Skin

Skin Integrity and Wound Care

Defining the Concept

  • Skin Integrity: The state of skin or other tissue when it is healthy and intact.   - When tissue is wounded, its normal integrity and continuity are disrupted.   - This disruption compromises the skin's function of protection, making it vulnerable to invasion by organisms.   - Source: Taylor, 2019

Functions of the Skin

  • Protection: Provides a barrier against environmental hazards.

  • Temperature Regulation: Helps maintain body temperature.

  • Psychosocial: Influences self-image and social interactions.

  • Sensation: Detects changes in the environment via nerve endings.

  • Vitamin D Production: Synthesizes vitamin D when exposed to sunlight.

  • Immunologic Function: Serves as the first line of defense against pathogens.

  • Absorption: Allows absorption of certain substances (e.g., nitroglycerin).

  • Elimination of Waste: Helps excrete waste products through sweat.

Factors Affecting the Skin

  • Healthy skin and mucous membranes defend against infection.

  • Factors that affect resistance to injury include:   - Underlying tissues and illnesses.   - Age: Resistance tends to decrease with age.   - Nutritional status: Adequately nourished and hydrated cells provide better protection against injury.   - Circulation: Adequate circulation is necessary to maintain cell life, as seen in areas like toe hair that may be affected by reduced arterial circulation.

Developmental Considerations

  • Changes in skin structure occur with aging.   - Maturation of epidermal cells is impaired.   - Circulation and collagen formation decline, increasing the risk of tissue damage from pressure.

Causes of Skin Alterations

  • Factors that contribute to skin injury:   - Very thin or very large individuals are more susceptible.   - Dehydration and desiccation lead to compromised skin turgor.   - Diaphoresis during illness predisposes skin to breakdown.   - Jaundice: Causes yellowish, itchy skin due to bile accumulation.   - Skin diseases such as eczema and psoriasis affect skin health.

Wound Categories

  • Types of wounds can be classified as follows:   - Intentional or Unintentional.   - Open or Closed.   - Acute or Chronic.   - Partial Thickness, Full Thickness, Complex (involving the dermis).   - Hematoma: A localized collection of blood outside of blood vessels, often presenting as a bruise.

Principles of Wound Healing

  • Intact Skin: Provides a natural barrier and is crucial for healing.

  • Hand Hygiene: Essential to practice and teach thorough handwashing.

  • Blood Supply: Adequate blood supply is necessary for normal responses to injury and healing.

  • Wound Environment: Normal healing is promoted when the wound is free of foreign material.

Principles Affecting Wound Healing

  • Overall Health: The general state of health significantly affects healing.

  • Medications: Certain medications (like steroids) can impair healing.

  • Hygiene: Maintaining proper hygiene helps promote effective healing.

Phases of Wound Healing

  1. Hemostasis: Immediate response to injury involving blood vessel constriction and clotting.

  2. Inflammatory Phase: Lasts about 2-3 days after hemostasis; involves immune response and debris clearance.

  3. Proliferation Phase: Begins within 3 days; new tissue is formed by fibroblasts. Capillary growth occurs, creating a foundation for scar tissue.

  4. Maturation Phase: Involves remodeling of collagen, resulting in a flat, thin, white scar.

Local Factors Affecting Wound Healing

  • Desiccation: Excess dryness can adversely affect healing.

  • Maceration: Excess moisture can damage tissue.

  • Trauma: Additional physical injury can hinder healing.

  • Edema: Swelling can impair circulation and healing.

  • Infection: Increases healing time and complications.

  • Excessive Bleeding: Can interfere with necessary clotting and healing processes.

  • Necrosis: Death of tissue reduces healing potential. Biofilm can develop, complicating wound management.

Systemic Factors Affecting Wound Healing

  • Age: Young and healthy adults tend to heal more rapidly than older adults.

  • Circulation and Oxygenation: Essential for cellular function and healing.

  • Nutritional Status: Malnutrition impairs wound healing.

  • General Health: Certain health conditions and medications can complicate healing.

Wound Complications

  • Infection: Presence of pathogens can hinder healing.

  • Hemorrhage: Excessive bleeding can complicate wound healing.

  • Dehiscence: The reopening of a wound, leading to complications.

  • Evisceration: Protrusion of internal organs through a wound.

  • Fistula: An abnormal connection between two body parts.

Psychological Effects of Wounds

  • Pain: Physical discomfort associated with wounds.

  • Anxiety and Fear: Emotional responses related to the wound and healing process.

  • Impact on Activities of Daily Living: Limitations due to wounds can affect daily routines.

  • Change in Body Image: Wounds can alter self-perception and image.

Factors in Pressure Ulcer Development

  • Braden Scale: A tool for assessing risk for pressure ulcers, particularly in individuals 65 and older.

