Skin Integrity and Wound Care Flashcards

Normal Structure and Function of the Skin

Epidermis - This is the outermost layer of the skin. - It undergoes regeneration approximately every $4$ to $6$ weeks. - It consists of five distinct sub-layers: - Stratum corneum - Stratum lucidum - Stratum granulosum - Stratum spinosum - Stratum germinativum (also known as the stratum basale)
Dermis - This layer is thicker than the epidermis. - It contains the following structures: - Sebaceous glands and sweat glands - Hair and nail follicles - Nerves and lymphatics
Subcutaneous Layer - Composed of adipose (fatty) tissue.
Factors Affecting Skin Integrity - Wounds - Vascular disease - Diabetes - Malnutrition - Age
Medical Adhesive-Related Skin Injuries (MARSI) - These injuries occur when the superficial layers of the skin are inadvertently removed by the application or removal of medical adhesives.

Wound Classification and the Healing Process

Criteria for Wound Classification - Skin integrity (open vs. closed) - Wound depth (superficial vs. full-thickness) - Amount of contamination (clean, clean-contaminated, contaminated, or infected) - Healing process (primary, secondary, or tertiary intention)
Phases of Wound Healing - Inflammatory Phase - Duration: Approximately $3$ days. - Key feature: The coagulation cascade is activated. - Proliferative Phase - Duration: Lasts for several weeks. - Key feature: The formation of granulation tissue. - Maturation Phase - Duration: Can last up to $1$ year. - Key feature: The development of scar tissue.
Factors Affecting Wound Healing - Oxygenation and tissue perfusion - Diabetes - Nutrition - Age - Infection
Complications of Wound Healing - Dehiscence: The partial or total separation of wound layers. - Evisceration: The protrusion of visceral organs through a wound opening. - Fistula formation: An abnormal passage between two organs or between an organ and the outside of the body.
Burn Classification - Superficial - Partial-thickness - Full-thickness

Pressure Injuries

Causes and Contributing Factors - Intensity of pressure - Duration of pressure - Medical devices (e.g., tubing, masks) - Friction and shear - Sensory loss or immobility - Moisture - Nutrition
Classification of Pressure Injuries - Stage 1 Pressure Injury - Characterized by non-blanchable erythema of intact skin. - The area is often painful and may differ in firmness or temperature (warmer or cooler) compared to surrounding tissue. - Stage 2 Pressure Injury - Involves partial-thickness skin loss with exposed dermis. - May present as intact or ruptured blisters. - Stage 3 Pressure Injury - Characterized by full-thickness skin loss. - May feature undermining (tissue destruction under intact skin edges) or tunneling (passageways extending from the wound). - Stage 4 Pressure Injury - Involves full-thickness skin and tissue loss. - May lead to osteomyelitis (infection of the bone). - Unstageable Pressure Injury - Full-thickness skin and tissue loss where the extent of damage is obscured by necrotic tissue (eschar) or slough in the wound bed. - Assessment cannot be completed until the necrotic tissue is removed. - Deep Tissue Pressure Injury (DTPI) - Presents as persistent, non-blanchable deep red, maroon, or purple discoloration.

Assessment Tools for Pressure Injury Risk

Norton Pressure Ulcer Scale - Parameters evaluated on a scale of $1$ to $4$ : - Physical Condition: Good ( $4$ ), Fair ( $3$ ), Poor ( $2$ ), Bad ( $1$ ). - Mental State: Alert ( $4$ ), Apathetic ( $3$ ), Confused ( $2$ ), Stupor ( $1$ ). - Activity: Ambulant ( $4$ ), Walks with assistance ( $3$ ), Chairbound ( $2$ ), Bedrest-bedbound ( $1$ ). - Mobility: Fully mobile ( $4$ ), Slightly limited ( $3$ ), Very limited ( $2$ ), Immobile ( $1$ ). - Continence: Continent ( $4$ ), Occasionally incontinent ( $3$ ), Usually incontinent of urine ( $2$ ), Incontinent of bowel and bladder ( $1$ ). - Scoring Interpretation: - $16\text{--}30$ : Low risk - $11\text{--}15$ : Moderate risk - $10$ or below: High risk
Braden Scale for Predicting Pressure Sore Risk - Sensory Perception: Ability to respond meaningfully to pressure-related discomfort. - $1$ . Completely Limited: Unresponsive to painful stimuli; limited ability to feel pain over most of the body. - $2$ . Very Limited: Responds only to painful stimuli; cannot communicate discomfort except by moaning. - $3$ . Slightly Limited: Responds to verbal commands but cannot always communicate discomfort. - $4$ . No Impairment: Responds to verbal commands; no sensory deficit. - Moisture: Degree to which skin is exposed to moisture. - $1$ . Constantly Moist: Dampness detected every time patient is moved. - $2$ . Very Moist: Linen must be changed at least once a shift. - $3$ . Occasionally Moist: Extra linen change required about once a day. - $4$ . Rarely Moist: Skin is usually dry. - Activity: Degree of physical activity. - $1$ . Bedfast: Confined to bed. - $2$ . Chairfast: Ability to walk severely limited or non-existent. - $3$ . Walks Occasionally: Walks very short distances during the day. - $4$ . Walks Frequently: Walks outside room at least twice a day. - Mobility: Ability to change and control body position. - $1$ . Completely Immobile: Makes no changes in position without assistance. - $2$ . Very Limited: Makes occasional slight changes but unable to move significantly independently. - $3$ . Slightly Limited: Makes frequent though slight changes independently. - $4$ . No Limitation: Makes major and frequent changes in position without assistance. - Nutrition: Usual food intake pattern. - $1$ . Very Poor: Never eats a complete meal; $2$ servings or less of protein per day; NPO or IV for more than $5$ days. - $2$ . Probably Inadequate: Rarely eats a complete meal; only $3$ servings of protein per day. - $3$ . Adequate: Eats over half of most meals; $4$ servings of protein per day. - $4$ . Excellent: Eats most of every meal; never refuses a meal; $4$ or more servings of protein. - Friction and Shear: - $1$ . Problem: Requires moderate to max assistance in moving; sliding against sheets is impossible to avoid. - $2$ . Potential Problem: Moves feebly; skin probably slides to some extent against sheets or restraints. - $3$ . No Apparent Problem: Moves in bed and chair independently; maintains good position.

