Skin Integrity and Wound Healing PDF

Skin integrity and wound management Prepared by/ Khaled Metwaly Lecturer-Nursing program Objectives At the end of this lecture the student will understand :  Anatomy of skin  Function of skin  Conditions and disorders affect the skin  Definition of Skin integrity  Risk Factors for...

Skin integrity and wound management Prepared by/ Khaled Metwaly Lecturer-Nursing program Objectives At the end of this lecture the student will understand :  Anatomy of skin  Function of skin  Conditions and disorders affect the skin  Definition of Skin integrity  Risk Factors for Impaired Skin Integrity  Factors Affecting Wound Healing  Phases of Wound Healing  Signs of wound infection  Nursing care to promote wound healing  Pressure ulcer ( stages , risk factors and nursing intervention )  Nursing Interventions to Protect Skin Integrity Outlines  Anatomy of skin  Function of skin  Conditions and disorders affect the skin  Definition of Skin integrity  Risk Factors for Impaired Skin Integrity  Factors Affecting Wound Healing  Phases of Wound Healing  Signs of wound infection  Nursing care to promote wound healing  Pressure ulcer ( stages , risk factors and nursing intervention )  Nursing Interventions to Protect Skin Integrity  Anatomy of skin The skin is made of multiple layers of cells and tissues, which are held to underlying structures by connective tissue. The skin is composed of two main layers:  the uppermost thin layer called the epidermis made of closely packed epithelial cells.  the inner thick layer called the dermis that houses blood vessels, hair follicles, sweat glands, and nerve fibers.  Beneath the dermis lies the hypodermis that contains connective tissue and adipose tissue (stored fat) to connect the skin to the underlying bones and muscles.  Functions of the skin The skin has three main functions: Protection. Thermoregulation. Sensation. Protection The skin acts as a protective barrier from:  Mechanical, thermal and other physical injury  Harmful agents.  Excessive loss of moisture and protein;  Harmful effects of UV radiation. Thermoregulation One of the skin’s important functions is to protect the body from cold or heat, and maintain a constant core temperature Sensation Skin is the ‘sense-of-touch’ organ that triggers a response if we touch or feel something, including things that may cause pain.  Conditions and disorders affect the skin As the body’s external protection system, your skin is at risk for various problems. These include: Allergies like contact dermatitis. Blisters. Bug bites, such as spider bites and mosquito bites. Skin cancer, including melanoma. Skin infections like cellulitis. Skin rashes and dry skin. Skin disorders like acne, eczema, psoriasis and vitiligo. Wounds, burns (including sunburns) and scars.  Definition of Skin integrity Skin integrity refers to the maintenance of healthy, intact skin that functions effectively as a protective barrier against external threats, such as pathogens, chemicals, and physical injury. It involves the preservation of the skin's structure, function, and ability to repair itself after damage.  Risk Factors for Impaired Skin Integrity Intrinsic Risk Factors (internal ) A- Age-Related Changes Thinning of the Skin: Reduced collagen and elastin make the skin more fragile. Decreased Subcutaneous Fat: Less cushioning over bony prominences increases pressure injury risk. Slower Healing: Aging slows the skin's ability to repair itself.  B. Chronic Medical Conditions Diabetes: Poor circulation and neuropathy increase the risk of skin breakdown, especially in the feet. Vascular Diseases: Conditions like peripheral artery disease (PAD) reduce blood flow to the skin. Immunosuppression: Conditions like HIV or chemotherapy weaken the immune system, increasing infection risk. Renal Failure: Can cause dry skin and increase susceptibility to injury.  C- Nutritional Deficiencies Protein Deficiency: Impairs tissue repair and wound healing. Vitamin and Mineral Deficiencies:  Vitamin C: Essential for collagen synthesis.  Zinc: Supports wound healing.  