  • Chronic Illnesses: Conditions that compromise mobility and nutrition increase risk.

  • Immobility: Lack of movement contributes to ulcer development.

  • Malnutrition: Insufficient nutrition impairs skin integrity and healing.

  • Incontinence: Fecal and urinary incontinence can cause skin breakdown.

  • Altered Level of Consciousness (LOC): Reduced awareness can lead to neglect of skin care.

Stages of Pressure Ulcers

  • Stage I: Non-blanchable erythema of intact skin.

  • Stage II: Partial-thickness skin loss that presents as an open wound.

  • Stage III: Full-thickness skin loss without involvement of underlying fascia.

  • Stage IV: Full-thickness skin loss with extensive tissue destruction.

  • Unstageable: Base of the ulcer covered by slough or eschar, rendering it difficult to assess the depth of the wound.

Measurement of a Pressure Ulcer

  • Size of Wound: Measurement of length and width.

  • Depth of Wound: Assessment of how deep the wound extends.

  • Presence of Tunneling: Identification of any tunnels that may form within the wound.

  • Clock Method: Use of clock positions to describe the location of features in the wound (e.g., 6 o'clock being the foot side).

  • Consideration of Mattress: Assessment of the patient’s mattress or surface during ulcer evaluation.

Cleaning a Pressure Ulcer

  • Frequency of Cleaning: Based on clinical judgment; as needed during dressing changes.

  • Cleaning Technique: Use careful, gentle motions to minimize further trauma.

  • Irrigation: Use 0.9% saline solution for irrigation to ensure proper cleaning.

  • Reporting: Important to report new slough or eschar, changes in size, or other significant observations.

Wound Assessment

  • Inspect for Exudate: Assessment of fluid draining from the wound and any sutures/staples.

  • Smell: Detect any unusual odors that may indicate infection.

  • Light Touch: Conduct light touch assessments to check for sensation.

  • Size: Accurately measure and note the size of the wound.

  • Patient Orientation: If the patient is oriented, assess pain levels and the output of any drains or tubes.

  • Complications: Watch for signs of complications during assessment.

Presence of Infection

  • Signs of Infection: Identifiable by:   - Inflammation: Redness, swelling, heat.   - Pain: Increased pain associated with the wound area.   - Loss of Function: Impaired ability to use the affected area due to pain and swelling.

Assessment of Wound Drainage

  • Know Your Exudate: Ability to understand and characterize the type of exudate present (e.g., serous, sanguineous, purulent).

Purposes of Wound Dressings

  • Comfort: Provides physical, psychological, and aesthetic comfort to the patient.

  • Removal of Necrotic Tissue: Assists in debridement of the wound.

  • Infection Prevention: Protects the wound from pathogens.

  • Absorption of Drainage: Manages exudate to prevent maceration.

  • Protection from Injury: Safeguards the wound from further damage and protects the surrounding skin.

  • Post-op Dressing Changes: The first dressing change after surgery is usually performed by the surgeon.

Cleaning a Wound

  • Frequency: Based on physician's orders; as needed.

  • Method/Products: Follow specific orders regarding cleaning methods and products.

  • Sterile vs. Unsterile: Adhere to guidelines regarding sterile vs. non-sterile procedures.

Types of Wound Dressings

  • Identification of common dressing types: e.g., 4x4 or 2x2 dressings.

Types of Drainage Systems

  • Open Systems: Example includes the Penrose drain.

  • Closed Systems: Examples include Hemovac and Jackson-Pratt drains.

Effects of Applying Heat

  • Peripheral Blood Vessels: Applying heat dilates peripheral blood vessels.

  • Tissue Metabolism: Heat application increases tissue metabolism.

  • Muscle Tension: Heat reduces muscle tension, aiding in pain relief.

  • Duration: Recommended duration of heat application is 15-30 minutes.

  • Safety Measures: Important to ensure safety to prevent burns or skin damage.

Devices to Apply Heat

  • Types of heat application devices include:   - Hot water bags or bottles.   - Electric heating pads.   - Aquathermia pads.   - Hot packs.   - Warm, moist compresses.   - Sitz baths and warm soaks.

Effects of Applying Cold

  • Peripheral Blood Vessels: Applying cold constricts peripheral blood vessels.

  • Muscle Spasms: Cold application reduces muscle spasms.

  • Comfort: Promotes comfort and pain relief.

  • Duration: Recommended duration of cold application is 15-30 minutes.

  • Safety Measures: Care must be taken to avoid frostbite or other cold-related injuries.

Devices to Apply Cold

  • Types of cold application devices include:   - Ice bags and cold packs.   - Hypothermia blankets.   - Cold compresses for moist cold application.