CHAPTER 22 - Skin Integrity and Wound Care

I. Introduction • Skin

• the largest organ in the body• maintains health• protects individual from injury

• Nursing Functions• maintaining skin integrity• promoting wound healing

• Impaired skin integrity is a threat to• older adults• clients with restricted mobility, chronic illnesses or trauma• clients undergoing invasive health care procedures

• To protect the skin and manage wounds effectively, know:• factors affecting skin integrity• physiology of wound healing• specific measures that promote optimal skin conditions

II. Skin Integrity • Intact skin

• presence of normal skin• skin layers uninterrupted by wounds

• Appearance of intact skin is influenced by:• Internal factors

• Genetics and heredity determine• skin color• sensitivity to sunlight• allergies

• Age influences• skin integrity (very young/old - fragile skin and susceptible to injury)• wounds heal more rapidly in infants and children

• Underlying health: chronic illnesses and treatments affect skin integrity• impaired peripheral arterial circulation - skin on legs damages easily• corticosteroids - causes thinning of the skin• certain antibiotics, chemotherapy drugs, psychotherapeutic drugs - increase sun-

light sensitivity• poor nutrition - can interfere with appearance and function of skin

• external factors• activity

III. Types of Wounds • Intentional trauma - occurs during therapy

• operations/surgery

• venipunctures• Unintentional wounds - accidental

• fractures in an automobile collision• Closed wound - tissues are traumatized without a break in the skin• Open wound - when the skin or mucous membrane surface is broken• Types of Wounds - according to how they are acquired (SEE TABLE 1 - p. 822)

• incision - sharp instrument• contusion - blow from a blunt instrument• abrasion - surface scrape• puncture - penetration of skin and often underlying tissue by a sharp instrument• laceration - tissues torn apart (machinery)• penetrating wound - penetration of skin and underlying tissues (bullet)

• Types of Wounds - according to the likelihood and degree of wound contamination:• Clean wounds

• uninfected, minimal inflammation• respiratory, GI , GU are not entered• primarily closed wounds

• Clean-contaminated wounds• surgical wounds in which respiratory, GI, GU has been entered• show no evidence of infection

• Contaminated wounds• open, fresh, accidental wounds• surgical wounds involving a major break in sterile technique or large spillage from

GI tract• show evidence of inflammation

• Dirty or infected wounds• wounds contain dead tissue• wounds with evidence of a clinical infection, i.e. purulent drainage

• Types of Wounds - by depth (excluding pressure ulcers and burns)• Partial thickness - confined to the skin (dermis and epidermis); heal by regeneration• Full thickness - involving the dermis, epidermis, subcutaneous tissue, possibly muscle

and bone; require connective tissue repair

IV. Pressure Ulcers • pressure ulcers - injury to the skin and/or underlying tissues, usually over a bony promi-

nence, as a result of force alone or in combination with movement; previously called de-cubitus ulcers, pressure sores, or bed sores.

• Healthy People 2010 - reduce pressure ulcers by 50% in nursing homes• Healthy People 2020 - reduce rate of pressure ulcer-related hospitalizations among

older adults• 2010 National Patient Safety Goals - prevent health care-associated pressure ulcers• Development of stage III or IV pressure ulcers - reportable event

A. Etiology of Pressure Ulcers

• due to localized ischemia that occurs when tissue is compressed between two sur-faces (e.g. bed and skeleton)• ischemia - a deficiency in the blood supply to the tissue

• causes lack of oxygen and nutrition• causes accumulation of metabolic wastes• results in tissue death

• prolonged, unrelieved compression also results in small blood vessel damage• reactive hyperemia - when the skin takes on a bright red flush due to vasodilation as

a result of compression followed by relief of pressure• vasodilation - an increase in diameter of a vessel; a process in which extra blood

floods to the area to compensate for the preceding period of impeded blood flow• reactive hyperemia lasts 1/2 to 3/4 the time it was compressed, if redness goes

away after this time = no tissue damage; if redness stays = tissue damage

B. Risk Factors1. Friction and Shearing

• friction - a force acting parallel to the skin surface which can abrade the skin; ex: sheets rubbing against skin• can abrade the skin = more prone to breakdown

