1. Skin Integrity and Wound Care
Teresa V. Hurley, MSN, RN

2. Skin Integrity Largest organ in the body Functions
First line of defense against microorganisms
Regulation of body temperature
Transmits sensations of pain, temperature,
touch and pressure
--Vitamin D production and absorption
--secretes sebum

3. Wounds
What are wounds ?
Break in skin or mucous membranes

4. Wound Classification Superficial
Deep (blood vessels, nerves, muscle, tendons, ligaments, bones)
Open Wound
Superficial or deep break in skin (abrasion, puncture, laceration)

5. Wound Classification
Closed: blunt force; twisting, turning, straining, bone fracture, visceral organ tear
Acute: trauma sharp object or blow
Surgical incision, gun shot, venipuncture
Chronic: pressure ulcers
Causality
Intentional: surgical incision
Unintentional: traumatic
Knife
Burn

6. Pressure Wounds Damage to tissues due to pressure Factors Immobility
Elderly
Skin moisture
Malnutrition (protein)
Shearing Forces
Friction
Risk Factors as outlined on Braden Scale

7. Pressure Ulcer Stages Stage I: No Skin Break
Skin temperature, consistency (firm), sensation (pain or itching)
Persistent redness in light skin tones
Persistent red, blue or purple hue in darker skin tones

8. Pressure Ulcer Stages Stage II: Superficial Stage III
Partial-thickness skin loss (epidermis and/or dermis
Abrasion, blister or shallow crater
Stage III
Full-thickness skin loss (subcutaneous damage or necrosis and may extend down to but not through fascia
Deep crater

9. Pressure Ulcer Stages
Stage IV: full thickness skin loss and destruction, necrosis of the tissue, damage to muscle, bone, tendons and joint capsules and sinus tract
Types of Dressings
Transparent film (Tegraderm, Bioclusive)
Hydrocolloid (Duoderm, Comfeel)
Hydrogel
Gauze Roll (Kerlix)
Provide moist environment
Loosen slough and necrotic tissue
Wick drainage from wound

10. Pressure Ulcer Assessment
Tissue Type
Granulation Tissue: red and moist
Slough: yellow stringy tissue attached to wound bed; removal essential for healing
Eschar: necrotic tissue which is brown or black appearance must be debrided

11. Pressure Ulcer Assessment
Wound Dimensions (L, W, D)
Wound Deterioration
Skin surrounding ulcer
Redness, warmth, edema
Exudate
Amount, color, consistency, odor

12. Wound Healing Primary Intention Secondary Intention: tissue loss
skin edges are approximated (closed) as in a surgical wound
Inflammation subsides within 24 hours (redness, warmth, edema)
Resurfaces within 4 to 7 days
Secondary Intention: tissue loss
Burn, pressure ulcer, severe lasceration
Wound left open
Scar tissue forms

13. Wound Healing Inflammatory Response Proliferative Phase: 3-24 days
Serum and RBC’s form fibrin network
Increases blood flow with scab forming in 3 to 5 days
Proliferative Phase: 3-24 days
Granulation tissue fills wound
Resurfacing by epithelialization
Remodeling: more than 1 year
collagen scar reorganizes and increases in strength
Fewer melanocytes (pigment), lighter color

14. Some Factors Influencing Wound Healing
Age
Nutrition: protein and Vitamin C intake
Obesity decreased blood flow and increased risk for infection
Tissue contamination: pathogens compete with cells for oxygen and nutrition
Hemorrhage
Infection: purulent discharge
Dehiscence: skin and tissue separate
Evisceration: protrusion of visceral organs
Fistula: abnormal passage through two organs or to outside of body

15. Therapeutic Modalities
Contingent on location, size, wound type, exudate, infection, dressed or undressed
Assessment
Inspect and palpate surrounding area
Wound edge approximation (healing ridge noted)
Presence and characteristics of drainage
Serous
Sanguineous
Serosanguineous
Purulent
Consistency, odor and amount

16. Wound Assessment Wound Closure Drains Staples Sutures Steri-strips
Penrose
Hemovac or Jackson Pratt exert low pressure

17. Some Dressing Types and Assistive Devices
Dry Dressings
Wet-to-Dry Dressings
Packing
Wound Vacuum Assisted Closure: apply local negative pressure to draw wound edges together; healing acclerated with the formation of granulation, collagen etc. to close wound or prepare for skin grafting
Electrical Stimulation
Abdominal Binders
Montgomery Straps

18. Heat and Cold Therapies
Vasodilation
Increases blood flow
Nutrient delivery
Removal of waste
Decreases venous congestion
Blood Viscosity Decreased
leuokocytes
antibiotics

19. Heat and Cold Applications
Muscle relaxation with decrease in pain from spasm and stiffness
Tissue Metabolism increased with increased warmth and blood flow
Increased capillary permeability promotes nutrient delivery and waste removal

20. Cold Applications Vasoconstriction
Reduce blood flow preventing edema formation and decreases inflammation
Local anesthesia
Cell metabolism decreased with o2 demands decreased
Increased blood viscosity promotes coagulation
Pain relief with decrease in muscle tension
Direct Trauma; superficial lacerations, arthritis

21. Complications
Heat application leads to reflex vasoconstriction within 1 hour
Complications
Epithelial cells damaged
Redness, tenderness, blistering

22. Complications Cold Reflex vasodilation Tissue ischemia Skin redness
Bluish purple mottling
Numbness
Burning pain
Tissues may freeze

23. Modalities
MD order: body site, type, frequency and duration of application
Moist or dry
Warm/Cold Compresses
Warm Soaks (relaxation, debride wounds)
Sitz Baths (rectal or vaginal surgery, hemorrhoids, episiotomy)
Aquathermia pads (muscle sprains, inflammation or edema)
Commerical Hot and Cold Packs

24. Contraindications Heat Site with active bleeding
Acute localized pain (appendicitis) leads to rupture
Cardiovascular (vasodilation to large areas leads to decrease blood supply to vital organs

25. Contraindications Cold
Site pre-existing edema prevents absorption of intersitial fluid
Neuropathy (unable to sense)
Shivering will intensify with acute elevations in temperature

26. Critical Thinking
What other factors need to be assessed before application of heat and cold therapies?
Circulatory?
LOC?
Sensory?