CHAPTER I
MEDICAL CONCEPT
This chapter will describe the medical concept of skin. It will consist of definition of skin, patophysiology of wound, wound healing, sign and symptom of wound, treatment of wound, and complication of wound.
A. Definition
Skin is largest organ of the integumentary system made up of multiple layers of epithelial tissues that guards underlying muscles and organs (Wikipedia, 2010).
1. Anatomy and physiology of skin
According to Desales (2010), the anatomy of skin are :
a. Epidermis
Composed of several thin layers : stratum basale, stratum spinosum, stratum granulosum, stratum lucidum and stratum corneum.
b. Dermis
Composed of a thick layer of skin that collagen and elastic fibers, nerve fibers, bloods vessels, sweat and sebaceous glands, and hair follicles.
c. Subcutaneous Tissues
Composed of a fatty layer of skin that contains bloods vessels, nerves, lymph, and loose connective tissues filled with fat cells.
2. Functions of the Skin
According to Scibd (2010), there are some function of the skin.
| Function | Mechanism | ||
| Elimination | Water, electrolytes, and nitrogenous wastes are excreted in small amounts in sweat | ||
| Absorption | 1 | ||
| Immunological | 2 | ||
| Production Vitamin D | A precursor for vitamin D is present in the skin, which in conjunction with ultraviolet rays from the sun, produced vitamin D. | ||
| Sensation | Millions of nerve ending in the skin provide the sense of touch, pain, pressure, and temperature. | ||
| Psychosocial | External appearance is a major contributor to self-esteem. | ||
| Temperature Regulation | The evaporation of perspiration draws heat from the skin. Blood vessels in the skin dilate to dissipate heat. In conditions, bloods vessels in the skin constrict to diminish heat loss. | ||
| Protection | Act as barrier to water, microorganism, and damaging ultraviolet rays of the sun. |
3. Factors Affecting skin Integrity
According to scibd (2010), There are 4 factors affecting skin integrity :
a. Unbroken and healthy skin and mucous membranes serve as first lines of defense against harmful agents
b. Resistance to injury of the skin and mucous membranes varies among people.
c. Adequately nourished and hydrated body cells are resistant to injury.
d. Adequate circulation is necessary to maintain cell life.
4. Classification of Wound
A wound is a Type of injury in which in the skin is torn, cut or punctured (an open wound), or where blunt force trauma caused/ a closed wound (Wikipedia, 2010).
a. By Cause
1). Intentional
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Involved a wound that is the result of planned therapy
2). Unintentional
Involved a wounds that is the result of unexpected trauma
b. By Severity of Injury
1). Superficial
Involves only the epidermal layer of skin
2). Penetrating
Involve penetration of the epidermal and dermal layers of skin and deeper tissues or organs
c. By status of Skin Integrity
1). Open
Involves a break in skin integrity or mucous membrane
2). Closed
Involves no break in skin integrity or mucous membrane
d. By Descriptive Qualities
1). Laceration
Involved tearing apart of tissues resulting in irregular wound edges
2). Abrasion
Involves scraping or rubbing the surface of the skin by friction
3). Contusion
Involves a blow from blunt object resulting in swelling, dicoloration, bruising, and/or eccymosis
4). Incision
Involves cutting the skin with a sharp instrument
5). Puncture
Involves penetration of the skin and often the underlying tissues by a sharp instrument
e. By Depth
1). Partial-Thickness
Involves only the epidermal and dermal layers of skin
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2). Full-Thickness
Involved the epidermal and dermal layers of skin, subcutaneous tissue and possibly, muscle and bone
f. By degree of Contamination
1). Clean
Uninfected wound in which no inflammation in encountered and the respiratory, gastrointestinal, genital, and/urinary tract are not entered
2). Clean/Contamination
Uninfected wounds in which no inflammation is encountered but the respiratory, gastrointestinal, genital, and/urinary tract have been entered
3). Contaminated
Open, Traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation
4). Infected
Old, traumatic wounds with evidence of a clinical infection (e.g., purulent drainage)
5. Types of wound drainage
According to Lois White and Gena Duncan (2002), there are 4 types of wound drainage:
a. Serous exudate
Serous exudate is composed primarily of serum (the clear portion of blood), is watery in appearance, and has a low protein level. This type of exudate is seen with mild inflammation resulting in minimal cappilary permeability changes and minimal protein molecule escape.(e.g.,seen in blister formation after a burn).
