1. Skin integrity and Wound care
Fall semester
2014

2. Skin integrity
Intact skin: presence of normal skin layers uninterrupted by wounds.
Impaired skin integrity is a threat to:
Elders
Client with restricted mobility
Chronic illness
Trauma
Those undergoing invasive health care procedure

3. Skin integrity
The skin is the body’s largest organ and the primary defense against pathogenic invasion.
The skin also contributes to temperature regulation, prevents loss of internal fluids, and provides sensory awareness.
The appearance of skin and skin integrity are influenced by:
Internal factors( genetics, age and status of person’s health, malnutrition)
External ( activity, sun and medications as AB and chemotherapy, corticosteroids)

4. Types of wound
Intentional: trauma occurs during therapy as operation, vein puncture and tumor excision
Unintentional: are accidental as fracture from car accident
and
Closed: tissue trauma without a break in the skin
Open: when the skin or mucous membrane surface is broken

5. Types of the wound according to the way they acquired
Incision: sharp instrument (open wound; deep or shallow)
Contusion: blow from a blunt instrument (closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels)
Abrasion: surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks) (open wound involving the skin)

6. Puncture: penetration of the skin &often the underlying tissue by a sharp instrument, either intentional or unintentional (open wound)
Laceration: tissue torn a part, often from accident( e.g., with machinery) (open wound; edges are often jagged)
Penetrating wound: penetration of the skin & the underlying tissue, usually unintentional (e.g., from bullet or metal fragments) (open wound)

7. Wound description according to degree of contamination
Clean wound: are uninfected wound in which minimal inflammation is encountered and the respiratory, genital, urinary tract are not entered. Clean wound are primarily closed wound
Clean-contaminated wounds: are surgical wounds in which respiratory, alimentary, genital or urinary tract has been entered, such wounds show no evidence of infection (high risk of infection)
Contaminated wounds: include open, fresh, accidental wounds & surgical wounds involving a major break in sterile technique there is an evidence of inflammation
Dirty or infected wounds: wounds containing dead tissue & wounds with evidence of a clinical infection, such as purulent drainage (old, accidental wounds)

8. Wound classification according to the depth of the wound
1. Partial thickness: confined to the skin, that is, the dermis and epidermis; heal by regeneration
2. Full thickness: involving the dermis, epidermis, subcutaneous tissue, &possibly muscle &bone; require connective tissue repair

9. Pressure ulcers Etiology:
Also called bedsores , pressure sores or decubitus ulcers: injury to skin (usually over a bony prominence) caused by unrelieved pressure.
Etiology:
Tissue is compressed between two surfaces a deficiency in blood supply to these tissues the cells are deprived of O2 and nutrient (pale) + waste products accumulates in cells
tissues die localized ischemia.
(when pressure is relieved, the skin takes on a bright red flush called reactive hyperemia due to vasodilation. Reactive hyperemia lasts ½ - ¾ as long as the duration of impeded blood flow to the area)

10. Risk Factors for Pressure Ulcers
Friction and shearing:
Friction: is a force acting parallel to the skin surface (sheets rubbing against skin create friction).
Shearing forces: is the combination of friction & pressure. It occurs commonly when a client assumes a sitting position.
Immobility no control to change position
Inadequate nutrition: causes wt. loss, muscle atrophy, loss of SC in which decrease the amount of padding between skin and bone. (diet low in protein, CHO, vit c, fluids, zinc)

11. Fecal & urinary incontinence: promotes skin maceration (tissue softened by prolonged wetting or soaking)
Decrease mental status: pt. with reduced level of awareness unconscious or heavily sedative are less able to respond to pain perception.
Diminished sensation paralysis, stroke, reduce ability to respond to heat or cold sensation
Excessive body heat: fever increase BMR thus increase the cell need for o2 especially in the pressure area, fever with infection may affect the body ability to deal with the compressed area.
Advanced age: aging process brings a lot of skin changes (loss of body mass, pain perception, thinning of epidermis, alteration in venous and arterial flow…)
Chronic disease (CVD, DM.) compromise O2 delivery and delay healing
Other factors: Poor lifting technique, incorrect positioning, repeated injections.

