NURS 305 - skin & wounds

skin

• risk factors, illness, disease, & age decrease strength

• 2 layers

  • epidermis

  • dermis

  • dermal-epidermal jxn

epidermis

• top layer of skin

dermis

• inner layer of skin

• collagen 

dermal-epidermal jxn

• separates dermis & epidermis 

epidermis layers

• stratum corneum

• stratum lucidum (thick skin)

• stratum granulosum

• stratum spinosum

• stratum basale

dermis layers

• papillae

• papillary reigon

• reticular region 

pressure injuries

• aka decubitis ulcer, pressure ulcer, bed sore 

• mostly over bony prominences 

• localized damage to skin/underlying soft tissue 

• compromises cellular metabolism/fxn → decreased or no blood flow → tissue death (ischemia)

pressure issue pathogenesis

• manner of development of disease

  • mechanical load

  • duration of pressure

  • tissue tolerance

mechanical load & pressure injuries

• force applied to soft tissue, skin, & underlying tissues by external object, surface, or device 

  • catheters, IV tubing 

• affects capillary circulation of underlying tissue 

  • when there is high capillary pressure → vessels occluded prolonged time → tissue ischemia

duration of pressure

• prolonged/intense 

tissue tolerance

• dependent on (increased risk)

  • decreased mobility/sensory perception

  • fecal/urinary incontinence 

  • bad nutrition 

• shear force bad!

blanching

• when normal red tones in skin are absent 

  • doesn’t turn white? nonblanchable 

• from decreased blood flow 

  • press → lighter color? blanchable!

nonblanchable skin

• deep tissue injury → stage one pressure injury 

hyperemia

• red tones

risk factors for pressure ulcer development

• impaired sensory perception

• impaired mobility

• LOC alteration

• shear 

• friction 

• moisture 

impaired sensory perception

• pt cannot detect pressure discomfort

• cognitive impairment 

  • needs more frequent skin assesment 

impaired mobility

• cannot independently change positions → illness/injury 

• nurse has to reposition!

LOC alteration

• confused, comatose, disoriented, expressive aphasia 

  • might be lying on smth and cannot verbalize 

expressive aphasia

• cannot verbalize need properly

shear

• force in sliding movement 

• when skin is pulled across bed & SQ tissue moves, but muscle/bone remains stationary 

• deep tissue injury

friction

• 2 surfaces sliding across one another

• ie: legs getting dragged across coarse linens 

• affects superficial surface of skin 

moisture

• prolonged? decreased resistance against pressure, friction, shear 

• incontinent, diaphoretic → frequent skin assessment 

repositioning

• have right amt of ppl! 

• assess what movement, height, ability to assist 

• totally immobile? have ppl w/ you! 

  • reduce friction/shear 

pressure injury classification

• 4 stages 

• we don’t do this → hospital/unit specialist 

• big in hospitals! happens? hospital doesn’t get reimbursed by insurance 

  • existing? document! assess! prove they didn’t get it in hospital 

    • photos, notification of dr, charting 

• assess, document, pictures, notify!

• w/ healing, stage stays the same- just in healing state

• what wound deterioration is occurring?

stage 1 pressure injury

• non-blanchable erythema of intact skin

  • bony prominences 

    • sacrum, back of head, elbows, heels 

  • prolonged pressure 

stage 2 pressure injury

• partial-thickness skin loss w/ exposed dermis 

• wound red/moist

• fluid filled blisters 

• common w/ incontinence, skin tears, burns, medical tape 

stage 3 pressure injury

• full thickness skin loss

• adipose & granulation tissue present 

  • granulation tissue - pink, moise 

stage 4 pressure injury 

• full-thickness skin & tissue loss

• fascia, muscle, tendon, ligament, cartilage, bone visible 

  • many tissues! 

• tunneling 

unstageable pressure injury

• obscured full-thickness skin & tissue loss obscured by slough/eschar 

  • exudate 

• debride to stage!

exudate

• drainage 

  • amt 

  • color

  • consistency 

  • odor 

slough

• avascular 

• moist 

• shiny

• remove!

eschar

• dead/scab tissue 

• black, brown 

• necrotic 

• remove!

granulation tissue

• red & moist 

• new vessels seen

deep-tissue pressure injury

• localized area of non-blanchable deep red, maroon, or purple discoloaration 

• can also be epidermal separation w/ dark wound bed/blood filled blister 

• intact or nonintact

• intense prolonged pressure, shear, friction

• + slough, eschar, exudate?

