Wound Care Assessment and Management

Skin Integrity and Wound Care: Part I

• Learning objectives include:
  • Describing skin structure and function.
  • Reviewing factors that alter skin structure and function.
  • Discussing components of a focused skin and wound assessment, including risk assessment tools.
  • Identifying appropriate nursing diagnoses.
  • Developing patient-centered goals.
  • Selecting and evaluating interventions for impaired skin integrity.

Normal Skin Structure and Function: Epidermis

• Outermost and thinnest layer that regenerates every 4-6 weeks.
• Five sublayers are:
  • Stratum corneum
  • Stratum lucidum
  • Stratum granulosum
  • Stratum spinosum
  • Stratum germinativum or basale

Normal Skin Structure and Function: Dermis

• Thicker than epidermis.
• Contains:
  • Sebaceous glands
  • Sweat glands
  • Hair and nail follicles
  • Nerves
  • Lymphatics
• Epidermal and dermal layers are joined by the basal membrane

Normal Skin Structure and Function: Subcutaneous Layer

• Primarily adipose tissue.
• Attaches the dermis to underlying muscles and bone.
• Delivers blood supply to the dermis, provides insulation, and cushioning.
• Size varies based on body location, weight, sex, and age.

Additional Factors Affecting Skin Integrity

• Wounds disrupt skin integrity.
• Vascular disease impairs the skin's ability to obtain required oxygen and nutrients.
• Diabetes affects microvasculature and skin pH.
• Malnutrition comorbidity, medication and process of aging.
• Medical adhesive-related skin injuries (MARSI) occur when superficial skin layers are removed by medical adhesive.

Altered Structure and Function of the Skin

• Wound classification includes:
  • Skin integrity (open vs. closed).
  • Wound depth (superficial, partial-thickness, full-thickness).
  • Amount of contamination (clean, clean contaminated, contaminated, infected, or colonized).
  • Healing process (acute vs. chronic; primary, secondary, or tertiary intention).

Phases of Wound Healing (Full-Thickness Wounds)

• Hemostasis: blood vessels constrict and clotting factors activate coagulation pathways to stop bleeding and form a temporary barrier to bacteria, and platelets release growth factors that attract cells needed for repair.
• Inflammatory: vasodilation occurs, plus plasma and blood cells leak; leukocytes arrive and macrophages appear to regulate wound repair, resulting in a clean wound bed.
• Proliferative: Epithelialization begins, granulation tissue forms, new capillaries are created, and collagen is synthesized, which contributes to strength and structural integrity.
• Contraction occurs in open wounds, reducing the size of the wound.
• Maturation (remodeling): collagen is remodeled for strength, resulting in a well-healed scar

Other Factors impacting healing:

• Oxygenation and Tissue Perfusion: chronic tissue hypoxia is associated with a reduction in collagen formation and decreased action/proliferation of fibroblasts/leukocytes; this impairs cell migration.
• Diabetes: changes in microvascular/macrovascular systems thicken the vessel wall, occlude blood flow, and decrease nutrient/oxygen supply.
• Nutrition: protein is needed by fibroblasts for collagen; deficiencies in vitamins C and A, plus zinc/copper, significantly impact wound healing.
• Infection: prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and leads to further tissue destruction.
• Age: inflammatory response/macrophage & fibroblast action is decreased or delayed, which reduces collagen synthesis and slows epithelialization; comorbidities are increased.

Complications of wound healing

• Dehiscence: partial or complete separation of tissue layers during healing.
• Evisceration: separation of tissue layers allowing protrusion of visceral organs through incision.
• Fistula formation: abnormal connection between two internal organs or an organ and the outside through the skin Examples: enterovaginal, enterocutaneous.

Types of Burns:

• Superficial: damage is to only the epidermis, causing pain and erythema (redness).
• Partial-thickness: destroys the epidermis and part/all of the dermis, causes blistering and pain.
• Full-thickness: destroys the epidermis, dermis, and part of the subcutaneous tissue; area appears white/brown, charred, and lacks sensation; cannot heal without surgery.