12. Stages of Pressure Ulcer Formation
Stage I: non-blanchable erythema of intact skin signaling potential ulceration
Stage II: partial-thickness skin loss involving epidermis and possibly dermis

13. Stages of Pressure Ulcer Formation
Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures

14. Wound Healing
Healing is a quality of living tissue, it is also called regeneration (renewal) of tissues.
1- Primary Intention (primary union or 1st intension healing): occur when tissue surface have been approximated (closed), and there is minimal or no tissue loss, characterized by Formulation of minimal granulation and scarring (surgical incision)

15. The difference between 2nd and 1st intention healing:
2- Secondary intention healing: Extensive wound, involves tissue loss, the edges cannot or should not be approximated such (as pressure ulcer)
The difference between 2nd and 1st intention healing:
The repair time is longer
Scarring greater
Susceptibility to infection greater

16. 3- Tertiary Intention Healing (Delayed Primary Intention): wound left open for 3-5 days to allow edema or infection to resolve or exudates to drain and then closed with suture

17. Phases of Wound Healing
It is the same for all wound but the rate of healing depend on:
Type of healing
Location and size of wound
Client health status
Phases of wound healing:
Inflammatory Phase
Proliferative Phase
Maturation Phase

18. Inflammatory Phase
Immediately after injury; lasts 3 to 6 days. 2 processes occur during this phase:
Hemostasis (cessation of bleeding): results from vasoconstriction of larger vessels in affected area, retraction of injured blood vessels, the deposition of fibrin (connective tissue) and the formation of blood clots which provide a matrix of fibrin that becomes the framework for cell repair.
Phagocytosis: leukocytes (neutrophils) move into interstitial space. Theses are replaced by macrophages which engulf microorganisms and cellular debris.

19. Proliferative Phase From post injury day 3 or 4 until day 21
Fibroblasts in wound start to synthesize collagen (a whitish protein substance adds strength to wound
Capillaries grow across wound increasing Bld supply and fibrin deposits in wound .
The capillary network develops tissue becomes red color called granulation tissue.
Epithelization: proliferation of epithelial tissue over the granulation, if failed dried plasma proteins and dead cells formed eschar

20. Maturation Phase From day 21 until 1 or 2 years post injury
Fibroblasts continue to produce collagen
Remodeling of the wound occur
Scar formation occur which is strong

22. Types of wound exudates
Exudate: is a fluid that are escaped from blood during inflammatory process and deposited in the tissue or in the tissue surface. 3 types:
A- Serous Exudate: consist of serum (clear protein of blood) derived from blood &serous membrane of body (watery& has few cells) (e.g., fluid in the blister from burn)
B- Purulent exudate: is thicker, presence of pus (leukocytes, dead tissue debris,& dead and living bacteria) blue, green, or yellow color depend on causative agents
C- Sanguineous (hemorrhagic) exudate: large amount of RBC indicate damage to capillaries (in open wounds, may be bright( fresh bleeding) or dark (old bleeding

23. Mixed Exudate Serosanguineous Purosanguineous
Clear and blood-tinged drainage, commonly seen in surgical incision
Purosanguineous
Pus and blood, commonly seen in new wound that is infected

24. Complications of Wound Healing
Hemorrhage: (massive bleeding) due to removal of clot, slipped stitch, erosion of blood vessel, risks increase in the 1st 48hr’s after surgery
Internal ( swelling and distension under skin, may called hematoma, if it large may cause compression in the blood vessels)
External (blood appear under dressing or escape. So apply sterile pressure dressing + check V/S)
Infection: impaired skin healing, become apparent 2-11 day post operative, cause change in wound color, pain, exudate, fever, increase WBC’s, hotness, tenderness and redness, foul odor

