Integumentary basics- Wound classification/ dressing basics/ skin components

Layers of skin

• Epidermis (B KLM)

  • keratinocytes, melanocytes, langerhans cells, basal cells

• Dermis

  • collagen, reticulum, fibroblasts, macrophages, lymphatic glands, blood vessels, nerve fibers

Skin receptors and function- Meissner’s corpuscles

• detect light touch and texture (MeLT)

Skin receptors and function- Merkel Disks

• Detect light tough, texture, and pressure

Skin receptors and function- pacinian corpuscles

• Detect deep pressure and vibration

Skin receptors and function- Ruffini endings

• Detect warmth, stretch deformation within joints

Skin receptors and function- Free nerve endings

• Detect pain, temperature, touch, pressure, tickle and itch

Skin receptors and function- krause end bulbs

• detect cold temperature

Pressure Ulcers- General

• Pressure wounds are located over bony pressure areas and are staged related to the depth of the wound bed

• Occur due to immobility

• A pressure injury CAN NOT BE BACKSTAGED

Pressure Ulcers- Stages

• Deep tissue injury- intact skin, purple maroon appearance

• Stage 1- intact skin with non-blancable redness

• Stage 2- partial thickness wound, superficial in nature with pink/ red wound bed (shallow)

• Stage 3- full thickness wound, subcutaneous fat tissue visible but no bone, tendon, or muscle exposed (deep)

  • slough/ eschar present, undermining and tunneling may occur

• Stage 4- full thickness with exposed bone, tendon, or muscle

  • slough/ eschar present, undermining and tunneling often occur

• Unstageable- wound bed covered with slough/ eschar (unable to identify the depth)

Pressure injury- interventions

• Positioning and pressure redistribution devices

  • Bed- every 2 hours

  • W/C- every 15 min

  • Frail patients- every 30 min

• Elevate heels and keep the head of the bed <30 degrees unless necessary

• avoid WB on bony prominence/ wounds

• Air-filled cushions reduce pressure and friction while sitting

• educate patients/ caregivers on pressure relief strategies

Arterial wounds/ insufficiency

• Arterial insufficiency- Refers to a lack of adequate blood flow to a region of the body

• Arterial wounds:

  • Location: Toes, lateral malleolus, heels, anterior shins

  • Drainage: Minimal Arterial insufficiency- Refers to a lack of adequate blood flow to a region of the body

  • Arterial wounds:

    • Location: Toes, lateral malleolus, heels, anterior shins

    • Drainage: Minimal to slight exudate (usually dry)

    • Wound margins: Discrete punched out

    • Wound appearance: pale

    • Edema: none

    • Odor: none

    • Pain: likely (ischemic) Arterial insufficiency- Refers to a lack of adequate blood flow to a region of the body

Venous wounds/ insufficiency

• Venous insufficiency- Refers to inadequate drainage of venous blood from a body part, usually resulting in edema and/or skin abnormalities and ulcerations

• Venous wounds:

  • Location: Near medial/ lateral malleolus, above malleoli, below knee

  • Drainage: moderate to heavy exudate

  • Wound margins: irregular borders

  • Wound appearance: hyperpigmentation (hemosiderin staining)

  • Edema: likely

  • Odor: strong

  • Pain: none

Interventions- Arterial disorders

• Best: supervised interval walking (ischemic pain)

• Positioning: legs down (dependent)

• Education: smoking cessation; diabetes/ lipid/ BP control

• Contraindication: Compression if ABI is abnormal; cold; vigorous massage

Interventions- Venous Disorders (CVI/ Venous Ulcers)

• Best: Compression therapy (walk with compression garments)

• Positioning: Elevation

• Education: Avoid prolonged sitting/ standing; encourage movement

• Contraindication: Heat on edematous limbs; prolonged dependent positioning; high-impact exercise with active ulcer

Key points to remember- Different types of wounds

• Diabetic ulcers- generally located on the WB surface of the foot

• Venous insufficiency- frequently are proximal to the medial malleolus. they are edematous

• Arterial ulcers- generally located on lateral malleolus, distal toes, or areas of trauma