b. Sanguineous exudate
Sanguineous exudate is clear with some blood tinge and is seen with surgical incisions.
c. 5
Purulent exudate
Purulent exudate is also called pus. It generally occurs with severe inflammation accompanied by infection. There are leukocytes, liquefied living and dead bacteria, dead tissue debris.
d. Hemmorhagic exudate
Hemmorhagic exudate has a large component of red blood cells (RBCs) due to cappillary damage. This type of exudate is usually present with severe inflammation. The colour of the exudate (bright red versus dark red) reflect whether bleeding is fress or old.
B. PATOPHYSIOLOGY
There are many types of wound in this concept. The patophysiology will foccused on pressure ulcers, burns, and incisions. Because these wound are common occurs in hospitals.
1. Pressure ulcers
According to Lois White and Gena Duncan (2002), the patophysiology of pressure ulcers are:
a. A pressure ulcers is a wound with a localized area of tissue necrosis
b. The underlying cause is pressure
c. The terms “pressure ulcer”, “decubitus ulcer”, and “bedsore” are synonymous
d. Most pressure ulcers occur in older adults as a result of a combination of factors:
1). Aging skin
2). Chronic illnesses
3). Immobility
4). Malnutrition
5). Fecal and urinary incontinence
6). Altered level of consciousness
e. 6
Two mechanism contribute to pressure to pressure ulcer development:
1) External pressure that compresses blood vessels
2) Friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
f. Risk factors for Pressure Ulcer Development
1) Dehydration
2) Diabetes Mellitus
3) Diminished pain awareness
4) Fractures
5) History of corticosteroid therapy
6) Immunosuppression
7) Multisystem trauma
8) Poor circulation
9) Previous pressure ulcers
10) Significant obesity or thinness
11) Malnutrition
12) Immobility
13) Apathy, confusion, or a comatose state
g. Moisture and warmth eventually lead to cell destruction
h. Pressure Ulcer Staging
According to Bennett (1995), The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin over the area under pressure. Local anemia resulting from poor circulation is called ischemia. Eschar is a thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
1) Stage I
(a) An observable pressure-related alteration of intact skin whose indicator, as compared with the adjacent or opposite area and body, may include changes in one or more the following:
(b) 7
Skin temperature (warmth or coolness)
(c) Tissue consistency (firm or boggy feel)
(d) Sensation (pain, itching)
2) Stage II
(a) Partial-thickness skin loss involving epidermis and/or dermis
(b) The ulcer is superficial and present clinically as an abrasion, blister, or shallow crater
3) Stage III
(a) Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
(b) The ulcer present clinically as a deep crater with or without under meaning of adjacent tissue.
2. Burns
According to Lois White and Gena Duncan (2002), the patophysiology of burns are:
a. Burns are among the most the devastating injuries that individual can suffer
b. Burn can be painfull and disfiguring, require long hospitalization
c. Major Cause of burn:
1) Exposure to the sun (for all age)
2) Assosiated with cigarete smoking and cooking(usually in adult)
3) Spilling hot liquid on themselves or by catching there clothes on fire as they by cook or smoke(usually occurs in elderly)
4) Spilling scalding liquids on themselves and playing with matches or ciggarete lighters (usually occurs in young children)
5) Indrustial acidents (usually occurs in yong adult)
d. Severity of burn
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Burns are classified according to the depth of the burns and the extent of skin surface involved. First-and second-degree burns are partial-thickness burns (within the epidermis and dermis). Third-degree and fourth-degree burns are full-thickness burns.
1) First degree
Involve only the epidermis, heal in about a week without scarring. This skin is hot, red, and painfull. For example is sunburns
2) Second degree
Damage the dermis and epidermis. The skin is red, hot, and painfull, blister form and tissue aroun the burn is adematous or swollen, with an ecxecessive amount of fluid. Heal in about two weeks without scarring. Example is spilling boiling water in the skin.
