Skin Integrity/Wound Care

Functions of Skin (6)

• Protects tissue from trauma/bacteria

• Prevents loss of water/electrolytes

• Allows temperature, pain, touch, pressure

• Regulates body temp → sweat, production and evaporation

• Synthesis of Vit. D

• Promotes wound repair

Risk Factors (10)

Older Age → thinner skin, less elasticity

Mobility Status → turn patients every two hours

Nutrition/Hydration → more is good

Sensation Level → ex: diabetic with nerve damage doesn’t feel pain

Impaired Circulation → edema

Medications → side effects

Moisture

Fever → adds to moisture

Infection → at risk

Lifestyle → tattoos/piercings

Health History Assessment

Ask about genetics, past illnesses, neuropathy, cancer, etc.

Physical Assessment Includes:

Color → pink, color

Texture/Turgor → no tenting, smooth

Moisture → dry

Temperature → normal, dorsal of hand

Lesions → scars

Braden Scale

Part of assessment → within 24 hours of admission

Assesses risk for pressure injuries/skin breakdown

Higher = better

0-23

Braden Scale Levels

< 9 = severe risk

10 - 12 = high risk

13-14 = moderate risk

15 - 18 = mild risk

Aspects of Braden Scale - 6

Sensory Perception

Moisture

Activity

Mobility

Nutrition

Friction/Shear

Pressure Injury

Pressure Intensity

Tissue Ischemia

Blanching

Pressure duration

Tissue tolerance

Hospital Acquired Pressure Ulcers

Pressure Intensity

Bony prominences → heels, ankles, hips, knees, etc.

= More pressure

Tissue Ischemia

Tissue not getting enough blood flow

Blanching

Skin is white/paler than surrounding area due to prolonged pressure

Add pressure and skin stays white → risk

Pressure Duration

Turn immobile patients every 2 hours!

Tissue Tolerance

Depends on factors like age, nutrition, etc.

Hospital Acquired Pressure Ulcers

Negligence + poor care

Stage 1 Pressure Ulcers

Intact skin with non-blanchable redness

Stage 2

Partial thickness skin loss involving dermis + epidermis

Stage 3

Full thickness tissue loss with visible fat

Stage 4

Full thickness tissue loss with exposed bone, muscle, or tendon

Unstageable

Full thickness tissue loss → covered in eschar or slough

Types of Debridement

Removal of necrotic tissue

• Mechanical

• Autolytic

• Chemical

• Surgical

Management of Pressure Injuries

• Debridement

• Education

• Nutrition

• Protein

• Hemoglobin levels

Mechanical debridement

• Irrigate with high-pressure syringe (saline/water)

• Wet-dry dressing change

PREMEDICATE PATIENT FOR PAIN!

Autolytic Debridement

Wet dressing used to keep area moist → promotes use of body’s own enzymes to remove necrotic tissue.

Chemical Debridement/Enzymatic Debridement

Topical enzyme applied w/ dressing → topical enzyme absorbs and helps drain bacteria with every time dressing is removed.

Surgical Debridement

Requires removing necrotic tissue manually → anesthesia!

Albumin

A protein in body → helps with wound healing

Low levels → slow wound healing

Hemoglobin

Low hemoglobin levels indicate reduced oxygen supply to tissue → can delay or worsen the pressure injury healing process.

Nurse Assesses Both

Skin Integrity AND Wound

Wound Culture

Prior to antibiotics!

Preventing Pressure Injuries

• Incontinence management (Moisture)

• Protect bony prominences

• Turn every 1-2 hours

• Support body

• Topical skin care

• Education

Primary Intention

Suturing wound to close → closed with purpose → fine scar

Secondary Intention

Wound left open to heal naturally, from bottom-up → more scarring and takes longer

Purposes of Dressings

Protects from contamination

Aids in hemostasis → stops bleeding

Absorbs drainage + debridement

Supports site

Thermal insulation

Keeps patients from seeing wound.

Types of Dressings → 5

Dry to Moist Gauze

Film Dressing

Hydrocolloid

Hydrogel

Wound Vacuum Assisted Closure

Film dressing

See-through, for minor or shallow wounds, uninfected

Hydrocolloid

Protects the wound from surface contamination, absorbs fluid, and is used on UNINFECTED SITES

Hydrogel

Maintains a moist surface to support healing, autolytic, and can be used on infected sites

Wound Vacuum Assisted Closure (VAC)

Uses negative pressure to support healing, uninfected

Jackson Pratt Drain

Squeeze to create suction into bulb

Hemovac Drain

Squeeze accordion bottle to create suction

Closed Wound Drainage Systems → Negative Pressure!

JP Drain

Hemovac

Wound VAC

Wound Complications

Infection → purulent drainage, smell

Hemorrhage

Fistula → abnormal passage from surgery/injury between body parts

Evisceration → surgical emergency! organ protruding outside the body → moist dressing + cover prior to surgery

Dehiscence → wound opens up, CALL PROVIDER