Tissue Integrity- Basic of Wounds Guest Ppt

Notes-2025by Lizzie Wounds

Epidermis

found thickest on the palms of your hands and soles of your feet (1.5mm thick)

SQ or Hypodermis

• deepest layer of the skin

• storing fat

• contains blood vessels

• hair follicle roots and nerves

Forming Scar Tissue

• not the same as normal skin tissue

• appears often discolored and lacks sweat glands and hair

Areas that experience repeated friction or pressure

• can form tough, thick skin known as a callus

• examples: hands of tennis players and fingertips of guatarists

Old Wives Tale of Wound Healing (not true tales)

• leaving a wound open to air good for it

• use hydrogen peroxide to clean a wound

• scabs are good

One of two: Epidermal 

• thin, avascular 

• regenerates every 4-6 weeks 

• function-maintains a barrier 

• includes 5 sublayers 

Two of two: Dermal

• provides strength, support, blood, and oxygen to the skin

• attached to epidermal layer with rete pegs

• contains collagen, fibroblasts, elastic fibers

Four Phases of Wound Healing:

1. Hemostasis

2. Inflammation

3. Proliferation

4. Remodeling

Phase 1: Hemostasis of Wound Healing

• stops bleeding

• day 1 to 3

Phase 2: Inflammation of Wound Healing

• Day 3 to 20 

• New Framework for blood vessel growth 

Phase 3: Proliferation or Granulation

• Week 1 to 6

• pulls the wound closed

Phase 4: Remodeling or Maturation

• Week 6 to 2 years 

• final proper tissue 

Factors that affect wound healing and treatment guidelines

• Wound Assessment

• Wound Size

• Tissue Quality

• Drainage

External Factors:

• blood flow

• infection

• clinical status

Wound Considerations:

• cause of the wound

• what does the wound “need”?

• who is caring for the wound

• role of bacteria in the wound

Acute Wounds:

• Surgical Incisions

  Closed/Open

• Skin tears

• Moisture Associated Skin Damage (MASD)

• Medical Adhesive related skin injury

• burn

Chronic Wounds: 

• Pressure Ulcer/Injury 

• Arterial Ulcer

• Venous Ulcer 

• Diabetic/Neuropathic Ulcer

Surgical Incisions: Closed

• Sutures

• Staples

• Glue

• Steri Strips

Surgical Incisions: Open

Skin Tears: Category I Linear type/Flap Type

• w/o tissue loss either linear or with a flap that closes the tear to within an approximation of 1mm of the wound edges

Skin Tears: Category II

• Partial tissue loss, considered scant when the loss is 25% or less and moderate 

• or loss when the tissue loss is more than 25%

Skin Tears: Category III

Complete tissue loss nor epidermal flap covering the injury

Moisture Associated Skin Damage (MASD)

• Intertriginous skin Damage (ITD)

  • in b/w skin folds 

  • Think “in the depth” 

  • Common locations are sacral slit, inframammary, under pannus 

  • can be with or without a fungal component 

• Incontinence Associated Dermatitis (IAD) 

  • caused from urinary and/ or bowel incontinence 

• Periwound dermatitis 

  • from wound drainage 

• Peristomal dermatitis 

  • from stoma output on skin 

Medical Adhesive Related Skin Injury (MARSI)

• Skin injury 

• results when skin to adhesive attachment is stronger than skin cell to skin cell attachment 

• as a result: the epidermal layers separate, or the epidermis separates completely from the dermis 

First-Degree (Superficial) Burns

• affect only the epidermis, or outer layer of skin

• burn site: red, painful, dry, and with no blisters

• Example: Mild sunburn

• long-term tissue damage is rare and usually consists of an increase or decrease in the skin color

Second-degree (partial thickness) burns

• involves the epidermis and part of the dermis layer of skin

• burn site appears red, blistered, and may be swollen and painful

Third-Degree (full thickness) burns

• destroy the epidermis and dermis and may go into the subcutaneous tissue

• burn site may appear white or charred

Fourth-Degree Burns: 

