1. Skin integrity and Wound care
Spring Semester
2016

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. 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

11. 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

12. 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)

13. 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.

14. Types of 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. Two 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: arise from bld monocytes to engulf microorganisms

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

21. Types of wound exudates
Exudates: 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 Exudates: 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 exudates: is thicker, presence of pus (leukocytes, dead tissue debris & dead living bacteria) blue, green, or yellow color depend on causative agents
C- Sanguineous (hemorrhagic) exudates: large amount of RBC indicate damage to capillaries (in open wounds, may be bright (fresh bleeding) or dark (old bleeding)

22. 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

23. Complications of Wound Healing
Hemorrhage: 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, exudates, fever, increase WBC’s, hotness, tenderness and redness, foul odor.

24. Dehiscence: Partial or total rupturing of sutured wound, occur 4-5 day post op, it is due to 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
Evisceration: Protrusion of the intestines through the incision.

26. Factors Affecting Wound Healing
Age: young, adult, or elderly
Nutritional status: diet, obesity
Lifestyle: exercise, smoking, poor hygiene
Medications: anti-inflammatory drugs (steroids, aspirin) AB interfere with MO resistance .
Contamination or infection

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

28. 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

29. 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
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

30. Laboratory Data:
Leukocyte count: decrease LEUKOCYTE 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 while intra-arterial clotting decrease bld supply to wound
Serum protein indicates nutritional status
serum albumin indicate nutritional status less than 3.5 g/dl increase risk for infection, and delay healing
Wound culture :rule out presences of infection
Sensitivity tests: to select the proper AB

31. Nursing Diagnoses Risk for Impaired Skin Integrity
Impaired Tissue Integrity
Risk for Infection
Pain

32. 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

33. Implementation
Supporting wound healing : maintain moist wound healing, nutrition and fluid, preventing infection and positioning
Preventing pressure ulcer
Treating pressure ulcer :RYB ( Red, Yellow, Black)
Dressing wound
Cleaning wound
Supporting and immobilizing wound
Heat and cold application

34. 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

35. Types of Wound Dressings
Transparent film
Impregnated non adherent
Hydrocolloids

36. Types of Wound Dressings
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. Figure 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.

39. Figure 36-14 Starting a bandage with two circular turns.

40. Figure 36-15 Applying spiral turns.

41. Figure 36-16 Applying spiral reverse turns.

42. Figure 36-18 Completing a recurrent bandage.

43. Figure 36-19 Applying a figure-eight bandage.

44. Figure 36-20 Large arm sling.

45. Figure Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

46. Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

47. Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

48. Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.