Skin Integrity and Wound Care

Normal Structure and Function of Skin

• Epidermis:
  • Outermost layer of the skin.
  • Regenerates every 4-6 weeks.
  • Consists of five sub-layers:
    • Stratum corneum
    • Stratum lucidum
    • Stratum granulosum
    • Stratum spinosum
    • Stratum germinativum or basale
• Dermis:
  • Thicker than the epidermis.
  • Contains sebaceous glands, sweat glands, hair and nail follicles, nerves, and lymphatics.
• Subcutaneous Layer:
  • Composed of adipose tissue.
• Factors Affecting Skin Integrity:
  • Wounds
  • Vascular disease:
    • Impair the skin’s ability to obtain required oxygen and nutrients.
  • Diabetes:
    • Affects the microvasculature but also the skin’s normally acidic pH.
  • Malnutrition
  • Age:
    • Changes to the skin, comorbidities, medications
• Medical Adhesive-Related Skin Injuries (MARSI):
  • Occur when superficial layers of skin are removed by medical adhesive (use adhesive remover pads).

Altered Structure and Function of the Skin

• Wound Classification:
  • Skin integrity: open/closed
  • Wound depth: superficial/ partial thickness/full thickness
  • Amount of contamination: clean/ clean contaminated/ contaminated/infected/ colonized
  • Healing process: primary/secondary/tertiary

Wound Healing Intention:

• Primary Intention:
  • Clean incision
  • Early suture
  • Hairline scar
• Secondary Intention:
  • Gaping irregular wound
  • Granulation
  • Epithelium grows over scar
• Tertiary Intention:
  • Increased granulation
  • Late suturing with wide scar
• Phases of Wound Healing:
  • Inflammatory Phase:
    • Approximately 3 days
    • Coagulation cascade occurs
  • Proliferative Phase:
    • Several weeks
    • Granulation tissue forms
  • Maturation Phase:
    • Up to 1 year
    • Scar tissue develops
• Factors Affecting Wound Healing:
  • Oxygenation and tissue perfusion
  • Diabetes
  • Nutrition
  • Age
  • Infection
• Complications of Wound Healing:
  • Dehiscence and Evisceration:
    • Caused by coughing, vomiting, straining
    • Patient may report a popping sensation with increase in drainage
    • Teach to splint wound
    • Cover wound with gauze moistened with a sterile normal saline and notify the physician immediately.
  • Fistula Formation
  • Burns:
    • Caused by heat, electricity, chemicals, radiation, extreme cold, or friction
    • Superficial:
      • Damage to only the epidermis, with resulting pain and erythema
    • Partial-thickness:
      • Damage to the epidermis and part or all of the dermis, causing blistering and pain.
    • Full-thickness:
      • Damage epidermis, dermis, and part of the subcutaneous tissue, cause the area to be white or brown, charred, and without sensation.
• Pressure Injury:
  • Intensity of pressure
  • Duration of pressure
  • Medical devices (oxygen tubing, a nasogastric [NG] tube etc)
  • Friction and shear
  • Sensory loss or immobility
  • Moisture (maceration)
  • Nutrition
• Classification of Pressure Injuries:
  • Stage 1 Pressure Injury:
    • Non-blanchable erythema of intact skin
    • An area that is painful and differs in firmness or in temperature from the surrounding tissue
  • Stage 2 Pressure Injury:
    • Partial-thickness skin loss with exposed dermis
    • Intact or ruptured blisters
  • Stage 3 Pressure Injury:
    • Full-thickness skin loss
    • Undermining
    • Tunneling
  • Stage 4 Pressure Injury:
    • Full-thickness skin and tissue loss
    • Osteomyelitis
  • Unstageable Pressure Injury:
    • Obscured full-thickness skin and tissue loss
    • Cannot be assessed until necrotic tissue (eschar) in wound bed is removed
  • Deep Tissue Pressure Injury:
    • Persistent non-blanchable deep red, maroon, or purple discoloration