• shearing force - a combination of friction and pressure as commonly occurs when a client assumes a sitting position in bed and the body tends to slide downward to-ward the foot of the bed• downward movement is transmitted to sacral bone and deep tissues• skin and superficial tissues adhere to bed linens, while deeper tissues move with

bone• shearing force between superficial and deep tissues damages blood vessels and

tissues in the area2. Immobility

• immobility - a reduction in the amount and control of movement a person has• people move when they experience discomfort• paralysis, extreme weakness, pain, decreased activity - hinder person’s ability to

change positions independently and relieve pressure3. Inadequate Nutrition

• prolonged inadequate nutrition causes:• weight loss• muscle atrophy• loss of subcutaneous tissue• ===> reduce amount of padding and increases risk of pressure ulcer

• pressure ulcer formation from inadquate:• protein• carbohydrates• fluids• zinc• vitamin C

• hypoproteinemia - predisposes to dependent edema

• edema ==> more prone to injury - skin is less elastic, less resilient, decreased vi-tality• increases distance between capillaries and cells - slower O2/metabolite diffu-

sion4. Fecal and Urinary Incontinence

• moisture from incontinence promotes maceration• maceration - softening of tissue by prolonged wetting or soaking, making the

epidermis more easily eroded and susceptible to injury• digestive enzymes in feces and urea in urine contribute to excoriation

• excoriation - loss of the superficial layers of the skin; also known as denuded area

• accumulation of secretions/excretions - irritating to skin, harbors microorganisms• prone to skin breakdown and infection

5. Decreased Mental Status• reduced level of awareness (unconscious, heavily sedated, dementia)

• less able to respond to pain associated with prolonged pressure6. Diminished Sensation

• due to pralysis, stroke or other neurologic disease• reduces person’s sensation in a body area

• reduces person’s ability to respond to trauma, injurious heat/cold, to tingling (signals loss of circulation)

• impairs the body’s ability to recognize and provide healing mechanisms for a wound

7. Excessive Body Heat• high body temp

• increases metabolic rate ==> increases oxygen demand - particularly severe in area under pressure

• severe infections/elevated temp - affect body’s ability to deal with effects of tissue compression

8. Advanced Age• more prone to impaired skin integrity because of the ff. changes:

• loss of lean body mass• thinning of epidermis• decreased strength and elasticity of skin (r/t collagen fibers)• increased dryness (r/t decreased sebaceous gland secretion)• diminished pain perception (r/t decrease in sensory endings)• diminished venous and arterial flow d/t aging vascular walls

9. Chronic Medical Conditions• diabetes, CVD - compromise O2 delivery by poor perfusion

• cause poor and delayed healing and increased risk of pressure sores10. Other Factors

• poor lifting/transferring techniques• incorrect positioning• hard support surfaces• incorrect application of pressure-relieving devices

C. Stages of Pressure Ulcers• Stage I - nonblanchable erythema - potential ulceration• Stage II - partial-thickness skin loss (abrasion, blister, shallow crater); dermis and pos-

sibly epidermis• Stage III - full-thickness skin loss (damage/necrosis of SQ tissue down to, but not

through underlying fascia)• Stage IV - full-thickness skin loss with tissue necrosis or damage to muscle, bone, or

supporting structures1. Risk Assessment Tools

• Systematic means of identifying clients at high risk for pressure ulcer development (needs to include data re: immobility, incontinence, nutrition, LOC)• Braden Scale - 23 points possible, below 18 is at risk

• sensory perception• moisture• activity• mobility• nutrition• friction and shear

• Norton’s Pressure Area Risk Assessment Form Scale - 24 points possible; 15 or 16 - indicators of risk• general physical condition• mental state• activity• mobility• incontinence• medications

• Use tools upon admission, changes in client’s condition or on a regular basis

V. Wound Healing • regeneration - renewal, as in renewal of tissues in wound healing• rate of healing depends on:

• type of healing• location and size of the wound• health of the client

A. Types of Wound Healing• primary intention healing - a type of wound healing that occurs where the tissue sur-

faces have been approximated and there is minimal or no tissue loss; characterized by the formation of minimal granulation tissue and scarring• aka primary union or first intention healing• ex: surgical incision• use of tissue adhesive• approximated - closed up; as in a healed injury to tissue surface

• secondary intention healing - a type of wound healing that occurs with a wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated; for example, healing of a pressure ulcer• differs from primary intention in 3 ways:

