N11 Topic 7 - Skin Integrity and Wound Care

What is the goal for problems in skin integrity and wounds? (2)

Maintain skin integrity

Promote wound healing

Who are at risk for impaired skin integrity? (4)

Older adults

Clients with restricted mobility

Chronically ill

Trauma patients

presence of normal skin and skin layers uninterrupted by wounds

Intact skin

Medication that causes thinning of the skin and allow it to be much more readily harmed

Corticosteroid

What are some medications that increase sensitivity to sunlight, predisposing a person to sunburn? (4)

Doxycycline

Tetracycline

Methotrexate

Tricyclic anti-depressants

__________ trauma occurs during therapy

Intentional

__________ wounds are accidental

Unintentional

If the tissues are traumatized without a break in the skin, the wound is __________

closed

The wound is open when the _____ or _____ surface is broken

skin or mucous membrane

Wound caused by sharp instrument

Incision

Caused by blow from a blunt instrument

Contusion

Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels

Contusion

Caused by surface scrape; open wound involving the skin

Abrasion

Caused by penetration of the skin and often the underlying tissues by a sharp instrument

Puncture

Tissues torn apart, often from accidents

Laceration

Penetration of the skin and the underlying tissues, usually unintentional

Penetrating wound

are uninfected wounds in which there is minimal inflammation and the gastrointestinal, genital, and urinary tracts are not entered

Clean wounds

are surgical wounds in which the gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.

Clean-contaminated wounds

include open, accidental, and surgical wounds involving a major break in sterile technique or spillage from the gastrointestinal tract

Contaminated wounds

include wounds with evidence of a clinical infection, such as purulent drainage or necrosis

Dirty or infected wounds

are confined to the skin, that is, the dermis and epidermis, and heal by regeneration

Partial thickness wounds

involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone, and require connective tissue repair

Full thickness wounds

consist of injury to the skin or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement

Pressure injuries

What’s the most common cause of pressure injury?

Ischemia

a deficiency in the blood supply to the tissue causing pressure injury

localized ischemia

When pressure is relieved, the skin takes on a bright red flush (erythema), called ___________

reactive hyperemia

After the skin has been compressed for a long time, it appears _____ then when the pressure is relieved, the skin takes on a bright ______

pale; red flush

The flush is due to ___________, a process in which extra blood floods to the area to compensate for the preceding period of impeded blood flow

vasodilation

How does friction causes skin abrasion leading to pressure ulcer?

Friction can abrade the skin or remove the superficial layers, making it more prone to breakdown

a combination of friction and pressure

Shearing force

occurs commonly when a client assumes a sitting position in bed

shearing force

refers to a reduction in the amount and control of movement an individual has

Immobility

Examples of immobility as risk factor for pressure injury

Paralysis

Extreme weakness

Pain

Decreased activity

Prolonged inadequate nutrition causes ________ (3)

weight loss

muscle atrophy

loss of subcutaneous tissue

How does prolonged malnutrition lead to pressure injuries?

Prolonged malnutrition > weight loss, atrophy, loss of subq tissue > decreased padding between skin and bones

Lack of what nutrients contributes to pressure injury formation?

Protein

Carbohydrates

Fluids

Zinc

Vitamin C

What causes hypoproteinemia and how does it lead to formation of pressure ulcer?

Inadequate intake or abnormal loss of protein > hypoproteinemia > dependent edema > decreases skin elasticity, resilience, and vitality / slows diffusion of O2 and metabolites

refers to tissue softened by prolonged wetting or soaking

skin maceration

How does incontinence lead to formation of pressure ulcer? (2)

moisture from incontinence > skin maceration > makes epidermis more easily eroded and susceptible to injury

digestive enzymes, urea, and GT drainage > skin excoriation

refers to area of loss of the superficial layers of the skin

skin excoriation

Skin excoriation is also known as

denuded area

MASD means ______

Moisture-related skin damage

IAD means ______

incontinence-associated dermatitis

Examples of outside-in damage to skin

MASD and IAD

Examples of inside-out damage to skin

true pressure injuries

Skin or tissue injury due primarily to moisture is referred to as

MASD or IAD

How does accumulation of secretions/excretions cause pressure ulcers? (3)

irritates skin

harbors microorganism

makes skin prone to breakdown and infection

What factor can cause pressure ulcer d/t lessened ability to recognize and respond to pain from pressure

Decreased mental status

Examples of reduced level of awareness/decreased mental status that can lead to pressure ulcer

Unconsciousness

Heavy sedation

Dementia

How does diminished sensation cause pressure ulcer?

Diminished sensation > reduce response to trauma, extreme heat and cold, signs of loss of circulation & impaired ability to recognize and provide healing for wound

Examples of diminished or loss of sensation

Paralysis

Stroke

Neurologic disease

Symptom of loss of circulation

pins and needles

How does body heat lead to formation of pressure ulcer?