• full thickness pressure injury

induration

• assess around wound

  • redness

  • warmth

  • pain

  • swelling 

medical device-related pressure injury

• sustained pressure/shear

• nonbony locations

• bc of poorly positioned/ill-fitting/incorrect device use 

• mostly face/head → ears 

  • O2 tubing, face masks

medical adhesive-related skin injury

• tape/other medical adhesives 9ostomy securing)

• erythema & other cutaneous abnormalities persist 30+ min after removal of device/adhesive

  • attachment btwn skin & adhesive stronger than skin cells → epidermis detaches from underlying skin layers

wounds

• classification

• process of wound healing

• repair

wound classifications

• surgical/trauma

• partial-thickness/full-thickness

• describes onset & duration of healing process, descriptive 

wound repair

• partial-thickness

• full-thickness

partial thickness wound repair

• needs inflammatory response

  • in 24hr, nutrients, blood flow, O2 move to area

• epithelial proliferation/migration 

• reestablishment 

epithelial proliferation/migration 

• new cell movement! 

• up to 7 days

• too dry? less cells 

  • keep bed moist. it needs O2

  • daily wound care

partial-thickness wound

• shallow, moist, painful

• regeneration healing 

full-thickness wound repair

• formation of new tissue takes longer

  • hemostasis

  • inflammatory

  • proliferative

  • maturation

hemostasis phase

• controls bleeding & bacteria 

• seals defect 

• vessels constrict & platelets gather 

  • fibrin forms to deal

inflammatory phase

• increased blood supply 

• vasodilation

• increase WBC

  • control bacteria

• growth 

  • collagen appears

proliferative phase

• filling wound w/ granulation tissue 

• wound contraction 

• new skin forming 

• needs good blood supply 

• anemia bad 

• zinc and protein!!!

maturation phase

• final 

• up to 1yr 

• less melanin 

  • scarring 

• skin not as strong 

full-thickness wound

• loss of dermis/epidermis 

• down to SQ

• painful, deep 

primary intention wound healing

• clean, surgical incisions 

• approximated edges 

• decreased risk for infection 

secondary intention wound healing

• loss of tissue 

• burns, stg 2 pressure ulcers 

• wound left open 

  • fills w/ scar tissue 

• takes longer

• increased risk of infection

tertiary intention wound healing

• delayed closure

• abdominal incisions often

• infection complications 

wound healing complications

• hemorrhage

• infection

• dehiscence

• evisceration 

hemorrhage

• hemostasis needed

• internal

  • distention

  • BP drop

  • LOC altered 

  • increase HR 

• external

infection assessment

• 2nd most common HAI

• skin infection 

• upped WBC helps police bacteria

• always assess for localized infection

  • erythema, wound drainage (color, amt), edema, fever

dehisecence

• injury fails to heal 

• separates

  • partial, total 

evisceration

• protrusion of visceral organ thru opening

• medical emergency

• sterile cover!

  • if kept out, blood flow can be compromised

• NPO! call surgical team!

• monitor for shock symptoms

types of exudate

• serous

• serosanguinous

• sanguineous 

• purulent 

serous

• clear

• watery

• plasma

• normal 

serosanguinous

• pale

• pink

• watery 

• normal 

sanguineous

• bright red, blood!

• can be normal initially

• eventual hemostasis 

purulent

• thick

• white/yellow/tan/brown/green

• infection indication!

prediction & prevention of pressure injuries

• risk assessment 

• economic consequences of pressure injuries 

risk assessment

• braden scale 

  • lower score, higher risk

• assess skin breakdown 

braden scale

• assesses

  • sensory perception

  • moisture

  • activity

  • mobility

  • nutrition

  • friction, shear risk 

• score ranges from 6-23

  • lower, more at risk

money & pressure injuries

• affects length of stays & costs for hospitals

• mediacid & medicare doesnt reimburse hospital wounds 

  • big!

factors influencing healing & injury formation

• nutrition

• tissue perfusion

• infection

• age

• psychosocial impact of wound 

nutrition

• important!

