Skin Integrity & Wound Care

Skin Integrity & Wound Care

• Wound classifications, pressure injury classifications, and wound healing processes should be distinguished

Wound Classification

• Partial thickness wounds do not extend through the dermis
• These wounds heal via regeneration and re-epithelialization
• Inflammatory response, epithelial proliferation/migration, and re-establishment of epidermal layers occur during healing
• Full thickness wounds extend beyond the dermis
• Damage extends below the epidermis into subcutaneous tissue or beyond like muscle, bone, tendons
• Trauma or burns are examples of full thickness wounds
• Acute wounds last less than 30 days
• Chronic wounds are non-healing and last more than 30 days

Factors Delaying Wound Healing

• Key factors include:
• Nutrition
• Blood supply
• Corticosteroid therapy
• Infection
• Smoking
• Friction
• Age
• Obesity
• Diabetes
• Poor general health
• Anemia

Wound Healing Complications

• Infection is more likely with bigger, deeper, and surgical wounds, and in vulnerable individuals
• Traumatic wound infections typically develop 2-3 days post-trauma, depending on severity and contamination

Manifestations of Infection

• Include:
• Erythema
• Increased drainage
• Changes in drainage consistency, color, or odor
• Warm surrounding skin
• Edema
• Fever
• Increased WBC count

Hemorrhage

• High risk during the first 24-48 hours post-op
• Dehiscence and evisceration can occur
• Adhesions and contractures can form

Wound Assessment: Measurement

• Size should include note of width, length, and depth
• Utilize the clock method, tunneling (tracts/canals extending through the wound)
• Undermining (tissue destruction extending under the wound edge) should be measured

Wound Assessment: Appearance

• Granulation tissue is soft, new, pink or red tissue that forms during healing
• Necrotic tissue is non-viable due to reduced blood supply
• Slough (yellow) is dead tissue, usually cream or yellow in color, with dead cells, fibrin, etc.
• Eschar is dry, black, hard necrotic tissue with dried blood

Wound Assessment: Drainage/Exudate

• Serous drainage is thin and clear

Causes of Pressure Injuries: Shear/Friction

• Force is applied parallel to the skin which stretches and distorts tissue
• This may cause vessel occlusion perpendicular to the skin surface
• Leads to ischemia and necrosis

Causes of Pressure Injuries: Pressure

• Force is applied perpendicular to the tissue
• This compresses tissue and causes ischemia (reduced blood flow) and necrosis
• This can rupture cells/vessels, deforming the tissue

Braden Pressure Ulcer Risk Assessment: Sensory Perception

• Completely limited: unresponsive to pain/discomfort, diminished consciousness/sedation or limited ability to feel pain over most of the body.
• Very limited: responds only to painful stimuli, cannot communicate pain/discomfort, or has pain/discomfort over 1/2 the body.
• Slightly limited: responds to verbal commands but cannot always communicate discomfort, or has sensory impairment limiting pain in 1-2 extremities
• No Impairment: Responds to verbal commands, has no limited ability to vocalize or feel pain or discomfort

Braden Pressure Ulcer Risk Assessment: Moisture

• Constantly moist: Skin is kept moist by perspiration, urine, and dampness is detected when moved/turned
• Often moist: Not always moist, linen changed at least once a shift
• Occasionally moist: Requires extra linen change daily
• Rarely moist: Skin usually dry, linen changed at routine intervals

Braden Pressure Ulcer Risk Assessment: Activity

• Bedfast: Confined to bed
• Chairfast: severely limited ability to walk, cannot bear weight, must be assisted into chair/wheelchair
• Walks occasionally
• Walks frequently: walks outside room at least twice a day and inside the room at least once every 2 hours during walking hours

Braden Pressure Ulcer Risk Assessment: Mobility

• Completely immobile: No changes in body/extremity position without assistance
• Very limited: Makes occasional, slight changes in position but unable to make frequent/significant changes without help
• Slightly limited: Makes frequent but slight changes in body position independently

Braden Pressure Ulcer Risk Assessment: Nutrition

• Very poor: Rarely eats a full meal, eats less than 1/3 of food offered, eats 2 or fewer protein servings daily, does not take dietary supplements or is NPO/ONLY IV fluids for 5+ days.
• Probably inadequate: Rarely eats a full meal, eats about 1/2 of food offered, about 3 servings of protein daily.
• Adequate: Eats over half of meals, eats 4 servings of protein, may occasionally refuse meals
• Excellent: Eats all meals

Braden Pressure Ulcer Risk Assessment: Friction and Shear

• Problem: Requires moderate to maximum assistance in moving, cannot move without sliding, frequently slides down in bed/chair and requires frequent repositioning
• Potential problem: Moves freely but requires help, skin slides against sheets during moves, decent position maintained but occasionally slides down
• No apparent problem: Moves in bed/chair without help, sufficient muscle strength, maintains good position at all times

