Skin Integrity and Wound Care

What are functions of the skin?

• Temp. Regulation- sweating 

• Psychosocial- puberty (think acne) 

• Sensation (should be able to feel where something is touching us) 

• Vitamin D production (skin is responsible for this) 

• Immunological- skin protects us-secretes oil from pores- doesn't foster bacteria 

• Absorption- medication patches 

• Elimination- body is constantly renewing- getting rid of dead skin and toxins 

How does the body regulate temp?

through sweating

How is the skin immunological?

skin protects us-secretes oil from pores- doesn't foster bacteria 

how does the skin practice elimination?

body is constantly renewing- getting rid of dead skin and toxins 

When is the skin the best source of protection we have?

if skin is intact

how are infants at risk for decreased skin integrity>

• skin is fragile- don't have callouses, more prone to skin breakdown 

• Also incontinent- sitting in wet feces/urine 

how are older adults more at risk for decreased skin integrity?

dried out skin, more prone to breakdown, immune system is breaking down  

how is mobility/activity important for skin integrity?

people who are moving around brings circulation/oxygenation 

how is nutrition important for skin integrity?

healthier and more hydrated you are, more mobile you are - helps with circulation

what does having a cast do for skin integrity?

makes it hard to get rid of dead skin cells + muscle atrophy

how can medications impair skin integrity?

can cause diarrhea- can create skin problems down in that area

what is a trauma wound?

falling and hurting yourself

what is a pressure related wound?

sitting, physical weight 

what is an example of a neuropathic/vascular wound?

diabetes patients- high sugar level messes with their blood vessels and nerves- sometimes can’t feel feet (diabetic neuropathy)- blood can’t get through vessels 

what is an open vs closed wound?

open (knee scrape) baseball bat hits- but skin doesn’t open (closed) 

what is an acute vs chronic wound?

acute heals quickly, chronic heals slowly

What is an incision?

a cut

What is a contusion?

a bruise

What is an abrasion?

a scrape

What is a puncture?

stab wound

What is a penetrating wound?

involve foreing object entering tissue- creating significant internal damage

What is avulsion?

skin rips off

What is a chemical wound?

a chemical burn

What is a thermal wound?

a wound from heat

What is an irradiation wound?

radiation burns skin

What is a pressure ulcer?

are localized injuries to skin and underlying tissue, usually over bony prominences like the sacrum, heels, or hips, caused by prolonged pressure, friction, or shear

what is a venous ulcer?

slow-healing, shallow, and often painful sores (typically 3–4 weeks or months to heal) found on the lower legs, usually near the ankles, caused by chronic venous insufficiency and poor blood flow

What is an arterial ulcer?

painful, deep, "punched-out" wounds on the lower legs, feet, or toes caused by severe, chronic lack of blood flow (ischemia) due to peripheral artery disease (PAD

What are diabetic ulcers?

an open sore or wound, typically on the bottom of the foot, affecting roughly 15% of patients with diabetes. Often caused by nerve damage (neuropathy) and poor circulation,

what is primary intention healing?

• Wound edges well approximated- has to have straight edges 

• Incision 

• Eventually will have a hairline scar 

What is secondary intention healing?

• Wound edge not well-approximated. (jagged edges or deeper) 

• Heals by granulation tissue formation 

• Ex: blister that pops open,  

• Wound bed should look red, beefy, moist 

• Sometimes you have to pack these wounds with gauze and saline to keep the area moist and help grow granulation tissue 

What is tertiary intention healing?

• Delayed primary intention 

• Big,big wound, when edges get close enough you might apply a suture 

what are the phases of wound healing?

1. hemostasis

2. inflammatory

3. proliferative

4. remodeling

What is the hemostasis phase for?

stops the bleeding!!

• blood vessels constrict, clotting begins

• trying to create a platelet plug to stop the bleeding

What is the inflammatory phase?

phagocytosis

vessels dilate and increase capillary permeability

exudate (fluid)- causes swelling/pain

redness and heat

mildy increased temp and WBC

what is phagocytosis?

• Leukocytes clean up bacteria and cellular debris 

• Macrophages release growth factors for new epithelial cells 

what do cytokines do?

released to promote cell repair

what happens to the body temp in inflammatory phase?

mildy increased temp and increased WBC

What is the proliferation phase?

fibroblastic, regenerative or connective tissue phase

What do fibroblasts do in proliferaiton phase?

form fibrin and synthesize collagen; produce growth factors to form blood vessels and endothelial cells 

What kind of tissue develops in proliferation phase?

Granulation tissue develops (capillaries grow across wound and bring O2 and nutrients)

What happens in the maturation phase?

• Collagen is remodeled to strengthen wound 

• New collagen compresses vessels desiccates (dries) area 

What is the maximum strength of scar tissue in maturation phase?

75-80% of that of unwounded skin 

What happens if a scar develops over a joint?

it may limit movement causing disability

How does pressure to wound affect healing?

limits blood flow to area

How does desiccation affect wound healing?

Drying up (dehydration) of wound 

How does maceration affect wound healing?

overhydration of cells

How does trauma to wound affect wound healing?

it delays wound healing

how does edema around wound affect wound healing?

• Affects blood supply to area 

• Sometimes can put int a drain 

How does infection delay wound healing?

Body uses energy to fight infection rather than heal wound 

How does excessive bleeding affect wound healing?

