Skin Integrity and Wound Care

What are some examples of pressure injuries

• pressure ulcer

• Bed sore

• Decubitus ulcer

What does the severity of a pressure injury depend on?

• pressure duration

• Tissue tolerance

• Pathogenesis: pressure intensity

• Tissue ischemia

• Blanching

What are some risk factors for getting a pressure injury?

• impaired sensory perception

• Impaired mobility

• Friction

• Moisture

What are some interventions to prevent a pressure injury from happening?

• assess patient on admission

• Repositioning schedule (every two hours)

• Pressure relieving surfaces

• Moisture management

• Nutritional support

What is a stage one pressure injury?

• Non-blanchable erythema of intact skin

• Change in sensation, temp, firmness (Can precede visual changes)

What is a stage two pressure injury?

• Partial thickness skin loss with exposed dermis

• wound bed viable, pink or red, moist

• May present as intact or ruptured blister

• Fat and deep tissues are not visible

What is a stage three pressure injury?

• Full thickness skin loss

• Fat is visible and granulation tissue is present

• Slough or eschar may be visible

What is a stage four pressure injury?

• Full thickness skin and tissue loss

• Exposed muscle, bone, tendons

• Slough or eschar may be present

• Tunneling

What is an unstageable pressure injury?

• Full thickness skin and tissue loss

• Extent of damage cannot be determined because it is obscured by eschar

What is a deep tissue pressure injury?

Localized area of non-blanchable dark discoloration or epidermal separation with dark wound bed of blood filed blister

What is the Braden scale used for?

Assessing the risk for injury

What are the components of the Braden scale to assess for injury?

• sensory perception: response to pressure-related discomfort

• Moisture: exposure of skin to moisture (incontinence)

• Activity: physical activity level

• Mobility: ability to change position

• Nutrition: usual food and intake pattern

• Friction and shear: risk from skin rubbing/sliding

How is the Braden scale scored?

• each item scored 1-4 except friction and shear 1-3

• 19-23: no risk

• 15-18: mild risk

• 13-14: moderate risk

• 10-12: high risk

• <9: highest risk

What is primary intentional healing

• Skin edges closed/approximated (surgical incision)

• Healing by epithelialization

• Heals quickly with minimal scaring

What is secondary intentional healing?

• Involves tissue loss like a laceration, burn, stage II pressure injury, etc

• Wound left open until it fills with scar tissue, not closed

• Heals by granulation tissue formation

• Leaves scar

What is tertiary intentional healing?

• Wound left open for days and then closed

• Contaminated wounds requiring observation

• Closure of wound delayed until infection risk resolves

What are the stages of wound healing?

• hemostasis/bleeding

  • Control blood loss

  • Seal defect/blood clots

• Inflammation

  • Secretion of histamine resulting in WBCs going to damaged tissue

  • Redness, warmth, swelling

• Proliferation with new tissue formation

  • New blood vessels

  • Granulation tissue fills wound, wound resurfaces by epithelialization

  • 3-4 days

• Remodeling and maturation

  • Several weeks

  • Collagen scar forms

What are some complications to wound healing?

• hemorrhage

• Infection

• Dehiscence

• Evisceration

What are some influences of wound formation and healing?

• nutrition

• Tissue perfusion (blood flow)

• Infection

• Age

• Diabetes

• Obesity

• Medications

Nursing process for wounds: assessment

• for pressure wounds: Assess for predictive measures, mobility, body fluids, and pain

• For surgical/traumatic wounds: assess emergency or stable setting, appearance, drainage, wound closures, COCA

Nursing process for wounds diagnosis/analysis

• Infection risk

• Acute or chronic

• Impairments: mobility, tissue integrity, perfusion

Nursing process for wounds: planning

• outcomes

• Setting priorities

• Teamwork

Nursing process for wounds: implementations

• health promotion: nutrition

• Acute care: Wound management (debridement, dressings, irrigation, packing, etc)

• Interventions: turning schedule, low air loss overlay on mattress, hydrocolloid dressing

• Heat/cold therapy

What is an air loss overlay

It goes on top of the mattress to redistribute the amount of pressure on bony prominences

What is a hydrocolloid dressing

Supports moist wound healing and protects the wound

What are the purposes of heat therapy?

• promote vasodilation

• Increase tissue metabolism

• Reduce muscle tension

• Relive pain/stiffness

What are some indications for the need for heat therapy?

• muscle pain/stiffness

• Menstrual cramps

• Healing injuries (24-48 hours)

What are some precautions to using heat therapy?

• limit to 20-30 minutes

• Avoid open wounds

• Minor for burns

• Extra cautious for older adults and children

What are some contraindications for using heat therapy?

• active bleeding

• Cardiovascular problems

• Areas with impaired sensation

What are the purposed of cold therapy?

• cause vasoconstriction

• Reduce inflammation/edema

• Slows nerve conduction

• Controls bleeding

What are some indications to use cold therapy?

• acute trauma, sprains/fractures

• Minor burns (immediate)

• Inflammation/swelling

• Post-surgical incisions

What are some precautions for using cold therapy?

• limit to 20 minutes

• Use barrier between ice pack and skin

• Avoid in patients with impaired circulation or cold sensitivity

What are some contraindications to using cold therapy?

• open wounds

• Circulatory insufficiency

• Cold sensitivity/allergy

What are the nurses responsibilities when giving heat/cold therapy?

• assess skin before and after

• Use protective layer

• Educate patient to report numbness, burning, etc

• Monitor for redness, blistering, etc

• Document type, location, duration, patient response