Skin Integrity and Wound Healing

age

\-infants and children: smooth, soft, fragile, permeable, lose heat easily (can’t thermoregulate)

\-older adults: thinning, decrease elasticity and collagen, decrease in muscle mass and subcutaneous fat

mobility status

\-healthy people move and shift positions unconsciously when they sense pressure/discomfort

\-dependent/lack of sensation can’t move regularly and have increased pressure

* paralysis, extreme fatigue, pregnancy, sedation, casts

nutrition status

\-protein and calories: aid in wound healing

\-dehydration leads to thinning, tenting, and dryness (skin tears and breakdown)

diminished sensation and cognition

\-can’t sense extreme temps (hot or cold)

\-wounds can go unnoticed

\-high-risk for pressure injury

\-can’t communicate pain/wounds effectively

impaired circulation

main cause of chronic wounds

impaired arterial circulation

restricts activity, produces pain, leads to muscle atrophy and tissue death

impaired venous circulation

engorged tissues, edema, ulceration, breakdown

NSAIDS

inhibit wound healing by slowing down the process

antibiotics

medication that causes an increased risk for sunburn

chemotherapy

weakens immune systems and decreases white blood cell count

skin moisture

\-excessive exposure to moisture leads to maceration

\-sources include incontinence and fever

maceration

microorganisms on skin leading to skin breakdown

exocriation

diaper rash

fever

\-can lead to maceration, increases metabolic rates

\-want to remove wet gowns/sheets off of patient immediately

contamination

presence of microorganisms in wound

\-all chronic wounds are considered contaminated

lifestyle factors

\-tanning

\-skin cleansing

\-smoking

\-piercings and tattoos

\-gym

\-dry, cracked skin from constant hand hygiene

\-skin folds (traps moisture)

closed wound

no breaks in the skin, but bruises or swelling exists, or scar tissue

open wound

break in the skin or mucous membranes

\-ex: abrasions, lacerations, puncture wounds

acute wounds

short duration, heal through the 3 phrases without complication

chronic wounds

exceed expected length of healing; takes months/years to heal completely

\-ex: pressure injury, arterial, venous, and diabetic ulcers

clean wound

uninfected wounds with minimal inflammation, small risk of developing infection

\-can be open or closed

clean-contaminated wound

surgical incisions that enter GI, respiratory, or genitourinary tracts

contaminated wounds

includes open, traumatic wounds or surgical incisions in which a major break in asepsis occured; high risk of infection

infected wound

bacteria is present in tissue

\-signs: erythema and swelling around wound, increased pain, inflammation, warm temp

abrasion

scrape of superficial layers of skin

abscess

localized collection of pus resulting from pathogen invasion; must be opened and drained to heal

contusion

closed wound by blunt trauma; ecchymosis

crushing

caused by force, leading to compression of tissues

excoriation

superficial wound, usually caused by scratching or mechanical force

incision

open, intentional wound caused by a sharp instrument

laceration

skin or mucous membrane tore open

\-ex: papercut, tissue has jagged edges

penetrating

open wound with cause lodged into body tissue

puncture

open wound caused by a sharp object; collapse of tissue around entry point; higher risk of infection

tunnel

wound with entry and exit sites

\-ex: gunshot wound and pressure injuries

superficial

involve only epidermal layer

partial-thickness

extends through epidermis but not fully through dermis

full-thickness

extends into subcutaneous, and even muscle and bone

regenerative/epithelial healing

wound affects only epidermis and dermis

\-no scar forms

primary intention healing

wound involves minimal to no tissue loss, little scarring is expected

\-surgical incision and sutures

secondary intention healing

a wound that involves extensive tissue loss that prevents wound edges from closing or shouldn’t be closed

\-if infected, tissue heals then is sutured closed and proceeds into tertiary phase

\-heals with granulation tissue; heals more slowly and develops more scar tissue

\-heals inside to outside

tertiary intention healing

2 surfaces of granulation tissue are brought together through suture; scarring is less than secondary

\-used when wound is clean-contaminated or contaminated

granulation tissue

beefy red color, thin, striations

bleeding

tissue capillaries are destroyed, causing blood to leak into wound; area vessels constrict to limit blood loss and coaggulation occurs

inflammation

characterized by edema, erythema, pain, increase in temp, and migration of WBC into wound tissues (platelets=clotting factors)

\-days 1-5

proliferative phase (granulation)

cells fill wound, granulation tissue forms, then epithelial cells grow into wound to seal it, and collagen fibers form

\-days 5-21

maturation/remodeling phase

begins 2nd-3rd week, collagen fibers made during proliferation phase are broken and remodeled into scar tissue

adhesive strips

used for closing superficial low tension wounds (skin tears or lacerations), closing skin that has been previously closed by subcutaneous tissue, or to give additional support after sutures/staples have been removed

\-can get wet, peel off on their own, can be medicated

sutures

creates small puncture wounds along track of laceration/incision; document how many were in place/removed