Large clots take up space and interfere with oxygen diffusion 

How does necrosis affect wound healing?

dead tissue prohibits wound healing

How does biofilm affect wound healing?

Clumps of bacteria encased in slimy proteins and sugar, hard for abx to to impact healing 

How does age affect wound healing?

Older adults/infants struggle to heal more 

How does circulation and oxygenation affect wound healing?

HTN, PVD, DM, Smoking 

How does nutritional status affect wound healing?

• Protein, carbs, fat, vitamins (A&C) and minerals 

• Total calories (30-40 gms/kg) 

• Hydration 

How do steroids affect wound healing?

make it harder

How do NSAIDS affect wound healing?

can increase bleeding

How does chemo affect wound healing?

affects rapidly growing cells

How does HIV affect wound healing>

makes you at risk for infection

How can you ensure adequate blood supply for wound healing?

mobilize, avoid tight bandages, relieve edema through proper positioning 

How can good nutrition facilitate wound healing?

adequate protein, high carb (spare protein for healing) maintain fluid balance 

How does rest affect wound healing?

splints and protective devices when appropriate, balanced activity schedule 

how can you reduce stress in wound healing?

promote comfort, relieve pain, supportive environment 

How can you prevent infection in wound healing?

aseptic technique for dressing changes/hand hygiene

What happens in wound infection?

microbes enter the wound

what indicates a wound has been infected?

Pain, warmth, redness, swelling (can use infrared thermometer) 

What constitues a chronic wound?

if the wound lasts longer than 28 days

What is a local wound and how would you treat it?

a wound that requires topical abx or special dressings

What is a systemic/spreading wound?

a wound where you maybe need oral or IV abx

What conditions can wound infection lead to?

osteomyelitis (bone infection) or sepsis

What is hemorrhage?

bleeding!!!

What can an internal hemorrhage cause?

hematoma

How should you maintain hemorrhage?

• check the wound for bleeding (surgeon normally performs first surgical dressing change

• change/reinforce dressing as needed

• monitor vitals

What vital signs indicated hemorrhage?

• low BP

• high HR

What is dehiscence?

partial or total separation of wound layers due to excessive stress on wounds that are not healed 

What is evisceration?

complete separation of wound with protrusion of viscera through incision 

• Primarily occurs with abdominal incisions 

How should you treat evisceration?

• place patient in low fowler’s

• cover with sterile towels moistned with sterile saline

• notify HCP immediately

What is a fistula?

abnormal passage or connection from an internal organ to outside the body or from one internal organ to another 

What can cause a fistula?

• caused by abscess or infection

• can be surgically created

• LEADS TO SKIN BREAKDOWN/DELAYED HEALING

How is a pressure injury formed?

• Blood vessels collapse due to pressure and cause tissue necrosis 

what are some risk factors of pressure ulcers/injuries?

• External pressure 

• Friction and Shear- have to move them up in the bed 

• Microclimate of skin 

How are external pressure injuries formed?

• Pressure over bony prominence occludes capillaries and decreases circulation to tissues 

• Duration of pressure more important than amount of pressure 

is duration or amount of pressure more important for development of PU?

DURATION

What happens in friction and shear

• Pressure over bony prominence occludes capillaries and decreases circulation to tissues 

• Duration of pressure more important than amount of pressure 

What points are at risk for pressure ulcers when lying supine?

• Heels 

• Elbow 

• Spine 

• Scapulae 

• Back of head 

What points are at risk for PU when side lying?

• Toes 

• Malleolous 

• Medial and lateral condyles 

• Greater trochanter 

• Iliac crest 

• Ribs 

• Acromian process 

• Ear 

What points are at risk for PU when lying prone?

• Toes 

• Knees 

• Genitalia (males) 

• Breasts (women) 

• Cheek and ear 

What points are at risk for PU when sitting in a wheelchair?

• Shoulder blade 

• Buttocks 

• Ball of foot 

• Heel 

how does nutrition and hydration prove a risk factor for pressure ulcers?

• Protein (albumin 3.5-5.5) 

• Vitamin C 

• Dehydration and edema 

What kinds of moisture can cause pressure ulcers?

Diaphoresis, incontinence, wound drainage 

How can mental status cause pressure ulcer development?

confusion, coma, apathy

What populations are at risk for pressure ulcer development?

• spinal cord injury

• TBI

• Disorders with sensory pereception issues (MG, ALS, GB)

What is the first sign of PU?

skin discoloration (blanchable hyepremia)

What is blanchable hyperemia?

Redness that pales when pressure applied

with continued pressure what will happen to blanchable hyperemia?

discolored area will not turn white when pressed (non blanchable erythema)

skin is warm, spongy, hard

What are the four stages of pressure ulcers/injuries?

1. non blanchable erythema (skin intact)

2. skin loss involving epidermis/dermis- may present as blister

3. partial thickness skin and tissue loss (damage to subcutaneous tissue, bone, tendon, NO MUSCLE YET)

4. full thickness skin and tissue loss with extreme destruction (bone, tendon, muscle visible)

What is an unstageable ulcer?

• full thickness skin loss, base of ulcer covered by slough/eschar

What is slough/eschar?

(thick, leathery necrotic tissue)

Can you stage an ulcer when there is slough on it?

Cannot stage until slough/eschar is removed to see base of wound bed