CHAPTER 36-SKIN INTEGRITY AND WOUND CARE

Skin Integrity

Intact skin - presence of normal skin and skin layers uninterrupted by wounds

Most common medications that cause damage to the skin:

- antibiotics - tetracycline or doxycycline

- chemotherapeutic drugs for cancer - methotextrate

- psychotherapeutic drugs - tricyclic antidepressants

- rashes (side effects)

Types of Wounds:

- intentional trauma - occurs during therapy (operations or venipunctures)

- unintentional trauma - accidental

Incision - sharp instrument (e.g., knife or scalpel)

Contusion - blow from a blunt instrument

Abrasion - surface scrape, either unintentional

Puncture - penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or
unintentional

Laceration - tissues torn apart, often from accidents

Penetrating wound - penetration of the skin and the underlying tissues, usually

unintentional (e.g., from a bullet or metal fragments)

Clean wounds - uninfected wounds in which there is minimal inflammation and primarily closed wounds

Clean-contaminated wounds - surgical wounds in which the rest of respiratory tract, GIT, genital or urinary tract has
been entered

Contaminated wounds - open, fresh, accidental wounds and surgical wounds involving a major break in sterile
technique or large amount of spillage from GIT (shows evidence of inflammation)

Dirty or Infected wounds - contains dead tissues and wounds with evidence of a clinical infection, such as purulent
drainage

Classifying wounds by depth:

- partial thickness

- dull thickness

Pressure Ulcers

- consists of injury to the skin or underlying tissues

- over bony prominence

- also known as decubitus ulcers, pressure sores or bed sores

- etiology - localized ischemia - deficiency in the blood supply to the tissue

- reactive hyperemia - bright red flush

- flush is due to vasodilation

Stages of Pressure Ulcers:

Stage 1: nonblanchable erythema signaling potential ulceration

Stage 2: partial-thickness skin loss involving epidermis and or dermis

Stage 3: full-thickness skin loss involving damage or necrosis of SQ tissues that may extend to but not through
underlying fascia

Stage 4: full-thickness skin loss damage to muscles and necrosis of tissue

Unstageable or unclassified - full-thickness skin or tissue loss --- depth unknown

Suspected deep tissue injury --- depth unknown: purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure or shear

Common pressure sites:

Risk Assessment Tools:

- Braden Scale for Predicting Pressure

Sore Risk

- Norton’s Pressure Area Risk Assessment

Scoring System

Wound Healing:

Healing - quality of living tissue

- aka regeneration (renewal) or tissues

Types of Wound Healing:

- primary intention - tissue surface are closed and there is minimal or no tissue loss (primary union or first intention
healing - INSIDE TO OUTSIDE HEALING)

- secondary intention - extensive wound and tissue loss

- repair time is longer

- scarring is greater

- susceptibility to injection is greater

- OUTSIDE TO INSIDE HEALING (formation of scabs)

- irregular edge of wound

Phases of wound healing:

Inflammatory phase - immediately after injury; lasts 3-6 days

Two major processes:

- hemostasis (cessation of bleeding) - results from vasoconstriction of larger blood vessels in the affected area

- formation of blood clots in the area

- retraction of injured blood vessels

- deposition of fibrin (connective tissue)

- Phagocytosis - macrophages engulfs microorganisms and cellular debris by a process known as phagocytosis

- macrophages secrete an angiogenesis factor which stimulates formation of epithelial buds at the end of
injured blood vessels

- during cell migration, leukocytes (neutrophils) move into the interstitial space

Proliferative phase - from day 3 or 4 to about day 21 post injury

- fibroblasts (connective tissue cells) which migrate into the wound starting about 24 hours after injury, begin
to synthesize collagen

- collagen - whitish protein substance that adds tensile strength to the wound

- capillaries grow across the wound, increasing blood flow

- fibroblasts move from the bloodstreams into the wound, depositing fibrin as the capillary network develops,
the tissue becomes a translucent red color

- the tissue, called granulation tissue, is fragile and bleeds easily

- granulation tissue matures

Maturation phase - day 21 and can extend 1 or 2 years after injury

- fibroblasts continue to synthesize collagen

- wound is remodeled and contracted

- scar becomes stronger but the repaired area is never as strong as the original tissue

- dark-skinned individuals, an abnormal amount of collagen is laid down. This can result in a hypertrophic scar
or keloid

- one method of documenting the progress of healing in pressure ulcers is to use the pressure ulcer scale for
healing (PUSH) tool

Types of wound exudate:

Exudate - fluid and cells, escaped from blood vessels during inflammatory phase

- serous exudate - consists chiefly of serum (the clear portion of the blood) derived from blood and the serous
membranes of the body, such as the peritoneum. It looks watery and has few cells.

