Maintaining Skin Integrity & Wound Care

Structure of Skin
Skin Layers Epidermis Dermis Subcutaneous Tissue- Fat and connective tissues Skin appendages nails, hair, sweat gland and sebaceous glands

Structure of Skin
Skin Layers
Epidermis Dermis Subcutaneous Tissue- Fat and connective tissues

Structure of Skin
Skin Layers Epidermis

Epidermis

Structure of Skin
Skin Layers Dermis is the thickest skin layer composed of connective tissue. Supports and nourishes the epidermis.

Dermis

Layers of the Dermis

Stratum corneum (SC) - dead and dying cells push their way to the skin surface (desquamation)

Layers of the Dermis

Stratum granulosa (SGR) keratinocytes lipids

Layers of the Dermis

Stratum spinonum (SS) separates stratum germination and stratum granulosa

Layers of the Dermis

Stratum germinaton (SG)

 Skin Layers

Structure of Skin

Subcutaneous Tissue
Fat and connective tissues

Subcutaneous Tissue (hypodermis)

Structure of Skin Skin appendages nails, hair, sweat gland and sebaceous glands

FUNCTION OF THE SKIN

Protection - from physical and chemical injury. Thermoregulation - Regulate body temperature. Sensation - skin contains nerves that are sensitive to pain, itch, vibration, heat/cold. Metabolism - ultraviolet rays from sun synthesizes Vitamin D. Communication - communicates through expressions and other non-verbal messages.

CHARACTERISTICS OF THE SKIN

Color Vary in races. The greater accumulation of melanin, the darker the skin tone.

Factors affecting skin integrity

1. Genetics / heredity
Skin color, sensitivity to sunlight, allergies

2. Age
Young & old skin are fragile Healing is rapid in infant & children

3. Health
Illnesses & their treatment affects skin integrity Cortecosteroids cause thinning of the skin causing harm.

 Antibiotics, chemotherapy drugs for cancer & psychotherapeutic drugs affects skin integrity Poor nutrition

4. Activity

CHARACTERISTICS OF THE SKIN (cont.)

Temperature - usually warm.

Moisture - normally dry, but moisture can accumulate in skin folds. Texture and Thickness - smooth with good elasticity. Odor - Usually free from odor.

LIFESPAN CONSIDERATIONS
Newborn and Infant Thinner and mores sensitive Susceptible to blistering, chafing and rashes from irritation Can develop heat

LIFESPAN CONSIDERATIONS
Toddler and Preschooler More prone to accidents and burns Use sunscreen

LIFESPAN CONSIDERATIONS
School-Age and Adolescent Many childhood diseases Adolescents develop pubic, axillary and other body hair. May develop acne.

LIFESPAN CONSIDERATIONS
Adults and Older adults Becomes thinner and less elastic and develops wrinkles. May have benign growths. Moles get larger. Skin tags.

FACTORS AFFECTING INTEGUMENTARY FUNCTION

Circulation skin needs good blood flow. Heart must be able to pump adequately. Volume of blood must be sufficient. Arteries and veins must be patent. Capillary pressure must be adequate.

 Circulation problems lead to Leg Ulceration -

 Circulation problems lead to Pressure Ulcers (decubitus) - result wh blood flow to skin is impeded usually by pressure Increased pressure Mental Status Moisture Nutrition and Metabolism

FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.)

Nutrition well balance diet Lifestyle and Habits - hygiene Condition of the Epidermis free from breaks

FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.)

Allergy Infections Abnormal Growth Rate

FACTORS AFFECTING INTEGUMENTARY FUNCTION (cont.)

Systemic Diseases

Trauma - accidental or surgical wounds

Excessive Exposure

MANIFESTATIONS OF ALTERED INTEGUMENTARY FUNCTION

Pain - stimulation of nerves in the skin due to alteration of the skin.

Highly sensitive, sharp, intense pain.

Pruritis - itching is usually allergy or inflammatory.

