skin integrity

factors affecting skin integrity

developmental

age

skin disruption

comorbid conditions

What is a wound?

a break or disruption in the normal integrity of the skin and tissues

Skin Integrity

*Intact skin- no break, protective barrier.

*Impared skin- damage to epidermis/dermis

*Impaired tissue- extends deeper into subcutaneous, connective , muscle,and bone.

Wound depth

*Superficial- abrasion, involves only epidermis.

*partial thickness- extends through epidermis into dermis: heals by regeneration

*full thickness- penetrate entire dermis into subcutaneous tissue: connective tissues repair.

Intentional

Clean, controlled ( surgical incisions)

Unintentional

Traumatic and irregular (laceration, abrasion)

Open

Break in skin or mucosa ( puncture)

Closed

No surface break ( contusion, hematoma)

Burns contamination

*Clean- uninfected

*Clean contamination - enter but under control condition.

*contaminated- open fresh accidental.

*infected- old traumatic dead tissue/ exist infection ( pus, odor)

inflammation phase 2- 3 days

Increase blood flow, fibrin accumulation, clot formation. Swelling red pain.

Homeostasis (immediate)

Blood clot to stop bleeding, vasoconstriction, platelets, fibrin clot form.

Proliferation phase 4- 21 days

Repair, growth of new tissue. Contrating wound edge to reduce area required healing. Resurface of epithelial cells

Maturation phase 21days - 1 year

remodeling phase , scar, strengthening of scar tissue.

Factors affecting wound healing LOCAL

*Pressure- disrupt blood supply

*Dessiccation- dehydrated cells; crust on wound

*maceration- dehydrated; tissue erosion

*excessive bleeding- large clot

*infection- bacteria

• trauma - delayed healing

*edema- swelling

Factors affecting wound healing SYSTEMIC

Developmental level

Age

Circulation/ oxygen

Nutrition status

Wound etiology

Immunosuppression

Adherence to treatment plan

Complications of wound healing

*hemorrhage- emergency pressure dressing

• dehiscence- separation

• evisceration- protruding organ/ tissue

• fistula formation- (infected fluid) passage to outside body

*infection- contaminated wound

pressure injury

localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device

Ulcer risk factors

Pressure

Friction

Shear

Immobility

Nutrition

Mental status

Age

Stages of pressure injuries

Stage 1: nonblanchable erythema of intact skin

Stage 2: partial-thickness skin loss with exposed dermis

Stage 3: full-thickness skin loss; not involving underlying fascia

Stage 4: full-thickness skin and tissue loss

Unstageable: obscured full-thickness skin and tissue loss

Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration

Stage 1

nonblanchable erythema of intact skin

Stage 2

partial thickness skin loss with exposed dermis

Stage 3

Stage 3: full-thickness skin loss; not involving underlying fascia

Stage 4

full-thickness skin and tissue loss

Unstageable

obscured full-thickness skin and tissue loss

Deep tissue pressure injury

persistent nonblanchable deep red, maroon, or purple discoloration

Nursing assessment of skin

Temperature

Texture

Moisture

Turgor

Vascularity

Tone

Scars/ lesions

assessing lesions

Asymmetry

Border

Color

Diameter

Elevated or evolved

Funny looking

Wound Assessment

Location

Size

Tunneling

Drainage

Wound edge

Wound bed

Patient response

serous

clear, thin, watery fluid

Serosanguineous

Pale, pink, watery; mixture of clear and red fluid

sanguineous

bright red, fresh blood

purulent

Green, thick, odor, infection

Psychosocial effects of wounds

Pain

Anxiety/ fear

Inability to perform ADL's

Change in body image

Nursing intervention

Skin hygiene

Turning/ position