Skin Integrity & Wound Management

Page 2:

• Define wound

• Describe factors affecting skin integrity

• Describe the four phases of wound healing

• Enumerate the four stages of pressure ulcer development

• Identify the manifestations of altered integumentary function

• Identify three major types of wound exudate

Page 3:

• Identify the main complications of and factors that affect wound healing

• Identify assessment data pertinent to skin integrity, pressure sites, and wounds

• Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing

• Identify physiological responses to and the purposes of heat and cold

• Demonstrate appropriate documentation and reporting of skin integrity and wound care

Page 4:

• Skin is one of the body’s vital organs and essential for maintaining life

• Has two layers: Epidermis and Dermis

Page 5:

• Cross Section of a Normal Skin

• Sweat pore

• Hair

• Epidermis

• Arrector pili muscle

• Sebaceous gland

• Eccrine sweat gland

• Dermis

• Hair follicle

• Nerve

• Papilla

• Arteriole

• Subcutaneous Venule tissue

Page 6:

• Protection

• Body temperature regulation

• Sensation

• Excretion

• Maintenance of fluid & electrolyte balance

• Vitamin D production and absorption

Page 7:

• Factors affecting skin integrity

• Lifestyle: drug use, occupation

• Age

• Changes in health status: dehydration, malnutrition

• Illness: diabetes, paralysis

• Therapeutic measures: medications, bed rest, Radiation therapy

Page 8:

• A break or disruption in the normal integrity of the skin and tissues

• Range from superficial cuts to deep third-degree burn

Page 9:

• Causes of Wound

• Surgery

• Trauma (burn)

• Pressure ulcer

Page 10:

• Wound can be classified according to:

  • Cause of wound

  • Cleanliness of wound

  • Thickness of skin loss

  • Status of skin integrity

Page 11:

• According to the cause of wound

  • Intentional wounds

  • Unintentional wounds

Page 12:

• According to the cleanliness of wound

  • Clean wounds

  • Contaminated wounds

  • Dirty and infected wounds

Page 13:

• Pressure ulcer

• Granulation tissue

• Epithelial edge

• Necrotic tissue

Page 14:

• Granulation tissues

• Eschar

• Slough

Page 15:

• According to the status of skin integrity

• Open Wound

  • Skin surface is broken - entry of microorganisms

  • Occurs from intentional or unintentional trauma

  • High risk for bleeding, infection

• Closed Wound

  • Skin surface is not broken, but soft tissue is damaged

  • Result from blow or force caused by trauma such as fall, or accident

  • Injury and bleeding inside

Page 16:

• According to the status of skin integrity

• I-Open wound:

  • Incised wound

  • Lacerated wound

  • Stab or punctured wounds

  • Abrasions

• II-Closed wound:

  • Contusion (Bruise)

  • Hematoma

Page 17:

• Type

• Cause

• Incision

• Cutting or sharp instrument; wound edges in close approximation & aligned

• Contusion (Bruise)

• Blunt instrument; usually disrupting skin surface; possible bruising

• Abrasion

• Rubbing or scraping epidermal layers

• Laceration

• Tearing of skin & tissue w/ blunt or irregular instrument

Page 18:

• Thermal Wound

• Incision Wound

Page 19:

• Contusion Wound

• Abrasion

Page 20:

• Laceration

• Penetrating

• Deep laceration wound

• Skin

• Fat

• Muscle

Page 21:

• Acute Wound

  • Heal within days – weeks

  • Wound edges are well approximated and risk of infection is low

  • Progress through the healing process without interruption

• Chronic Wound

  • Healing is delayed >30 days

  • Wound edges are not approximated and risk of infection is high

  • Wound that has arrested in one of the wound healing stages usually inflammatory phase

Page 22:

• Classification of Wounds

  • Intentional Wounds vs. Unintentional Wounds

  • Open vs. Close Wounds

  • Acute vs. Chronic Wounds

Page 23:

• Manifestations of altered integumentary function

  • Pain

  • Pruritus - itching

  • Rash - A rash is an area of irritated or swollen skin

  • Lesions - A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma

Page 24:

• Healing: is a complex mechanism by which the body repairs damaged tissue through a series of cellular and biochemical events

Page 25:

• Stages/phases of wound healing

  • Inflammatory Phase

  • Proliferative Phase

  • Remodeling (Maturation) Phase

Page 26:

• WOUND HEALING

• Hemostasis

• Blood clot

• Inflammatory

• Scab

• Fibroblast

• Macrophage

• Blood vessel

• Proliferative

• Fibroblasts proliferating

• Subcutaneous fat

• Remodeling

• Freshly healed epidermis

• Freshly healed dermis

Page 27:

• Systemic factors:

  • Immune cellular, Nutrition, Circulation and Oxygenation

• Individual factors:

  • Age, obesity, smoking, drug therapy and stressors

• Local factors:

  • Local wound environment

  • The nature and location of the injury

  • Presence of pressure, infection or necrosis (the death of body tissue)

Page 28:

• Psychological Effects of Wounds

• Pain

• Anxiety & Fear

Page 29:

• Wound Assessment

• Appearance, Drainage, Pain, & Types of Drains

Page 30:

• Inspection for sight and smell

• Palpation for appearance, drainage, and pain

• Sutures, drains or tube, manifestation of complications

Page 31:

• Serous drainage

  • Clear and watery

  • Composed mainly by serous portion of blood and from serous membranes

  • It’s normal during the inflammatory stage of wound healing, and smaller amounts are considered normal

• Sanguineous drainage

  • Looks like blood (fresh bleeding)

  • Seen in deep partial- and full-thickness wounds

  • A small amount is normal during the inflammatory stage

Page 32:

• Serosanguineous

  • Mixture of blood and clear, watery fluid

  • Pale red to pink in color

• Seropurulent

  • Thin, watery, cloudy and yellow to tan in color

• Purulent drainage

  • Made up of WBCs, liquefied dead tissue and bacteria

  • Thick, musty or foul-odor, usually yellow, green, greenish or brown in color

  • It’s never normal in a wound bed, and is often associated with infection or high bacteria levels

Page 33:

• Type

• Appearance

• A. Serous

  • Clear, watery plasma

• B. Purulent

  • Thick, yellow, green, tan, or brown

• C. Serosanguineous

  • Pale, red, watery: mixture of serous and sanguineous

• D. Sanguineous

  • Bright red: indicates active bleeding

Page 34:

• Sanguineous

• Serosanguineous

• Serous

• Purulent

• Dep

• One with

Page 35:

• Wound is swollen

• Wound is deep red in color

• Wound feels hot on palpation

• Drainage is increased and possibly purulent

• Foul odor may be noted

• Wound edges may be separated with dehiscence present

Page 36:

• Wound Management

  • Dressings

  • Drains

  • Debridement

Page 37:

• Pressure injury

• Is defined as localized damage to the skin and underlying tissue that usually occurs over a boney prominence or is related to the use of a device

Factors influencing pressure injury development (Page 38)

• External pressure over an area

• Friction: When two surfaces rub against each other

• Shear: When one layer of tissue slides over another layer. Shearing forces can occur when a patient is moved carelessly or slides down in bed

Risk for pressure injury development (Page 39)

• Immobility

• Nutrition and hydration: negative nitrogen balance

• Obesity: poor vascular supply, weight

• Moisture: diaphoresis urine, wounds, feces

• LOC: drowsy, sedated, comatose =1 position

• Age: epidermis thins with age, < blood flow

Mobility and immobility (Page 40)

• Mobility refers to the ability to engage in activity and free movement

• Immobility refers to the lack of ability to move freely

Causes of immobility (Page 41)

• Neurological causes

• Musculoskeletal system causes

• Psychological causes

• Cardiovascular system causes

• Others: environmental causes

Effect of immobility on the body (Page 42)

• Metabolic changes: decrease in BMR, altered carbohydrates, proteins, fats metabolism

• Results in increased body fat and loss of lean body mass

• Fluid and electrolyte imbalances

Impaired Skin Integrity related to Immobility (Page 43)

• Previously called: a decubitus ulcer, a pressure sore, a pressure ulcer, a bedsore

• A wound caused by unrelieved pressure that damages underlying tissue

• Can be caused by external pressure transmitted inward or from the bone and proceeds outward

Pressure ulcers and their causes (Page 44)

• Pressure ulcers are wounds caused by unrelieved pressure that damages underlying tissue

• The pressure interferes with tissue blood supply, leading to vascular compromise, tissue anoxia, and cell death

• Tend to be located over bony prominences

Predictive instrument for pressure injury risk assessment (Page 45)

• AHCPR (Agency for Health Care Policy and Research) established guidelines to identify at-risk individuals needing prevention and the specific factors placing them at risk

• Braden Scale or Norton Scale are most commonly used risk assessment tools

Braden Scale categories (Page 46)

• Sensory perception: ability to respond meaningfully to pressure-related discomfort