Elevated body temperature > increased metabolic rate > increased need for O2 > more burden on oxygen deficient cells under pressure > reduced ability to cope

Effects of aging on skin

• body mass

• epidermis

• strength/elasticity

• sebaceous gland

• pain perception

• blood flow

loss of lean body mass

thin epidermis

decreased strength/elasticity d/t change in collagen fibers

decreased oil produced by sebaceous gland > increased dryness

diminished pain perception > decreased cutaneous end organs

decreased blood flow d/t aging vessels

Chronic medical conditions affect skin integrity by:

compromise oxygenation and perfusion > delayed healing & vulnerable to pressure injury

Other factors from the nurse’s end that contributes to ulcer formation (4)

poor lifting and transferring techniques

incorrect positioning

hard support surfaces

incorrect application of pressure-relieving devices

Identify 13 factors contributing to pressure ulcer formation

1) Friction and shearing

2) Immobility

3) Prolonged inadequate nutrition

4) Fecal and urinary incontinence

5) Decreased mental status

6) Diminished sensation

7) Excessive body heat

8) Old age

9) Chronic medical condition

10) Poor lifting and transferring techniques

11) Incorrect positioning

12) Hard support surfaces

13) Incorrect application of pressure-relieving devices

Rule of 30 in positioning

minimize pressure on the _____ and ______ by raising the _________ no more than 30° and turning the client __________ degrees

sacrum and coccyx

head of bed

laterally 30°

Stage ___ of Pressure Injury Formation

skin is unbroken and reddened, but does not blanch

1

Stage ___ of Pressure Injury Formation

partial-thickness skin loss

2

Stage ___ of Pressure Injury Formation

full-thickness skin loss and damage that may reach as deeply as the fascia

3

Stage ___ of Pressure Injury Formation

the edges of the skin surrounding the injury roll under and the damage extends under the rolled tissue

3 with epibole

refers to rolled or curled-under closed wound edges that may be dry, callused, or hyperkeratotic

epibole

Stage ___ of Pressure Injury Formation

full-thickness skin loss with tissue death or damage to underlying structures

4

Stage ___ of Pressure Injury Formation

full-thickness loss. The full extent of the injury cannot be determined due to slough or eschar

Unstageable or unclassified

refers to cornified or dried out dead tissue

Eschar

refers to liquefied or wet dead tissue

Slough

Stage ___ of Pressure Injury Formation

depth unknown: dark area of discolored intact skin due to damage of underlying soft tissue

Deep tissue pressure injury

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area

Stage 1 Pressure Ulcer

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ ruptured serum-filled blister

Stage 2 Pressure Ulcer

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Stage 3 Pressure Ulcer

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling

Stage 4 Pressure Ulcer

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Deep Tissue Injury

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed

Unstageable

Pressure injury documentation should include:

Location

Stage

Size - length, width, depth

Tunneling or undermining

Slough or eschar

Exudate/drainage - amount, color, odor

Granulation

Description of surrounding tissue

Support surface

Pain

What are some risk assessment tools for pressure injury?

Braden Scale for Predicting Pressure Sore Risk

Norton’s Pressure Area Risk Assessment Scoring System

What are the pressure areas when a patient is in supine position?

Occipital bone

Scapulae

Elbows/Olecranon process

Sacrum

Calcaneus

What are the pressure areas when a patient is in prone position?

Zygomatic bone

Shoulder/Acromial process

Breasts

Genitalia

Patella

Phalanges

What are the pressure areas when a patient is in lateral position?

Parietal and temporal bone

Ear

Acromial process

Ilium

Greater trochanter

Medial and lateral knees

Medial and lateral malleolus

What are the pressure areas when a patient is in Fowler’s position?

Vertebrae/Spinal processes

Sacrum

Pelvis

Calcaneus

Assessing common pressure site

• Temperature of room

• First examination technique? Capillary refill

• Presence of what?

• Second examination technique? Temperature compared to surrounding skin

• Bony prominences/dependent body areas

Not too cold, not too hot

Inspect for discoloration. Pressure areas should have brisk capillary refill when gently pressed with finer or thumb

Inspect for abrasions and excoriations

Palpate temperature of pressure area. Increased temperature is abnormal and may be due to inflammation. Same temperature compared to surrounding tissue is normal

Palpate over bony prominences/dependent body areas for edema. Edema feels spongy or boggy

a quality of living tissue; it is also referred to as renewal of tissues

Healing

refer to the steps in the body’s natural processes of tissue repair

phases of healing

Type of healing

occurs where the tissue surfaces have been closed and there is minimal or no tissue loss; for example, a closed surgical incision

Primary intention healing

Also called first intention healing; characterized by the formation of minimal granulation tissue and scarring

Primary intention healing

Type of healing

Use of tissue adhesive, a liquid glue that can be used to seal clean lacerations or incisions and may result in less noticeable scars

Primary intention healing

Type of healing

A wound that is extensive and involves considerable tissue loss; edges cannot or should not be approximated

Secondary intention healing

Type of healing

Healing of a pressure injury

Secondary intention healing

Difference between primary and secondary intention healing (3)

1) Repair time is longer in secondary

2) Scarring is greater in secondary

3) Susceptibility to infection is greater in secondary

Type of healing

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 skin adhesives

Tertiary intention healing

Type of healing

Tertiary intention healing is also called

Delayed primary intention

Three phases of wound healing

Inflammatory

Proliferative

Maturation/Remodelling

Phase of healing
begins immediately after injury and lasts 3 to 6 days

Inflammatory Phase

What are two major processes during the inflammatory phase?

Hemostasis and Phagocytosis

the cessation of bleeding

Hemostasis

How is hemostasis achieved? State the four processes.

1) Vasoconstriction of large blood vessels

2) Retraction of injured blood vessels

3) Deposition of fibrin

4) Formation of blood clot

In the inflammatory phase, the blood supply to the wound increases, bringing with it oxygen and nutrients needed in the healing process. The area appears __________ and _________ as a result.

reddened and edematous

The _____________ also secrete an angiogenesis factor, which stimulates the formation of epithelial buds at the end of injured blood vessels

macrophages

_______ is the second phase in healing, extends from day or to about day _ postinjury

Proliferative; 3 or 4; 21

is a whitish protein substance that adds tensile strength to the wound

Collagen