• longer repair time• greater scarring• greater susceptibility to infection

• tertiary intention - a type of wound healing that occurs with wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures; also called delayed primary in-tention

B. Phases of Wound Healing1. Inflammatory Phase

• initiated immediately after injury• lasts 3-6 days• 2 major processes

• hemostasis - the cessation of bleeding• results from vasoconstriction of larger blood vessels, retraction of injured blood

vessels, deposition of fibrin, formation of blood clots• fibrin - connective tissue• blood clots provide matrix of fibrin - framework for cell repair• scab forms on the surface - aids hemostasis, inhibits contamination of wound • below scab - epithelial cells migrate from edges to serve as a barrier between

the body and the environment• phagocytosis - a process by which macrophages engulf microorganisms and

cellular debris• vascular and cellular responses intended to remove foreign substances and

dead and dying tissues• blood supply to wound increases• area is reddened and edematous• exudate is normal and helps cleanse the wound, but overproduction of this ex-

udate impairs wound healing• leukocytes (neutrophils) migrate into interstitial space• after 24 hours - macrophages begin phagocytosis and secrete angiogenesis

factor - stimulates epithelial buds at end of injured blood vessels2. Proliferative Phase

• 3 or 4 - 21 days post injury• fibroblasts begin to synthesize collagen

• collagen - a whitish protein substance that adds tensile strength to the wound during the proliferative phase

• capillaries grow across the wound, increasing blood supply• fibroblasts deposit fibrin• tissue becomes translucent red granulation tissue

• granulation tissue - tissue that is a translucent red color generated as the capil-lary network develops during the proliferative phase; it is fragile and bleeds easily

• wound that does not close by epithelialization becomes eschar• eschar - dried plasma proteins and dead cells that cover an area when a wound

does not close by epithelialization• secondary intention - serosanguinous drainage

3. Maturation Phase• begins on ~day 21 up to 1 or 2 years post injury • fibroblasts continue to synthesize collagen - reorganize into a more orderly struc-

ture• wound is remodeled and contracted

• keloid - a hypertrophic scar resulting from an abnormal amount of collagen laid down in a wound in the maturation phase

C. Types of Wound Exudate• exudate - material, such as fluid and cells, that has escaped from blood vessels dur-

ing the inflammatory process and is deposited in tissue or on tissue surfaces• nature and amount vary according to:

• tissue involved• intensity and duration of inflammation• presence of microorganisms

• serous exudate - exudate that consists chiefly of serum or clear portion of the blood; it looks watery and has few cells; example: fluid in a blister from a burn

• purulent exudate - thicker than serous exudate because of the presence of pus, liq-uefied dead tissue debris, and dead and living bacteria; may be blue, green or yellow-tinged• pus - part of a purulent exudate which consists of leukocytes• suppuration - the process of pus formation

• sanguineous exudate - exudate that consists of large amounts of red blood cells, in-dicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma; frequently seen in open wounds

• serosanguineous - describes exudate that consists of clear and blood-tinged drainage commonly seen in surgical incisions

• purosanguineous discharge - consists of pus and blood, often seen in a new wound that is infected

D. Complications of Wound Healing1. Hemorrhage

• hemorrhage - massive bleeding; abnormal amount of blood escaping from a wound; may be caused by a dislodged clot, a slipped stitch, or erosion of a blood vessel

• internal hemorrhage• swelling or distention of area• possibly, sanguineous drainage from a surgical drain

• hematoma - a localized collection of blood underneath the skin that may appear as a reddish blue swelling or bruise

• may be dangerous - may place pressure on blood vessels and obstruct flow• risk of hemorrhage - greatest in first 48 hours after surgery• in case of hemorrhage (emergency)

• apply pressure dressings to area• monitor VS• may need surgical intervention

2. Infection• contamination of wound with microorganisms may impair wound healing and lead to

infection• competes with new cells for O2 and nutrition• by-products can interfere with healthy surface condition

• if colonization becomes excessive or invades tissues ==> infection• change in wound color• pain• odor• drainage• confirmed through CX• severe infection: fever, elevated WBC

• immunosuppressed individuals - especially susceptible to wound infections• contamination of wound from:

• time of injury (e.g., motor vehicle crash)• during surgery (e.g., surgery involving the intestines)• postoperatively (2-11 days post-op)