25. Dehiscence: Partial or total rupturing of sutured wound, occur 4-5 day post op.
Evisceration: Protrusion of the intestines through the incision.
Risk factors including: obesity, poor nutrition, multiple trauma, excessive coughing and sneezing, sudden straining and dehydration, it is managed by (large sterile dressing soaked in N|S, place pt in bed with knee bent, then notify doctor

27. Factors Affecting Wound Healing
Age: Young, Adult, or Elderly
Nutritional status: diet. Obesity
Lifestyle: Exercise, smoking, poor hygiene
Medications: anti-inflammatory drugs (steroids, aspirin) prolong use of antibiotics.
Contamination or infection

28. Nursing Process: Assessment
Nursing history
Review of systems
Skin diseases
Previous bruising
General skin condition
Skin lesions
Usual healing of sores

29. 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
Untreated wounds
Location
Extent of tissue damage
Wound length, width, and depth
Bleeding
Foreign bodies
Associated injuries
Last tetanus toxoid injection

30. Treated wounds Pressure Ulcers Appearance Size Drainage
Presence of swelling
Pain
Status of drains or tubes
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
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

31. Laboratory Data:
Leukocyte count: decrease LEUKOCTE COUNT delay healing increase risk for infection.
Hemoglobin level: Low Hgb poor O2 delivery to tissue
Blood coagulation: prolonged coagulation times result in severe bleeding, while hypercoagulability lead to intravascular clotting and decrease bld supply to the wound
Serum protein indicates nutritional status (for rebuilding cells). Albumin if less than 3.5 g/dl increase risk for infection and delay healing
Wound culture: confirm or rule out presences of infection
Sensitivity tests: to select the apropriate AB

32. Nursing Diagnoses (NANDA)
Risk for Impaired Skin Integrity: applies to pressure ulcers and wounds extending through the epidermis but not through the dermis.
Impaired Skin Integrity: altered epiderms and/or dermis
Impaired Tissue Integrity: applies to pressure ulcers and wounds extending into SC tissues, muscles, or bones.
Risk for Infection: with severe skin impairment, pt is immunosuppressed
Pain: RT nerve involvement within the tissue impairment

33. 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

34. Implementation
Supporting wound healing : maintain moist wound healing, nutrition and fluid, preventing infection and positioning
Preventing pressure ulcer
Treating pressure ulcer :RYB (Protect (cover) red, cleanse yellow, and debride black)
Dressing wound
Cleaning wound
Supporting and immobilizing wound
Heat and cold application

35. Dressing wound Purposes: To protect the wound from mechanical injury
To protect the wound from infection
To maintain moist wound healing
To absorb drainage
To prevent hemorrhage
To splint or immobilize the wound

36. Types of Wound Dressings
Transparent film
Impregnated no adherent
Hydrocolloids
Clear absorbent acrylic
Hydrogel
Polyurethane foam
Alginate

37. Types of Bandages Gauze Elasticized Binders
Restrain 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

38. Heat and cold application
Heat and cold are applied for local and systemic effects.
Local Effects of Heat
Vasodilation & increase bld flow bringing O2, nutrients, antibodies & leukocytes.
Increases capillary permeability (may result in edema)
Often used for musculoskeletal problems.
Produces sedative effect

39. Local effects of cold Vasoconstriction
Decreases capillary permeability
Decreases cellular metabolism
Slows bacterial growth
Decreases inflammation
Local anesthetic effect by slowing nerve conduction rate and blocking nerve impulses

40. Contraindication of heat and cold application
Neurosensory function of the patient.
Impaired mental status: need monitoring to ensure safety.
Impaired circulation: risk for tissue damage
Immediately after injury or surgery: heat increases bleeding and swelling
Open wound: cold decreases blood flow to the wound thus inhibit healing.

41. Methods for Applying Dry and Moist Heat
Dry heat
Hot water bottle
Aquathermia pad
Disposable heat pack
Electric pad
Moist heat
Compress
Hot pack
Soak
Sitz bath

42. Methods for Applying Dry and Moist Cold
Dry cold
Cold pack
Ice bag
Ice glove
Ice collar
Moist cold
Compress
Cooling sponge bath