\-1st 24 hours they must stay dry, site determines how long they stay in

absorbent

sutures used in deep tissues, dissolvable

nonabsorbent

sutures used in superficial tissues, require removal

staples

fast, easy way to close an incision; nurses can remove only

\-common sites: arms, legs, abdomen, scalp, or bowel

surgical glue

used in clean, low-tension wounds; ideal for skin tears

\-wound must be closed (edges touching) to be glued shut

serous exudate

clear, watery in consistency and contains very little cellular matter; typically seen from clean wounds

sanguineous exudate

bloody drainage; seen with deep wounds

serosanguineous drainage

combination of bloody and serous drainage; seen in new wounds

purulent

thick, malodorous drainage from infected wounds (pus)

purosanguineous exudate

red-tinged pus; indicates small vessels within wound ruptured; bloody-pus

hemorrhage

rapid blood loss; causes include slipped suture, dislodged clot, or infection

\-any surgery is at risk 24-48 hours post-op

internal hemorrhage

hematoma; red-blue collection of blood under skin

\-commonly seen in abdomen

external hemorrhage

bleeding outside wound

dehiscence

separation of 1st layers of tissue

\-associated with abdominal wounds/surgeries

\-coughing, vomiting, or lifting something to heavy can be a cause

\-pop sensation occurs

\-bedrest, elevate HOB 20 degrees, flex knees, get abdominal binder, then call physician

evisceration

total separation of layers of a wound with internal viscera protruding through incision

\-surgical emergency

\-organ can become necrotic

\-cover area with sterile towels soaked in sterile saline, knees bent, no abdominal binder, call physician

fistulas

abnormal passage connecting 2 body cavities or a cavity and skin

\-ex: rectum into urethra; increase risk of infection

wound assessment

\-location

\-size

\-undermining or tunneling

\-periwound

* skin surrounding wound; pink, red, or white color

\-wound base

\-drainage

\-pain

\-nutritional status

slough

yellow, string-like substance; adheres to wound bed

eschar

necrotic tissue; black, thick

clean

starting to regenerate, pale, no granulation tissue present yet; shiny and smooth

epithelial

light pink or pearly white; epidermis that is regenerating

laboratory data

\-blood studies

\-wound cultures

\-swabbing

\-needle aspiration

\-tissue biopsy

risk factors

\-impaired circulation

\-reduced O2 supply

\-limited mobility or reduced sensation

\-health history

\-pressure

\-friction

\-shearing

\-moisture

pressure ulcers

\-focused skin assessment, especially on pressure points

\-Braden scale: looks at mobility, nutrition for risk of pressure injuries

* total score: lower the score, the greater the risk for pressure injuries

stage 1 pressure injuries

\-redness that is nonblanchable; in contact skin; usually over a bony prominence

\-may be painful, firm, soft, warmer/cooler compared to adjacent tissue

\-discoloration remains >30 mins after pressure is relieved

stage 2 pressure injuries

\-involves partial-thickness loss of dermis

\-open but shallow with a red-pink wound; no slough

\-may be an intact or open serum-filled blister, or a dry/shiny ulcer

stage 3 pressure injury

\-full thickness skin loss with damage or necrosis subcutaneous tissue; adipose is visible

\-undermining may be present

\-deep crater

stage 4 pressure injuries

\-full-thickness loss with extensive necrosis or damage to muscle or bone

\-exposed bone/tendon

\-slough or eschar present

\-requires a full year to heal

deep tissue injury

\-area of skin that is intact but persistently discolored

\-purple or deep red, painful, blister

\-very painful, feels squishy

unstageable pressure injury

\-involves full-thickness skin loss

\-completely covered by eschar

pressure injury interventions

\-prevention

\-manage moisture

\-minimize pressure

\-optimize nutrition and hydration

\-client/family teaching

\-barrier cream

adjunctive wound care therapies

\-surgery

\-electrical stimulation

\-hyperbaric oxygen therapy

\-tissue growth factors

\-ultrasound

\-bioengineered skin substitutes

\-nitric oxide

\-maggot therapy

isotonic cleanse

\-normal saline

\-doesn’t damage granulation tissue

hypotonic cleanse

\-sterile water

\-can dry out tissue

antiseptic solution

only used on non-healing tissue

penrose drain

flexible, flat latex tube that is placed in the wound bed but not sutured in place; used with abscesses to pull out rest of exudate

jackson-pratt

suction device; fills with blood and pouch expands; sutured in place, emptied 1x shift

\-holds 30 mL

hemovac

accordion, squished close to create suction and will fill with blood

\-holds 100 mL

woundvac

sponge with suction tube placed through it with clear dressing over top, painful

debridement

removal of dead tissue and foreign material from a wound

sharp

using a scalpel to remove tissue; can’t do as a nurse

mechanical

using wet-to-dry dressings; irrigate wound, put a wet dressing in it

enzymatic

uses a proteolytic agent (protein) to breakdown necrotic tissuea

autolysis

uses a moisture-retaining dressing and body enzymes and defense mechanisms to breakdown necrotic tissue

\-contraindicated in the presence of infection

biotherapy

medical-grade larvae used to dissolve dead and infected tissue

absorbent

absorbs exudate; don’t use on dry wounds

aligantes

comes from algae, highly absorbent

antimicrobial

contains iodine or silver; concern is allergies

collagens

absorbs exudate

foams

provides comfort

gauze

only used to help clean a wound, never used to pack a wound

hydrocolloids and hydrogels

contains water, used on dry wounds

skin sealants and moisture barriers

barrier cream to protect skin