Skin Integrity and Wound Care

Skin Integrity and Wound Care Notes

Normal Structure and Function of Skin

Epidermis

• Outermost layer of the skin.

• Regenerates every 4-6 weeks.

Dermis

• Thicker than the epidermis.

• Contains:

  • Sebaceous glands

  • Sweat glands

  • Hair and nail follicles

  • Nerves

  • Lymphatics

Subcutaneous Layer

• Composed of adipose tissue fat.

Factors Affecting Skin Integrity

• Wounds

• Vascular disease: circulation and good blood flow in the hands and feet.

• Diabetes

• Malnutrition: Lab Albumin: for wound healing I need the following: vitamin A, C, and E, copper, zinc, and protein.

• Age

• Medical adhesive-related skin injuries (MARSI): Occur when superficial layers of skin are removed by medical adhesive.

Altered Structure and Function of the Skin

Wound Classification

• Skin integrity

• Wound depth

• Amount of contamination

• Healing process

Phases of Wound Healing

• Inflammatory Phase

  • Duration: Approximately 3 days.

  • Involves the coagulation cascade.

  • Wound is red, warm, swollen, and tender.

• Proliferative Phase

  • Duration: Several weeks.

  • Characterized by the formation of granulation tissue (healthy and healing tissue).

• Maturation Phase

  • Duration: Up to 1 year.

  • Results in the formation of scar tissue.

  • All healed up and has scar tissue.

Factors Affecting Wound Healing

• Oxygenation and tissue perfusion

• Diabetes

• Nutrition

• Age

• Infection: hinder healing

Complications of Wound Healing

• Dehiscence: Wound ruptures along a surgical incision.

  • Wounds split open often due to coughing or movement.

• Evisceration: Protrusion of viscera through an incision.

  • First cover the organs with sterile saline-soaked gauze and notify doctor.

  • Do not push the organs back in.

  • Maintain moisture and prevent further damage and await surgical intervention.

  • Nutrition expected is total parental nutrition (TPN) with a central venous catheter (CVC) increasing the risk for infection and is a concern for patients with wounds.

  • To prevent we would sprint the pillow and put pressure on the belly to get the patient to cough.

• Fistula formation: Abnormal connection between two organs or vessels.

Burns

• Superficial

• Partial-thickness

• Full-thickness

Pressure Injury

• Related to: locations elbow, face, back, feet, butt, knees, and ears.

  • Intensity of pressure: how much pressure and how long?

  • Duration of pressure: how long was the pressure.

  • Medical devices: blood pressure cuffs, telemetry leads, oxygen devices, IV’s, Foley catheter, and restraints.

  • Friction: rubbing against a surface.

  • Shear: pulling of the skin.

  • Sensory loss or immobility: inability to feel discomfort or move away from pressure.

  • Moisture: prolonged exposure to moisture weakens skin including: incontinence, IV fluid leaks, sweat, or spills.

  • Nutrition: malnutrition impairs wound healing.

Classification of Pressure Injuries

• Stage 1 Pressure Injury

  • Non-blanchable erythema of intact skin.

  • Area may be painful and differ in firmness or temperature from surrounding tissue.

• Stage 2 Pressure Injury

  • Partial-thickness skin loss with exposed dermis.

  • May present as intact or ruptured blisters.

  • Blisters may be intact or not (do not pop blisters).

• Stage 3 Pressure Injury

  • Full-thickness skin loss with exposure to epidermis and dermis may see muscle or adipose tissue.

  • May involve undermining (overhanging tissue) and tunneling (evaluated with sterile Q-tip to measure depth).

  • The most painful.

• Stage 4 Pressure Injury

  • Full-thickness skin and tissue loss with exposure to bone and tendons.

  • May involve osteomyelitis (bone and muscle inflammation or infection).

• Unstageable Pressure Injury

  • Obscured full-thickness skin and tissue loss.

  • Cannot be assessed until necrotic tissue (eschar) in the wound bed is removed.

• Deep Tissue Pressure Injury

  • Persistent non-blanchable deep red, maroon, or purple discoloration.

Assessment

Physical Assessment

• Use of assessment tools: assessment of pressure injuries

  • Braden scale: Risk assessment for pressure injuries.

  • Norton scale: Risk assessment for pressure injuries.