Vitamin A: Promotes skin health. Dehydration: Reduces skin elasticity and increases dryness. D. Impaired Mobility Immobility: Prolonged pressure on bony areas (e.g., sacrum, heels) increases the risk of pressure ulcers. Paralysis or Neurological Disorders: Conditions like spinal cord injury reduce the ability to reposition independently. E-Skin Conditions Eczema or Psoriasis: Chronic inflammation weakens the skin barrier. Dermatitis: Irritation or allergic reactions can damage the skin. Fragile Skin: Conditions like epidermolysis bullosa make the skin prone to tearing. F. Obesity or Low Body Weight Obesity: Increases pressure on skin folds and reduces blood flow. Low Body Weight: Lack of subcutaneous fat reduces cushioning over bony areas Extrinsic Risk Factors (External) These are factors related to the external environment, care practices, or mechanical forces. A. Pressure Prolonged Pressure: Constant pressure on bony prominences (e.g., sacrum, heels, elbows) reduces blood flow, leading to tissue ischemia and pressure ulcers. B. Shear and Friction Shear Forces: Occur when layers of skin slide over each other (e.g., sliding down in bed), damaging blood vessels and tissues. Friction: Rubbing of skin against surfaces (e.g., bed linens) can cause abrasions. C. Moisture Incontinence: Prolonged exposure to urine or feces can cause maceration and skin breakdown. Excessive Sweating: Creates a moist environment that weakens the skin barrier. Wound Drainage: Fluid from wounds can irritate surrounding skin. D- Poor Hygiene Inadequate Cleaning: Failure to clean the skin properly can lead to irritation and infection. Harsh Cleaners: Using soaps with high pH or abrasive materials can damage the skin. E. Medical Devices Tubes and Catheters: Devices like nasogastric tubes or urinary catheters can cause pressure or friction injuries. Oxygen Masks: Prolonged use can irritate facial skin. F. Environmental Factors Heat and Humidity: Can cause excessive sweating and skin irritation. Cold Weather: Dries out the skin, making it more prone to cracking. G. Medications Corticosteroids: Prolonged use can thin the skin and impair healing. Chemotherapy: Can cause skin sensitivity and increase infection risk. Anticoagulants: Increase the risk of bruising and skin tears.  Wound healing Wound healing is a complex physiological process that restores function to skin and tissue that have been injured.  Factors Affecting Wound Healing Multiple factors affect a wound’s ability to heal and are referred to as local and systemic factors. Local factors refer to factors that directly affect the wound, whereas systemic factors refer to the overall health of the patient and their ability to heal. Local factors affecting wound healing  Localized blood flow  Oxygenation of the tissue  Presence of infection or a foreign body,  Venous sufficiency  Systemic Factors Affecting Wound Healing Age. Older adults have an altered inflammatory response that can impair wound healing. Obesity. Obese individuals frequently have wound complications, including infection, hematoma formation, pressure injuries, and venous injuries. Medications. Medications such as corticosteroids impair wound healing due to reduced formation of granulation tissue..  Cont..Systemic Factors Affecting Wound Healing Nutrition. Nutritional deficiencies can have a profound impact on healing and must be addressed for chronic wounds to heal. Alcohol consumption. Research shows that exposure to alcohol impairs wound healing and increases the incidence of infection Smoking. Smoking impacts the inflammatory phase of the wound healing process, resulting in poor wound healing and an increased risk of infection.[ Cont..Systemic Factors Affecting Wound Healing Diabetes. Diabetes causes delayed wound healing due to many factors such as neuropathy, atherosclerosis (a buildup of plaque that obstructs blood flow in the arteries resulting in decreased oxygenation of tissues), a decreased host immune resistance, and increased risk for infection Stress. Stress causes an impaired immune response that results in delayed wound healing. Phases of Wound Healing? There are four wound healing phases that every wound goes through, including: 1. Hemostasis 2. Inflammation 3. Proliferation 4. Maturation  Phases of wound healing Phase 1: Hemostasis The objective of the hemostasis phase of wound healing is to stop any bleeding. To do so, your body activates its blood clotting system. When your blood clots at the opening of a wound, it prevents you from losing too much blood and it is the first step of your wound closing up. Phase 2: Inflammation in wound healing Once phase one is complete and your body is no longer bleeding, your body activates its key defense mechanism – inflammation. This phase works to kill bacteria and remove debris with white and other blood cells. Inflammation ensures that your wound is clean and ready for new tissue to start growing. Phase 3: Proliferation in wound healing Once your wound is clean, your body will begin the proliferation phase of wound healing. This stage involves closing your wound. Phase three can be broken down into three semi-phases, including: 1. Filling the wound - with new connective tissue and blood vessels. 