Skin Care, Aseptic Technique and Prevention for the Pressure Ulcers

Normal Wound Healing

l Phases of normal wound healing
1. Three phase: inflammation, proliferation / granulation or fibroplastic phase, and maturation /
remodeling phase.
2. The classic model of overlapping phases of wound healing describes a process that is continuous,
its phase not entirely distinct.
Inflammation Ø The normal immune system reaction to injury.
Ø Temporary repair initiated by coagulation (clotting factors, platelets) and short-
term decreased blood flow.
Ø Oxygen is delivered via increased blood flow to keep cells alive and functioning.
Ø Permanent repair is facilitated by creating a clean wound, setting the stage for the
next phase of healing.
Ø Time frame: day of injury to approximately day 10.
Ø If this phase is interrupted or delayed, chronic inflammation can result, lasting
from months to years.
Proliferation Ø Three major components: re-epithelialization, fibroplasia with angiogenesis, and
wound contraction.
Ø Time frame: day 3 of injury to approximately day 20.
Ø The formation of granulation tissue is the hallmark of tissue healing during the
proliferative phase.
Ø Collagen synthesis occurs but the resulting new scar tissue is fragile and must be
protected.
Ø Wound contraction is predominantly mediated by myofibroblasts.
Ø Linear, square, and rectangular wounds contract more rapidly than circular
wounds.
Maturation Ø Two distinct components: consolidation and maturation stages.
Ø Time frame: approximately day 9 of injury up to 2 years.
l Critical factors contributing to normal wound healing
1. The role of oxygen in wound healing
- The presence of edema and necrotic tissue makes it more difficult for oxygen to reach the wound.
- Since compression can reduce edema and debridement can reduce the presence of necrotic tissue.
2. The role of moisture in wound healing
- The concept of a moist environment is to facilitate wound healing.
A. Covering the wound with a barrier (occlusive dressing(閉合式敷料), also called moisture
reteneive dressing) to preserve adequate wound hydration.

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 - Advantages
A. Retaining an appropriate amount of endogenous fluids on the wound.
B. Moisture softens wound scab (痂) and escher (焦痂).
C. Maintain appropriate wound surface temperature.
D. Protect the wound surface from trauma and from bateria and other contaminants.
- Occlusive dressings could be applied over infected wounds
A. With the use of a systemic antibiotic and a close watch for signs of change in the patient’s
symptoms, clinicians may be able to utiliza occlusive or moisture.
3. The role of nutrition in wound healing
- Iron, vitamin B12 and folic acid: for RBC delivering oxygen to tissues.
- Vitamin C and zinc: for tissue repair.
- Vitamin A: to stimulate collagen synthesis.
- Arginine: to enhance healing and immune function.
- Protein and calorie needs.
Abnormal Wound Healing and Chronic Wound
l Factors contributing to abnormal wound healing
1. Local factors
- Pressure, trauma and edema Signs of potential infection:
- Desiccation (乾燥) - Change in wound drainage (amount, color, and oder)
- Infection - Inflammation (redness, swelling, heat, pain)
- Necrosis - Change in the quality of granulation tissue
- Incontinence - No measureable wound contraction within 2 – 4 weeks
2. Systemic factors - Tissue culture biopsy results of greater than 105
- Age organisms/g of tissue
- Body size
- Chronic disease (coronary artery disease, peripheral vascular disease, cancer, and DM).
- Nutritional status
- Vascular insufficiency
- Medications (steroids, NSAIDs, immunosuppressive agents, and radiation therapy).
3. Iatrogenic factors
- Any injury illness that occurs as the result of medical care, including:
A. Poor wound management (e.g., inappropriate cleaning, inappropriate dressings techniques,
and lack of moisture)
B. Infection (e.g., improper use of gloves and other protective devices, and lack of proper
hand washing)
C. Sheer injuries (skin tears)
D. Ischemia resulted from unrelieved pressure
Integumentary and Vascular Disorders (Chronic Wound)
l Pressure ulcers (pressure injury)
1. Localized damage to the skin and underlying soft tissue usually over a bony prominence or related
to a medial or other device.
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 2. Occurring as a result of intense pressure, prolonged pressure or pressure in combination with shear.
3. Risks factors:
- Insrinsic factors: aging, chronic disease, impaired mobility and limited activity, incontinence,
poor nutrition, sensory impairment, use of steroids.
- Extrinsic factors:
Pressure Ø 70 mmHg for 2 hours results irreversible tissue damage in animal models.
Ø Healthy capillary pressure: 20 – 40 mmHg. Average 32 mmHg.
Ø Pressure injuries can developwithin 2 – 6 hours.
Friction Ø Occurs during transferring and repositioning.
Shearing Ø When patient’s head elevated > 30 degrees
Ø When gravity causes a seated patient to slid down.
4. Six primary bony areas: sacrum, coccyx, greater trochanter, ischial tuberosity, calcaneus, lateral
malleolus (related to position).

