodeling or contraction• Scar stronger

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Inflammation-38

Healing Skin wound

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Inflammation-39

Healing - Skin Scar

TYPES OF WOUND HEALINGTYPES OF WOUND HEALING

• Primary intention

• Secondary intention

• Tertiary intention

TYPES OF WOUND HEALING (cont.)TYPES OF WOUND HEALING (cont.)

• Primary intentionPrimary intention

– Edges of wound approximated.

– Granulation is not visible and scarring is minimal.

Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. It is also called primary union or first intention healing.

e.g. closed surgical incision

Primary intention healing is healing of a wound where the wound edges heal directly touching each other.

TYPES OF WOUND HEALING (cont.)TYPES OF WOUND HEALING (cont.)

• Secondary intentionSecondary intention

– Extensive tissue loss.– Wound gradually fills with soft tissue

buds. – Epithelial cells grow over this to form skin.

It is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated. e.g., pressure ulcer.

Secondary intention healing differs from primary

intention healing in three ways:-1- The repair time is longer 2- Scarring is greater 3- Susceptibility to infection is greater

TYPES OF WOUND HEALING (cont.)TYPES OF WOUND HEALING (cont.)

• Tertiary intentionTertiary intention – Delay ensues between injury and

approximation– Also known as delayed primary intention

Hand abrasion

Approximate days since injury

0 2 17 30

Exudate

• Material such as fluid and cells that have escaped from blood vessels during inflammatory process

• Deposited in tissue or on tissue surface

• 3 major types– Serous– Purulent– Sanguineous (hemorrhagic)

Serous Exudate

• Mostly serum• Watery, clear of cells• E.g., fluid in a blister

Purulent Exudate

• Thicker• Presence of pus• Color varies with organisms

Sanguineous Exudate

• Hemorrhagic• Large number of RBCs• Indicates severe damage to capillaries

Mixed Exudate

• Serosanguineous– Clear and blood-tinged drainage

• Purosanguineous– Pus and blood

FACTORS AFFECTING HEALINGFACTORS AFFECTING HEALING

• Systemic FactorsSystemic Factors– NutritionNutrition -

nutritional deficiencies retard healing.

Circulation and Oxygenation -

Hemoglobin levels– Immune Immune

Cellular Cellular Function Function ImmunosuppresImmunosuppressive Drugssive Drugs

• Individual FactorsIndividual Factors– Age, Obesity,

Smoking, Medications, and Stress

• Local FactorsLocal Factors– Nature of the Injury– Presence of Infection– Local Wound

Environment

COMPLICATIONS OF WOUND HEALINGCOMPLICATIONS OF WOUND HEALING

• Hemorrhage and Interstitial Hemorrhage and Interstitial Fluid LossFluid Loss

• HematomasHematomas - localized collection of blood.

• InfectionInfection– Local and SystemicLocal and Systemic

• Indicated by yellow/black coloration of wound itself.

• Other S&S.

• DehiscenceDehiscence - total or partial disruption in wound edges.

• EviscerationEvisceration - protrusion of viscera through abdominal wound opening.

• FistulaFistula - Abnormal passageway that forms between two organs.

DEHISCENCE & EVISCERATIONDEHISCENCE & EVISCERATION

• Dehiscence: edges of wound fail to join may lead to.

• Evisceration: portion of the viscera (usually bowel loop) protrudes thru incision.

• May lead to peritonitis & septic shock.

• Most likely during 6-7 days post-op.

IMPLEMENTATION IMPLEMENTATION for Dehisence or Eviscerationfor Dehisence or Evisceration

• Provide reassurance & support.• Use sterile towel/dressing saturated with NS &

place them over viscera.• Take V.S.• Tell client to stay in bed.• Have someone stay with client.

• Place waterproof sterile drape over area.• Call physician ASAP.• Moisten every hr with NS.

PREVENTION PREVENTION for Dehisence or Eviscerationfor Dehisence or Evisceration

• Client with poor healing should be given adequate supply of protein, vitamins, & calories.