2. Contracting the edges of the wound - this will feel like the wound is tightening towards the center. 3. Covering the wound - Epithelial cells (cells that create a protective barrier between the inside and outside of your body) flood in and multiply to close your wound completely. Phase 4: Maturation in wound healing During this phase, the new tissue that your body built in phase three, needs to strengthen and build flexibility.  Signs of wound infection Wounds should be continually monitored for signs of infection. Signs of localized wound infection  Erythema (redness).  induration (area of hardened tissue).  Pain.  Edema.  purulent exudate (yellow or green drainage).  wound odor  Nursing care to promote wound healing  Minimize pressure and shear for patients with pressure injuries. For example, a patient with a pressure injury should be repositioned at least every two hours to minimize pressure.  Educate patients with neuropathy and decreased sensation about preventing further injury. For example, a patient with diabetes should wear well-fitting shoes and never go barefoot to prevent injuries.  Control edema in patients with venous ulcers through the use of compression dressings.  Promote adequate perfusion to patients with arterial ulcers. For example, in most cases, the extremity of a patient with an arterial ulcer should not be elevated. Manage blood sugar levels in patients with diabetes mellitus for optimal healing. Promote good nutrition and hydration for all patients with wounds. Consult a registered dietician to assess the patient’s nutritional status and develop a nutrition plan if needed. Document ongoing assessment findings and wound interventions for good communication and continuity of care across the multidisciplinary health care team. Concerns about the healing of a chronic wound or the dressings ordered should be communicated to the health care provider. Referral to a specialized wound care nurse is often helpful.  Pressure Ulcer Pressure injuries are defined as “localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear.  Stages of pressure ulcer Stage 1 pressure injuries are intact skin with a localized area of non-blanchable erythema where prolonged pressure has occurred. pressed. Stage 2 pressure injuries are partial-thickness loss of skin with exposed dermis. Stage 3 pressure injuries are full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed. Stage 4 pressure injuries are full-thickness tissue loss like Stage 3 pressure injuries, but also have exposed cartilage, tendon, ligament, muscle, or bone. Risk factors of pressure ulcer Immobility. This might be due to poor health, spinal cord injury or another cause. Incontinence. Skin becomes more vulnerable with extended exposure to urine and stool. Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can make you lose sensation. Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals every day to maintain healthy skin and stop the breakdown of tissues. Medical conditions affecting blood flow. Health problems that can Nursing Interventions to Protect Skin Integrity and prevent pressure ulcer A. Risk Assessment Conduct Regular Skin Assessments: Inspect the skin daily for redness, swelling, dryness, or breakdown. Use validated tools like the Braden Scale or Norton Scale to assess the risk of pressure ulcers. Identify High-Risk Patients: Elderly, immobile, or critically ill patients. Patients with diabetes, incontinence, or malnutrition. B. Pressure Ulcer Prevention Repositioning: Turn and reposition patients every 2 hours (or as needed) to relieve pressure on bony prominences. Use pillows, foam wedges, or specialized mattresses to redistribute pressure. Support Surfaces: Use pressure-relieving devices such as air mattresses, gel pads, or alternating pressure mattresses. Avoid Shear and Friction: Use lift sheets or devices to move patients rather than dragging them. Apply barrier creams or dressings to protect vulnerable areas. C-Moisture Management Incontinence Care: Clean and dry the skin promptly after episodes of incontinence. Use absorbent pads or moisture-wicking fabrics. Skin Cleansing: Use pH-balanced cleansers to avoid skin irritation. Avoid excessive scrubbing or hot water, which can damage the skin.  