3) Third degree
All dermal structur are destroyed and cannot be regenerated subcutaneous tissue damaged.
4) Fourth degree
Fourth degree burns which extend to the underlying muscles and bones, appear white to black or charred with dark network of thrombosed cappillaries visible inside the wound. Fourth degree burns results from fires explosion, and nuclear radiation
- Incision
Incision is a cut or a wound made by cutting with a sharp instrument that produced surgically that creates an opening into an organ or space in the body.(Elsevier,2009)
Here will explain about Types of wound, Warning sign, and Risk.
a. 9
Types of wound or incision closure
There are four major types of closure used in Canada and the United States as of 2003. (Rebecca Frey,2010)
1) SURGICAL SUTURES
Sutures, or stitches, are the oldest method still in use to close an incision. The surgeon uses a sterilized thread, which may be made of natural materials (silk or catgut) or synthetic fibers, to stitch the edges of the cut together with a special curved needle. There are two major types of sutures, absorbable and nonabsorbable. Absorbable sutures are gradually broken down in the body, usually within two months. Absorbable sutures do not have to be removed. They are used most commonly to close the deeper layers of tissue in a large incision or in such areas as the mouth. Nonabsorbable sutures are not broken down in the body and must be removed after the incision has healed. They are used most often to close the outer layers of skin or superficial cuts.
2) SURGICAL STAPLES
Surgical staples are a newer method of incision closure. Staples are typically made of stainless steel or titanium. They are used most commonly to close lacerations on the scalp or to close the outer layers of skin in orthopedic procedures. They cannot be used on the face, hand, or other areas of the body where tendons and nerves lie close to the surface. Staples are usually removed seven to 10 days after surgery.
3) STERI-STRIPS
Steri-strips are pieces of adhesive material that can be used in some surgical procedures to help the edges of an incision grow together. They have several advantages, including low rates of infection, speed of application, no need for local anesthesia, and no need for special removal. Steri-strips begin to curl and peel away from the body, usually within five to seven days after surgery. They should be pulled off after two weeks if they have not already fallen off. Steri-strips, however, have two disadvantages: they are not as precise as sutures in bringing the edges of an incision into alignment; and they cannot be used on areas of the body that are hairy or that secrete moisture, such as the palms of the hands or the armpits.
4) 10
LIQUID TISSUE GLUES
Tissue glues are the newest type of incision closure. They are applied to the edges of the incision and form a bond that holds the tissues together until new tissue is formed. The tissue glues most commonly used as of 2003 belong to a group of chemicals known as cyanoacrylates. In addition to speed of use and a low infection rate, tissue glues are gradually absorbed by the body. They are less likely to cause scarring, which makes them a good choice for facial surgery and other cosmetic procedures. They are also often used to close lacerations or incisions in children, who find them less frightening or painful than sutures or staples. Like Steri-strips, however, tissue glues cannot be used on areas of high moisture. They are also ineffective for use on the knee or elbow joints.
b. Warning signs
Patients who notice any of the following signs or symptoms should call their doctor:
1) 11
fever of 100.5°F (38°C) or higher
2) severe pain in the area of the incision
3) intense redness in the area of the incision
4) bruising
5) bleeding or increased drainage of tissue fluid
c. Risks
Some patients are more likely to develop infections or to have their incision split open, which is known as dehiscence. Risk factors for infection or dehiscence include:
1) obesity
2) diabetes
3) malnutrition
4) a weakened immune system
5) taking corticosteroid medications prescribed for another disorder or condition
6) a history of heavy smoking
C. Wound Healing
Here will be explained about the phase, the affecting factor, and systemic factor of wound healing (Scibd,2010).
1. Phase of wound healing
a. Defensive (inflammatory) phase
Begins immediately after injury, lasting 3-4 days, and consist of two major processes:
1) Hemostasis
(a) 12
Vasoconstriction of severed blood vessels
(b) Aggregation of platelets along damaged blood vessels walls to form a platelet plug.
(c) Invasion of fibrin fibers into the platelet plug to form a fibrin clot
(d) Contraction of the fibrin clot to express fluid (serum) out of the clot and form a scab which provides external protection from invasion by microorganisms.