• Monitor dietary deficiencies.• Assess wound during dressing change,

treat infection early, use strict sterile technique.

• Do not bandage wound to tightly.

Nursing Process: Assessment

• Nursing history– Review of systems– Skin diseases– Previous bruising– General skin condition– Skin lesions– Usual healing of sores

Assessment Data

• Inspection and palpation– Skin color distribution– Skin turgor– Presence of edema– Characteristics of any skin lesions– Particular attention paid to areas that are

most likely to break down

Assessment Data

• Untreated wounds– Location– Extent of tissue damage– Wound length, width, and depth– Bleeding– Foreign bodies– Associated injuries– Last tetanus toxoid injection

Assessment Data

• Treated wounds– Appearance– Size– Drainage– Presence of swelling– Pain– Status of drains or tubes

Risk Factors for Pressure Ulcers

• Advanced age• Chronic mental conditions• Poor lifting and transferring

techniques• Incorrect positioning• Hard support surfaces• Incorrect application of pressure-

relieving devices

Assessment of Pressure Ulcers

• Location of the ulcer related to a bony prominence• Size of ulcer in centimeters including length (head to

toe), width (side to side), and depth• Presence of undermining or sinus tracts• Stage of the ulcer• Color of the wound bed • Location of necrosis or eschar• Condition of the wound margins• Integrity of surrounding skin• Clinical signs of infection

Assessment of Pressure Sites

• Inspect pressure areas for discoloration and capillary refill or blanche response

• Inspect pressure areas for abrasions and excoriations

• Palpate the surface temperature over the pressure area sites

• Palpate bony prominences and dependent body areas for the presence of edema

Assessment of Laboratory Data

• Leukocyte count• Hemoglobin level• Blood coagulation studies• Serum protein analysis

– Albumin level• Results of wound culture and

sensitivities

Nursing Diagnoses

– Risk for Impaired Skin Integrity– Impaired Skin Integrity: – Impaired Tissue Integrity – Risk for Infection– Pain

Goals in Planning Client Care

• Risk for Impaired Skin Integrity– Maintain skin integrity– Avoid or reduce risk factors

• Impaired Skin Integrity– Progressive wound healing– Regain intact skin

• Client and family education– Assess and treat existing wound– Prevention of pressure ulcers

Measures to Prevent Pressure Ulcers

• Providing nutrition• Maintaining skin hygiene• Avoiding skin trauma• Providing supportive devices

Providing Nutrition

• Fluid intake• Protein, vitamins, zinc• Dietary consult• Weight/lab data monitoring

Maintaining Skin Hygiene

• Mild cleansing agents• Avoid hot water• Moisturizing lotions/skin protection• Reduce irritants

Avoiding Skin Trauma

• Smooth, firm surfaces• Semi-Fowler’s position• Frequent weight shifts• Exercise and ambulation• Lifting devices• Reposition q 2 hours• Turning schedule

Risk Assessment Tools

• Braden Scale for Predicting Pressure Sore Risk

• Norton’s Pressure Area Risk Assessment Form Scale

Nursing Assessment: Braden Scale Risk to Develop Pressure Ulcers (Braden, B. 1988)

• Sensory Perception: 1-4 Score ____– Completely limited to No Impairment

• Mobility: 1-4 Score_____– Completely Immobile to No Impairment

• Nutrition: 1-4 Score _____– Very poor to Excellent

• Activity: 1-4 Score_____– Bedfast to Walks frequently

• Friction/Shear :1-4 Score _____– Problem, potential or none– Total Score: determines Risk Above 16=Minimal risk– 15-16=Low Risk; 13-14=Moderate Risk; 12 or below=High

Risk

Figure 36-3 Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Four Stages of Pressure Ulcer Formation

A B

C D

STAGES OF PRESSURE ULCERS (STAGES OF PRESSURE ULCERS (DECUBITUS)DECUBITUS)

•Non blanching erythemaNon blanching erythema

STAGES OF PRESSURE ULCERS (DECUBITUS)STAGES OF PRESSURE ULCERS (DECUBITUS)•Partial-thickness skin loss.Partial-thickness skin loss.

