Skin integrity
Skin Integrity and Wound Care
Overview
Presenter: Kristi Tisdale MSN, RN
Objectives
Discuss the factors affecting skin integrity.
Identify wounds based on accepted classification schemes.
Distinguish between primary, secondary, and tertiary intention healing.
Describe the three phases of wound healing.
Identify types of wound closures.
Describe the types of wound drainage.
Review major complications of wound healing.
Explain the factors involved in the development of pressure ulcers.
Discuss assessment tools.
Assess and categorize pressure ulcers.
Discuss types of dressings and how and when to use them.
Describe guidelines for heat and cold therapy.
Discuss nursing interventions to decrease the risk of pressure ulcers.
Identify types of wound drains.
Differentiate different forms of wound debridement.
Discuss the different types of tissues in a wound bed.
Functions of the Skin
Protection: Acts as a barrier against pathogens and injuries.
Sensation: Contains sensory receptors for touch, pain, and temperature.
Temperature Regulation: Maintains homeostasis by regulating body temperature through sweat and blood flow.
Absorption/Elimination: Absorbs certain substances and eliminates waste products.
Vitamin D Formation: Synthesizes vitamin D when exposed to sunlight.
Immune Response: Engages in protective immune responses against infections.
Factors Affecting Skin Integrity
Age-Related Variations: Skin elasticity decreases with age, making it more susceptible to damage.
Impaired Mobility: Reduced movement increases the risk of pressure ulcers due to prolonged pressure on specific areas.
Nutrition and Hydration: Poor nutrition and dehydration can lead to skin breakdown.
Decreased Sensation or Cognition: Lack of sensory awareness increases the risk of neglecting wounds.
Altered Circulation: Poor blood flow can impede healing and increase the risk of pressure injuries.
Moisture, Fever: Excess moisture can weaken skin integrity; fever can affect tissue perfusion.
Medications: Some medications may affect skin integrity by altering blood flow or moisture levels.
Contamination or Infection: Increases risk of delayed healing or complications.
Lifestyle: Smoking or poor hygiene can negatively impact skin integrity.
Types of Wounds and Classifications
Wounds are classified based on:
Type of Wound
Length of Time the Wound has Existed
Condition of the Wound
1. Type of Wounds
Closed Wounds:
Skin surface is intact; damages soft tissue or causes hemorrhage.
Examples: Contusion (bruise).
Open Wounds:
Skin is broken, providing a portal for infection.
Examples:
Abrasion (scrape)
Incision (surgical cut)
Laceration (irregular tear)
Puncture (e.g., venipuncture).
2. Length of Time the Wound has Existed
Acute Wounds:
Short duration, typically heal within days to weeks.
Chronic Wounds:
Do not progress normally through healing stages, often stagnant in the inflammatory phase.
3. Condition of the Wound
Clean:
No infection; no inflammation present.
Clean-Contaminated:
Surgical wounds that may be slightly contaminated but not infected.
Contaminated/Infected:
Presence of pathogens or necrotic tissue.
Types of Specific Wounds Considered:
Abrasion
Avulsion
Contusion
Crushing
Incision
Laceration
Penetrating
Puncture
Pressure Ulcers
Arterial Ulcers
Venous Ulcers
Diabetic Ulcers
Neuropathic Ulcers.
Types of Wound Healing
Regeneration:
Occurs in epidermal wounds without scarring.
Primary Intention:
Clean surgical incisions with edges approximated.
Closed with sutures, staples, or glue; minimal scarring observed.
Secondary Intention:
Edges are not approximated; tissue loss is present.
Healing occurs from the inner layer to the surface.
Tertiary Intention:
Granulating tissue is brought together; involves delayed closure of the wound edges.
Phases of Wound Healing
Hemostasis: Initial phase where bleeding stops.
Inflammatory Phase:
Characterized by edema, redness, pain, heat, and leukocytosis.
Proliferative Phase:
Involves tissue repair and granulation tissue formation.
Maturation Phase:
Epithelialization occurs and the tissue undergoes remodeling.