MANIFESTATIONS OF ALTERED INTEGUMENTARY FUNCTION

Rash - caused by excessive heat, allergy , communicable disease or stress. Lesions - involves loss of structure or function of
normal tissue.

Vary is size.

TYPES OF WOUNDS
Broad Categories
Accidental unintentional Injury Surgical - planned therapy

Description
Abrasion - friction of the skin Puncture - penetrating wound Laceration - ragged tear Contusion - closed with bleeding into underlying tissues

Skin Integrity
Open - break in Skin Closed - no break but soft tissue injury

Types of wound
1. Intentional trauma occurs during therapy. E.g. operations or venipunctures 2. Unintentional wounds are accidental e.g. fracture in the arm

DEGREE OF WOUND CONTAMINATION

Clean

Closed surgical wound that did not enter GI, respiratory, or GU systems

DEGREE OF WOUND CONTAMINATION

Clean Contaminated
Wound entering GI, respiratory or GU systems.

DEGREE OF WOUND CONTAMINATION

Contaminated
Open, traumatic wound, surgical wound with break in asepsis.

DEGREE OF WOUND CONTAMINATION

Infected

Wound site with pathogens present.

Classifying wound by DEPTH

Partial thickness- confined to the skin, dermis, epidermis, & heal by regeneration Full thickness- involving the dermis, epidermis, subcutaneous tissue & possibly muscle and bone; require connective tissue repair.

WOUND HEALING

Wounded skin is repaired by regeneration or damaged tissues with connective repair.

Partial and full thickness wounds are healed by 4 phases.

WOUND HEALING
PHASE 1 Inflammatory phase

Lasts 3-5 days.

Two major Processes: hemostasis and phagocytosis

 Hemostasis= which is the cessation of bleeding = results from vasoconstriction of the larger blood vessels in the affected area. = deposition of fibrin and the formation of blood clots in the area.

 Blood clots form from blood platelets.

Provide a matrix of fibrin that becomes the framework for cell repair.

Scab form on the surface of the wound

 In phagocytosis there is attraction of leukocytes to the wound bed and engulfing of microorganisms and cellular debris by macrophages

The functions of the inflammatory response include:

1) The delivery of effector molecules and cells to the sites of infection. 2) The formation of a physical barrier to the spread of the tissue damage or infection. 3) Wound healing and tissue repair

WOUND HEALING
Inflammation-13

Inflammation - Mechanism

1. 2. 3. 4. 5.

Vasoconstriction Vasodilatation Exudation - Edema Emigration of cells Chemotaxis

Shashi-Mar 2000

Proliferative Phase of Wound Healing

From post injury day 3 or 4 until day 21post injury Collagen synthesis Collagen whitish protein substance that adds tensile strength to the wound. Granulation tissue formation Eschar dried plasma protein & dead cells

Maturation Phase of Wound Healing (remodeling)

From day 21 until 1 or 2 years post injury Collagen organization Remodeling or contraction Scar stronger

TYPES OF WOUND HEALING

Primary intention Secondary intention Tertiary intention

TYPES OF WOUND HEALING (cont.)

Primary intention
Edges of wound approximated. Granulation is not visible and scarring is minimal.

Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. It is also called primary union or first intention healing. e.g. closed surgical incision Primary intention healing is healing of a wound where the wound edges heal directly touching each other.

TYPES OF WOUND HEALING (cont.)

Secondary intention
Extensive tissue loss. Wound gradually fills with soft tissue buds. Epithelial cells grow over this to form skin.

It is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated. e.g., pressure ulcer. Secondary intention healing differs from primary intention healing in three ways:1- The repair time is longer 2- Scarring is greater 3- Susceptibility to infection is greater

TYPES OF WOUND HEALING (cont.)