•Involving the epidermis and Involving the epidermis and possibly the dermis.possibly the dermis.

•Examples: Abrasion, blister, or Examples: Abrasion, blister, or shallow crater.shallow crater.

STAGES OF PRESSURE ULCERS (DECUBITUSSTAGES OF PRESSURE ULCERS (DECUBITUS))•Full-thickness skin lossFull-thickness skin loss

•Involving damage or necrosis of Involving damage or necrosis of SQ tissue that may extend down SQ tissue that may extend down to, but not through, underlying to, but not through, underlying fascia.fascia.

•A deep crater.A deep crater.

STAGES OF PRESSURE ULCERS (DECUBITUSSTAGES OF PRESSURE ULCERS (DECUBITUS))•Full-thickness skin loss with Full-thickness skin loss with tissue necrosis or damage.tissue necrosis or damage.

•Involves damage to muscle, bone Involves damage to muscle, bone or supporting structures, such as a or supporting structures, such as a tendon or joint capsule.tendon or joint capsule.

•Sinus tracts may be present.Sinus tracts may be present.

Providing Supportive Devices

• Mattresses• Beds• Wedges, pillows• Miscellaneous devices

Treating Pressure Ulcers

• Minimize direct pressure• Schedule and record position changes• Provide devices to reduce pressure areas• Clean and dress the ulcer using surgical

asepsis• Never use alcohol or hydrogen peroxide• Obtain C&S, if infected• Teach the client• Provide ROM exercise

RYB Color Guide for Wound Care

• Red (protect)• Yellow (cleanse)• Black (debride)

• Red: protect by gentle cleansing, cover with protective barrier such as duoderm, hydrogel, or transparent film.

• Yellow: cleanse to remove nonviable tissue by applying moist to moist normal saline dressings, irrigating the wound, alginate dressings and topical antimicrobial

• Black: debridement can be done by sharp, mechanical, chemical, or autolytic, maggots. Debridement is mostly done by PT

Debridement may be achieved in four different ways:

1. Sharp debridement, a scalpel or scissors is used to separate and remove dead tissue.

2. Mechanical debridement through scrubbing force or mist to moist dressings.

3. Chemical debridement collagenase enzyme agents such as papain – urea.

4. A utolytic debridement , dressing that contain wound moisture, such as hydrocolloid and clear absorbent dressings.

Promoting Wound Healing

• Fluid intake• Protein, vitamin, and zinc intake• Dietary consult• Nutritional supplements• Monitor weight/lab values

Maintaining Skin HygieneMaintaining Skin Hygiene

• Use mild cleansing agents that do not disrupt the skin’s “natural barriers,”_

• avoid using hot water, exposure to cold and low humidity;

• apply moisturizing lotions while the skin is moist after bathing;

• keep skin clean, dry and free of irritation and maceration by urine, feces, sweat, and dry skin completely after a bath. Apply skin protection (dimethicone-based creams or alcohol-free barrier films) if indicated._Avoid massaging over bony prominences since massage may lead to deep tissue trauma.

Types of Wound DressingsTypes of Wound Dressings

• Transparent film• Impregnated nonadherent• Hydrocolloids• Clear absorbent acrylic• Hydrogel• Polyurethane foam• Alginate

Transparent filmTransparent film

• is used to provide protection against contamination and friction, to maintain a clean moist surface that facilitates cellular migration, to provide insulation by preventing fluid evaporation, and to facilitate wound assessment.

Impregnated nonadherent dressingsImpregnated nonadherent dressings

• are used to cover, soothe, and protect partial- and full-thickness wounds without exudate.

Hydrocolloid dressingsHydrocolloid dressings

• are used to absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; to protect the wound from bacterial contamination, foreign debris, and urine or feces; and to prevent shearing.

Clear absorbent acrylic dressingsClear absorbent acrylic dressings

• maintain a transparent membrane for easy wound bed assessment, provide bacterial and shearing protection, maintain moist wound healing, and can be used with alginates to provide packing to deeper wound beds.