Interventions Aimed at Reducing Pressure Injury Risk

• Get patient Braden scale score 23 to 6
• Score 23-19: no additional pressure support is required, but educate, weight-shift, assess the skin, and evaluate changes in condition
• Score 18-15 (Mild) and 14-13 (Moderate): use a high-specification foam mattress or static air overlay
• Consider a cushion for the chair, bed-cradle, or gooseneck, and reposition frequently
• Promote activity and manage individual risk factors like nutrition, shear, friction, and continence, educate on condition changes
• Score 12-10 (High) and 9-6 (Severe): dynamic air overlay or cushion, dynamic mattress, replacement or low air loss. Consider nutritional assessment and small postural shifts

Pressure Injury Staging

• Stage 1: Intact skin with non-blanchable redness over a bony prominence which may differ in color or be painful, firm, soft, warmer, or cooler than adjacent tissue
• Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink/red wound bed, without slough, or as an intact/ruptured serum-filled blister
• Should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation
• Stage 3: Full thickness tissue loss with visible subcutaneous fat, but bone, tendon, or muscle are not exposed, may include both undermining and tunneling
• The depth varies by anatomical location, areas of adiposity can develop into extremely deep wounds
• Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle which may have slough or eschar, includes undermining and tunneling
• Unstageable: Full thickness tissue loss with the wound bed has slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black)
• Suspected Deep Tissue Injury: Localized purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear
• May be preceded by painful, firm, mushy, boggy, warmer or cooler tissue, evolution may be rapid

Effective Wound Management

• Debridement: Removal of nonviable, necrotic tissue
• Wound Irrigation:
• Use a syringe, often with angiocath
• Use irrigation solution (NS or commercial wound cleaner) with the catheter 1 inch above the wound's surface
• Flush until drainage is clear
• Obtain a wound culture after cleaning
• Wound Dressing: Purpose - To protect from contamination, aid in hemostasis, absorb drainage, physically support wound site, provide thermal insulation and a moist environment

Wound Dressing: Function

• Protection, deliver medication, and/or absorb drainage

Wound Dressing: Types

• Gauze absorbs drainage
• Montgomery straps for open wounds, healing by tertiary intention
• Abdominal binder keeps surgical wounds secure and assists with pain management
• Hydrocolloid dressing is a sticky dressing and provides moisture or insulation with two layers; gel and foam

Nurse's Role in Wound Therapy

• Understands the nurse's role in providing care for clients who require negative pressure wound therapy or hyperbaric therapy

Negative Pressure Wound Therapy

• VAC Granulofaom dressing promotes granulation
• VAC therapy removes fluids, promotes a moist wound healing environment, removes infectious materials, protects the wound environment, promote perfusion, and draw wound edges together

Hyperbaric Therapy

• Hyperbaric chamber where the patient lies down
• Inhaling pure oxygen in a pressurized chamber to aid wound healing
• Air pressure is increased 2-3 times higher than normal
• Gather more air to enhance new blood vessels and tissues

Clinical Decision Making

• Nurses may use a Penrose drain for passive, open drainage
• Nurses may also place a Jackson Pratt (JP) drain or Hemovac drain
• Closed suction systems, actively pulling fluid from a wound using a bulb (JP) or collection container that creates a NEGATIVE pressure when squeezed

Repair of Full Thickness Wounds: Primary Intention

• Little or no tissue loss, wound edges well-approximated, heals rapidly
• Example: Closed surgical incision with staples, sutures, or liquid glue to seal laceration

Repair of Full Thickness Wounds: Secondary Intention

• Loss of tissue, wound edges widely separated, un-approximated (pressure injury open burn areas), longer healing time
• Examples: burns or pressure ulcers

Repair of Full Thickness Wounds: Tertiary Intention

• Widely separated, deep wounds: Spontaneous opening of a previously close wound, risk of infection, extension drainage and tissue debris, closed later, long healing time
• Example: Abdominal wound initially left open until infection is resolved and then closed

Mobility and Immobility

• Immobility can affect musculoskeletal, respiratory, cardiovascular, metabolic, gastrointestinal, urinary, integumentary, neurological, and psychological systems

Musculoskeletal Anatomy

• Skeletal muscles are the working elements of movement
• Bones provide stability and structure
• Ligaments connect bones and cartilage
• Osteoblasts build bone
• Osteoclasts deconstruct bone
• The musculoskeletal system requires mechanical use/stress to maintain cell health
• Parathyroid hormone increases serum calcium through bone resorption
• Bone marrow stores stem cells that respond to erythropoietin for red blood cell production

Musculoskeletal Assessment

• Muscle strength, tone, mass
• Decreased with immobility
• Careful monitoring for poor positioning, activity/exercise intolerance, gait and assistive devices, and range of motion is important
• Contractures can occur