Pressure Injuries

• Factors:
  • Intensity of pressure: Acceptable capillary closing pressure is exceeded in chairs or hard surfaces.
  • Duration of pressure: Has a cumulative effect.
  • Medical Devices: injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes
  • Friction and shear: opposing stresses on the skin result in hyperangulation/stretching capillaries, damaging them/ability to transport blood.
  • Sensory loss/immobility lead to breakdown
• Moisture (maceration, incontinence-related dermatitis) & Nutrition

Pressure injury

• Stage 1 pressure injury is intact, non-blistered skin with non-blanchable erythema/persistent redness, area feels painful and differs in firmness or differs in temperature to surrounding tissue.
• Stage 2 pressure injury is a partial-thickness wound involving the epidermis and/or dermis, and has a shallow and superficial pink wound bed, it does not extend below the level of the dermis, with potential for intact/ruptured blisters.
• Stage 3 pressure injury Full-thickness wounds extend which extend into the subcutaneous tissue but not through fascia to muscle, bone, or connective tissue, and cause undermining or tunneling.
• Stage 4 pressure injury is a full-thickness wound with exposed muscle, bone, or connective tissue; carries high risk for osteomyelitis.
• Unstageable pressure injury is a dull-thickness wound with necrotic tissue making it impossible to assess the depth or involvement of underlying structures until necrotic tissue is removed.
• Deep tissue pressure injury Area of intact skin that can rapidy progress even when treated appropriately, is purple or maroon or a blood-filled blister.

Assessment

• Braden and Norton scales are used to predict pressure sore risk.

Wound Assessment

Important factors include:

• Location and size
• Presence of undermining or tunneling
• Drainage
  • Serous drainage: clear, watery fluid from plasma.
  • Serosanguineous drainage: pink or pale red with a mix of serous fluid and red, bloody fluid.
  • Sanguineous drainage: indicates bleeding and is bright red.
  • Purulent drainage: thick, indicates infection, and can be yellow, greenish, or beige.
• Conditions of wound edges/surrounding tissue.
• Wound bed (looking for granulation, necrotic, subcutaneous type tissues, muscle or bone)
• Red Yellow Black classification (RYB): The wound bed should be beefy red and shiny or moist in appearance Yellow is a type of slough tissue and black is necrotic tissue.
• Patient response

Wound Assessment: Tools

• The Wound Characteristic Instrument: Used to assess any open wound.
• Pressure Sore Status Tool (PSST): assigns a numerical score based on 13 wound attributes.
• Pressure Ulcer Scale for Healing (PUSH): Score based on three characteristics.

Measuring a Wound

• Performed using a metric system with a facility-provided ruler with increments in centimeters or millimeters and that sterile cotton-tipped applicators can be used to measure the depth
• Wound size changes over time, so size can indicate either healing or negative progression.
• Measure laterally by determining how wide the wound is and vertically to determine the length of the the wound.

Documentation

Items that should be documented following a wound assessment are:

• Color, consistency, and odor type of drainage; as well as the type of tissue present in the wound.
• Changes in the skin surrounding the wound that may indicate infection and areas where undermining measurements taken.
• Number the wounds on a diagram to show how many are present
• Patient pain or discomfort

Wound Assessment: Anatomy

• Assessment includes:
  • Periwound skin
  • Wound edges
  • Odor and pain
  • Signs of infection

Wound Color/Tissue Classification

• Black/brown wounds/eschar is full-thickness tissue destruction and are described as necrotic or desiccated tissue. If the goal is debridement chemical debdridment may be used.
• Yellow wounds/Slough tissue represents nonviable tissue, and purulent drainage may be present. Use moisture-retentive dressings can enhance debridement process.
• Red wounds/granulation is a result of an increasing number of blood vessels in the wound and select a dressing that maintains a clean and moist wound environment.