• Pressure ulcers- result of unrelieved external pressure on an area

Burn- Epidermal

• Vascularity: intact

• Color: Erythematous, pink/ red

• Surface appearance/ pain: delayed pain; tenderness

• Swelling/ healing/ scarring: minimal edema, heals spontaneously

Burns- Superficial partial thickness

• Vascularity: Blanching with brisk capillary refill

• Color: Bright pink/ red

• Surface appearance/ pain: very painful

• Swelling/ healing/ scarring: moderate edema; heals spontaneously, minimal scarring

Burns- Deep partial thickness

• Vascularity: Blanching with slow capillary refill

• Color: Mixed red and waxy white

• Surface appearance/ pain: Sensitive to pressure, but insensitive to light touch/ pinprick

• Swelling/ healing/ scarring: marked edema, slow healing, scarring

Burns- Full-thickness

• Vascularity: no blanching

• Color: white (ischemic)

• Surface appearance/ pain: Anesthetic; body hairs pull out easily

• Swelling/ healing/ scarring: Area depressed, requires skin grafting; scarring +

Burns- Subdermal

• Vascularity: none

• Color: Charred

• Surface appearance/ pain: Anesthetic, muscle, and nerve damage present

• Swelling/ healing/ scarring: Tissue loss, heals with skin graft or flap, scarring +

Rule of 9’s- Adult

• Head (A): 4.5

• Arm (A): 4.5

• Leg (A): 9

• Torso (A): 18

• Perineum: 1

Rule of 9’s- Child

• Head (A): 8.5

• Arm (A): 4.5

• Leg (A): 6.5

• Torso (A): 18

• Perineum: 1

Scars

• Normal: Flat and similar to skin color

• Hypertrophic scar: a healed wound with thick fibrous tissue that remains within the original wound border

• Keloid: condition which excessive scar tissue grows outside of the original margins of the wound

Types of wound drainage

• Transudate- clear, thin, and watery

• Serous- clear/ amber, thin and watery

• Serosanguineous- Clear/ tinge of red/ brown, thin and watery

  • indicates a wound is healing

• Sanguineous- Bloody, bright red fluid, indicates inflamed wound

• Pus- yellow/ brown, moderate to very thick

• Infected pus- hues of yellow, blue, and green, thick, and usually indicates infection, drainage may be foul

  • may not indicate infection as WBC macrophage necrotic tissue

Maceration

• wound is too moist, edges and periwound will become macerated

  • identified as white, friable, overly hydrated, and sometimes wrinkled skin

  • Cause: inappropriate wound care, uncontrolled wound drainage, perspiration, or incontinence

Desiccation

• If a wound lacks moisture, the wound and periwound will become desiccated

  • It is identified as cracked, with dry or flaky edges, and the tissue within the wound bed may be hard or crusty

  • Cuase: inappropriate wound care, inadequate moisture, infection, dehydration

Debridement- Selective

• Removal of only nonviable tissues from a wound

• Sharp debridement- use of scalpel, scissors, forceps (precise removal)

• Enzymatic debridement- use of a topical application of enzymes (collagenase)

• Autolytic debridement- Use of the body’s own mechanisms to remove nonviable tissue

• Biologic (maggot therapy)- Sterile larvae digest necrotic tissue

Blue SEA

Debridement- Nonselective

• Removal of both non-viable and viable tissues from a wound

  • > 50% dead tissue

• Wet to dry dressing- application of a moistened gauze over area of necrotic tissue to be completely dried and removed

• Wound irrigation- moves necrotic tissue from wound bed using pressurized fluid

• Hydrotherapy: using a whirlpool with agitation directed toward a wound requiring debridement

Dressings

• Based on exudate and if the wound is infected

• Heavy exudate: calcium alginates, hydrofibers

• Moderate exudate: foams

• Minimal exudate: hydrogel dressing, hydrocolloid

• Very mild exudate: transparent films

• Infected wounds: hydrofiber, hydrogels, calcium alginates, and gauze

  • NO HYDROCOLLOIDS IN INFECTED WOUNDS