D Nutrition and Hydration Promote Adequate Nutrition: Ensure patients receive sufficient protein, vitamins (e.g., vitamin C, zinc), and calories to support skin healing. Hydration: Encourage adequate fluid intake to maintain skin elasticity and prevent dryness. E. Skin Care Products Moisturizers: Apply emollients to prevent dryness and cracking. Barrier Creams: Use products containing zinc oxide or dimethicone to protect against moisture and irritation. Antimicrobial Dressings: Apply to high-risk areas to prevent infection. F. Education and Collaboration Patient and Family Education: Teach patients and caregivers about the importance of skin care, repositioning, and nutrition. Interdisciplinary Collaboration: Work with dietitians, physical therapists, and wound care specialists to develop comprehensive care plans. Special Considerations in nursing intervention Diabetic Patients: Monitor for signs of neuropathy or poor circulation, which increase the risk of skin breakdown. Encourage regular foot inspections and proper footwear. Elderly Patients: Address age-related skin changes, such as thinning and reduced elasticity. Critically Ill Patients: Use advanced support surfaces and monitor for early signs of pressure ulcers.  References 1.National Pressure Ulcer Advisory Panel (NPUAP). (2016). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2.European Pressure Ulcer Advisory Panel (EPUAP). (2019). International Guidelines: Pressure Ulcer Prevention and Treatment. 3.Berman, A., Snyder, S., & Frandsen, G. (2021). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Pearson. 4.Doughty, D. B., & McNichol, L. L. (2016). Wound, Ostomy, and Continence Nurses Society Core Curriculum: Wound Management. Wolters Kluwer. 5.Gray, M., & Giuliano, K. K. (2018). Incontinence-Associated Dermatitis: A Comprehensive Review and Update. Journal of Wound, Ostomy, and Continence Nursing, 45(2), 124-134. 6.Posthauer, M. E., Banks, M., Dorner, B., & Schols, J. M. (2015). The Role of Nutrition for Pressure Ulcer Management: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance White Paper. Advances in Skin & Wound Care, 28(4), 175-188. 7.Registered Nurses' Association of Ontario (RNAO). (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team.  Norton, D., McLaren, R., Exton-Smith, A. N., & Staffing Committee of the Royal College of Nursing. (1975). A study of major and minor decubitus ulcers. The Lancet, 2(7949), 845-848. European Pressure Ulcer Advisory Panel, & National Pressure Ulcer Advisory Panel. (2009). Pressure ulcer risk assessment and prevention: a European perspective. Journal of Tissue Viability, 18(1), 1-46. Lyder, C. H. (2009). Pressure ulcer prevention: A review. Journal of Wound, Ostomy, and Continence Nursing, 36(2), 117-127. European Pressure Ulcer Advisory Panel, & National Pressure Ulcer Advisory Panel. (2009). Pressure ulcer risk assessment and prevention: a European perspective. Journal of Tissue Viability, 18(1), 1-46. Lyder, C. H. (2009). Pressure ulcer prevention: A review. Journal of Wound, Ostomy, and Continence Nursing, 36(2), 117-127. European Pressure Ulcer Advisory Panel, & National Pressure Ulcer Advisory Panel. (2009). Pressure ulcer risk assessment and prevention: a European perspective. Journal of Tissue Viability, 18(1), 1-46. Lyder, C. H. (2009). Pressure ulcer prevention: A review. Journal of Wound, Ostomy, and Continence Nursing, 36(2), 117-127. European Pressure Ulcer Advisory Panel, & National Pressure Ulcer Advisory Panel. (2009). Pressure ulcer risk assessment and prevention: a European perspective. Journal of Tissue Viability, 18(1), 1-46. Cox J. Wound care 101. Nursing. 2019;49(10):8. ↵ [PubMed] [CrossRef] 11. Cox J. Wound care 101. Nursing. 2019;49(10) ↵ [PubMed] [CrossRef] 12. Cox J. Wound care 101. Nursing. 2019;49(10) ↵ [PubMed] [CrossRef] 13. Cox J. Wound care 101. Nursing. 2019;49(10) ↵ [PubMed] [CrossRef] 14. Cox J. Wound care 101. Nursing. 2019;49(10) ↵ [PubMed] [CrossRef]