Tertiary intention Delay ensues between injury and approximation Also known as delayed primary intention

Hand abrasion

Approximate days since injury

0 2 17 30

Exudate
Material such as fluid and cells that have escaped from blood vessels during inflammatory process Deposited in tissue or on tissue surface 3 major types
Serous Purulent Sanguineous (hemorrhagic)

Serous Exudate
Mostly serum Watery, clear of cells E.g., fluid in a blister

Purulent Exudate
Thicker Presence of pus Color varies with organisms

Sanguineous Exudate
Hemorrhagic Large number of RBCs Indicates severe damage to capillaries

Mixed Exudate
Serosanguineous
Clear and blood-tinged drainage

Purosanguineous
Pus and blood

FACTORS AFFECTING HEALING

Systemic Factors Nutrition nutritional deficiencies retard healing. Circulation and Oxygenation Hemoglobin levels Immune Cellular Function Immunosuppre ssive Drugs Individual Factors Age, Obesity, Smoking, Medications, and Stress Local Factors Nature of the Injury Presence of Infection Local Wound Environment

COMPLICATIONS OF WOUND HEALING

Hemorrhage and Interstitial Fluid Loss Hematomas - localized collection of blood. Infection Local and Systemic Indicated by yellow/black coloration of wound itself. Other S&S. Dehiscence - total or partial disruption in wound edges. Evisceration - protrusion of viscera through abdominal wound opening. Fistula - Abnormal passageway that forms between two organs.

DEHISCENCE & EVISCERATION

Dehiscence: edges of wound fail to join may lead to.

Evisceration: portion of the viscera (usually bowel loop) protrudes thru incision. May lead to peritonitis & septic shock.

Most likely during 6-7 days post-op.

IMPLEMENTATION for Dehisence or Evisceration

Provide reassurance & support. Use sterile towel/dressing saturated with NS & place them over viscera. Take V.S. Tell client to stay in bed. Have someone stay with client. Place waterproof sterile drape over area. Call physician ASAP. Moisten every hr with NS.

PREVENTION for Dehisence or Evisceration

Client with poor healing should be given adequate supply of protein, vitamins, & calories. Monitor dietary deficiencies. Assess wound during dressing change, treat infection early, use strict sterile technique. Do not bandage wound to tightly.

Nursing Process: Assessment

Nursing history
Review of systems Skin diseases Previous bruising General skin condition Skin lesions Usual healing of sores

Assessment Data
Inspection and palpation
Skin color distribution Skin turgor Presence of edema Characteristics of any skin lesions Particular attention paid to areas that are most likely to break down

Assessment Data
Untreated wounds
Location Extent of tissue damage Wound length, width, and depth Bleeding Foreign bodies Associated injuries Last tetanus toxoid injection

Assessment Data
Treated wounds
Appearance Size Drainage Presence of swelling Pain Status of drains or tubes

Risk Factors for Pressure Ulcers

Advanced age Chronic mental conditions Poor lifting and transferring techniques Incorrect positioning Hard support surfaces Incorrect application of pressurerelieving devices

Assessment of Pressure Ulcers

Location of the ulcer related to a bony prominence Size of ulcer in centimeters including length (head to toe), width (side to side), and depth Presence of undermining or sinus tracts Stage of the ulcer Color of the wound bed Location of necrosis or eschar Condition of the wound margins Integrity of surrounding skin Clinical signs of infection

Assessment of Pressure Sites

Inspect pressure areas for discoloration and capillary refill or blanche response Inspect pressure areas for abrasions and excoriations Palpate the surface temperature over the pressure area sites Palpate bony prominences and dependent body areas for the presence of edema

Assessment of Laboratory Data

Leukocyte count Hemoglobin level Blood coagulation studies Serum protein analysis
Albumin level

Results of wound culture and sensitivities

Nursing Diagnoses
Risk for Impaired Skin Integrity Impaired Skin Integrity: Impaired Tissue Integrity Risk for Infection Pain

Goals in Planning Client Care

Risk for Impaired Skin Integrity
Maintain skin integrity Avoid or reduce risk factors

Impaired Skin Integrity

Progressive wound healing Regain intact skin

Client and family education

Assess and treat existing wound Prevention of pressure ulcers

Measures to Prevent Pressure Ulcers

Providing nutrition Maintaining skin hygiene Avoiding skin trauma Providing supportive devices

