Chapter 48 Skin Integrity and Wound Care The skin is the body’s largest organ, comprising 15% of the total body weight. The skin provides: A protective barrier against disease-causing organisms A sensory organ for pain, temperature, and touch Vitamin D synthesis Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing pattern will help students recognize alterations that require intervention.

Scientific Knowledge Base: Skin Dermal-epidermal junction Separates dermis and epidermis Epidermis Top layer of skin Dermis Inner layer of the skin The epidermis has several layers. The stratum corneum is the thin, outermost layer that is flattened with dead keratinized cells. The basal layer divides, proliferates, and migrates towards the epidermal surface. The dermis provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs. The dermis is made of collagen, blood vessels, and nerves.

Pressure Ulcers Pressure ulcer Pathogenesis Pressure sore, decubitus ulcer, or bed sore Pathogenesis Pressure intensity Blanching Pressure duration Tissue tolerance A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. Pressure is the major contributor to pressure ulcers. If pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia occurs. If left untreated, tissue death results. Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in dark-skinned clients. See Box 48-2 for characteristics of dark skin at risk for skin breakdown. Pressure duration assesses low and extended pressures. Low pressures over a prolonged period of time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures.

Risk Factors for Pressure Ulcer Development Impaired sensory perception Alterations in LOC Impaired mobility Shear Friction Moisture These six factors contribute to pressure ulcer formation. Clients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations. Clients who are unable to independently change positions are at risk because they cannot change or shift off of bony prominences. Clients who are confused or disoriented or who have alterations in LOC are unable to protect themselves. Sheer is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface. The presence and duration of moisture on the skin reduces the skin’s resistance to other physical factors.

Classification of Pressure Ulcers Stage I Intact skin with nonblanchable redness Stage II Partial-thickness skin loss involving epidermis, dermis, or both Stage III Full-thickness tissue loss with visible fat Stage IV Full-thickness tissue loss with exposed bone, muscle, or tendon The National Pressure Ulcer Advisory Panel (NPUP) has defined pressure ulcers.

Wounds Classification Wound healing Repair Complications Two methods are currently used to classify skin wounds: Describe the status of skin integrity, cause of the wound, severity or extent of the injury or damage and cleanliness of the wound (see Table 48-1) Describe qualities of the wound tissue such as color (Figure 48-7). wound healing occurs by primary or secondary intention. Primary intention occurs when the edges are approximated. Secondary intention occurs when the wound heals with scar tissue. The form wound repair takes depends on the wound’s thickness. Partial thickness will heal via the inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers. Full-thickness wounds heal via inflammatory response, proliferation, and remodeling. Complications includes hemorrhage, infections, dehiscence, evisceration, and fistulas.

Nursing Knowledge Base Prediction and prevention of pressure ulcers Norton Scale Physical and mental condition, activity, mobility, and continence Braden Scale Sensory perception, moisture, activity, mobility, nutrition, and friction and shear When a client develops a pressure ulcer, the length of stay is extended and the overall cost of care increases. Even though preventive measure are expensive they should be used. Prevention includes special beds and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.

Factors Influencing Pressure Ulcer Formation and Wound Healing Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds For maintenance of skin and wound healing, clients need 1500 kcal/day. At times enteral or parenteral nutrition may need to be provided. See Chapters 44: Nutrition, Chapter 50: Care of Surgical Clients. Clients need vitamins A and C, calories, and proteins to heal. See Table 48-5. Tissue perfusion occurs when tissue oxygenation fuels cellular function. Clients who are in shock or who are diagnosed with diabetes mellitus are at risk for poor tissue perfusion. Wound infection prolongs the inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction. Signs of wound infection include: pus; change in odor, volume, or redness of tissue; fever; or pain. Body image changes due to a wound may cause problems with self-concept.

Assessment Skin Presence of ulcers Mobility Nutrition and fluid status Pain Existing wounds, appearance, character Wound culture Baseline assessments as well as continual assessments all provide valuable data that will indicate skin integrity as well as any risks for pressure ulcer development. Box 48-5 presents skin integrity assessment questions.

