Skin Integrity & Wound Healing

Age:
- Older adult skin experiences decreased elasticity, diminished moisture, reduced collagen production, hyperpigmentation, and is more susceptible to injury.
Mobility status:
- Limited mobility can lead to increased pressure, shearing forces, and friction, all of which can cause skin breakdown.

Nutrition/hydration:
  - Protein: Essential for skin maintenance, repair of minor defects, and preservation of intravascular volume.
  - Vitamin C, zinc, copper: Vital for collagen formation.
  - Dehydration: Leads to poor skin turgor.
Sensation level:
- Diminished sensation heightens the risk of pressure injuries and skin breakdown.
Moisture: Excessive moisture from incontinence or sweating can compromise skin integrity and contribute to the development of dermatitis.

Impaired circulation:
- Poor circulation negatively affects tissue metabolism, impacting skin health.
Medications:
- Side effects from various medications may include itching and rashes, further compromising skin integrity.

Moisture:
- Excess moisture can cause skin maceration, leading to breakdown.
Fever:
- Increases metabolic rate and can lead to increased moisture loss.

Infection:
- Infections impede the healing process, complicating wound management.
Lifestyle:
- Activities such as tanning, bathing practices, and body modifications (piercings, tattoos) can affect skin integrity.

Open/Closed: Wounds can be categorized based on whether the skin is broken.
Acute/Chronic: Acute wounds heal in a predictable time frame, whereas chronic wounds do not.
Clean/Contaminated/Infected:
- Clean wounds are free from infection, contaminated wounds carry a chance of infection, while infected wounds already have bacterial growth.
Superficial/Partial or Full Thickness:
- Superficial wounds involve only the epidermis, while partial thickness extends into the dermis, and full thickness reaches subcutaneous tissue or beyond.
Penetrating: These wounds involve a deep penetration through the skin into underlying tissues.

Regeneration:
- Occurs in epidermal wounds, with no scar formation.
Primary Intention:
- Clean surgical incisions with edges that are approximated result in minimal scarring.

Secondary Intention:
- Occurs when wound edges are not approximated. Healing involves tissue loss and progresses from the inner layer of tissue outward.
Tertiary Intention:
- Involves bringing together granulating tissue with delayed closure of wound edges.

Inflammatory Phase:
- This phase includes hemostasis, where severed vessels constrict, followed by inflammation characterized by the release of bradykinin, histamine, serotonin, and prostaglandins, leading to vasodilation and increased capillary permeability.
Proliferative Phase:
- Fibroblasts enter the wound, synthesize collagen, and new blood and lymph vessels form. Epithelial cells proliferate and migrate to close the wound.
Maturation Phase:
- Involves remodeling of collagen fibers. The tensile strength of the tissue increases, and wound contraction occurs.

Adhesive strips: Used to close small wounds.
Sutures:
- Used for larger incision closures, stitches are placed in the skin.
Surgical staples:
- Metal fasteners holding the edges of skin together.
Surgical glue:
- An adhesive that helps to seal the wound and decrease infection risk.

Serous exudate: Clear, straw-colored drainage.
Sanguineous: Contains blood; the drainage is red.
Serosanguineous: A mix of serum and blood, appearing pink.
Purulent: Thick, yellow drainage that contains pus.
Purosanguineous exudate: Contains blood in addition to pus, often indicative of infection.

Hemorrhage: Excessive bleeding that may interfere with healing.
Infection: Bacterial proliferation that can delay healing.
Dehiscence: Wound edges separate, leading to potential reopening of the wound.
Evisceration: Protrusion of internal organs through a wound opening.
Fistula Formation: An abnormal connection between two body parts, resulting in improper drainage.

Focused Skin Assessment:
- Braden Scale: Assesses risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A total score below 18 indicates risk.
- Norton Scale: Evaluates the patient’s overall physical condition, mental state, activity level, mobility, and incontinence.
Wound Assessment: Evaluates location, size, undermining, appearance, drainage, redness, swelling, pain, and nutritional status.

Blood Studies: Assess for underlying issues.
Wound Cultures:
- Techniques include swabbing, needle aspiration, and tissue biopsy to detect infections.

Cleansing/Irrigating Wounds: Essential for infection control.
Caring for Drainage Devices:
- Jackson-Pratt and Hemovac devices need appropriate management.
Debriding Wounds:
- Various techniques such as mechanical, enzymatic, autolysis, biotherapy, or sharp debridement can be employed based on the case.

Applying Negative Pressure Wound Therapy: Enhances healing environment.
Dressing Wounds:
- Can include gauze, transparent film, hydrocolloids, or hydrogels depending on the wound type.
Supporting/Immobilizing a Wound: Use of binders and bandages to limit movement of the area.
Applying Heat and Cold: Adjusts local circulation and can aid in pain management.

Nurses play a significant role in the prevention and treatment of pressure injuries.
These injuries affect approximately 15% of hospitalized clients due to unrelieved pressure causing ischemia.

Intrinsic Factors:
- Include immobility, impaired sensation, poor nutrition, dehydration, aging, fever, infection, and edema may increase risk.
Extrinsic Factors:
- Include friction, pressure, shearing forces, and moisture affecting skin integrity.

Determines the stage of pressure injuries from 1 to 4 based on tissue involvement, identifying tissue necrosis in stages 3 and 4.
Unstageable Pressure Injury: Occurs when the extent of tissue damage cannot be fully determined.
PUSH Tool: Utilized for assessing pressure injury severity and healing progress.

A nursing administrator investigates an increasing trend in pressure injuries among residents in a nursing home. Possible reasons could include inadequate staffing, lack of training on skin care, increasing patient acuity, insufficient resources for preventive care, or equipment failures..

Prevention Measures:
- Includes meticulous skin care, moisture control, adequate nutrition, frequent repositioning, and utilization of therapeutic mattresses.
Client and Family Teaching: Educate about the importance of prevention measures and signs of skin integrity impairment.