Skin Integrity and Wound Care

Exam 1 NURS 300

Layers of the skin

Epidermis and dermis (separated by the dermal-epidermal junction membrane)

Function: thermoregulation, protection from pathogens

Epidermis

Top layer

Several layers

Flattened, dead, keratinized skin cells

Function: protect underlying cells/tissues from dehydration, prevents entrance of certain chemicals, allows for evaporation of water off of skin, permits absorptions

Dermis

Inner layer

Contains mostly connective tissue

Collagen, blood vessels, and nerves

Function: tensile strength, mechanical support, protection of underlying bones, muscles, organs

Types of wounds

Partial-thickness, full-thickness, primary intention, secondary intention

Partial-thickness

Damage to epidermis, may go into dermis

Heals through epithelialization

Full-thickness

Damage that extends beyond two layers of skin (into subQ tissue, may even see bone)

Heals from deeper to higher areas

Primary intention

Surgical incision that is sutured or stapled

Implications: heals through epithelialization, minimal scar formation

Secondary intention

Surgical wounds that have contamination or tissue loss, pressure injuries, or burns

Heals using granulation tissue formation, wound contracting, and epithelialization

Wound healing complications

Hemorrhage, infection, dehiscence, evisceration

Hemorrhage

Lots of bleeding, not normal

May indicate dislodged surgical suture, infection, etc

Signs of Infection

Erythema

Increased wound drainage (thick, color, odor)

Periwound warmth, edema, pain

WBC may be increased

Possible presence of fever

Dehiscence

Partial or full separation of wound layers

Risk: obesity, poor nutrition, infection, underlying disease

Serosanguineous drainage could be an indication (but not factual evidence of dehiscence)

Evisceration

Total separation of wound layers

Emergent

Keep inside tissues moist

Risk factors to pressure ulcers

DM, incontinence, impaired sensory perception, older adults, spinal cord injury, long term homes/community care, hospice

Decreased mobility (unable to reposition themselves) or perception of pain is major risk factor

Stage 1 pressure ulcer

intact skin, but localized non-blanchable erythema

Stage 2 pressure ulcer

partial-thickness skin loss

exposed dermis

(no presence of eschar, slough, granulation)

Stage 3 pressure ulcer

full-thickness skin loss

adipose is visible

slough, eschar, and granulation may be visible

Stage 4 pressure ulcer

full-thickness skin and tissue loss

exposed palpable fascia, muscle, tendon, cartilage, or bone

slough and eschar may be visible

tunneling often occurs

Unstageable pressure injury

Concealed full-thickness skin and tissue loss

Typically the extent can’t be determined due to eschar or slough covering it

Once removed, stage 3 or 4 pressure injury may be revealed

Dry, intact eschar should not be removed

Deep Tissue Pressure Injury (DTPI)

Intact or non-intact non-blanchable skin

Deep red/maroon/purple

Results from intense prolonged pressure

May resolve without skin loss or evolve rapidly

Risk assessment

Braden’s Scale

Norton’s Scale

Measurement of pressure injuries

Width (with disposable ruler)

Height (with disposable ruler)

Depth (with sterile cotton tip)

Undermining and land mining (with sterile cotton tip)

Documentation of pressure injuries

Location

Size (width, height, depth, undermining, tunneling)

Color

Drainage

Type of wound bed (granulation, slough, eschar)

Pt reports of pain and discomfort

Types of drainage

Serous, purulent, serosanguineous, sanguineous

Serous

normal drainage

Purulent

Could be indicative of infection

Serosanguineous

Not totally indicative of a problem, but need to keep and eye on it

Sanguineous

Can be common during inflammatory phase

After this stage, may be indicative of damaged capillaries or trauma

Large amounts can be a cause for concern

Heat therapies

warm compress (musculoskeletal injury), warm soaks (promote blood flow), hot packs

Cold therapies

Cold packs, cold, moist and dry compress (soft tissue injury), cold soak (decreases blood flow), ice bags or collars