Skin Integrity and Wound Care Documentation and Informatics, Study Guides, Projects, Research of Nursing

Download Skin Integrity and Wound Care Documentation and Informatics and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Sherpath Ch. 48 Skin Integrity and Wound Care Page 1 of 15 NUR100 Sherpath skin overview + skin integrity Chapter 26 - Documentation and Informatics 1. “if you did not write it, you did not do it” 2. Proper documentation, Telephone orders, verbal orders, Informed Consent, purpose of medical records, discharge summary Principles of informatics Chapter 48- Skin Integrity and Wound Care 1. Wound closures-primary, secondary, tertiary intention; 2. Dehiscence vs. Evisceration, proper nursing care for each Principles of wound care, proper wound care 3. Stages of pressure ulcers, levels of tissue involvement, Braden scale Infection vs Inflammation 4. Nursing interventions for all the above, including the primary, secondary and tertiary preventions 5. Principals of delegation 6. Patient teaching Chapter 26 Key Points • The medical record is a document with comprehensive information about a patient’s health care encounter, as well as demographic, administrative, and clinical data. o Serves: ▪ as a major communication tool between staff members ▪ a single data access point for everyone involved in the patient’s care. electronic medical record (EMR) VS electronic health record (EHR) • a record of one care episode e.g. o an inpatient stay o an outpatient appointment • a longitudinal record of health care that includes: o the inpatient and outpatient health care episodes from one or more care settings. • Core components of EHRs 1. health information 2. diagnostic results. MAY ALSO INCLUDE 3. provider order entry system (CPOE – Computerized Provider Order Entry) 4. decision support (DSS -- Computerized Decision Support Systems) • Registered nurses are responsible for reviewing documentation by UAP for all patients under their care. • Use of an electronic health record (EHR) system can yield positive results in efficiency and patient care safety, but EHR use is not without challenges, such as staff adjustments to the new technology and workflow and the need for back-up plans in case of EHR system failure. • EHR security is controlled through assignment of individual passwords and verification codes that identify users who have the right to enter the record. • EHR security depends on adherence to safe practices by staff when using the EHR. • Standards for documentation are established by each health care organization’s policies and procedures. Sherpath Ch. 48 Skin Integrity and Wound Care Page 2 of 15 • General principles of medical record documentation from the Centers for Medicare and Medicaid Services (2010) include: • Completeness and legibility of all documentation • Inclusion of the reasons for each patient encounter, including assessments and diagnoses • Documentation of the plan of care, the patient’s progress, and any changes in diagnosis and treatment • Expected nursing documentation includes the nursing assessment, the care plan, interventions, the patient’s outcomes or response to care, and assessment of the patient’s ability to manage after discharge. • Nursing documentation must be factual and nonjudgmental, with proper spelling and grammar, and should reflect thoughtful professional nursing practice. • Standardized nursing language should be used whenever possible in documentation. • Nurses must be aware of the dangers of using abbreviations that may be misunderstood and compromise patient safety, and should use only accepted abbreviations. • Medical records are legal documents. • Specific legal considerations related to medical records include handling of errors and changes, timeliness of documentation, and confidentiality and security of information. • Within a medical record, nursing documentation may be done in a narrative format or in a problem- oriented format. • PIE, APIE, SOAP, and DAR notes are all recognized as common variations of formatted problem-oriented nursing documentation. • Flow sheets and checklists are used to document routine care and observations that are recorded on a regular basis, such as vital signs and intake and output measurements. • Charting by exception is documentation that records only abnormal or significant data. • A medication administration record (MAR) is a list of ordered medications, including the specific dosages and administration schedule, on which the nurse documents medications given or not given. • Many facilities using electronic medication administration records (eMARs) use bar-coded medication administration. • An RN who takes a verbal or telephone order must repeat the order verbatim to the provider to confirm accuracy and then enter the order into