3. Dehiscence with Possible Evisceration• dehiscence - the partial or total rupturing of a sutured wound; usually involves an

abdominal wound in which the layers below the skin also separate; occurs 4-5 days post-op

• evisceration - the protrusion of the internal viscera through an incision• factors that increase risk:

• obesity• poor nutrition• multiple trauma• failure of suturing• excessive coughing• vomiting• dehydration

• management:• support wound with large sterile dressings soaked in sterile NS• client in bed with knees bent• notify surgeon

E. Factors Affecting Wound Healing1. Developmental Considerations

• healthy children and adults heal more quickly than in older adults d/t (BOX 2):

• vascular changes• less flexible collagen tissue• less elastic scar tissue• changes in immune system, reeducation of antibodies and monocytes• nutritional deficiencies• diabetes or CVD• slower cell renewal - delayed healing

2. Nutrition• wound healing - additional demands on the body• require: protein, carbs, lipids, vit. A and C, minerals (iron, zinc, copper)• malnourished - need time to improve nutritional status• obese - increased risk of infection, slower healing because adipose tissue has a

minimal blood supply3. Lifestyle

• regular exercise - good circulation = quicker healing• smoking - reduces amount of hemoglobin = limits O2-carrying capacity; constricts

arterioles4. Medications

• anti-inflammatory drugs (steroids/aspirin) - interfere with healing• anti-neoplastic drugs - interfere with healing• antibiotics - long-term use may increase susceptibility to wound infection

VI. Nursing Management

A. Assessing1. Assessment of Skin Integrity

• examination of integument - routine assessment during regular care• remove barriers like anti embolic stockings, braces, other devicesa) Nursing History and Physical Assessment• nursing HX

• review of systems• skin diseases• previous bruising• general skin condition• skin lesions• usual healing of sores

• physical assessment• inspection /palpation - skin color, turgor, edema, lesions• particular attention in areas most likely to break down

• in skin folds - under breast• areas that are frequently moist - perineum• areas that receive extensive pressure - bony prominences

2. Assessment of Woundsa) Untreated Wounds• seen shortly after injury

• principles of care:• control severe bleeding

• direct pressure• elevation

• prevent infection• cleaning with NS• covering with a clean dressing

• control swelling and pain - ice over wound and surroundings• if severe bleeding/suspected internal bleeding, assess for shock

• rapid pulse• cold clammy skin• pallor• lowered BP

b) Treated Wounds• aka sutured wounds• assessed for progress of healing• inspect during changing of dressing, or dressing is inspected and other data

(e.g., pain)• observe appearance, size, drainage, swelling, pain, status of drains/tubes• amount of drainage:

• minimal - stains dressings• moderate - saturates without leakage prior to scheduled dressing change• heavy - overflows prior to scheduled dressing change• description, amount and type of dressing material used

• undermining - wound reaches under the skin surface; may cause sinus tracts or tunneling• assess using sterile swab• caused by infection and have significant drainage• treatment: antibiotics, irrigation, surgical incision to open and drain the tract,

vacuum therapy for large tractsc) Pressure Ulcers• assess:

• location, r/t bony prominence• size in cm (length, width, depth)• presence of undermining or sinus tracts, location• stage• color of wound bed, location of necrosis or eschar• condition of the wound margins• integrity of surrounding skin• signs of infection: redness, warmth, swelling, pain, odor, exudate (color)

d) Laboratory Data• support clinical assessment of healing progress• decreased leukocyte count

• delay healing

• increase possibilityy of infection• hemoglobin below normal

• poor O2 delivery to tissues• blood coagulation studies

• prolonged coagulation - excessive blood loss, prolonged clot absorption• hypercoagulability - intravascular clotting - deficient blood supply

• serum protein• nutritional reserves for regeneration• albumin below 3.5 g/dL - poor nutrition, increase risk of poor healing/infection

• wound CX & sensitivity - presence of infection, selection of antibiotic• REVEIW SKILL 1: Obtaining a Wound Drainage Specimen for Culture

B. Diagnosing• NANDA diagnoses for clients who have skin wounds or who are at risk for skin break-

down:• Risk for Impaired Skin Integrity• Impaired Skin Integrity - pressure ulcers and wounds extending through the epider-

mis but not through the dermis• Impaired Tissue Integrity - pressure ulcers and wounds extending into SQ tissue,

muscle, or bone• Additional diagnoses:

• Risk for Infection• Acute Pain

C. Planning• Goals for Risk for Impaired Skin Integrity

• maintain skin integrity• avoid potential associated risks

• Goals for Impaired Skin Integrity• demonstrate progressive wound healing• regain intact skin w/n specified time frame

1. Planning for Home Care• Assessment:

• Client and Environment• current level of knowledge• self-care abilities• self-care abilities for wound care• facilities• current level of nutrition

• Family• caregiver availability, skills, responses• family role changes and coping• alternate potential primary or respite caregivers

• Community

• resources• Client Teaching: Skin Integrity

• Maintaining intact skin• nutrition• positioning• turning/repositioning schedule• application of appropriate skin protection agents/devices• report persistent reddened areas• potential sources of skin trauma and how to avoid

• Promoting wound healing• nutrition• wound assessment and documentation• principles of asepsis; hand hygiene, use of dressings• signs of infection and complications to report• pressure ulcer prevention• wound care cleaning/dressing• pain control, if needed

D. Implementing1. Supporting Wound Healing

a) Moist Wound Healing• dressing and frequency of change should support moist conditions• wound beds that are too dry or disturbed too often fail to heal

b) Nutrition and Fluids• at least 2,500 mL fluid intake unless contraindicated• adequate vitamins and minerals• protein, vit. C, A, B1, and B5, and zinc• refer to dietitian

c) Preventing Infection• prevent entrance of microorganisms• prevent transmission of pathogens to or from the client to others• TABLE 3: Preventing Infection

• SP• wear gloves when touching blood/body fluids/mucous membranes or non in-

tact skin, when handling items or surfaces soiled with blood or body fluids• wash hands if contaminated and after removing gloves

• Wound care• wash hands before and after• gloves, masks, protective eyewear as appropriate• touch open or fresh wound only with sterile gloves/instruments• remove/change dressings over closed wounds when wet

d) Positioning• position client to keep pressure off wound (off-loading• transfer and position without shear or friction damage

• encourage mobility - activity enhances circulation• ROM turning schedule - client who cannot move independently

2. Preventing Pressure Ulcers• identify clients at risk - reassess all clients daily• reliably implement prevention strategies for all clients at risk

• optimize nutrition and hydratio• inspects skin daily• minimizes pressure• manages moisture - keep client dry and moisturize skin

a) Providing Nutrition• consider supplements for nutritionally compromised• diet should support wound healing• monitor weight to help assess nutritional status• monitor lab work (lymphocyte count, protein/albumin, Hgb)

b) Maintaining Skin Hygiene• obtain baseline, reassess daily• bathing:

• minimize force and friction• use mild cleansing agents• avoid using hot water - increases dryness/irritation

• avoid exposure to cold and low humidity• treat dry skin with moisturizing lotions after bathing• keep clean and dry• apply skin protection if indicated

c) Avoiding Skin Trauma• provide a smooth, firm, and wrinkle-free foundation on which to sit or lie• position, transfer and turn client correctly• HOB <30 unless contraindicated• don’t use baby powder/cornstarch; instead use moisturizing creams and protec-

tive films• shift weight 10-15º q15-30min; exercise or ambulate• use a lifting device; lift, don’t drag• reposition at least q2h; avoid trochanter on lateral position• avoid massage over bony prominences, may lead to deep tissue trauma

d) Providing Supportive Devices• pressure on bony prominences should remain below capillary pressure• for clients confined to bed:

• overlay mattress• replacement mattress• specialty beds - provide pressure relief, eliminate shearing and friction, de-

crease moisture• ex: high-air-loss beds, low-air-loss beds, kinetic therapy beds

• other devices:• gel flotation pads

• pillows and wedges• heel protectors• memory foam mattress/chair pad• alternating pressure mattress• water bed• static low-air-loss bed• active or second-generation LAL bed• air-fluidized bed

3. Treating Pressure Ulcers• infections - most serious complications• follow agency protocols and PCP orders

• The RYB Color Code• based on color of open wound

• protect/cover red - late regeneration phase; protect by:• gentle cleasing• protecting periwound skin w/ alcohol-free barrier film• filling dead space with hydrogel/alginate• cover with appropriate dressing• change as infrequently as possible

• cleanse yellow - liquid to semiliquid “slough” (purulent drainage/previous in-fection); cleanse by:• removal of nonviable tissue by:

• damp-to-damp normal saline dressings• irrigation• using absorbed dressing mat’s: impregnated hydrogel/alginate dressings• topical antimicrobial per MD

• debride black - thick necrotic tissue/eschar• debridement - removal of the necrotic material in black wounds• remove nonviable tissue by:

• sharp debridement - scalpel/scissors• mechanical debridement - scrubbing or damp-to-damp dressings• chemical debridement - collegians enzyme• autolytic debridement - uses own drainage to break down eschar• also larval therapy

• wound is then treated as yellow, then as red4. Dressing Wounds

• purpose:• protect from mechanical injury• protect from microbial contamination• provide/maintain moist wound healing• provide thermal insulation• absorb drainage/debridement/both• prevent hemorrhage

• splint or immobilize site to facilitate healing and prevent injurya) Types of Dressings• depends on:

• location, size, type of wound• amount of exudate• requires debridement or infected• frequency of dressing change, ease/difficulty of application, cost(1) Transparent Dressings• for wounds including ulcerated or burned areas• advantages:

• act as temporary skin• nonporous, nonabsorbent, self-adhesive, do not require changing• wound can be assessed through them• remains moist, can retain a small amount of serous exudate - promotes ep-

ithelial growth, hastens healing, reduces risk for infection• elastic - can be placed over a joint w/o disrupting mobility• adhere only to skin area and not onto wound• allow client to shower/bathe w/o removing dressing

(2) Hydrocolloid Dressings• frequently used over pressure ulcers• advantages:

• last 3-7 days• water-resistant• can be molded to uneven surfaces• act as temporary skin, effective bacterial barrier• decrease pain• absorb moderate drainage, on slow draining wounds• contain odor

• limitations:• occlusive, opaque, obscure visibility• limited absorption capacity• can facilitate anaerobic bacterial growth• can soften and wrinkle at edges• may be difficult to remove, may leave a residue on skin

• do not use on:• infected wounds• wounds with deep tracts or fistulas

(3) Securing Dressings• tape dressing over wound• ensure dressing covers entire wound and does not come off• use correct type of tape• steps:

• place tape so that dressing cannot be folded back; place strips at ends of dressing and space them evenly

• tape must be long and wide enough to adhere to several inches of skin on each side, but not too long or wide that it comes loose

• place tape in opposite direction from body action5. Cleaning Wounds

• removal of debris (foreign materials, slough, necrotic tissue, bacteria, etc.)a) Wound Irrigation and Packing• irrigation/lavage - washing or flushing out of an area

• sterile technique for wound irrigation• use piston syringes or sterile straight catheters, not bulb syringes• pressure = 5-8psi• solutions:

• sterile NS• lactated Ringer’s• antibiotic solutions

• REVIEW SKILL 2: Irrigating a Wound• packing - gauze used to pack wounds that require debridement

• moist 4x4 non-cotton-filled gauze packed in the wound to absorb exudate, but not allowed to dry before removal

• vacuum-assisted closure - use of suction equipment to apply negative pressure to wound; sterile foam sponges, transparent adhesive drape, vacuum tubing

b) Supporting and Immobilizing Wounds• bandages and binders - purpose:

• supporting a wound (e.g., fractured bone)• immobilizing a wound (e.g., strained shoulder)• applying pressure (e.g., elastic bandages)• securing a dressing (e.g., extensive abdominal surgical wound)• retaining warmth (e.g., flannel bandages on rheumatoid joint)• promote healing, provide comfort, prevent injury(1) Bandages• bandage - a strip of cloth used to wrap some part of the body

• gauze most common - light, porous, readily molds to body, inexpensive• used on fingers, hands, toes, feet• supports dressings• permits air circulation• can be impregnated with medications

• elasticized• provides pressure to an area• used as tensor bandages or partial stockings• provides support and improves venous circulation in legs

• width depends on size of body part to be bandaged• padding used to cover bony prominences or separate skin surfaces• before applying:

• know purpose• assess area requiring support for:

• swelling• presence of and status of wounds• presence of drainage• adequacy of circulation• pain

• also assess:• ability of client to reapply• capabilities of client re: ADL’s, required assistance

