skin

Identify the factors that affect skin integrity and wound healing.
Identify patients at risk for pressure injury development.
Discuss the general principles of wound management.
Identify wound types and their associated nursing interventions.
Describe the skills and knowledge to assess and apply a variety of wound management techniques including asepsis measures.
Discuss assessment and evaluation tools utilized to predict pressure-ulcer risk in addition for documentation of existing wounds.
Discuss hot and cold therapy and when to use safely and effectively.
Evaluate patient responses to interventions utilized to promote skin integrity and circulation.

Abscess: Collection of infected fluid that has not drained.
Bandages: Piece of gauze or other material used to cover a wound.
Biofilm: A thick grouping of microorganisms.
Debridement: Cleaning away devitalized tissue and foreign matter from a wound.
Dehiscence: Separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound.
Dermis: Layer of the skin below the epidermis.
Desiccation: Dehydration; the process of being rendered free from moisture.
Dressing: Protective covering placed over a wound.
Epidermis: Superficial layer of the skin.
Epithelialization: Stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink.
Erythema: Redness of the skin.

Layers of Skin:
- Epidermis
- Dermis
- Subcutaneous
Components:
- Hair
- Capillaries
- Muscle
- Sweat Gland
- Sebaceous Gland
- Sensory Nerve Ending
- Fat, Collagen, and Fibroblasts

Types:
- Abrasion
- Abscess
- Contusion
- Crushing
- Incision
- Laceration
- Penetrating
- Puncture
- Tunneling
- Degloving
- Amputation

Types of Tissue:
- Granulation: Healthy, beefy red, moist.
- Slough: Necrotic tissue (yellow, tan, brown).
- Eschar: Necrotic tissue (dark brown/black).
- Adipose: Fat, yellow in appearance if healthy.
- Anatomical structures: Bone, tendon, muscle, organs, etc.
- Epithelium: Pearly white or pink new skin that starts from the edges and migrates to close the wound; forms “islands” when they touch each other.

Inflammatory Phase:
- Immediate (1-5 Days)
- Hemostasis: Constriction of blood supply and platelet aggregation to slow bleeding.
- Inflammation: Increase in vascular permeability, fibroblast proliferation, edema, pain, erythema, temperature elevation, and phagocytosis while a scab forms.
Proliferative Phase:
- Lasts 5-21 days
- Granulation, new collagen, new capillaries, contraction, epithelialization (resurfacing with new epithelial cells).
Maturation/Remodeling Phase:
- Final phase that begins around 3 weeks to 2 years.
- Scab falls off, and collagen scar strengthens. Scar tissue is only 80% as strong as the original tissue.

Primary Intention:
- Little or no tissue loss.
- Clean wound; edges approximated, low risk of infection, heals rapidly.
Secondary Intention:
- Loss of tissue; edges not approximated; contaminated/dirty wounds with longer healing time.
- Heals from bottom layer up, which poses an increased risk of infection and scarring.
Tertiary Intention:
- Wound is widely separated; it spontaneously opens a previously closed wound.
- Closes when free of infection with longer healing time and requires aseptic techniques with dressing changes, resulting in less scarring than secondary intention.

Types of Drainage:
- Purulent: Thick, yellow, or tan—indicates high bioburden infection.
- Serous: Thin, clear, straw-colored fluid.
- Sanguineous: Blood.
- Serosanguineous: Blood mixed with serous fluid, indicates pseudomonas if in large amounts.

Observations include:
- Moisture Associated Skin Damage (MASD): Denuded skin (loss of epidermis or inflammation due to moisture).
- Excoriated Skin: Abraded or mechanically scratched skin.
- Skin Injuries: Skin tears that can occur from tape, dermatitis (fungal or irritant), allergic reactions.

Types of Treatments/Dressings:
- Minimal to No Drainage: Gels (plain or antimicrobial), hydrocolloids (non-infected and dry wounds), transparent films (avoid pooling fluid).
- Moderate to Heavy Drainage: Calcium alginates/hydrofibers (absorbent, gel up), super absorbents (high output wounds), foams (moderate drainage), and collagen/specialty dressings for specific wounds.

Types of Complications:
- Hemorrhage
- Infection
- Dehiscence
- Evisceration
- Fistula formation

Healthy Wound:
- Red, no signs of infection.
- Continued redness or swelling indicates infection.
Infected Wound:
- Presents with pus, red streaks, and pronounced redness or dehiscence.

Factors:
- External pressure
- Friction/shearing
- Temperature/moisture
- Cognitive impairment
- Impaired mobility

Stages:
- Stage I: Intact skin with localized, non-blanchable erythema; firm or soft, warmer or cooler compared to surrounding skin.
- Stage II: Partial thickness wound presenting as a shallow, open ulcer; red/pink wound bed.
- Stage III: Full thickness wound; subcutaneous tissues visible.
- Stage IV: Full thickness wound exposing bone, tendon, or muscle.
- Suspected Deep Tissue Injury (SDTI): Localized purple/maroon area with damage.
- Unstageable: Wound bed covered with sufficient slough and/or eschar to preclude staging.

Interventions Include:
- Cleansing membranes, irrigating wounds, managing drainage devices, and types of dressings.
- Controlling infection, securing dressings, immobilizing wounds.
- Employing hot and cold therapy safely.

Braden Scale:
- Score 19-23: Not at risk.
- Score 15-18: Preventative interventions.
- Score 13-14: Moderate risk.
- Score 10-12: High risk.
- Score 6-9: Very high risk.