2) Inflammation
(a) Injury to tissues resulting in secretion of multiple products of inflammation into the blood stream from the injured tissues. Leads to a clinical sign of inflammation: dolor (pain)
(b) Vasodilation of local blood vessels, resulting in excess local blood flow and an increase in nutrients to the injured tissues. Leads to two clinical sign of inflammation: tumor (swelling or edema).
(c) Increased permeability of capillaries, resulting in leakage of large quantities of fluid into the interstitial spaces to cushion the injured tissues and dilution of the concentration of microorganisms or toxic products that may have entered the injured tissues. Leads to a clinical sign of inflammation: tumor ( swelling or edema).
(d) Chemotaxis ( attraction of white blood cells [ WBCs] to injured tissues), resulting in migration of tissues macrophages, neutrophils, and monocytes to the injured tissues and phagocytosis of microorganisms and debris in the injured tissues.
(e) Encouragement of actions to avoid further injury to or inflammation of the injured tissues. Leads to a clinical sign of inflammation: functiolaesa ( loss of function).
(f) 13
Walling off injured tissues and lymphatics from remaining tissues to delay spread of microorganisms or toxic products
b. Proliferative phase
1) Begins 3 or 4 days after injury, lasting up to 3 weeks.
2) Macrophages stimulate the migration of fibroblasts to the wound to synthesize collagen and ground substance (proteogylean).
3) The collagen and proteogylean synthesized by fibroblasts forms a scaffold, or framework, for final repair of the wound and can be felt as a “ healing ridge “ under the suture. The more collagen and ground substance added to the scaffold, or framework, the greater the tensile strength of the wound.
4) Macrophages also stimulate the formation of “ buds” in capillaries surrounding the wound that grow into new blood vessels (angiogenesis) and reestablish blood flow across the wound.
5) The collagen and proteogylean deposits and capillary “ buds” form the new granulation tissues in the wound, which is translucent red, fragile, and, bleeds, easily.
6) Proliferation of epithelial cells across the wound as granulation tissues matures.
c. Maturation phase
1) Begins after 21 days after injured, lasting month and even years.
2) Firbroblasts continue to synthesize collagen and proteogylean and add it to the wound to increase its tensile strength
3) The collagen and proteogylean fibers, laid haphazardly during the proliferative phase, reorganize into a more orderly structure.
2. Factors Affecting Wound Healing
There are some factor affecting wound healing :
a. Pressure
b. Desiccation
c. 14
Maceration
d. Trauma
e. Edema
f. Infection
g. Necrosis
3. Systemic Factors
Beside some factor that affecting wound healing above, there are systemic factor that can also affecting. According to Scibd (2010), there are five systemic factor :
a. Age
b. Circulation and Oxygenation
c. Nutritional Statusc
d. Wound Condition
e. Medication and Health Status
D. Sign and Symptom from Wound
According to mckinley (2008), the sign and symptom of wound are:
1. Redness or excessive swelling in the wound area
2. Throbbing pain or tenderness in the wound area
3. Red streaks in the skin around the wound or progressing away from the wound
4. Pus or watery discharge collected beneath the skin or draining from the wound
5. Tender lumps or swelling in your armpit, groin or neck
6. Foul odor from the wound
7. Generalized chills or fever
E. 15
Treatments
There are three treatment of wound :
1. Education
Education of client and care family is an important nursing function (ayello, `1993, 1995;Mezey, and Amella, 1997). There are variety of education tool, including videotapes and written materials, that can be used by the nurse when teaching client and family to prevent and treat pressure sores. Written material are available on variety of topic, including dressing changes; there are also guides for measuring wounds and charts of positioning client (Perry and Potter,2003).
2. Cleansing
The process of cleansing a wound involves selecting both an appropriate cleansing solution and using mechanical means of delivering that solutions without causing injury to the healing wounds tissue (AHCPR, 1994).