Assessment

• Physical Assessment:
  • Assessment tools:
    • Braden scale
    • Norton scale
      • Scores: 16-30, Low risk; 11-15, moderate risk; 10 or below, high risk.
• Wound Assessment:
  • Location
  • Size
  • Presence of undermining or tunneling
  • Drainage:
    • Amount, color, consistency, and odor (serous, sanguineous, serosanguineous, purulent)
  • Conditions of wound edges and surrounding tissue
  • Wound bed:
    • Determine type of tissue (granulation tissue, necrotic tissue, subcutaneous tissue, muscle, or bone), and color of the wound.
    • Usually classified as Red Yellow Black (RYB)
      • Red: Healthy regeneration of tissue
      • Yellow: Presence of purulent drainage and slough
      • Black: Presence of eschar that hinders healing and requires removal
  • Patient response
  • Tools for the assessment of wound healing (to track wound healing over time):
    • Pressure Sore Status Tool (PSST)
    • Pressure Ulcer Scale for Healing (PUSH)

Nursing Diagnosis Examples

• Impaired Skin Integrity
  • Supporting Data: Pressure injury on his left buttocks; paralyzed and has loss of sensation below the waist as a result of a motor vehicle accident 8 years ago: stage 2 pressure injury right buttocks 4 years ago, healed; losing weight due to eating less; albumin 2.5 g/dL, prealbumin 15 mg/dL
• Impaired Tissue Integrity
  • Supporting Data: Pressure, immobility, stage 3 pressure injury on the coccyx
• Acute Pain
  • Supporting Data: Trauma, pain in the area of the wound rated by the patient at 8 of 10

Planning

• Collaborate with patient and other members of interprofessional health care team
• Include specific evaluation criteria

Implementation and Evaluation

• Interventions to Preserve Skin Integrity:
  • Turning and positioning:
    • Every 2 hours (more frequent for high risk patients)
    • Head of the bed should be elevated no more than 30 degrees
    • Reposition hourly while sitting in a chair
  • Skin hygiene:
    • Maintains healthy skin
    • Preserve normal skin pH
    • Use a moisture barrier ointment
  • Pressure-reducing mattresses and support surfaces
    • Spread out body weight over a greater surface area
    • Do not replace assessment, modification of risk factors or regular position changes
• Interventions Related to Wound Care:
  • Wound cleansing and irrigation
    • Solution should be room temperature or warmed
    • Irrigation force should be strong enough to be effective without damaging new tissue
  • Debridement
    • Sharp – uses a sharp instrument (scalpel, curette, or scissors) to remove necrotic tissue.
    • Mechanical - nonselective form of debridement that removes the necrotic tissue but also can remove or disturb exposed viable tissue (ex. wet/damp-to-dry dressings and whirlpools)
    • Enzymatic – applies topical agents containing enzymes to remove necrotic tissue
    • Autolytic – uses occlusive dressings (hydrocolloids and transparent films) and hydrogels, contraindicated in infected wounds
    • Biologic – uses maggots to break down necrotic tissue
  • Dressings
    • Gauze dressings
    • Transparent films
    • Hydrocolloid dressings
    • Foams
    • Alginates
    • Gels
  • Drains
    • Reduce the chance of infection
    • Preventing blood, serum, or pus from collecting in the surgical area
    • Closed or open systems
    • May or may not be sutured into place
  • Negative-pressure wound therapy
  • Suture care
  • Bandages and binders
  • Heat and cold application
    • Reduces pain, improves circulation, and reduces swelling
    • May require a doctor’s order, which should include
      • Type of application
      • Length of the treatment
      • Frequency
      • Body part to be treated
    • Complications
      • Loss of the body’s normal ability to sense temperature extremes, which may result in damage to tissue
• Evaluation
  • It is essential to evaluate whether the patient has achieved the agreed-on goals.
  • Although this often is considered the last step in the nursing process, it is really an integral part of an ongoing process, whereby the effectiveness of interventions is assessed, and the plan of care is revised as necessary.