• Moisture: degree to which skin is exposed to moisture

• Activity: degree of physical activity

• Mobility: ability to change and control body position

• Nutrition: usual intake pattern

• Friction and Shear

Braden Scale scoring and risk levels (Page 47)

• Each category measured from 1-4 with low score having most limitation

• Overall score: Maximum of 23, little or no risk

• A score of 16 or less indicates 'at risk'

• A score of 9 or less indicates 'high risk'

• Implement preventive measures for 'at risk' and 'high risk' clients

Pressure injury most common sites (Page 49)

• Occiput, shoulder blades, back of shoulder, buttocks, heel, elbow, sacrum, ischial tuberosity, ear, thigh, knees, toes, rib cage

Staging Pressure Ulcers (Page 51-54)

• Stage 1: Non-blanchable erythema of intact skin, does not resolve in 30 minutes but remains for longer than 2 hours after pressure is relieved

• Stage 2: Partial thickness loss, skin loss involving epidermis, dermis, or both, appears as an abrasion, blister, or shallow crater surrounded by erythema and induration

• Stage 3: Full-thickness tissue destruction involving subcutaneous tissue, muscle layer intact

• Stage 4: Extensive damage involving muscle, bone, or supporting structures, requires surgical intervention

Diagnosing and outcome identification (Page 55-56)

• Diagnosing: Disturbed Body Image, Deficient Knowledge related to wound care, Impaired Tissue Integrity, Impaired Skin Integrity, Risk for Impaired Skin Integrity, Risk for Infection

• Outcome identification: Maintain skin integrity, demonstrate self-care measures to prevent pressure ulcer development, demonstrate self-care measures to promote wound healing, demonstrate evidence of wound healing, remain free of signs and symptoms of infection, demonstrate appropriate wound care measures before discharge

Implementing interventions (Page 57)

• Provide physical, psychological, and aesthetic comfort

• Maintain a moist wound environment

• Protect the wound from further injury

• Protect the skin surrounding the wound

• Stop bleeding

• Wound debridement

• Reduce pain

• Identify and treat the cause

• Prevent, eliminate, or control infection

• Absorb drainage

Pressure injury prevention (Page 58-59)

• Relieve pressure on vulnerable areas

• Reduce shear and friction and stimulate circulation

• Inspect the person's skin, keep the skin clean and dry

• Minimize irritation from chemicals

• Encourage a balanced diet and daily exercise

• Repositioning every hour

• Using support surfaces with pillows and mattresses

• Clean the wound, apply dressing, remove damaged tissue, wound debridement

Wound dressings (Page 60)

• Number and type of dressings used depend on the location, size, type, depth of the wound, presence of infection, and amount and type of drainage

• Dry gauze dressings, special gauze dressings, nonadherent gauzes, transparent films

Note

Page 61

• Heat and cold therapy is applied to the body for local and systemic effects.

Page 62

• Heat application:

  • Dilates blood vessels

  • Increases metabolism

  • Reduces muscle tension

  • Relieves pain

  • Increases cardiac output, sweating, PR, and decreases BP

• Cold application:

  • Constricts blood vessels

  • Reduces muscle spasms

  • Promotes comfort

  • Increases BP, shivering, and goosebumps

Page 63

• Assessment:

  • Physical and mental status

  • Health history and completing a physical examination

  • Area of application

  • Ability to tolerate heat and cold applications

  • Assessing the condition of equipment

Page 64

• Diagnosing:

  • Acute Pain

  • Ineffective Tissue Perfusion

  • Chronic Pain

  • Risk for Injury

Page 65

• Outcome Identification and Planning:

  • Verbalize increased comfort

  • Demonstrate wound healing and increased comfort

Page 66

• Implementing - Applying Heat:

  • DRY HEAT:

    • Hot water bags

    • Electric heating pads

    • Aquathermia Pads

    • Hot Packs

  • MOIST HEAT:

    • Warm Moist Compresses

Page 67

• Implementing - Applying Cold:

  • DRY COLD:

    • Ice bags

    • Cold compresses

    • Cold packs

  • MOIST COLD:

    • Cold Pack

Page 68

• References:

  • Taylor, Lllis, Lynn & LeMone. Fundamentals of Nursing, The Art and Science of Nursing Care. 2018, 8th Ed. Lippincott Williams & Wilkens.

  • Craven, Ruth, Hirnle & Jensen. Fundamentals of Nursing: Human Health and Function. 2017 8th Ed. Lippincott Williams & Wilkens.