- example is the fluid in a blister from a burn.

- purulent exudate - thicker than serous exudate because of the presence of pus, which consists of leukocytes,
liquefied dead tissue debris, and dead and living bacteria.

- suppuration - process of pus formation

- sanguineous exudate - consists of large amounts of red blood cells, indicating damage to capillaries that is
severe enough to allow the escape of red blood cells from plasma. This type of exudate is frequently seen in
open wounds.

- serosanguineous exudate - consisting of both clear and blood-tinged drainage, is commonly seen in surgical
incisions

Purosanguineous discharge, consisting of pus and blood, is often seen in a new wound that is infected

Complications of Wound Healing:

Hemorrhage - massive bleeding

- hematoma - localized collection of blood underneath the skin that may appear as a reddish blue swelling

- infection - contamination of a wound surface with microorganisms (colonization)

- surgical infection is apparent 2 to 11 days postoperatively

- organisms compete with new cells for oxygen and nutrition

Dehiscence with possible evisceration:

- Dehiscence - partial or total rupturing of a sutured wound

 - factors:

- obesity, poor nutrition, multiple trauma, failure of stunning, excessive coughing, straining,
sneezing, vomiting, and dehydration

- evisceration - pritrusion of internal viscera through incision

Wound dehiscence - more likely to occur 4-5 days postop

Factors affecting wound healing:

- developmental considerations

- nutrition

- lifestyle

- medications

Assessing wounds:

- assess location and extent

- inspect for bleeding

- control severe bleeding

- inspect wound for foreign bodies

- tetanus toxoid injection

- prevent infection

- control swelling and pain (ice)

- assess client for signs of shock (severe bleeding or internal bleeding)

Nursing Diagnoses:

- risk for pressure ulcer

- risk for impaired skin integrity

- impaired tissue integrity

Treating Pressure Ulcers:

The RYB Color Code: RED YELLOW BLACK

Red wounds are usually in the late regeneration phase of tissue repair

- protect red wounds by gentle cleansing (use of a noncytotoxic wound cleanser applied without pressure)

- protecting periwound skin with alcohol-free barrier film

- filling dead space with hydrogel or alginate

- covering with an appropriate dressing such as transparent film, hydrocolloid dressing, or a clear absorbent acrylic
dressing

- changing the dressing as infrequently as possible

Yellow wounds - characterized primarily by liquid to semiliquid “slough” that is often acompanied by purulent
drainage or previous infection

- cleanses yellow wounds to remove nonviable tissue

- methods used may include applying damp-to-damp normal saline dressings, irrigating the wound, using absorbent
dressing materials such as impregnated hydrogel or alginate dressings, and consulting with the primary care
provider about the need for a topical antimicrobial to minimize bacterial growth

Black wounds - covered with thick necrotic tissue, or eschar.

- black wounds require debridement (removal of the necrotic material)

- removal of nonviable tissue from a wound must occur before the wound can be staged or healed

Debridement may be achieved in four different ways:

- sharp

- mechanical

- chemical

- autolytic

Sharp debridement - scalpel or scissors is used to separate and remove dead tissue

Mechanical debridement - accomplished through scrubbing force or damp-to-damp dressings

Chemical debridement - more selective than sharp or mechanical techniques

Autolytic debridement - dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound
drainage against the eschar

Dressing Wounds:

Dressings are applied for the following purposes:

• To protect the wound from mechanical injury

• To protect the wound from microbial contamination

• To provide or maintain moist wound healing

• To provide thermal insulation

• To absorb drainage or debride a wound or both

• To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages)

• To splint or immobilize the wound site and thereby facilitate healing and prevent injury

Types of Dressings:

Various dressing materials are available to cover wounds. The type of dressing used depends on (a) the location,
size, and type of the wound; (b) the amount of exudate; (c) whether the wound requires debridement or is
infected; and (d) such considerations as frequency of dressing change, ease or difficulty of dressing application,
and cost