Cleaning a pressure ulcer (William & wilklinz, 1997) :
a.Clean with each dressing change
b. Use careful, gentle motions to minimize trauma
c.Use 0,9% NS solution to irrigate and clean the ulcer
d. Report any drainage or necrotic tissue
3. Dressing
According to William & wilklinz (1997), Dressing the pressure ulcer include:
a. Keep ulcer tissue moist and surrounding skin dry
b. Place moist dressing only on the wound surface
c. Use dressing that absorb exudates but maintains moints environment
d. Use skin sealant on surrounding skin
e. Secure dressing with the least amount of tape possible
f. Use wet to dry dressing for debridement, when ordered
g. Pack wound cavities loosely with dressing material
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When the skin becomes broken, a dressing help reduce exposure. The dressing technique will vary depending on the goal of the treatment of the treatment plant for the wound.
Purposes of dressings.A dressing may serve several purposes:
a) Protecting a wound from microorganism contamination
b) Aiding homeostasis
c) Promoting healing by absorbing drainage and debriding a wound
d) Supporting and splinting the wounds site
e) Protecting the client from seeing the wound (if perceived as unpleasant)
f) Promoting thermal insulation of the wound surface
g) Providing maintenance of high humidity between the wound and dressing
F. Complication
Wound complications include:
1. Infection
2. Hemorrhage
3. Dehiscence
4. Evisceration
These complications increase the risk for generalized illness and death,
1. Infection
a. Bacteria can invade a wound at the time of trauma, during surgery, or at any time after the initial wound occurs
b. Wound infections also occur as a result of nosocomial infection
c. Symtoms of infections include purulent drainage; increased drainage, pain, redness, and swelling in and around the wound; increased body temperature; and increased white blood cell count.
2. Wound infections can lead to other complications:
a. Osteomyelitis (bone infection)
b. Sepsis (presence of phatogenic organism in the blood or tissue)
3. Hemorrhage
a. Hemorrhage may occur from a slipped suture
b. 17
Dislodged clot from stress at the suture line or operative site
c. Erosion of a blood vessels by a foreign body
d. Infection
e. Internal hemorrhage causes the formation of a hematoma
f. Large accumulation of blood can put pressure on surrounding blood vessels and cause tissue ischemia
4. Dehiscence
Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds are not healed
5. Evisceration
Evisceration is the most serious complication of dehiscence
a. Increase in the flow or serosanguineous fluid from the wound between postoperative days 4 and 5 is a sign of an impending dehiscence
b. Dehiscence and Evisceration of an abdominal incision as a medical emergency
CHAPTER II
NURSING CARE CONCEPT
This chapter will describe about the nursing care concept that included assesment, nursing diagnosis, planning, and evaluation.
A. Assesment
Here will explain about assessment for Skin. The Assessment are Subjective and Objective data.
1. Subjective Data
Here will explain about Subjective data of Assessment. There are Nursing History and Focused data.
a. Nursing History
According to Estes (2002), The various components of the past health history are linked to skin pathology and skin information.
Past health history: medical history (skin specific and non skin specific), surgical history (keloid and sear formation, plastic surgery for birthmarks, skin graft, reconstructive surgery, excision biopsy), communicable diseases, childhood illness, accident special needs, allergies.
Family history: skin diseases that are familial in nature are listed
Social History: The component of the social history are linked to skin pathology (alcohol use, drugs use, tobacco use, sexual practice, travel history, work environment, home environment, hobbies activities, stress, and economic status. Ethic background).
Specific health history questing regarding the skin:
1) Do you use lotions, perfumes, cologne, cosmetics, soaps, oils, shavings cream, after shave lotion, electric or standard razor?
2) What type of home remedies do you use for skin lesions and rashes?
3) How often do you bathe and shower?
4) 18
Do you use a tanning bed or salon?
5) 19
What type of sun protection do you use?
6) Have you ever had reactions to jewelry that you wore?
7) Do you wear hats, visors, glovers, long sleeves or pants, sunscreen when in the sun?
8) How much time do you spend in the sun?
b. Focus Data
We can use PQRST methods to assess the condition of wound related with pain of client (Crisp and Taylor, 1991).
P : Provoking or triggers is factor that trigger the occurrence of pain
Q : Quality or the quality of pain (e.g: painblunt sharp)
R : Region or regions, namely the area travel to other area.
