Skin Integrity and Wounds

Open wounds

Wound that results from trauma (incisions, abrasion, laceration); opens skin barrier making it prone to infection

Closed wounds

Wound that results from force, blow or strain; may cause soft tissue damage or hemorrhage

Acute wounds

Wound edges are well-approximated, low risk of infection; only lasts days to weeks (e.g. surgical incision)

Chronic wounds

Healing process of wound impaired (stuck in inflammatory process); high risk of infection, wound edges not approximated, normal healing delayed

Factors that affect wound healing

-Nutrition (vitamin C, protein, zinc)

-Perfusion/oxygenation (nutrient delivery)

-Infection delays healing

-Chronic diseases (diabetes, vascular), age, medications

Braden Scale

Measures sensation, moisture, activity, nutrition, friction/shear to determine risk of pressure ulcer

Risk factors for pressure injury development

Immobility, older patients, malnourished, decreased sensation, urinary incontinence, critical/chronic diseases

Stage 1 Pressure Injury

Nonblanchable, intact skin

Stage 2 Pressure Injury

Partial thickness; blister/shallow ulcer

Stage 3 Pressure Injury

Full thickness, fat visible, no bone/tendon visible

Stage 4 Pressure Injury

Full thickness, bone/tendon/muscle visible

Unstageable Pressure Injury

Depth of injury covered in slough (soft, yellow, moist; near necrotic tissue) or eschar (dry, brown, necrotic)

Deep Tissue Injury

Purple/maroon color, intact skin, underlying drainage

Primary intention

Wound edges well-approximated and closed immediately; clean surgical incision

Secondary intention

Wound left open to heal naturally via granulation; tissue loss, pressure injuries, burn; more scarring

Tertiary intention

Wounds left open first (infection present), then closed later (4-7 days) after infection clears; less scaring than secondary but more than primary

Management of Wound Cleaning

-Avoid noncytotoxic solutions (hydrogen peroxide/betadine) on healthy tissue (use NS instead)

-Clean from least contaminated to most contamined

-Remove slough/necrotic tissue

Gauze

Basic wound drainage, absorbs fluids

Transparent dressing

Wound dressing that allows you to see and monitor wound

Hydrocolloid dressing

For low to moderate drainage, maintains moist environment for healing and protects from contaminants

Foam dressing

For moderate to heavy drainage, cushioning, absorbs exudate

Alignate dressing

For heavy drainage or bleeding wounds (very absorbent)

Serous drainage

Clear, watery fluid

Sanguineous drainage

Red, bloody fluid

Serosanguineous drainage

Pink, mixed water + blood

Purulent drainage

Thick yellow/green, indicates infection

Open drainage

Fluid drains out onto dressing or gauze; higher risk of infection

-e.g. Penrose drain (passive drainage by gravity)

Closed drainage

Fluid collected in sealed device to protect wound and lower risk of infection

JP drain (bulb suction)

Soft bulb creates suction (negative pressure) to pull fluid out

Hemovac (spring suction)

Larger spring device that maintains suction for post-op drainage; more volume than JP

Wound VAC (negative pressure suction)

Uses vacuum pressure to remove fluid, decrease swelling, and promote wound healing

Hot therapy

Increases blood flow, relaxes muscles, increases wound healing (every 15-20 mins, check frequently)

-Indications — muscle spasms, stiffness, pain and chronic

-Contraindications — burns, open wounds, bleeding

Cold therapy

Decreases blood flow, reduces swelling, numbs pain (every 15-20 mins, use barrier, check frequently)

-Indications — Acute injuries, inflammation, bruising

-Contraindications — Poor circulation, cold intolerance, open wounds

Hemostasis

Clot formation occurs (vascular spasm, platelet plug formation, coagulation); immediate

Inflammatory Phase

-Last 2-3 days

-WBCs called to site to promote healing

-Pain, redness, swelling, fever, malaise, exudate formed (fluids leaks out)

Proliferation Phase

Repair phase (connective tissue) involving granulation tissues, foundation of scar tissue formation

-Lasts several weeks (focus on nutrition and oxygenation)

Maturation Phase

Begins after 3 weeks (can continue for months or years); scar is formed (collagen deposited continually which compresses blood vessels

Friction

Skin rubs against another surface (e.g. sheets); results in abrasion on top layer of skin

Shearing

Skin in place, underlying tissues move (stretches vessels and damages deeper tissues) (ischemia risk)