Nursing Diagnoses

• Impaired tissue integrity
  • Support: Pressure, immobility, stage 3 pressure injury.
• Impaired skin integrity
  • Support: Pressure injury, loss of sensation, stage 2 pressure injury, losing weight, albumin 2.5 g/dL, prealbumin 15 mg/dL (may indicate poor nutrition).
• Acute pain
• Support: Trauma, pain rated at 8 of 10.

Person Centered Care: Planning stage

• Understand how cultural beliefs and practices impact wound care.
• Use gender congruent caregivers and professional translators when possible.
• Recognize family caregivers when giving information.
• Remind patients to communicate any at-home care

Goals for person-centered care in management of wounds

• Identify and respect the patients, spiritual practice or cultural practice when related to wound healing
• Dressing changes Require respect for a patient privacy.
• Identify individual measures to minimize a patient's discomfort during a dressing, change by understanding his or her values and beliefs about pain management
• Assess and try to understand the different meanings of blood and wounds and how they affect patients.
• provide an opportunity for Family caregivers to be present during dressing changes

Person-centered skin care includes recognizing:

• Skin tone.
• Providing patient and caregiver education.
• Considering the social effects of a pressure injury.
• Awareness that hair in some cultures cannot be shaved.
• Consider primary language and reading ability when using printed materials.
• Pressure injuries cause pain and resultant disability

Skin Integrity and Wound Care: Part II

• Comprehensive wound and periwound assessment aids progress of healing and promotes early identification of wound infections.
• Ongoing assessment of chronic wounds and periwound area identifies risk factors.
• Topical antimicrobial agents, polyurethane film, silicone, or foam dressings are effective in promoting wound healing.

Dressings, Bandages, and Binders: Safety Guidelines

• Perform hand hygiene and use appropriate gloves.
• Verify that Wound closure techniques are accurate
• Ensure that the proper treatment plan is in place
• Verify that wound drainage devices don't cause pressure on adjacent skin.

Applying a dressing

• Dry Gause dressings, are used to provide wound healing by little drainage do not interact with wound tissues and cause little wound irritation.
• Moist dressings, such as moisture and gauze can increase the absorptive ability of the dressing to collect exuding wound debris, and mechanically debride the wound.

Applying a dressing: Delegation

• Applying, dry and moist dressing may be delegated to assistant personnel the nurse is responsible for assessing and a evaluating patient:
• Unique modifications of change
• Reporting pain fever, bleeding,
• reporting potential contamination

Applying a dressing: Unexpected outcomes and related

• Inflammation, monitor patients inform health care provider
• Wound bleeds, observe amount of drainage contact, the patient

Applying a dressing: Unexpected outcomes and related

• If area has assess wound
• Sensation , protect if this happens cover patient lie

Application of a pressure bandage is first step in hemorrhage control. Pressure dressing exerts pressure over a bleeding site and assists temporary in controlling and anticipated bleeding The skill of applying or pressure dressing and emergency situation cannot be delegated to a AP. The nurse can direct that AP to asssit as needed. Assist the nurse is directed,. Observe the pressure dressing during activities so has to remain in place and no viable.

Applying a pressure bandage: unexpected outcomes and related interventions

• The continued bleeding of fluid can cause an electrolyte imbalance or the heart can stop
• If the pressure dressing is too tight contact and check circulation and adjust as.

Applying Transparent Dressing

• This is clear, adherents and prevents dehydration, a film
• May for people on high risk skin

Applying Transparent Dressing: Delegation

• This is delegatable if wounds are selected, nurse is responsible

Applying Transparent Dressing: Related outcomes and interventions

• Fluid accumulation, notify health care provider
• does it stay in place, make sure to evaluate size

Hydrocolloid, Hydrogle , Fome

• This is adhesion agent and wound debridement
• It's Glycerin. Water based, may require you to cannot be delegated to A.P. The nurse directs AP to

Hydrocolloid, Hydrogle: Unexpected

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Assess your knowledge of wound assessment, healing, and pain management. This quiz covers wound bed color, epithelial tissue regeneration, pain interventions, and complications. Test your familiarity with PUSH tool and pain assessment.