Skin Integrity & Wound Care

Partial Thickness Wound

Epidermis + part of dermis

• inflammatory response

• epithelial proliferation

• resurfacing

Full Thickness Wound

extends to dermis —> hypodermis

• hemostasis

• inflammatory response

• proliferation

• remodeling - scar tissue forms

Primary Intention

edges are approximated (close together)

• sutures aid this

Secondary Intention

1. Edges left open

2. Wound bed fills with granulation tissue

3. Once filled, epithelialization occurs across surface

4. Scar tissue form

*Greater risk for infection

Tertiary Intention

• wound intentionally left open for days

• closed later after infection resolves or drainage decreases

Granulation Tissue

should be:

• Surface - pink, red, moist

• Edges - clean & intact

Hemorrhage

External Hemorrhage - direct visualization of bleeding

Internal Hemorrhage 

• Hematoma - localized collection of blood under tissues (24-48 hours postop)

Infection

• 2nd most common HAI

• Presents in 2-3 days up to 30 days

• Risks: dirty wounds + underlying conditions

Dehiscence

partial or total separation of wound layers

• greatest risk 3-11 days post-op

• Triggers: Out of Bed activity, coughing

• Increase in drainage —> infection

• Patients at greater risk: DM, infection, poor nutrition, obesity

Evisceration

total separation + protrusion of visceral organs (SURGICAL EMERGENCY)

• DO NOT push organs back in

• moist gauze

• NG suction

Fistula

abnormal connection/passageway between 2 structures

Serous

clear & watery

Purulent

thick, yellow, green, tan, or brown

Serosanguineous

pale, red, watery mixture

Sanguinous

bright red, bloody

Debridment

remove non-viable tissue

Dressing Change Best Practice

Know

• ordered dressing type

• if drains are present

• what equipment is needed

Pre-medicate w/ Anelgesics (timed so pain med works during the change)

Review prior assessments (compare progress or decline)

• eMAR & Handoff report

Measure & Photograph (often weekly)

Securement of Dressings

• Use skin barrier wipes so tape doesn’t destroy skin

• “Picture framing” is outdated—cover the whole dressing instead

• Remove tape with the direction of hair; if not possible, push the skin away rather than pulling tape upward

Jackson Pratt (JP)/Hemovac

• Constant, low pressure vacuum to remove & collect

• Empty when 50% full or once per shift

• Chart COCA (Color, Odor, Consistency, Amount)

Concerns w/ Drainage

• Sudden increase or decrease in drainage

• Foul smell

Negative Pressure Wound Therapy

NEGATIVE PRESSURE WOUND THERAPY (Wound VAC)

• Pulls wound edges together

• Removes fluid and exudate

• Reduces edema

• Promotes angiogenesis (new blood vessels)

• Increases granulation tissue formation

Diabetic Ulcers

• limb amputations (10x greater prevalance)

• slow wound healing

• neuropathy - loss of sensation in hands & feet

Decreased

• bloodflow

• angiogenesis

Increased

• inflammation

• circulating glucose

PVD: Venous

• wet, weeping, edematous edges

• develops above ankle

PVD: Arterial

• pulses faint

• skin cool to touch

• minimal or no edema

• clear demarcation (well-defined, punched out areas)

Pathogenesis of Pressure Ulcers

• Pressure Intensity - ischemia, blanching

• Pressure Duration

• Tissue Tolerance

• Bony Prominences

• Medical Device Locations

Frequency of Assessment for Pressure Ulcers

• Acute care: admission, within 8 hrs, then q24–48 hrs & ANY CHANGE IN CONDITION

• ICU: admission + q24 hrs

• Long-term care: admission + weekly OR with client change

• Home care: admission + every visit