5. Pressure injury classification system: the National Pressure Ulcer Advisory Panel (NPUAP).
- Based on depth of tissue destruction and no other characteristics of the wound.
l Arterial insufficiency and ulceration
1. Lack of adequate blood flow to a body part.
- Trophic changes are present (e.g., abnormal nail growth, dry skin).
- Other signs: decreased pulses, pallor on elevation, and rubor when dependent.
2. Arterial wounds more frequently lead to loss of limb and death.
3. Tests and measurements: ankle-brachial index (ABI)
- A ratio of the lower extremity (LE) pressure divided by the upper extremity (UE) pressure.
- UE at brachial artery, and LE at posterior tibial and the dorsalis pedis arteries.

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l Venous insufficiency and ulceration
1. Venous insufficiency refers to inadequate draining of venous blood from a body part, usually
resulting in edema and/or skin abnormalities and ulceration.
2. Swelling of unilateral or bilateral Les relieved in the earaly stages by elevation.
3. Complinats of itching, fatigue, aching, heaviness in involved limbs.

Venous ulcers Arterial ulcers

Prevalence 80% of all leg ulcers, particularly chronic Between 10 – 25% of LE ulcers
venous insuffivienvy
Possible Varicosity (靜脈曲張), Deep vein thrombosis Arteriosclerosis obliterans (閉塞性動脈硬
risk factors (DVT), CVI, aging, pregnancy, obesity, lack of 化), diabetes, hypertension, renal or cardiac
exercise, and sedentary lifestyle disease, smoking
History History of CVI, increasing with age, lingering Ø History sugesstive of pheripheral
swelling, slow healing, repeated infection, and arterial disease, painful cramping or
frequent recurrence of skin breakdown caching of the Les during walking
(intermittent claudication), nocturnal
pain, ischemic rest pain
Ø The majority of patients with arterial
insufficiency also have diabetes
Classic site Proximal to the medial malleolus Usually over the toes, foot, and ankle
on LEs
Wound bed Granulation tissue is usually present Usually necrotic and pale, lacking
franulation tissue
Exudate Usually high, tissue is wet Usually low
level
Skin temp. Increase in skin temp. Cool on palpation
Pain Ø No significantly painful unless associated Often painful, even without infection
with excessive edema or infection
Ø Usually complaints of minor dull leg pain
are relieved with elevation
Edema Present markly Absent or mild
Associated Cenous eczema, hemosiderosis (血鐵質沉著), Trophic changes, gangrene (壞疽) may be
features lipodermatosclerosis (脂性硬皮病), atrophie present
blanche (白色萎縮)
Treatment Compression therapy Surgery for artery insufficiency