Consequences of Impaired Mobility

• Disuse atrophy is one such consequence
• Immobility can cause permanent or temporary impairment
• This can lead to atrophy from disuse, deconditioning, and an increased risk for falls
• Osteoporosis: increased osteoclast activity which increases risk for pathologic fractures
• Joint contractures are a fixation of a joint from atrophy, disuse, or shortening of muscle fibers
• Foot drop is a permanent plantar flexion from a stroke cause impaired ambulation

Musculoskeletal Intervention

• Encourage active range of motion, actively assisted, or passive as needed
• 5 times per session; BID or TID
• Positioning and body alignment: reposition q2h bed; q1h chair and shift q15min and with consideration of Supportive devices and pressure points
• Promote ambulation and assistive devices
• Heat Application Increases blood flow, tissue metabolism, relaxes muscles, eases joint stiffness and pain, and Moist heat with warm compresses soaks and sitz baths
• Dry heat with hot pack
• Cold Application: Decreases inflammation, prevents swelling, reduces bleeding/fever, diminishes muscle spasms, decreases pain by decreasing nerve conduction
• Moist cold with compresses or soaks, Dry cold with an ice bag

Musculoskeletal: Heat and Cold Precautions

• Impaired skin integrity
• Immobility
• Impaired sensory perception
• Avoid prolonged exposure
• Avoid cold with certain conditions - intolerance, Raynaud's, open wounds
• Monitor bony prominences
• Avoid heat over metal, abdomen of pregnant patients, within 24 hours of trauma, bleeding, edema

Respiratory Anatomy

• Breathing requires the musculoskeletal system
• The respiratory cage must have full mobility for optimized breathing
• Oxygen and carbon dioxide are exchanged between alveoli and capillaries
• Asymmetric chest wall movement can impact breathing and oxygenation

Respiratory Assessment

• Assess, through, osculation, fill respiratory cycle, assessing asymmetric chest wall movement
• Note the work of breathing, like dyspnea, tachypnea, or pleurisy
• Auscultate all lung fields, especially areas of dependence by noting crackles, wheezes, and diminished breath sounds
• Assess both cough with/without sputum production by noting color, amount, and consistency

Consequences of Impaired Mobility

• Atelectasis results from secretions obstructing a bronchiole or bronchus and causing alveoli collapse
• Hypostatic Pneumonia can also occur because inflammation from stasis or pooling of secretions, decreased and weekend respiratory muscles, and bacteria proliferation

Respiratory Interventions

• Pulmonary hygiene q1-2h
• Deep breathing exercises
• Incentive spirometry - MUST BE ACCESSIBLE
• Controlled coughing
• Deep breaths then fried cough and suction if poor cough
• Manage pain
• Provide fluids to prove thin secretions

Cardiovascular Anatomy

• Mobility of the extremities promotes venous return of blood (Maintains preload)
• Cells require adequate perfusion to engage in metabolism
• Remaining mobile helps to sustain proper response of the autonomic nervous system
• Sympathetic nervous system- alpha receptors cause arterial vasoconstriction and tachycardia
• Parasympathetic nervous system- normal heart rate or bradycardia

Cardiovascular Assessment

• Assess vital signs for tachycardia or orthostatic hypotension
• Assess Perfusion by noting weak peripheral pulses, peripheral edema, dependent edema, and capillary refill
• Assess Cardiac Workload by noting Apical impulse, S3
• Thrombus - Bilateral cald circumference. Tenderness or cramping

Interview and Assessment

• Perform an assessment to identify potential complications of immobility:
• Patient Interview
• Patient preferences, values, beliefs, and needs
• Effect of impaired mobility on physical, psychological, social status
• Symptoms: pain, stiffness, difficulty moving, appetite and diet, sleep, urination and bowel patterns, exercise routine, home safety and potential hazards
• Physical assessment
• General survey and alignment, height and weight, activity tolerance
• Inspect mobility status starting for most supportive position
• Active range of motion and palpitate swelling, pain, stiffness. Active assisted or passive range of motion, auscultation, percussion

Implement Nursing Actions to Reduce Complications

• Importance of Proper Body Alignment, Reduces strain on musculoskeletal structure, aids in maintaining adequate muscle tone Contributes to balance and conservation of energy, Health Promotion of Mobility
• Prevention of work-related injuries, exercise related to client and injuries
• Utilize the ADPIE clinical decision-making model to provide care for clients with alterations in body systems due to impaired mobility:

Mobility-Related Nursing Diagnoses

• Related directly to immobility
  • Impaired mobility (partial immobility)
  • Risk for dishes Syndrome (Complete immobility)
• Related to Consequences of Immobility
  • Impaired Airway Clearance, impaired sleep, risk for impaired skin integrity, risk for constipation, or social isolation