Nursing Diagnosis and Planning The assessment will reveal important information regarding the client’s status. Use NANDA-I–approved diagnoses. Write client goals and outcomes specific to the client’s needs.

Implementation Health promotion Topical skin care Positioning Protect bony prominences, skin barriers for incontinence. Positioning Turn every 1 to 2 hours as indicated. Support surfaces Decrease the amount of pressure exerted over bony prominences. Support surfaces include mattresses, integrated bed systems, mattress replacement, overlay or set cushion. Table 48-8 presents support surfaces.

Acute Care Wound management Debridement Nutrition Client education Mechanical, autolytical, chemical, or surgical/sharp Nutrition Client education You will want to take a holistic approach to wound management. You will want to work with the dietician, wound care nurse, and pharmacist to ensure all client needs are met. An individualized plan of care must be developed for each client, taking into account age, nutrition, present medical conditions, and other contributing factors. Client education is a must. You need to impress on the client and client’s family the importance of nutrition, fluids, and body positioning.

Dressings Dry or moist Hydrocolloid Hydrogel Wound V.A.C. Gauze Protects the wound from surface contamination Hydrogel Maintains a moist surface to support healing Wound V.A.C. Uses negative pressure to support healing The use of dressings requires an understanding of wound healing and factors that influence healing. A variety of dressing materials are available. You will learn various dressing techniques in the nursing skills lab. The choice of dressings and the method of dressing a wound influence healing. A proper dressing does not allow a full thickness wound to become dry with scab formation.

Dressings Changing Securing Comfort measures Know type of dressing, placement of drains, and equipment needed. Securing Tape, ties, or binders Comfort measures Carefully remove tape. Gently cleanse the wound. Administer analgesics before dressing change. Follow health care facility for policies and procedures. Document findings and report to other staff members. For very complex dressing care, consult with the wound care/enterostomal nurse or carefully develop a step-by-step procedure to provide consistent wound care. Make sure to offer pain medications before beginning wound care/dressing changes.

Wound Cleansing Cleansing Irrigation Suture Care Drainage Evacuation Apply noncytotoxic solution. Irrigation Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle Suture Care Consult health care facility policy. Drainage Evacuation Portable units that exert a safe, constant, low-pressure vacuum to remove and collect drainage Wound cleansing removes surface debris, preventing the invasion of healthy tissue. Normal saline works best. Betadine, hydrogen peroxide, and acetic acid are toxic to fibroblasts, the key component in wound healing. Always refer to health care facility policy and procedures for wound care and wound irrigation. If available, consult the enterostomal/wound care nurse.

Bandages and Binders Bandages Binder application Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin Binder application Breast, abdominal, sling At times, simple gauze dressings do not supply adequate immobilization or support to a wound. Bandages and binders are applied over or around dressings to provide extra protection and/or therapeutic benefits by creating pressure over a body part, immobilizing a body part supporting a wound, reducing or preventing edema, or securing a splint or dressing. When binder or bandages are applied, an assessment must be made. Ask students what they should assess? Answers may include: inspect skin for abrasions, edema, discoloration, open wounds, circulatory impairment (coolness, pallor, cyanosis, pulses, swelling, numbness or tingling).

Heat and Cold Therapy Assessment for temperature tolerance Bodily responses to heat and cold Factors influencing heat and cold tolerance Education Before beginning heat or cold therapy, you will need to identify and understand the normal body responses to localized temperature variations. Heat and cold applied to an injured body part provides therapeutic benefit. Ask students to identify when heat and cold are used. Answers may include: Heat: arthritis, degenerative joint disease, localized muscle strain, menstrual cramping, hemorrhoid, perianal inflammation or local abscess. Cold: direct trauma such as sprain, strain, fracture, muscle spasms, superficial laceration, minor burn, arthritis, after an injection or joint trauma. Education will be an important component. Those who suffer from decreased sensations should be very careful when using these therapies.

Evaluation Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals.