Skin Integrity

Skin Integrity Overview

  • Factors Affecting Skin Integrity

    • Wounds

    • Vascular Disease

    • Diabetes

    • Aging Process

    • Malnutrition

    • Medications

    • Medical Adhesive-Related Skin Injuries (MARSIs)

Wound Classification

  • Wound Classification

    • Cause: Determined by the origin of the wound.

    • Description of Skin Integrity: Overall assessment of skin condition.

    • Wound Depth (Thickness): Assessment of the tissue layers affected.

    • Presence of Infection: Evaluating if the wound is infected.

    • Chronic or Acute: Determining the ongoing nature of the wound.

  • Types of Wounds:

    • Open Wound: A break in the skin surface, includes;

    • Abrasion: Scraping of the skin.

    • Puncture: A pointed object pierces the skin.

    • Incision: A clean cut.

    • Closed Wound: The skin remains intact but there may be underlying damage, includes;

    • Bruising: Discoloration from bleeding under the skin.

    • Pressure-Related Injury: Damage from prolonged pressure.

    • Fractures: Break in the bone under the skin.

  • Note: Skin integrity does not indicate the severity of underlying damage.

Wound Depth

  • Categories of Wound Depth:

    • Superficial: Involves only the epidermis.

    • Partial Thickness: Involves the epidermis and part of the dermis.

    • Full Thickness: Extends through the subcutaneous layer, and may involve muscle and bone.

  • Assessment of Structures: Essential for understanding healing, scarring, and whether the wound is chronic.

Healing Process

  • Healing Process Types:

    • Primary Intention:

    • Tissue surfaces approximated (closed), with minimal or no tissue loss.

    • Characterized by quick healing and minimal scarring.

    • Secondary Intention:

    • Extensive tissue loss where edges cannot be approximated.

    • Longer repair time with greater scarring and increased susceptibility to infection.

    • Tertiary Intention:

    • Wound is initially left open to resolve issues such as edema or infection.

    • Closure occurs later with sutures, staples, or adhesive closures.

  • Phases of Wound Healing:

    • Inflammatory Phase: Initial response to injury, characterized by redness, swelling, and warmth.

    • Proliferative Phase: Involves granulation tissue formation and resurfacing.

    • Maturation Phase: Remodeling of tissue and scarring.

Nursing: Factors Affecting Wound Healing

  • Factors:

    • Oxygenation and Perfusion: Adequate blood supply is crucial for healing.

    • Diabetes: Can impair healing processes.

    • Nutrition: Essential for tissue repair and health.

    • Age: Older adults may experience slower healing.

    • Infection: Presence of infection complicates healing.

Complications of Wounds

  • Dehiscence: The surgical wound opens up after closure.

  • Evisceration: Protrusion of internal organs through the open wound.

  • Fistulas: Abnormal connections between two internal organs, or between an organ and the outside of the body, often leading to complications.

Skin Integrity - Burns

  • Types of Burns:

    • Superficial: Involves only the outer layer of skin.

    • Partial Thickness: Involves both the outer layer and part of the underlying layer.

    • Full Thickness: Extends deeper into tissues, possibly affecting muscle or bone.

Pressure Injuries

  • Definitions:

    • Decubitus Ulcer: A pressure ulcer which develops from prolonged pressure on the skin.

    • Pressure Ulcer: An injury to skin and underlying tissue as a result of prolonged pressure.

  • Prevention Strategies:

    • Identify risk factors and reduce pressure on bony prominences.

    • Improve tissue tolerance to pressure.

    • Ensure skin is dry, intact, protected, and perfused.

    • Adequate nutrition is necessary for skin health.

Causes of Pressure Injuries

  • Primary Cause: Pressure intensity and duration.

  • Other Contributing Factors:

    • Medical device-related injuries.

    • Friction and shear forces.

    • Sensory loss or immobility in patients.

    • Skin moisture, particularly moisture associated skin damage (MASD).

    • Nutritional factors.

Staging of Pressure Injuries

  • Stages of Pressure Injuries:

    • Stage 1: Intact skin with non-blanchable erythema.

    • Stage 2: Partial thickness skin loss involving the epidermis and/or dermis.

    • Stage 3: Full-thickness skin loss extending into the subcutaneous tissue; not affecting muscle or bone.

    • Stage 4: Full-thickness skin loss with damage and exposure to muscle, bone, or supporting structures, and elevated risk for osteomyelitis.

  • Other Classifications:

    • Unstageable: Eschar or slough that obstructs staging.

    • Suspected Deep-Tissue Pressure Injury: Intact skin with discoloration or blistering indicating deep tissue injury.

  • Notes: Healing pressure injuries will not regress or drop in staging criteria.

Assessment of Wounds

  • Factors to Assess:

    • The presence of risk factors for pressure ulcers.

    • Actual wound characteristics including;

    • Location

    • Size

    • Presence of undermining or tunneling

    • Type of drainage present

    • Edges and surrounding tissue quality

    • Condition of the wound bed

    • Patient's response to treatment.

  • Drainage Types:

    • Serous: Clear, watery fluid.

    • Serosanguineous: Mixed fluid containing blood and serum.

    • Sanguineous: Bloody drainage indicative of hemorrhage.

    • Purulent: Thick, yellow-green drainage indicative of infection.

Nursing Diagnoses Related to Skin Integrity

  • Common Nursing Diagnoses:

    • Impaired Skin Integrity: Documenting supporting data.

    • Impaired Tissue Integrity: Documenting supporting data.

    • Acute Pain: Documenting supporting data.

Planning and Goal Setting

  • Post-Diagnosis Planning:

    • Goals determined through collaboration with the patient, fostering mutual understanding.

    • Goals drive the selection of nursing interventions.

Interventions and Evaluation

  • Nursing Interventions:

    • Regular turning and positioning of patients.

    • Maintaining skin hygiene.

    • Utilizing pressure-reducing mattresses.

    • Wound cleansing and irrigation methods.

    • Performing debridement as necessary.

    • Appropriate dressing management, including the use of drains, sutures, bandages, and other closures.

    • Application of heat and cold as indicated.

  • Evaluation of Goals: Goals can be categorized as:

    • Met: Goals achieved as planned.

    • Partially Met: Some goals achieved, but not all.

    • Unmet: Goals not achieved, requiring reevaluation and adjustment of care.