Skin Integrity and Wound Care

Skin Integrity and Wound Care

• The skin is the largest organ, comprising about 15% of total adult body weight
• It acts as a protective barrier against pathogens, a sensory organ, and synthesizes vitamin D
• Skin injury poses safety risks and initiates a healing response
• Nurses assess and monitor skin integrity to maintain healthy skin

Anatomy and Physiology of Skin

• The skin consists of two layers: the epidermis and the dermis, separated by the dermal-epidermal junction
• The epidermis, the top layer, includes the stratum corneum, which is the thin, outermost layer containing dead, keratinized cells

Epidermis Layers

• The cells originate from the basal layer, divide, proliferate, and migrate towards the epidermal surface before flattening and dying
• This movement ensures replacing surface cells lost during normal desquamation
• The thin stratum corneum protects against dehydration and chemical agents, allows water evaporation, and permits topical medication absorption

Dermis Info

• The dermis is the inner skin layer providing tensile strength, mechanical support, and protection, differing from the epidermis by consisting mostly of connective tissue and few skin cells
• Collagen, blood vessels, and nerves are found in the dermal layer
• Fibroblasts are responsible for collagen formation

Skin Structure Importance

• Intact skin guards from chemical and mechanical injury
• The epidermis resurfaces wounds and the dermis restores structural integrity via collagen
• Aging alters skin characteristics, making it more vulnerable to damage

Wounds

• A wound is a disruption of tissue integrity and function

Assessing Wounds

• Location and extent of tissue damage
• Measuring wound length, width, and depth
• Associated injuries such as fractures or head trauma
• Determining when the client last had a tetanus toxoid injection if the wound is contaminated

Assessing Pressure Ulcers

• Assessing pressure ulcers involves noting the location of the ulcer
• Measuring the size of the ulcer in centimeters
• Checking for undermining using the clock face method to describe
• Determining the stage, color of the wound bed, necrosis location, condition of wound margins and surrounding skin, and clinical signs of infection

Types of Wounds

• Intentional: Planned (e.g., surgical incisions)
• Unintentional: Accidental injuries
• Closed wounds: Tissues are traumatized without a break in the skin
• Open wounds: Skin or mucous membrane surface is broken
• Clean wounds: Uninfected with minimal inflammation, primarily closed.
• Clean-contaminated wounds: Surgical, in which the respiratory, gastrointestinal, genital, or urinary tract has been entered, but without evidence of infection
• Contaminated wounds: Open, fresh, accidental. Major break in sterile technique or spillage from the gastrointestinal tract
• Dirty or infected wounds: Contain dead tissue. Evidence of clinical infection, such as purulent drainage or necrosis
• Partial thickness wounds: Confined to skin
• Full thickness wounds: Involve skin, subcutaneous tissue, and possibly muscle and bone requiring connective tissue repair
• Incision: Caused by a sharp instrument, sealed as part of treatment
• Contusion: Caused by blunt trauma, skin appears bruised
• Abrasion: A surface scrape
• Puncture: Penetration by a sharp instrument
• Laceration: Torn tissues
• Penetrating wound: Entry into underlying tissues

Pressure Ulcers

• Pressure ulcers stem from impaired skin integrity due to prolonged pressure

Risk factors for Pressure Ulcers

• Older adults
• Those with spinal cord injuries or fractured hips
• Acutely ill or in long-term/community care
• Individuals with diabetes
• Patients in critical care
• Tissue receives oxygen/nutrients and eliminates waste via the blood
• Impaired blood flow interferes with cellular metabolism
• Prolonged intense pressure affects cell metabolism leading to tissue death

Etiology of Pressure Ulcers

• Ischemia results from prolonged, unrelieved pressure that compresses the tissue
• Cells become deprived of nutrients and oxygen
• Metabolic waste products accumulate
• Tissue dies

Pathogenesis of Pressure Ulcers

• Pressure intensity
• Pressure duration
• Tissue tolerance

Pressure intensity

• Capillary closing pressure is the amount needed to collapse a capillary
• Normal capillary pressure range of 15 to 32 mmHg
• If external pressure exceeds the range, tissue ischemia will occur

Reduced Sensation Effects

• Reduced sensation prevents responses to discomfort, leading to tissue ischemia and death

Hyperemia assessment

• Assess hyperemia by pressing fingers over area
• If it blanches and erythema returns you have transient hyperemia, if it does not, you have nonblanchable erythema, and probable deep tissue damage

Pressure Duration

• Both low pressure (prolonged duration) and high intensity (short duration) can cause tissue damage

Tissue Tolerance

• Tissue tolerance relies on structural integrity
• Shear, friction, and moisture affect skin tolerance
• Systemic factors like poor nutrition, increased aging, hydration status, and low blood pressure affect tolerance

Risk Factors of Pressure Ulcers

• Friction is force acting parallel to skin surface
• Shearing force is a combination of forces
• Immobility
• Inadequate nutrition leading to weight loss, atrophy, and loss of subcutaneous tissue
• Fecal and urinary incontinence can cause maceration which is the softening of tissue due to excessive moisture
• Decreased mental status
• Diminished sensation

Classification of Pressure Ulcers

• Assessment includes the depth of tissue involvement
• Pressure ulcer staging describes pressure ulcer depth at the point of assessment

Stage 1 Pressure Ulcer

• Nonblanchable erythema of intact skin signaling potential ulceration
• May be painful, firm, soft, warmer, or cooler
• Difficult to detect in dark skin tones

Stage 2 Pressure Ulcer

• Partial thickness skin loss with a red-pink wound bed
• Shallow
• Open ulcer or blister
• Should not be used to describe skin tears

Stage 3 Pressure Ulcer

• Full thickness skin loss with damage or necrosis
• Subcutaneous fat may be visible
• May include undermining and tunneling
• Depth varies depending on anatomical location

Stage 4 Pressure Ulcer

• Full thickness skin loss with tissue necrosis
• Damage to muscle, bone, or supporting structures
• May include undermining and tunneling

Unstageable Pressure Ulcer

• Full thickness tissue in which the depth is obscured by slough or eschar

Granulation Tissue

• Red moist tissue with new blood vessels

Assessing Wounds

• Untreated wounds are usually seen shortly after an injury

Assessing Treated Wounds

• Assessed to determine progress of healing
• Can be inspected during dressing changes

Dressings

• Dressings should be inspected regularly
• Estimating the amount of wound drainage can be done with minimal amount of staining to heavy or overflowing drainage, and will indicate the need for a dressing change

Wound Extentions

• Wounds sometimes extend under the skin surface
• Can result in a sinus tract or tunnel
• Can assess size of the wound with a sterile swab to determine the length
• Often caused by infection and needs antibiotics
• Surgical incision may be needed

Pressure Injuries

• Note the following: location, size in centimeters, presence of undermining or sinus tracts location on a clock, stage, color of wound bed, condition of wound margins, of the surrounding skin, and clinical signs of infection,

Mechanical Devices for Reducing Pressure

• gel flotation pads
• pillows and wedges
• heel protectors
• memory foam
• alternating pressure
• Static/ active air loss beds
• Air fluidized beds etc

Types of Wound Healing

• Primary intention
• Minimal tissue loss.
• Characterized by minimal granulation tissue and scarring
• Secondary intention
• The edges cannot or should not be approximated
• Repair time is longer
• Tertiary intention
• left for 3-5 days to allow edema

Phases of Wound Healing

• Inflammatory Phase
• Begins immediately after injury; lasts 3-6 days
• Hemostasis and phagocytosis
• Increased blood supply (oxygen, nutrients)
• Edematous
• Exudate of fluid and cell debris Types of Wound Exudate ○ Serous ○ Purulent ○ Sanguineous ○ Serrasanguinous ○ Purosanguinous
• Proliferative Phase: From day 3/4-21 post injury ○ Fibroblasts ○ Collagen- for the strength of the wound ○ Capillaries increase ○Mariginal Epithelial migrate
• What to do if is doesn't close by epithelialization: Eschar appears

Wound Management

○ Secondary intention wound- cover with fibrin ○ Maturation happens on day 23- after 1 2 years ○ Scar becomes stronger: hypertrophic/ keloid scar ○ Factors Affecting Wound healing ○ What to do if there’s a blood vessel, or infection due to slippage or erosion etc ○ What to do if a wound ruptures/ surgical error ○ Risk factors: ○ Obesity ○ coughing etc

Wounds

Splint or immobilize the wound site prevent infection Excessive bacteria- Clean! Avoid little exudate Irrigation range- 4-15 psi Piston syringe catheter: gives 8 psi

Bandages

pad with circular, spiral, figure 8 Pad the area with bony Secure End appropriately

Heat And Cold

Heat: vasodilation, delivery of nutrients, reduces viscosity of blood, muscle tension, increases waste and capillary permeability for open wounds Cold Vasoconstriction Prevents edema/formation, is localized Malignancy of joint injury

Dry/Moist

Dry less burns Dry does not cause skin masseration Retains temperature

Cleaning a Wound and Applying a Dry, Sterile Dressing

Goal: Restore skin integrity while being sterile

1. PPE and hand hygiene to start 2)Clean and remove 3)Document drainage
2. Check for suture or wound problems\
3. Check all supplies and maintain a working sterial field open supply \
4. Clean sterile /chlorhexidine and work outwards\
5. Pat dry and apply dressing if needed
6. 8. Cover 100% and tape to ensure secure seal\
7. Reapply and review every shift

Irragation

PPE and Hand Hygiene Review the chart Position person with basin at bottom

wound cultures and assessment/treatment

culture it review documentation measure to test maintain sterility maintain comfort levels