• needs

  • protein

  • vit a, c (collagen)

  • zinc

  • good calories 

tissue perfusion

• good O2 in blood → good O2 in tissues 

infection

• prevent/treat?

  • healing faster! 

• remove so collagen & new tissue can form 

age

• at risk

  • very old

    • decreased healing, less mobile, skin thinner 

  • very young

psychosocial wound impact

• body image! 

• how pt responds to wound 

• hideous? can’t contribute like before?

  • alters wound healing

• good outlook?

  • good healing

critical thinking

• knowledge of normal skin & muscle physiology, pathogenesis of injury, pressure injury stages, normal wound healing, pathophysiology of underlying diseases

  • provides scientific basis to approach assessment for pt 

• examine wound & observe how healing occurs → helps recognize abnormalities 

• previous experience 

• info gathered from pt 

• be creative! 

• be diligent! prevents injury/breakdown 

assessment

• thru pts eyes

• environment

• skin

• wounds & pressure injuries 

• surgical & traumatic wounds

• psychosocial 

assessment thru pts eyes

• pt & fam need to be included 

• involve them!

environment assessment

• good for healing? 

• safe? 

• positioning?

• devices?

• interruptions in healthcare access?

skin assessment

• hospital protocol & policy

  • every 4hr, more prn 

• braden scale 

• clinical judgement 

• check medical devices 

more frequent skin assessment

• high risk

  • cognitive impairments

  • chronic illness

  • altered mental status, ICU, oncology, hospice 

pressure ulcer sites

1. occipital bone

2. scapula

3. spinous process

4. elbow

5. iliac crest

6. sacrum 

7. ischium

8. achilles tendon 

9. heel

10. sole

11. ear

12. shoulder

13. anterior iliac spine

14. trochanter 

15. thigh

16. medial knee

17. lateral knee

18. lower leg 

19. medial malleolus

20. lateral malleolus 

21. lateral edge of foot

22. posterior knee

wound & pressure injury assessment

• predictive measures

• mobility

• nutritional status

• body fluids (incontinence)

• pain 

  • makes pt want to move less 

wound & pressure injury predictive measures

• determining risk factors 

• whats working against pt?

  • age

  • mobility

  • body fluids

  • pain

  • cognitive impairments

surgical & traumatic wound assessment in emergency setting assessment

• abrasions

• lacerations

• puncture 

abrasions

• superficial

• partial thickness

• small amt of bleeding 

lacerations

• more bleeding

• deeper

puncture wound

• small 

• deep 

• internal bleeding risk 

surgical & traumatic wounds assessment in stable setting

• dressings! 

  • protect & stabilize

  • change as ordered 

  • can be painful

    • assess, give meds

surgical & traumatic wound appearance assessment

• approximation

• size

• erythema

• swelling

• edema

• drainage 

character of wound drainage assessment 

• color

• odor

• consistency

• amt 

surgical & traumatic wound palpation

• how far is pain/sensitivity?

• not aggressive!

surgical & traumatic wound drain assessment

• for drainage

  • removes from body 

  • helps regeneration 

• JP (jackson pratt), pressure, hemovac

• depends on surgeon/dr preference, wound bed, & body part

surgical & traumatic wound closure assessment

• instrumentation! 

• surgical intervention

  • sutures

  • staples 

• depends on provider preference, wound, what body part 

surgical & traumatic wound culture assessment

• obtained when infection suspected

• collect during wound care! 

• medicate pt → collect specimen 

psychosocial assessment

• fear?

• coping?

• effect on everyday life?

• work?

nursing diagnosis ex

• what matters? priorities! risks lower

  • risk for infection

  • acute/chronic pain

  • impaired nutritional intake 

  • impaired peripheral tissue perfusion

  • impaired mobility 

setting priorities

• know skin breakdown risks 

• appropriate recognition, management, & treatment of wound severity 

implementation

• promotion 

• acute care

health promotion

• educate! 

• nutrition

• prevention of pressure injuries 

pressure injury prevention education

• topical skin care & incontinence management 

• positioning 

topical skincare & incontinence management education

• be diligent w/ hygiene! 

• skin clean & dry 

  • not too long in fluids 

positioning education

• turn q2h

• get ppl to help 

• use pillows to relieve pressure 

• rotisserie! 

• gives bony prominences O2, nutrients, air, less pressure