HydrogelsHydrogels

• are used to liquefy necrotic tissue or slough, rehydrate the wound bed, and fill in dead space.

Polyurethane foamsPolyurethane foams

• absorb up to heavy amounts of exudate, providing and maintaining moist wound healing.

Alginates (exudate absorbers)Alginates (exudate absorbers)

• are used to provide a moist wound surface by interacting with exudate to form a gelatinous mass, to absorb exudate, to eliminate dead space or pack wounds, and to support debridement.

Types of BandagesTypes of Bandages

• Gauze– Retain dressings on wounds– Bandage hands and feet

• Elasticized– Provide pressure to an area– Improve venous circulation in legs

• Binders– Support large areas of body

• Triangular arm sling; straight abdominal binder

Figure 36-10Figure 36-10 The strips of tape should be placed at the ends of the The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The dressing and must be sufficiently long and wide to secure the dressing. The

tape should adhere to intact skin.tape should adhere to intact skin.

Figure 36-11Figure 36-11 Dressings over moving parts must remain secure in spite of Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the the client’s movement. Place the tape over a joint at a right angle to the

direction the joint movesdirection the joint moves..

Figure 36-11 (continued)Figure 36-11 (continued) Dressings over moving parts must remain secure Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle in spite of the client’s movement. Place the tape over a joint at a right angle

to the direction the joint moves.to the direction the joint moves.

Figure 36-11 (continued)Figure 36-11 (continued) Dressings over moving parts must remain secure Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle in spite of the client’s movement. Place the tape over a joint at a right angle

to the direction the joint moves.to the direction the joint moves.

Figure 36-12Figure 36-12 Montgomery straps, or tie tapes, are used to secure large Montgomery straps, or tie tapes, are used to secure large dressings that require frequent changing.dressings that require frequent changing.

Figure 36-13Figure 36-13 Vacuum-assisted closure (VAC) system for wounds. Vacuum-assisted closure (VAC) system for wounds.

Cleaning woundsWound cleaning involves the removal of

debris ( i.e., foreign materials, necrotic tissue,

bacteria).- Wound irrigation and packing

Supporting and immobilizing wounds

Bandages: strip of cloth used to wrap some part of the bodyBinders : is a type of bandage designed for a specific body part.Bandages and binders serve various purposes:• Support a wound• Immobilizing a wound• Applying pressure• Securing a dressing• Retaining warmth

Administer Heat and Cold Therapy

• Heat and cold therapies require nursing care that assesses both the vasoconstriction and vasodilation of an individual.

Local effect of heat

• Sedative effect to relief pain and aches• Vasodilatation and increase blood flow to the

affected area• Bringing oxygen and nutrients, antibodies, and

leukocytes• Promote soft tissue healing• It is often used for clients with

musculoskeletal problems such as arthritis.

Disadvantages:• Increase capillary permeability which cause edema

Local effect of Cold

• Vasoconstriction, which decrease the blood supply and nutrients to the affected area.

• Decrease cellular metabolism• Decrease removal of wastes• Prolonged exposure to cold results impaired

circulation, cell deprivation, and subsequent cell damage

Advantages:• Slow bacterial growth, decrease inflammation• Local anesthetic effect

Systemic effects of cold and heat

Heat applied to a localized body area, or large body area, it may cause excessive vasodilatation, drop in blood pressure, fainting, especially for those with pulmonary and cardiac problems.

Cold application cause vasoconstriction, increase in blood pressure. Shivering is the body response to cold.

For all local applications of heat and cold, the nurse need to follow these guidelines:

• Client’s ability to tolerate the therapy• Contraindication of treatment such as bleeding• Explain the application to client• Assess skin area • Ask the client to report any discomfort• Return to the client after 15 minutes• Remove the equipment at the designed time• Examine the area and record the result

• Conditions that necessitate precautions in the use of heat and cold applications:– Neurosensory impairment– Impaired mental status– Impaired circulation– Open wounds, broken skin, scar formation, edema