• damage underlying bones, muscles, and tendons 

• no pain nerve endings are destroyed

First-Degree Burn (Superficial)

• painful

• no edema

• redness

• blanches with pressure

Second Degree Burn (Partial Thickness)

• blistered

• moist

• painful

Third-Degree Burn (Full-thickness)

• dry

• discolored

• no pain

Chronic Wounds 

• have high levels of inflammatory markers 

• high bacteria count 

• failed to progress in 30 days 

• often long healing items complicated by infections 

Pressure Injury

• localized injury to the skin and/or underlying tissue usually over a bony prominence,

• or under a medical device, as a result of pressure,

• or pressure in combination with shear and or friction

Common Sites for Pressure Injuries

• Back of the head

• shoulder

• elbow

• buttocks

• heel

• ear

• hip

• thigh

• leg

• rib cage

• knees

• toes

• sacrum

Braden Scale: Sensory Perception 

• measures the person’s ability to detect and respond to discomfort or pain related to pressure on parts of their body

• ability to feel pain 

• level of consciousness of a patient (can they react to the pressure)

Braden Scale: Moisture

• excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin by causing the skin tissue to become macerated

• risk for epidermal erosion

• assesses the degree of moisture the skin is exposed to

Braden Scale: Activity

• looks at a patient’s level of physical activity since very little or no activity can encourage atrophy of muscles and breakdown of tissue

Braden Scale: Mobility

• looks at the capability of a patient to adjust their position independently

• assesses physical competency to move and can involve the client’s willingness to move

Braden Scale: Nutrition 

• assessment of a client’s nutritional status looks at their normal patterns of daily nutrition

• eating only portions of meals or having imbalanced nutrition can indicate a high risk in this category 

Braden Scale: Friction and Shear

• amount of assistance a client need and the degree of sliding on beds or chairs that they experience

• assess sliding motion can cause shear

• shear is the skin and bone moving in the opposite direction causing breakdown of cell membranes and capillaries

Risk Factors

• intrinsic vs extrinsic

• can they tolerate the pressure or shearing

  • incontinent

  • over age 75

  • vascular status

  • feeling?

  • nutritional status?

• having skins?

• external factors

External Factors that Mitigate the risk factors

• repositioning

• specialty mattresses

• wicking pads

• barrier

• nutrition

• proper moisture management

• of pressure bony prominences

Pressure Injury Stage 1

• intact skin with non-blanchable redness of a localized area

• usually over bony prominence

• darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area

• must touch to determine

Pressure Injury Stage 2

• partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, no slough

• present as an intact or open/ruptured serum-filled blister

• shiny or dry shallow ulcer without slough or bruising

This stage should not be used to

describe skin tears, tape

burns, perineal dermatitis,

maceration or excoriation.

Pressure Injury Stage 3

• Full thickness tissue loss

• SQ fat may be visible but bone, tendon or muscle are not exposed

• slough may be present but does not obscure the depth of tissue loss

• include undermining and tunneling

• depth varies by anatomical location 

Pressure Injury Stage 4

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

• Slough or eschar may be present on some parts of the wound bed=

• include undermining and tunneling

Pressure Injury- Deep Tissue Injury (sDTI)

• Purple or maroon localized area of discolored intact skin or blood-filled blister

• due to damage of underlying soft tissue from pressure and/or shear

• the area may be preceded by tissue that is painful, firm, mushy, boggy, warner or cooler as compared to adjacent tissue

Pressure Injury- Unstageable

• full thickness tissue loss

• base of the ulcer is covered by slough (yellow, tan, gray, green, brown)