(2) Basic Turns for Roller Bandages(a) Circular Turns - used to anchor and terminate bandages; not applied di-

rectly over wound(b) Spiral Turns - used for body parts that are fairly uniform in circumference(c) Spiral Reverse Turns - used for body parts that are not uniform in cir-

cumference(d) Recurrent Turns - used to cover distal parts of the body(e) Figure-Eight Turns - used to bandage elbow, knee, or ankle - permit

some movement after application(3) Binders• binder - a type of bandage designed for a specific body part; for example, the

triangular binder or sling fits the arm(a) Arm Sling(b) Straight Abdominal Binder

c) Heat and Cold Applications• for local and systemic effects

(1) Local Effects of Heat• causes vasodilation• increases blood flow bringing O2, nutrients, antibodies, leukocytes• promotes soft tissue healing• increases suppuration• possible disadvantage: increases capillary permeability

• may result in edema• may increase preexisting edema

• commonly used for:• joint stiffness from arthritis• contractures• low back pain

(2) Local Effects of Cold• lowers temperature of skin and underlying tissues• causes vasoconstriction

• vasoconstriction - narrowing of the vessels, which reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness

• prolonged exposure to cold• impaired circulation• cell deprivation• damage to tissues from lack of O2 and nutrients

• bluish purple mottled appearance of the skin• numbness• blisters• pain

• commonly used for:• sports injuries - limits swelling and bleeding

(3) Systemic Effects of Heat and Cold• heat applied to a large area may cause:

• excessive peripheral vasodilation = drop in BP ==> fainting• extensive cold applications

• BP increase because of shunting• shivering - normal response of body to warm itself

(4) Thermal Tolerance• precautions in use of hot and cold applications:

(a) neurosensory impairment• unable to perceive too much heat/cold(b) impaired mental status

• have ALOC and need monitoring to ensure safety(c) impaired circulation

• PVD, diabetes, CHF - at risk for tissue damage with heat or cold(d) immediately after injury or surgery

• heat increases bleeding and swelling(e) open wounds

• cold decreases blood flow and inhibits healing(5) Adaptation of Thermal Receptors• sudden change in temperature initially stimulates receptors strongly

• declines rapidly during first few seconds• declines more slowly during next half hour as they adapt to new temp

• clients may be tempted to change temperature of thermal application because of adaptation• increasing hot applications can result in serious burns• decreasing cold applications can result in pain and serious impairment of

circulation(6) Rebound Phenomenon• occurs at the time the maximum therapeutic effect of the hot or cold applica-

tion is achieved and the opposite effect begins• thermal applications must be halted before the rebound phenomenon begins

d) Applying Heat and Cold• dry heat

• hot water bottle• aquathermia pad• disposable heat pack• electric pad

• moist heat• compress

• hot pack• soak• sitz bath

• dry cold• cold pack• ice bag• ice glove• ice collar

• moist cold• compress• cooling sponge bath

• for all local applications of heat or cold• determine ability to tolerate therapy• identify conditions that might contraindicate treatment• explain application to client• assess skin area to which it will be applied• ask client to report any discomfort• return to client 15 minutes after application and observe local area, stop if

problems occur• remove at designated time• examine area and record client’s response(1) Hot Water Bag - generally 30 minutes(2) Aquathermia Pad - generally 30 minutes(3) Hot and Cold Packs(4) Electric Heating Pads(5) Ice Bags, Ice Gloves, and Ice Collars(6) Compresses• compress - a warm or cold moist gauze dressing applied to a wound(7) Soaks(8) Sitz Baths - generally 20 minutes• sitz bath (hip bath) - used to soak a client’s perineal or rectal area(9) Cooling Sponge Baths - to reduce fever accompanied by antipyretics; usu-

ally takes about 30 minutes; reassess VS at 15 minutes and after sponge bath

E. Evaluating • Use data collected during care:

• skin status over bony prominences• nutritional and fluid intake• mental status• signs of healing, etc.

• If outcome not achieved, ask:• has physical condition changed?• risk factors correctly identified?• appropriate devices/techniques used?

• unable to comply with instructions? why?• appropriate pressure-relieving devices used? were they applied correctly?• repositioning scheduled adhered to?• nutritional and fluid intake adequate?• appropriate measures to control incontinence used?• wound supported and immobilized?• stringent aseptic practices for cleaning/dressing changes?• medications interfering with healing?• nonviable tissue removed?• appropriate dressing applied for moist wound healing?