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 Pitting scale
1+ Identation is barely detectable
2+ Slight identation visible when skin is depressed, returns to
normal on 15 sec
3+ Deeper identation occurs when pressed and returns to
normal within 30 sec
4+ Identation lasts for more than 30 sec
Skin and Tissue Assessment
l Conducting skin and tissue assessment
1. Risk factors and risk assessment
- Condutct a structured assessment as soon as possible (within a maximum of 8 hours after
admission or first visit in community settings).
- The risk assessment includes assessment of activity / mobility and skin status.
- Using a risk assessment tool that is valid and reliable (Braden scale).
1分 2分 3分 4分 分數
感覺知覺程度 完全昏迷對疼 昏迷但對疼痛有 清醒但部分感官 清醒正常
(sensory perception) 痛沒有反應 反應 受損
潮濕程度 皮膚持續潮濕 皮膚經常潮濕，更 皮膚偶爾潮濕，更 乾燥，乾淨
(moisture) 換床單每天 < 3 次 換床單每天 1 次
活動力 臥床不動 受限於輪椅 可偶爾下床行走 可經常下床行
(activity) 走
移動力 完全無法自行 大部分需他人協 少部分需他人協 可自行翻身
(mobility) 翻身 助翻身 助翻身
營養狀態 禁食或進食流 攝取熱量每天小 維持管灌可滿足 正常飲食滿足
(nutrition) 質 5 天以上 於 1200 卡 大部分需求 需求量
摩擦力 有此問題 有潛藏問題 沒有明顯問題
(friction / shear)
備註 總分 23
分數≥16(低危險)：每日皮膚評估一次
分數 12 – 15 (中等危險)：每 2 小時翻身一次＋皮膚評估
分數≤11(高危險)：每 2 小時翻身拍背一次＋皮膚評估＋氣墊床使用
2. In individuals at risk of pressure injury, conduct a comprehensive skin assessment.
- Conduct a head-to-toe assessment with particular focus on skin overlying bony prominences
including sacrum, ischial tuberosities, greater trochanters and heels.
3. Inspect skin for erythema in individuals identified as being at risk of pressure ulceration.
- Differentiate the cause and extent of erythema.
- Use the finger or the disc method to assess whether skin is blanchable or non-blanchable.
- Avoid positioning the individual on an area of erythema wherever possible.
4. Inspect the skin under and around medical devices at least twice daily for the signs of pressure-
related injury on the surrounding tissue.
5. Conduct a brisk skin assessment when the patient is repositioned each time.
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l Skin and wound assessment
Skin assessment
1. The following factors in every skin assessment:
- Including skin temperature, edema, dryness, color, itching, bruising, and change in tissue
consistency in relation to surrounding tissue.
- Assessing localized pain.
Wound assessment
1. Wound location
- Areas with least pressure, most perfusion (e.g., face) will close more rapidly than areas with
most pressure least perfusion (e.g., sacrum, heel).
2. Wound size (width, length, and depth) – wound measurement
- Linear measurement: the length and width are measured as linear distance from wound edge to
wound edge.
- Wound tracings: make a tracing of the wound on transparent paper with a permanent marker.
- Photograph
- Wound molds
3. Measuring wound tunneling
- Put on gloves and gently insert the applicator into the sites where undermining occurs.
- Clock method for record, and preogressing in a clockwise direction, document the deepest sites
where the wound.
4. Exudate
- The amount of exudate.
- Color and viscosity.
5. Thickness and color of the wound
- Thickness: describing a wound as partial or full thickness identifies the depth of the wound.
A. Partial-thickness wounds: extend the first layer of skin (the epidermis) and into, but not
through the second layer of skin (the dermis).
- A three-color concept: for use with traumatic, surgical and other wounds that heal by secondary
intention (open wound bed).
A. Red: indicates clean, healthy granulation tissue.
B. Yellow: indicates the presence of exudates or slough and the need for wound cleaning.
C. Black: indicates the presence of eschar (necrotic tissue), which slows healing and provides
a site for microorganisms to proliferate.
6. Pain: may indicate infection, swelling, or edema.
7. The Pressure Ulcer Scale for Healing (PUSH).
Prevention of Pressure Injuries and Skin Care
l Repositioning principle and early mobilization
1. Reposition the individual in such a way that pressure is relieved or redistributed.
2. Avoid positioning the individual on bony prominences with existing non-blanchable erythema.
3. For individuals who are frail, or have existing wounds, a turning schedule could as freuqnet as every
30 minutes (standard time intervals is per 2 hours).
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 4. Inspect the skin for additional damage each time the individual is turned or repositioned.
5. Do not massage or vigorously rub skin that is at risk of pressure injry.
6. Increase activity as rapidly as tolerated.
l Repositioning individuals in bed
1. Use the 30° tilted side-lying position (alternately, right side, back, left side) or the prone position if
the individual can tolerate this and his medical condition allows.
- Avoid 90° side-lying position that may increase pressure on some bony areas.
2. Limit head-of-bed elevation to 30° for an individual on bedrest.
- Fowler’s position greater than 30° may place pressure and shear on the sacrum and coccyx.
3. Use pillows or other devices to offload the large skin folds and prevent skin-on-skin pressure.
4. At each rotation, assess the face and other body parts that may be at risk.
5. Avoid areas of high pressure, especially under the Achilles tendon.
- Use a pillow under the calf to elevate the heels.
l Repositioning seated individuals
1. Select a seated posture that is acceptable for the individual and minimizes the pressures and shear
exerted on the skin and soft tissues.
- Provide adequate seat tilt to prevent sliding forward in the wheelchair or chair, and adjust
footrests and armrests to maintain proper posture and pressure redistribution.
2. Limit the time and individual spends seated in a chair without pressure relief.
- Use a pressure redistributind seat cushion.
- Shift weight every 15 minutes.
- Limit sitting to three times a day in periods of about 15 minutes.
l Positioning devices
1. Do not use ring or donut-shaped devices.
2. Consider using silk-like fabrics rather than cotton to reduce shear and friction.
3. The following devices should not be used to elevated heels: synthetic sheepskin pad, conut-type
device, intravenous fluid bags, and water-filled gloves.
l Support surfaces
1. Consider the need for moisture and temperature control when selecting a support surface cover.
2. Do not apply heating device directly on skin surfaces or pressure injury.
l Wound care
1. Handwasking is the most effective means to reduce contamination (at least 30
seconds to a minute).
2. Aseptic technique (e.g., gloving, dressing).
3. Wound cleaning technique for pressure injury, wound, and burn
- Linear wound
A. From top to buttom, and work outward the incision in lines running parallel to it.
- Open wound
A. In full circles beginning in the center and working toward the ourside
B. Clean to at least 2.5 cm beyond the end of the new dressing or 5 cm
beyond the wound margins, use a new pad for each circle.
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