Norton Pressure Ulcer Scale

• Parameters:

  • Physical condition

  • Mental state

  • Activity

  • Mobility

  • Continence

• Scoring:

  • 16-30: Low risk

  • 11-15: Moderate risk

  • 10 or below: High risk

Braden Scale for Predicting Pressure Sore Risk

• Parameters:

  • Sensory perception

  • Moisture

  • Activity

  • Mobility

  • Nutrition

  • Friction and shear

Wound Assessment

• Location

• Size

• Presence of undermining or tunneling

• Drainage

  • Serous: clear, pale, yellow watery fluid.

  • Sanguineous: red bloody fluid.

  • Serosanguineous: pink to pale red bloody fluid.

  • Purulent: pus, creamy yellow, green, white, tan color with odor.

• Condition of wound edges and surrounding tissue

  • Approximated: edges comes together cleanly and heal by primary intention.

  • Unappoximated: edges do not come together, heal from the inside out and heals by secondary intention.

  • Maceration: provides a clue to the amount of drainage produced by the wound. Appears pale, soft, wrinkled skin; signs of infection (redness, warmth, induration) more breakdown more wound.

• Wound bed

  • Usually classified Red Yellow Black (RYB). The wound bed should be beefy red and shiny or moist in appearance. The wound would need debridement if yellow and/or black tissue is present.

• Patient response

• Tools for assessment of wound healing:

  • Pressure Sore Status Tool (PSST)

  • Pressure Ulcer Scale for Healing (PUSH)

Nursing Diagnosis Examples

• Impaired Skin Integrity

  • Supporting Data: Pressure injury on left buttocks, paralysis, loss of sensation, healed stage 2 pressure injury, weight loss, 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 interprofessional healthcare team.

• Include specific evaluation criteria.

Implementation and Evaluation

Interventions to Preserve Skin Integrity

• Turning and positioning: Every 2 hours.

• Skin hygiene: Maintain healthy skin and preserve normal skin pH.

• Pressure-reducing mattresses and support surfaces: Spread out body weight over a greater surface area.

  • Important: These do not replace assessment, modification of risk factors, or regular position changes.

Interventions Related to Wound Care

• Wound Cleansing and Irrigation

  • Solution should be at room temperature or warmed promoted vasodilation.

  • Irrigation force should be strong enough to be effective without damaging new tissue.

• Debridement

  • Sharp: use of scalpels, curette, or scissors to cut things out.

  • Mechanical: use of wet/damp to dry dressings with saline moisturized dressing.

  • Enzymatic: chemicals to breakdown enzymes.

  • Autolytic: the wound cleans itself.

  • Biologic: maggots.

• Dressings

  • Gauze dressings: suitable for wounds with a lot of dressing.

  • Transparent films: not suitable for wounds with a lot of drainage.

  • Hydrocolloid dressings: helps pull out extra moisture.

  • Foams: used for packing wounds.

  • Alginates: contains algae.

  • Gels: adds moisture to a wound.

    • Use information from table 29.2

• Drains

  • Reduce the chance of infection by preventing blood, serum, or pus from collecting in the surgical area.

  • Closed or open systems.

  • May or may not be sutured into place.

    • Hemovac and Jackson-Pratt (JP) Drain: are closed drain that works by bulb suction, keep compressed to maintain suction, and dependent to the drainage area.

    • Penrose Drain: open drain used when not much drainage is expected. Requires preset gauze squared, safety pin, and not sutured.

• Negative-pressure wound therapy

  • Wound Vac: uses a vacuum like device to pull fluid out of larger wounds that are not approximated well.

• Suture care

  • Are used to bring the edges a wound together to speed up wound healing and reduce scar formation.

• Bandages and binders

  • Are placed over wound dressings to secure a dressing or splint to provide support and protection to the healing wound.

  • When a bandage is applied assess the 5 P’s of circulation: pain, pallor, pulselessness, paresthesia, and paralysis within 30 minutes of the application. If any P’s are present remove and rewrap to reduce constriction.

• 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

      • Heat: vasodilation

      • Cold: vasoconstriction

  • Complications

    • Loss of the body’s normal ability to sense temperature extremes, which may result in damage to tissue

Evaluation

• Essential to evaluate whether the patient has achieved the agreed-on goals.

• Evaluation is an integral part of an ongoing process.

• Assess the effectiveness of interventions and revise the plan of care as necessary.

  • Key review points

    • What is special about these types of skin care things?

    • Dressing and debridement types and what do those actually mean?

    • When are they good to use and when are they contraindicated?

    • How do I differentiate the pressure injuries?

    • What puts my patient at more risk for skin problems?

    • What do I need in order to promote healing as far as nutrition and all those things?