Wound Closures
Various methods are utilized, including:
Adhesive Strips
Sutures
Staples
Glue
Negative Pressure Wound Therapy
Hyperbaric Oxygen Therapy
Types of Wound Drainage
Serous Exudate:
Clear and watery, straw-colored.
Sanguineous:
Bloody drainage.
Serosanguineous:
A mix of bloody and straw-colored fluid, light pink to blood-tinged.
Purulent:
Thick, yellow, containing pus.
Purosanguineous Exudate:
Red-tinged pus.
Major Complications of Wound Healing
Hemorrhage: Excessive bleeding.
Infection: Presence of pathogenic organisms leading to complications.
Dehiscence: Wound edges re-open.
Evisceration: Protrusion of internal organs through the wound.
Fistula Formation: Abnormal connection between two body parts (e.g., rectum and vagina).
RYB Wound Classification
R = Red = Protect:
Indicates wounds in the proliferative stage needing protection through nursing interventions like gentle cleansing and moist dressings.
Y = Yellow = Cleanse:
Indicates presence of exudate/slough; requires surgical and cleaning interventions.
B = Black = Debride:
Indicates necrotic tissue (eschar) needing removal before healing can progress.
Tissues in the Wound Bed
Granulation Tissue: Vascular connective tissue that replaces necrotic tissue.
Epithelial Edge: Surrounds the wound, signifies healing.
Necrotic Tissue: Dead tissue requiring debridement for healing to occur.
Factors Affecting Pressure Injury Development
Intrinsic Factors:
Immobility, impaired sensation, malnourishment, aging, fever.
Extrinsic Factors:
Friction, pressure, shearing, moisture exposure.
Common Sites for Pressure Injuries
Occipital bone
Scapula
Vertebrae
Sacrum
Calcaneus
Coccyx
Humerus
Sternum
Areas with bony prominences are prone to pressure injuries.
Categorization of Pressure Injuries: Staging
Stages I-IV: Classified by extent of tissue involvement.
Unstageable: Some injuries obscured by slough or eschar.
Suspected Deep Tissue Injury: Persistent nonblanchable deep red, maroon, or purple discoloration.
Nursing Assessments/Interventions to Decrease the Risk of Pressure Injuries
Focused skin assessment.
Braden Scale: Numeric values for 6 risk factors related to skin integrity (sensory perception, moisture, activity, mobility, nutrition, friction/shear).
Wound assessment, considering location, size, appearance, drainage, redness, swelling.
Nursing’s Role in Pressure Injuries
Prevention: Meticulous skin care, hydration, and nutrition.
Repositioning: Frequent movement to alleviate pressure.
Use of Therapeutic Mattresses: To relieve pressure and promote healing.
Client/Family Teaching: Engage and educate them on pressure ulcer prevention.
Nursing Interventions Related to Wound Care
Cleansing/Irrigating: Keep the wound clean.
Caring for a Drainage Device:
Types include Jackson-Pratt, Hemovac, and Penrose drains.
Debriding a Wound: Types include sharp, mechanical, chemical, enzymatic, and autolysis methods.
Types of Drains
Various drains assist in fluid removal from wounds to promote healing.
Dressings
Telfa: Non-stick gauze.
Gauze: Woven cotton in various sizes and shapes.
Transparent Dressings: Clear adhesive film.
Absorbent Dressings: Thick gauze; absorbs drainage.
Alginates: Seaweed derived; promotes moist environment.
Antimicrobials: Dressings containing antibiotics.
Collagens: Proteins fostering new tissue growth.
Foams: Hold moisture and protect the wound.
Hydrocolloids: Promote autolytic debridement and protect while maintaining moisture.
Hydrogels: Water-based polymers maintaining a moist environment.
Heat Therapy
Effects: Dilates blood vessels, increases metabolism, reduces blood viscosity, and relaxes muscles.
Devices for Heat Therapy
Hot water bags/bottles, electric heating pads, aquathermia pads.
Moist heat applications, Sitz baths, warm soaks.
Cold Therapy
Effects: Constricts blood vessels, reduces muscle spasms, promotes comfort.
Devices for Cold Therapy
Ice bags, cold packs, hypothermia blankets, and moist cold applications.