Providing Nutrition
Fluid intake Protein, vitamins, zinc Dietary consult Weight/lab data monitoring

Maintaining Skin Hygiene

Mild cleansing agents Avoid hot water Moisturizing lotions/skin protection Reduce irritants

Avoiding Skin Trauma

Smooth, firm surfaces Semi-Fowlers position Frequent weight shifts Exercise and ambulation Lifting devices Reposition q 2 hours Turning schedule

Risk Assessment Tools

Braden Scale for Predicting Pressure Sore Risk Nortons Pressure Area Risk Assessment Form Scale

Nursing Assessment: Braden Scale Risk to Develop Pressure Ulcers (Braden, B. 1988)
Sensory Perception: 1-4 Score ____ Completely limited to No Impairment Mobility: 1-4 Score_____ Completely Immobile to No Impairment Nutrition: 1-4 Score _____ Very poor to Excellent Activity: 1-4 Score_____ Bedfast to Walks frequently Friction/Shear :1-4 Score _____ Problem, potential or none Total Score: determines Risk Above 16=Minimal risk 15-16=Low Risk; 13-14=Moderate Risk; 12 or below=High Risk

Figure 36-3

Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowlers position.

Figure 36-3 (continued)

Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowlers position.

Figure 36-3 (continued)

Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowlers position.

Figure 36-3 (continued)

Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowlers position.

Four Stages of Pressure Ulcer Formation

STAGES OF PRESSURE ULCERS (DECUBITUS)

Non blanching erythema

STAGES OF PRESSURE ULCERS (DECUBITUS)

Partial-thickness skin loss. Involving the epidermis and possibly the dermis. Examples: Abrasion, blister, or shallow crater.

STAGES OF PRESSURE ULCERS (DECUBITUS)

Full-thickness skin loss Involving damage or necrosis of SQ tissue that may extend down to, but not through, underlying fascia. A deep crater.

STAGES OF PRESSURE ULCERS (DECUBITUS)

Full-thickness skin loss with tissue necrosis or damage.

Involves damage to muscle, bone or supporting structures, such as a tendon or joint capsule.
Sinus tracts may be present.

Providing Supportive Devices

Mattresses Beds Wedges, pillows Miscellaneous devices

Treating Pressure Ulcers

Minimize direct pressure Schedule and record position changes Provide devices to reduce pressure areas Clean and dress the ulcer using surgical asepsis Never use alcohol or hydrogen peroxide Obtain C&S, if infected Teach the client Provide ROM exercise

RYB Color Guide for Wound Care

Red (protect) Yellow (cleanse) Black (debride)

 Red: protect by gentle cleansing, cover with protective barrier such as duoderm, hydrogel, or transparent film.

 Yellow: cleanse to remove nonviable tissue by applying moist to moist normal saline dressings, irrigating the wound, alginate dressings and topical antimicrobial

 Black: debridement can be done by sharp, mechanical, chemical, or autolytic, maggots. Debridement is mostly done by PT

Debridement may be achieved in four different ways:

1. Sharp debridement, a scalpel or scissors is used to separate and remove dead tissue. 2. Mechanical debridement through scrubbing force or mist to moist dressings.

3. Chemical debridement collagenase enzyme agents such as papain urea. 4. A utolytic debridement , dressing that contain wound moisture, such as hydrocolloid and clear absorbent dressings.

Promoting Wound Healing

Fluid intake Protein, vitamin, and zinc intake Dietary consult Nutritional supplements Monitor weight/lab values

Maintaining Skin Hygiene

Use mild cleansing agents that do not disrupt the skins natural barriers,_ avoid using hot water, exposure to cold and low humidity; apply moisturizing lotions while the skin is moist after bathing;

 keep skin clean, dry and free of irritation and maceration by urine, feces, sweat, and dry skin completely after a bath. Apply skin protection (dimethicone-based creams or alcohol-free barrier films) if indicated._Avoid massaging over bony prominences since massage may lead to deep tissue trauma.