• and/or eschar (tan, brown, black) in the wound bed

Pressure Injury Prevention 

• Support surfaces 

• Repositioning/ offloading 

• Moisture control 

• Toilet Scheduling 

• Regular Risk assessments 

• Minimize friction and shearing forces 

• Nutrition/Hydration 

• Barriers 

Arterial Ulcers

• consequences of obstruction or stenosis of an arterial lumen

• interferes with blood transport to peripheral capillary bed

• local ischemia results in necrosis and ulceration

Arteral Ulcers

• Usually found tips of toes

• wound bed pale or necrotic

• little to no exudate

• painful

• diminished or absent pulses 

Venous Ulcers

• Venous HTN

  • Failure of Venomotor Pump Mechanism 

    • Obstructed deep veins 

    • Valvular dysfunction 

    • faulty calf muscle pump

• Backflow into superficial system 

• Venous Ulceration 

• drain a ton 

Venous Ulcers

• between ankles and knees 

• wound base dark red or may be covered with slough 

• moderate to large amounts of exudate 

• wound edges are irregular 

• edema is common 

• good pulses 

Diabetic Foot Ulcer 

• Round, punched out lesions 

• High infection rate 

• associated with neuropathy 

• minimal drainage

• painless

• when infected lots of drainage 

Wound Assessment

• location 

• type of wound 

• size of wound 

• condition of the wound bed 

• characteristics of wound exudate 

• wound margins and peri wound skin 

• pain 

• nutritional status 

Characteristics of healthy granulation tissue 

Healthy: 

• bright red 

• moist 

• shiny

• doesn’t bleed easily 

Characteristics of unhealthy granulation tissue:

• dark red/ bluish discoloration or pale 

• dehydrated 

• dull 

• bleeds easily 

Dressing Selection

• Appropriate for the wound type, tissue, depth and exudate volume

• Maintain moist wound healing to reduce friction at wound surface

• Minimizes pain and trauma when removing

• Remains intact longer to reduce the need for frequent dressing changes

• Optimizes wound bed preparation

• Preserves peri-wound skin

reevaluate the dressing if it is causing pain or bleeding/trauma to wound or surrounding skin 

soaking is required for removal 

What injury is this?

• Arterial ulcer (on the finger!) and a MASD 

What injury is this?

• Fournier gangrene (poorly controlled diabetic) in his perinium 

• Tx: VAC 

What is the inury?

• Pressure Injury

• Stage 4 (bone or tendon) and Unstagable (slough)

What injury is this?

• Stage 1

• non-blanchable

What Injury?

Incontinence Associated Dermatitis which became a unstageable pressure injury

What injury?

• Incontinence Associated Dermatitis

• frequently loss stool (c diff)

What Injury?

• yellow tissue, irregular edges,

• Post-surgical wound: Dhesis

• Negative Pressure Wound therapy 

What injury?

• Abscess (had a boil, I and D done)

• Wound filler

• wet to dry

What injury?

• Forinere gangrewre ??(infection froi labaia rto right flank

• I and D proeedcuree to wash out

• Negative 2PRessure Wound PRessure Woiudn therayp

What injury?

• Venous leg ulcer

• Tx: absorptive dressings, Compression therapy

• the most common leg ulcer in the US 

• makes up 60% of chronic wounds are leg ulcers

• WEAR COMPRESSION SOCKS

What injury?

• Arterial ulcer (tip/top)

• tip of the toe is turning black before the base of the toe

• Must call vascular surgeon

• no way to treat it, goal is to keep it dry once developed, and prevent wet gangrene

also control pain

What injury?

• Diabetic foot ulcer

• poorly controlled, collapsed arch of the foot, its down instead of up 

• podiatric surgeon is needed

What injury?

• Surgical incision that was left open for 3 days, lumbar incision, with hardware in

• Tx: insulation negative pressure therapy

• Veraflow Therapy: keep it as clean and bacteria free as quick as possible

What injury?

• Atypical wound

• antimicrobial cleaning, IV antibiotics, compression therapy 

What injury?

• Unstageable pressure injury of the heel 

• don’t properly offload the heel 

• Acceptable to OTA, black eschar over a heel pressure injury you can leave it intact, acts a biological dressing, ew 

• if the edges separates or become unstable can remove it