the paper or electronic system, documenting it as a verbal or phone order and including the date, time, provider’s name, and RN’s signature. • Admission and discharge summaries are important parts of the medical record because they provide health care professionals concise and pertinent information about a patient’s hospital visit. • The term kardex continues to be used generically for certain patient information held at a nursing unit station. Chapter 48 Overview of Skin Skin Basics (body’s largest organ - 6 pounds) 1. Regulation of Heat - Steadies body temperature through: o the ability to dilate and constrict blood vessels o to produce perspiration in response to changes in internal and external temperature 2. Sensation - Provides tactile feedback: o to aid in identification of objects in the environment o to alert us to danger by transmitting the sensations of: • pressure • pain • temperature extremes 3. Production of Vitamin D - Produces vitamin D in the presence of sunlight (duhr?) 4. Release of Toxins - Assists with: o elimination of toxins and wastes from the body o maintenance of fluid and electrolyte balance 5. Protection - Forms an effective barrier against environmental hazards such as: • ultraviolet light • chemicals • microbes • pathogens Sherpath Ch. 48 Skin Integrity and Wound Care Page 5 of 15 Classification by wound depth Superficial or partial thickness Superficial wounds affect only the epidermis. Partial-thickness wounds affect the epidermis and the dermis but do not extend through the dermis to the subcutaneous layer. These wounds tend to heal quickly, without scarring, unless outside factors such as infection delay the normal healing process. Deep or Full-Thickness Deep wounds extend through the dermis into the subcutaneous layer. Wounds can extend beyond the subcutaneous layer into the muscle, bone, or other underlying structures. Full-thickness wounds tend to heal slowly and leave scarring. Full-thickness wounds are more likely to become chronic in nature. Classification by Contamination Level Wounds can also be classified on the basis of contamination. These wounds are known as clean, clean contaminated, contaminated, infected, or colonized. Classification Characteristics Clean • No infection and minimal risk for infection, e.g., wound from a closed-surgical incision made in the controlled, sterile environment of the operating room that does not involve bacteria- containing organ systems. • Wound was not contaminated during trauma or from the incident in which the wound occurred, e.g., laceration received during an automobile crash. Clean Contaminated • Similar to a clean wound, but with greater risk of infection. • Surgical involvement of organ system, e.g., bowel surgery with some increased risk for infection, but not as significant as contaminated. Contaminated • High risk for infection due to a break in sterile technique during surgery, or from the perforation of a hollow organ (bowel, etc.) before surgery allowing for spillage of bacteria- laden material into the surgical area. • Wound was contaminated during certain types of trauma or accidents with a high risk for infection, such as penetrating trauma or a fall. Infected • Presence of a bacterial count of at least 105 per gram of tissue. • Presence of clinical signs: Redness (erythema), warmth, and increased drainage that may or may not be purulent (contain pus). Colonized • Contains one or more organisms present on the surface of the wound in a swab culture, but no overt sign of infection below the surface. • Common in chronic wounds and may contribute to delayed wound healing. Classification by Healing Process Wounds may be classified by their progression through the wound healing process. Classification Characteristics Primary Intention • Quick, uncomplicated healing of an acute wound with minimal scar tissue. • Examples: Surgical incisions or traumatic wounds in which the edges of the wound can be brought together (approximated). Sherpath Ch. 48 Skin Integrity and Wound Care Page 6 of 15 Classification Characteristics Secondary Intention • Healing in which new tissue fills in from the bottom and sides of the wound until the wound bed is filled. • Examples: Chronic wounds or wounds associated with disease processes such as diabetes or vascular disease, or with other factors that have inhibited proper wound healing. Tertiary Intention • Healing in which the wound is initially left open for a while after injury and a delay occurs between injury and closure. • Examples: Contaminated surgical wounds left open to allow observation and better drainage (common in GI tract); closed later when infection risk is reduced. Wound Classification: Burns Burns are tissue injuries caused to the skin by heat, electricity, chemicals, radiation, extreme cold (hypothermia/frostbite), or friction. Wounds from burns are classified according to the depth of the lesion, e.g. superficial or extending into the subcutaneous layer, muscle, and bone. When burns occur over a large percentage of the body, the patient is at risk for serious complications such as infection and fluid and electrolyte imbalance. Classification Characteristics Superficial (First Degree) • Affect only the epidermal layer of the skin but may extend somewhat deeper • Result in pain and redness Superficial and Deep Partial-Thickness (Second-Degree) • Superficial: Affect epidermal layer and upper third of dermis • Deep partial-thickness: Affect deep layers of the dermis and destroy structures within the dermis • Result in extreme pain and blistering Full-Thickness and Deep Full-Thickness • Damage the subcutaneous tissue, muscle, and bone • Result in white or brown areas, charring, and loss of sensation Staging of Pressure Ulcers Pressure ulcers are also known as decubitus ulcers and bedsores; however, the term pressure ulcer more clearly reflects the underlying cause of the wound. A pressure ulcer is injury to skin caused by pressure from bony prominences and/or shearing. Pressure ulcers are classified by type of visible tissue. This is also called staging. Stage I • Intact, non-blistered skin • Non-blanchable erythema or persistent redness in the area of pressure (abnormal reactive hyperemia) • Painful area that differs in firmness and temperature from surrounding tissues Sherpath Ch. 48 Skin Integrity and Wound Care Page 7 of 15 Stage II Partial-thickness wound involving the epidermis and dermis Shallow and superficial with a pink wound bed Also includes intact or ruptured blisters from pressure that have not yet cratered Stage III • Full-thickness wounds extending into the subcutaneous tissue, but not into fascia, muscle or bone • May include undermining (tissue loss around edges and under intact skin, forming a lip around the wound) • May include tunneling (narrow passage-way extending out from the wound) Stage IV • Full-thickness wound that is deeper than a stage III wound • Involves exposure of muscle, bone, or connective tissue (tendons, cartilage) • Infection of the bone, if exposed, is highly likely Unstageable • Full-thickness wound with necrotic tissue (eschar) • Assessment of wound depth or involvement of underlying tissues is not possible Suspected Deep Tissue Injury Sherpath Ch. 48 Skin Integrity and Wound Care Page 10 of 15 o Prolonged inflammatory phase o Delayed collagen synthesis o Inadequate or no epithelialization that can lead to additional tissue destruction o Failure of the wound to progress through normal phases of healing o Development of a chronic wound • Wounds showing no progress toward healing despite appropriate treatment must be assessed for an underlying infection and treated aggressively for infection, if present. Factors contributing to pressure ulcers Intensity • Unrelieved pressure exceeding the normal 12 to 32 mm Hg due to immobility or inability to sense pressure- related pain leads to tissue ischemia. • Tissue ischemia leads to actual pressure ulcers. • Subcutaneous tissue and muscle tissue are more susceptible to pressure than other tissues. Duration • Low levels of pressure over long periods of time can damage the skin and underlying tissue as much as high levels of pressure over a short period of time. o Pressure has a cumulative effect on tissues. Tissues exposed to pressure, even when pressure is removed, may experience considerable damage when re-exposed to the same degree or a lesser degree of pressure later. Friction/Shear • Friction involves the rubbing together of two surfaces, e.g. the skin and bed. While friction damages the epidermal layer, greater damage occurs from shear. • Shear is the opposing stress of the skin and the surface of the bed as the patient’s weight pulls the person downward. This pull results in hyperangulation and stretching of the blood vessels, affecting their ability to transport blood. Sensory loss, Immobility • Patients with neurologic conditions such as spinal cord injury, those with chronic conditions that lead to neuropathies, as in diabetes, patients with dementia or brain injury, and those who are in traction or restraints or who are unable to reposition themselves independently are at risk because they are: o Unable to feel pain (the warning sign of tissue ischemia). o Unable to respond by moving and/or changing positions independently. Moisture • Incontinence contributes to the development of pressure ulcers due to the effects of maceration, a condition in which excessive moisture causes softening of the skin, leaving it vulnerable to breakdown. • More recent studies show that while the skin may become macerated and the enzymes found in stool can lead to perineal inflammation and dermatitis, the damage from moisture is confined to the more superficial layers Kottner, Balzer, Dassen, and Heinze, 2009; Pieper, Langemo, and Cuddigan, 2009). Malnutrition • Compromised nutrition inhibits the ability of tissues to withstand the forces of pressure and shear and to combat infectious agents when patients have: o Unintentional weight loss of 5% or more o Low body mass index (BMI) o Deficiencies in vitamins A, C, and E and the minerals zinc and copper Sherpath Ch. 48 Skin Integrity and Wound Care Page 11 of 15 o Protein-calorie malnutrition Complications Dehiscence, Evisceration • When healing tissues of surgical incision are under physical stress, they are at risk for two primary complications of wound healing: o Dehiscence: Partial or complete separation of tissue layers o Evisceration: Total separation of tissue layers, allowing protrusion of visceral organs through incision • Usually occur 5 to 9 days after surgery and are related to a delay in collagen synthesis. • If a wound is healing properly, a 1-cm-wide ridge, or area of induration, can be palpated next to incision line. A ridge is indicative of new collagen being laid down in the wound. If a “healing ridge” is not felt, the wound is at increased risk for dehiscence and evisceration. • Symptoms include a “popping” sensation accompanied by an increase in drainage from wound. Sutures and staples may be applied to keep wound closed. Fistula • Abnormal connections between two internal organs or between a protruding internal organ and (through the skin) the outside of body. • Identified by names of organs involved: o Enterovaginal: opening between the intestines (entero) and the vagina, allowing intestinal content to drain into the vagina. o Enterocutaneous: opening between the intestines (entero) and the skin (cutaneous). • Usually result from: o Specific disease processes o Treatment modalities o Factors of poor wound healing • Predispose the affected person to fluid and electrolyte loss and imbalance, nutritional deficits, and alterations in skin integrity, particularly if the fistula is draining material that is naturally destructive to the skin’s surface, e.g., exposure to digestive enzymes normally found in fluids from the small intestine can cause extensive damage to skin in a short time. Sherpath Ch. 48 Skin Integrity and Wound Care Page 12 of 15 Key Points • Knowledge of various wound classifications facilitates communication with patients and health care professionals. • Classification by skin integrity includes open wounds, in which the skin’s surface is broken, and closed wounds, in which the skin's surface remains intact. • Wounds classified by depth include superficial, partial-thickness, and full-thickness (deep) wounds, based on the depth of skin layers involved. • Wounds classified by level of contamination include clean, clean contaminated, contaminated, infected, and colonized, based on degree of wound contamination. • Wounds classified according to the healing process are known as primary, secondary, or tertiary intention. • Burns are classified according to depth of the burn, e.g., superficial (first degree), partial-thickness (second degree), or full-thickness (third degree). • Pressure ulcers are classified based on type or stage of ulcer, from stage I to unstageable. • The phases of wound healing include the inflammatory phase (blood clotting and the natural process of cleaning the wound), the proliferative phase (repair, filling in the wound bed with new tissue, and resurfacing the wound with skin), and the maturation phase (skin remodeling). • Factors that affect wound healing are similar to those that affect the skin’s integrity. • Factors that can affect and ultimately slow or delay wound healing include disease, smoking, age, nutrition, and infection. • Complications of wound healing include dehiscence, evisceration, and fistulas. • A pressure ulcer is a wound to the skin and/or underlying tissue, usually over a bony prominence, and is the result of pressure, or pressure in combination with shear. • Nursing plays a critical role in the identification of patients at risk for pressure ulcers, and the prevention and resolution of the pressure ulcers. Assessment related to Skin Integrity Focused Assessment • Temperature • Overall color • Local variations in color • Presence of excessive moisture or dryness • Odor • Texture • Turgor • Integrity • Presence of wounds • Presence of risk factors associated with skin breakdown or impaired healing Focused Questions • How do you describe the overall condition of your skin? • Have you ever had any skin problems? If so, what, and when? • Describe your skin care regimen. • Describe your diet. Have you experienced any recent unintended weight loss?