Wounds and Skin Integrity Lecture Review
Wounds and Skin Integrity
Skin Anatomy and Function
Epidermis: 1^{st} layer, no blood vessels, regenerates.
Dermis: 2^{nd} layer, connective tissue, nerves, blood vessels, hair.
Subcutaneous: 3^{rd} layer, anchors skin, stores fat, insulates, cushions.
Functions: Protection, temperature regulation, psychosocial, sensation, Vitamin D production, immunologic, absorption, elimination.
Factors Affecting Skin Integrity
Unbroken/healthy skin defends.
Resistance affected by age, tissue amount, illness.
Nourished/hydrated cells resist injury; adequate circulation is essential.
Thin and obese individuals, dehydrated, or excessively perspiring individuals are susceptible.
Jaundice causes yellowish, itchy skin; skin diseases like eczema/psoriasis cause lesions.
Types of Wounds
Open: Avulsion, Chemical, Thermal, Pressure Ulcers, Venous/Arterial/Diabetic ulcers, Incision, Laceration, Abrasions, Puncture, Penetrating.
Closed: Contusion (blunt instrument injury, skin intact), Irradiation, Pressure ulcers (Stage I).
Phases of Wound Healing
Hemostasis: Immediate; vasoconstriction, clotting, vasodilation, exudate formation.
Inflammatory: 2-3 days; leukocytes/macrophages clean, fibroblasts fill wound.
Proliferation: Several weeks; fibroblasts secrete collagen/growth factors, granulation tissue forms.
Maturation: ext{Begins around } 3 ext{ weeks and lasts years} ; collagen remodeling, scar finalization.
Factors Affecting Wound Healing
Local: Pressure, Desiccation (dehydration), Maceration (overhydration), Trauma, Edema, Infection, Excessive bleeding, Necrosis, Biofilm.
Systemic/External: Age (younger/healthy heal faster), Circulation/oxygenation, Nutritional status, Wound etiology, Health status (corticosteroids, radiation delay healing), Immunosuppression, Medications, Adherence to treatment plan.
Types of Wound Healing Intentions
Primary intention: Clean incision, early suture, minimal scarring.
Secondary Intention: Gaping wound, granulation tissue fills, epithelium grows over scar.
Tertiary Intention: Delayed suturing after granulation tissue forms, wider scar.
Complications of Wound Healing
Infection, Hemorrhage, Dehiscence, Fistula formation.
Evisceration: Most serious dehiscence complication (protrusion of viscera).
Intervention: Immediately cover with saline-dampened sterile towels, call MD, keep patient in low Fowlers.
Nutritional Requirements for Wound Healing
Protein/amino acids, Energy (calories), Fluid, Vitamin A, Vitamin C, Zinc, Copper, Iron.
Pressure Ulcers
Definition: Localized tissue necrosis over bony prominence due to pressure + shear or friction.
At-Risk: Aging skin, chronic illness, malnutrition, incontinence, altered consciousness, spinal cord injuries, neuromuscular diseases.
Mechanism: Pressure, Friction, Shear (one tissue layer slides over another, separates skin).
Braden Scale: Predicts pressure sore risk. Total score 12 or less represents HIGH RISK.
Pressure Ulcer Staging
Stage I: Intact skin, non-blanchable erythema.
Stage II: Partial-thickness skin loss (epidermis/dermis), superficial (abrasion, blister, shallow crater).
Stage III: Full-thickness skin loss (subcutaneous tissue damage, not through underlying fascia), deep crater, with/without undermining.
Stage IV: Full-thickness skin loss with extensive destruction (muscle, bone, supporting structures), can involve sinus tracts.
Unstageable: Covered with eschar or slough, requires debridement.
Arterial vs. Venous Ulcers
Arterial: Insufficient blood supply. Punched out, smooth edges, pain at night relieved by elevating leg, cool to touch, pale/shiny/thin skin, minimal hair/drainage.
Venous: Pooling blood. Shallow, superficial, irregular shape, painful (edema, phlebitis, infection), usually lower legs or ankles.
Nursing Process for Wounds
Assessment: Head-to-toe, location, size, depth, general appearance, drainage (color, amount, odor, consistency), undermining, tunneling, sinus tract, surrounding skin, blanching.
Diagnosis: Impaired skin/tissue integrity, disturbed body image, knowledge deficit, risk for infection.
Planning/Outcome: No skin breakdown, no signs/symptoms of infection, patient verbalizes understanding.
Intervention (Prevention): Assess screen, cleanse skin, moisturize, avoid massage over bony prominences, protect from moisture, minimize friction/shear, ensure adequate nutrition, improve mobility (turning every 2 hours).
Intervention (Wound Care): Promote tissue repair, restore integrity. Cleanse with saline to remove debris/exudate. Pre-medicate for pain.
R (Red): Protect (granulation tissue).
Y (Yellow): Cleanse (exudate, dead cells).
B (Black): Debride (necrotic eschar).
Evaluation: Continuous; change plan of care for non-healing wounds, multidisciplinary approach.
Wound Drainage Systems
Open systems: Penrose drain.
Closed systems: Jackson-Pratt drain, Hemovac drain.