S : Severity or malignancy, namely intensity
T : Time or times, in the attack duration, frequency and causes
So we can use PQRST methods to arrange some questions that will be asked to the client, like :
1. What do you feel on your wound now?
2. What is the provoking that can appear pain on your wound?
3. Are you feel pain in your wound? And how about the pain scale?
4. Where is the location of pain on your wound?
5. How often you feel pain on your wound?
6. When the pain appear on your wound?
7. How often you feel pain on your wound?
8. Can you doing some activity by yourself or depend on the other people?
9. What is the kind of food that you consume during have wound?
10. How do you take care your wound?
2. Objective Data
According to Kozier (1991), In here will explain about Objective data. There are Physical Examination and Laboratory Data.
a. Physical Examination
The nurse conducts a physical examination to assess common pressure sites and the characteristic of an existing pressure ulcer. When pressure ulcer is present, the nurse notes following:
1) Location
2) Size of lesion centimeters, measure length, width, and depth.
3) Stage of the ulcer
4) Color of the wound bed and location of necrosis
5) Condition of the wound margins
6) Integrity of surrounding skin
7) Clinical sign of infection, such as redness, warmth, swelling, pain, odor, and exudates (note color of exudates)
8) The amount of time the lesion has been known to exist
9) Any previously used treatment
Inspection of skin
Color (assess for coloration, bleeding, ecchymosed, and vascularity (no ecchymosis, frank bleding, or vascular), inspect the lesion (location, elevation, color, odor, size). (Estes, 2002)
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Palpation of the skin:
Moisture (palpate all nonmucous membrane skin surfaces for moisture using the dorsal surfaces of the hands and fingers), tenderness, texture, temperature, turgor (palpate the skin turgor, or elasticity, which reflects the skin state of hydration), edema (palpate the skin edema, or accumulation of fluid in the intercellular spaces). (Estes, 2002)
b. Laboratory data
There are some examination for Laboratory data. The laboratory data are :
1. Albumin levels of less than 3, 5 mg/dl
2. Total lymphocyte count of less than 1.000/mm3
3. Coagulation studies
4. Wound cultures
B. Nursing Diagnose
(Koizer,1991)
The NANDA nursing diagnosis that related to clients who have skin wounds or who are risk for skin breakdown are High risk for impaired skin integrity. Impaired skin integrity, and impaired tissue integrity. Impaired skin integrity commonly applies to stage I and stage II pressure ulcers and to superficial wound extending through the epidermis but not through the dermis. Impaired tissue integrity applies to stage III and stage IV pressure ulcers and to wounds extending into subcutaneous tissue, muscle, or bone (Krasner, p.36).
C. 28
EVALUATION
To judge whether patient outcomes have been achieved, the nurse uses data collected during care, such as skin status over bony prominences and perineal area, nutritional fluid intake, mental status and soon. (kozier, 1991)
If outcomes are not achieved, the nurse should explorer the reason why:
1. Has the patient physical condition changed?
2. Were risk factors correctly identified?
3. Were appropriate lifting devices and techniques used?
4. Did the patient fail to comply with instructions about moving and turning?
5. Were appropriate pressure-relieving used, and they applied correctly?
6. Was the repositioning schedule adhered to?
7. If the patient is at home, was support service adequate? Did have the support person have the ability to perform required care?
REFERENCES
Desales.2010.Skin.http://.desales.edu/skin1b.htm.Accessed at 5th April 2010
Kozier, Barbara.1991.Fundamental of Nursing.Sidney: Mosby.
Lois White and Gena Duncan.2002.Medical-Surgical Nursing.united state:Delmar
Mckinley.2008. handouts/wound_infection_symptoms http://www.mckinley.illinois.edu/.html. Accessed at 5th May 2010
NANDA International.2007.Nursing Diagnose: definition and clasification 2007-2008.Philadelphia:NANDA
Potter and Perry’s.2003.Fundamental of Nursing. Sidney: Mosby.
Sribd.2010.Skin Integrity and Wound Care.http://www.sribd.com. Accessed at 5th April 2010
Wikipedia.2010.skin.http://wikipedia.org. Accessed at 18th April 2010
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