Comprehensive Wound Assessment

Physical Assessment of the Wound - Location - Size (length, width, and depth) - Presence of undermining or tunneling - Drainage (amount, color, consistency, and odor) - Condition of wound edges and surrounding tissue (periwound) - Wound bed characteristics (e.g., color, tissue type) - Client response (e.g., pain level)
Assessment Tools for Wound Healing - Pressure Sore Status Tool (PSST) - Pressure Ulcer Scale for Healing (PUSH)

Nursing Diagnoses and Planning

Examples of Nursing Diagnoses - Impaired Skin Integrity - Supporting Data: Pressure injury on left buttocks; paralyzed with loss of sensation below the waist; history of stage $2$ injury; weight loss; albumin of $2.5\,g/dL$ ; prealbumin of $15\,mg/dL$ . - Impaired Tissue Integrity - Supporting Data: Immobility resulting in a stage $3$ pressure injury on the coccyx. - Acute Pain - Supporting Data: Trauma and pain rated at $8$ out of $10$ .
Planning - Collaborating with the client and the interprofessional health care team. - Including specific evaluation criteria to measure progress.

Implementation of Care

Interventions to Preserve Skin Integrity - Turning and positioning: Perform at least every $2$ hours. - Skin hygiene: Maintains healthy skin and preserves normal skin pH. - Support surfaces: Use pressure-reducing mattresses to spread body weight over a larger area (note: these do not replace the need for repositioning).
Wound Care Interventions - Cleansing and Irrigation - Solutions should be room temperature or warmed. - Irrigation force must be strong enough to be effective but not so strong that it damages new granulation tissue. - Debridement (Removal of Necrotic Tissue) - Sharp (surgical) - Mechanical (e.g., wet-to-dry dressings) - Enzymatic (chemical agents) - Autolytic (body's own enzymes) - Biologic (e.g., medicinal maggots) - Dressings - Gauze, Transparent films, Hydrocolloids, Foams, Alginates, and Gels.
Drains - Function: Reduce infection risk by preventing the collection of blood, serum, or pus in a surgical area. - Types: Closed or open systems. - Attachment: May or may not be sutured into place.
Advanced Therapies - Negative-pressure wound therapy (NPWT) - Suture care - Bandages and binders
Heat and Cold Application - Benefits: Reduces pain, improves circulation, and reduces swelling. - Requirements: Typically requires a doctor’s order including type, length of treatment, frequency, and specific body part. - Complications: Potential damage to tissue if the client cannot sense temperature extremes.

Evaluation

It is essential to evaluate if the client has achieved the agreed-on goals.
Evaluation is an integral part of an ongoing process to assess intervention effectiveness and revise the care plan.

Questions & Discussion

Q: A nurse is providing care for a client with a full-thickness wound. The nurse knows that this type of wound heals by secondary intention and involves the formation of granulation tissue during which phase of wound healing? - A: a. Proliferative.
Q: The nurse is assessing a client for risk factors for developing pressure injuries. Select three factors that contribute to pressure injury development. - A: a. Moisture, b. Sensory loss, and potentially Friction/Shear (though only a, b, and c/d options were listed, moisture and sensory loss are primary factors).
Q: Indicate a common pressure injury site for a client in a seated position. - A: The primary site for a seated patient is the ischial tuberosity (buttocks).