Types of Wound Dressings

Transparent film Impregnated nonadherent Hydrocolloids Clear absorbent acrylic Hydrogel Polyurethane foam Alginate

Transparent film
is used to provide protection against contamination and friction, to maintain a clean moist surface that facilitates cellular migration, to provide insulation by preventing fluid evaporation, and to facilitate wound assessment.

Impregnated nonadherent dressings

are used to cover, soothe, and protect partialand full-thickness wounds without exudate.

Hydrocolloid dressings
are used to absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; to protect the wound from bacterial contamination, foreign debris, and urine or feces; and to prevent shearing.

Clear absorbent acrylic dressings

maintain a transparent membrane for easy wound bed assessment, provide bacterial and shearing protection, maintain moist wound healing, and can be used with alginates to provide packing to deeper wound beds.

Hydrogels
are used to liquefy necrotic tissue or slough, rehydrate the wound bed, and fill in dead space.

Polyurethane foams
absorb up to heavy amounts of exudate, providing and maintaining moist wound healing.

Alginates (exudate absorbers)

are used to provide a moist wound surface by interacting with exudate to form a gelatinous mass, to absorb exudate, to eliminate dead space or pack wounds, and to support debridement.

Types of Bandages
Gauze
Retain dressings on wounds Bandage hands and feet

Elasticized
Provide pressure to an area Improve venous circulation in legs

Binders
Support large areas of body
Triangular arm sling; straight abdominal binder

Figure 36-10 The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing. The tape should adhere to intact skin.

Figure 36-11 Dressings over moving parts must remain secure in spite of the clients movement. Place the tape over a joint at a right angle to the direction the joint moves.

Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the clients movement. Place the tape over a joint at a right angle to the direction the joint moves.

Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the clients movement. Place the tape over a joint at a right angle to the direction the joint moves.

Figure 36-12

Montgomery straps, or tie tapes, are used to secure large dressings that require frequent changing.

Figure 36-13

Vacuum-assisted closure (VAC) system for wounds.

Cleaning wounds Wound cleaning involves the removal of debris ( i.e., foreign materials, necrotic tissue, bacteria). - Wound irrigation and packing

Supporting and immobilizing wounds

Bandages: strip of cloth used to wrap some part of the body Binders : is a type of bandage designed for a specific body part. Bandages and binders serve various purposes: Support a wound Immobilizing a wound Applying pressure Securing a dressing Retaining warmth

Administer Heat and Cold Therapy

Heat and cold therapies require nursing care that assesses both the vasoconstriction and vasodilation of an individual.

Local effect of heat

Sedative effect to relief pain and aches Vasodilatation and increase blood flow to the affected area Bringing oxygen and nutrients, antibodies, and leukocytes Promote soft tissue healing It is often used for clients with musculoskeletal problems such as arthritis.

Disadvantages: Increase capillary permeability which cause edema

Local effect of Cold

Vasoconstriction, which decrease the blood supply and nutrients to the affected area. Decrease cellular metabolism Decrease removal of wastes Prolonged exposure to cold results impaired circulation, cell deprivation, and subsequent cell damage

Advantages: Slow bacterial growth, decrease inflammation Local anesthetic effect

Systemic effects of cold and heat

Heat applied to a localized body area, or large body area, it may cause excessive vasodilatation, drop in blood pressure, fainting, especially for those with pulmonary and cardiac problems. Cold application cause vasoconstriction, increase in blood pressure. Shivering is the body response to cold.

For all local applications of heat and cold, the nurse need to follow these guidelines:
Clients ability to tolerate the therapy Contraindication of treatment such as bleeding Explain the application to client Assess skin area Ask the client to report any discomfort Return to the client after 15 minutes Remove the equipment at the designed time Examine the area and record the result

 Conditions that necessitate precautions in the use of heat and cold applications:
Neurosensory impairment Impaired mental status Impaired circulation Open wounds, broken skin, scar formation, edema