Unit 6 Skin Integrity

Contributing Factors to Skin Integrity

Chemical, developmental, microbiological, physical, physiological, psychosociocultural, and iatrogenic.

Chemical

Ex; soap, urine, detergent, acids/bases

Developmental

Older adults has poor turgor and drier skin. Very young and the very old are to be considered as they face their respective challenges.

Microbiological

Microbes are normally seen in the older population more (they are more susceptible)

Ex; Microbes — Direct transmission

Physical

• Friction (sheering force) » Use Pull Sheets instead

• Pressure on bony prominences

• Environmental temperature extreme

Physiological

• Loss of mobility

• Malnutrition

• Dehydration

• Decreased sensory perception (can’t feel skin tears or ulcers forming)

• Diabetics » nephropathy = diminished nerves » can’t feel for abnormal (many develop diabetic foot ulcers)

Psychosociocultural

Different culture have a different value on hygiene and skin care

Iatrogenic

• Imposed bed rest » may make them more prone

• Surgery » may be immobile for some period of time

Clinical Manifestations of Skin

Types of skin lesions, types of wound healing, phases of wound healing, types of exudate

Types of Skin Lesions

Pustules (have pus inside), papules, incisions, lacerations, abrasions, urticarial (hives)

Types of Wound Healing

Primary Intention, Secondary Intention, Tertiary Intention

Primary Intention

Edges of the skin are approximated (“knit together” -ex; Surgery - stitches, surgical glue, a cut) (open wound)

Secondary Intention

Bed wounds, ulceration/cavity. Heals from the inside out (creates scaring) (Deeper wound)

Tertiary Intention

Wound is left open — packing is left in the wound on purpose

Phases of Wound Healing

Phase I, Phase II, Phase III

Phase I Wound Healing

Inflammatory Phase (LAS)

Phase II Wound Healing

Proliferative Phase: formulation of granulated tissue (fresh new tissue) Hydrocolloid dressing is used to keep moist and facilitates granulation

Phase III Wound Healing

Maturation phase: Remodeling of the tissue and scaring. Scar will shrink over time.

Types of Exudate

Ex; Serous, serosanguineous, sanguineous

Wound Care (Planning and Intervention)

Medical vs Surgical Asepsis, Cleansing of Wounds, Methods

Medical vs Surgical Asepsis

Chronic pressure ulcers would require surgical asepsis (Stage IV)

Cleansings of Wounds

Solutions: Isotonic saline, wound cleanser

Methods

• Avoid overdrying the wound. Moist would facilitate healing (as long as there is no exudate)

• Avoid excessive cleaning of the wound as well — you want to maintain the pH of the wound

• Wipe from clean to dirty

Dressings

Protect, maintains moisture, absorbs excessive moisture

Dressing Types

Gauze, Transparent Films, Hydrocolloid, Hydrogels, Alginates

Gauze

Dry, non-adherent (won’t get stuck, or impregnated) protects against bacteria

Transparent Films

You can see through them (IV site)

Hydrocolloid

Hydrophilic self-adhering layers absorb exudate and promotes healing as well as a warm environment

Hydrogel

Water based » Moisturizes

Alginates

Absorbs drainage (good for healing pressure ulcers)

Obtaining Wound Culture Reason

You want to know what bacteria inhabit the wound and what prevents it from healing. — What antibiotics/topical cream can be used to kill the organism?

Obtaining Wound Culture Directions

• Medicate for pain if needed before procedure

• Perform hand hygiene and assemble supplies

• Follow standard precautions

• Cleanse wound with normal saline

• Rotate sterile swab back and forth over clean area of granulation tissue

• Place swab in culture medium without contaminating and label

• Place in biohazard transport bag with requisition without contaminating

Pressure Ulcers (Assessment of Risk and Prevention)

• Braden scale (16 or less = high risk, 23 is the best score) Abbreviation M&M fans

  • Moisture

  • Mobility

  • Friction and sheer

  • Activity

  • Nutrition

  • Sensory perception

• Prevention

  • Keep sheets wrinkle-free, provide adequate nutrition (vitamin C, A, D, E, zinc), protective layers (lotions, creams), specialty mattresses, educate patient about the importance of hygiene

Stages of Pressure Ulcers

I, II, III, IV, Unstageable, Suspected Deep Tissue Injury

Stage I Pressure Ulcers

Red, non-blanchable, can use meplix to cover, massage around the wound

Stage II Pressure Ulcers

Blistered or broken (Dermis layer) (Top layer of skin is broken (superficial))

Stage III Pressure Ulcers

Subcutaneous tissue involvement. Might involve necrosis, some drainage is present. The wound involves the epidermis.

Stage IV Pressure Ulcers

Deeper tissue is involved. All skin layers are damaged. Undermining (caving) present, may be able to pack underneath skin folds.

Unstageable

Unable to see how deep: Necrosis prevents staging (Eschar- leathery/black & Slough- yellowing/cream. Needs to be removed before you can stage the wound.

Suspected Deep Tissue Injury

Discolored, purple, skin intact, but severe tissue damage (ecchymosis)

Assessment- Check and Treat the Skin

• Location

• Size

  • Measured in centimeters

  • Measure width and depth

• Color (Green, yellow, and black)

• Drainage

  • Red – granulous

  • Yellow – infected

  • Black - necrotic

• Feel (objective)

• Sensation (subjective)

• Stage of Healing

  • Stage IV’s can take years to heal

Treatment

Medical Asepsis may be acceptable for pressure ulcers. Different treatments for different pressure ulcers: red, yellow, and black ulcers.

Red Ulcers

Indicative of granulation tissue. Use protective covering, ex; bioclusive drressing- tegaderm.

Yellow Ulcers

Cleanse and remove debris. Use absorbent dressing, ex; carocin, carogauze.

Black Ulcers

Debride necrotic tissue; surgical, enzymatic- (can be put on a gauze that can eat at the dead tissue) ex; collinginase, enzymes- eat at the necrotic tissue

Wound Vac

• Negative pressure system

  • Keeps microorganisms out of the wound

• Sucks exudate out

• Enhances blood flow

• Creates healing at the cellular level

Prevention

Encourage patients to eat and Drink

Repositioning

Turn and position (minimal q2h)

Skin Care

Check and change your incontinent patients » barrier sprays and creams