1. Skin Integrity and Wound Care
Dr. Abdul-Monim Batiha
Assistant Professor
Critical Care Nursing
Philadelphia University

2. Factors Affecting Skin Integrity
Genetics and heredity
Age
Chronic illnesses and their treatments
Medications
Poor nutrition
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3. Risk Factors for Pressure Ulcers
Friction and shearing
Immobility
Inadequate nutrition
Fecal and urinary incontinence
Decreased mental status
Diminished sensation
Excessive body heat
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4. Risk Factors for Pressure Ulcers
Advanced age
Chronic mental conditions
Poor lifting and transferring techniques
Incorrect positioning
Hard support surfaces
Incorrect application of pressure-relieving devices
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5. Risk Assessment Tools Braden Scale for Predicting Pressure Sore Risk
Norton’s Pressure Area Risk Assessment Form Scale
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6. The Braden Scale for Predicting Pressure Sore Risk consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A total score of 23 points is possible. An adult who scores below 18 points is considered at risk.

7. Figure 36-2 Braden Scale for Predicting Pressure Sore Risk
Figure Braden Scale for Predicting Pressure Sore Risk. (From “Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention,” by U.S. Department of Health and Human Services, PPPPUA Pub No , pp. 16–17, 1992, Rockville, MD: Public Health Service. Copyright © Barbara Braden and Nancy Bergstrom, Reprinted with permission.)

8. Figure 36-2 (continued) Braden Scale for Predicting Pressure Sore Risk
Figure 36-2 (continued) Braden Scale for Predicting Pressure Sore Risk. (From “Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention,” by U.S. Department of Health and Human Services, PPPPUA Pub No , pp. 16–17, 1992, Rockville, MD: Public Health Service. Copyright © Barbara Braden and Nancy Bergstrom, Reprinted with permission.)

9. Four Stages of Pressure Ulcer FormationB
Figure 36-1 Four stages of pressure ulcers. A, stage I: nonblanchable erythema signaling potential ulceration; B, stage II: partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis; C, stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue; D, stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present. C D
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10. Four Stages of Pressure Ulcer Formation
Stage I: nonblanchable erythema signaling potential ulceration
Stage II: partial-thickness skin loss involving epidermis and possibly dermis
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
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11. Differentiate primary and secondary wound healing.

12. Primary Intention Healing
Tissue surfaces closed
Minimal or no tissue loss
Formulation of minimal granulation and scarring
It is also called primary union or first intention healing. An example is a closed surgical incision.
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13. Secondary Intention Healing
Extensive tissue loss
Edges cannot be closed
Repair time longer
Scarring greater
Susceptibility to infection greater
An example is a pressure ulcer.
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14. Tertiary Intention Healing (Delayed Primary Intention)
Initially left open
Edema, infection, or exudate resolves
Then closed
(Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention).
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15. Describe the three phases of wound healing.

16. Inflammatory Phase of Wound Healing
Immediately after injury; lasts 3 to 5 days
Hemostasis (the cessation of bleeding)
Phagocytosis (engulfing of microorganisms and cellular debris by macrophages).
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17. Proliferative Phase of Wound Healing
From post injury day 3 or 4 until day 21
Fibroblasts (connective tissue cells) begin to synthesize collagen, a protein that adds tensile strength to the wound. Capillaries grow across the wound, increasing the blood supply.
Fibroblasts deposit fibrin, and granulation tissue is formed. Granulation tissue is a translucent red color. It is fragile and bleeds easily.
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18. Maturation Phase of Wound Healing
From day 21 until 1 or 2 years post injury
Collagen organization
Remodeling or contraction
Scar stronger but is never as strong as the original tissue.
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19. Identify three major types of wound exudate.

20. 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)
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21. Serous Exudate Mostly serum Watery, clear of cells
E.g., fluid in a blister
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22. Purulent Exudate Thicker Presence of pus Color varies with organisms
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23. Sanguineous Exudate Hemorrhagic Large number of RBCs
Indicates severe damage to capillaries
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24. Mixed Exudate
Serosanguineous (hemorrhagic) exudate consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from the plasma.
Mixed exudates include serosanguineous (consisting of clear and blood-tinged drainage) and purosanguineous discharge (consisting of pus and blood).
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25. Complications of Wound Healing
Hemorrhage
Infection
Dehiscence
Evisceration
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26. Factors Affecting Wound Healing
Age
Nutritional status
Lifestyle
Medications
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27. Identify assessment data pertinent to skin integrity, pressure sites, and wounds.

28. Nursing Process: Assessment
Nursing history
Review of systems
Skin diseases
Previous bruising
General skin condition
Skin lesions
Usual healing of sores
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29. 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
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30. Assessment Data Untreated wounds Location Extent of tissue damage
Wound length, width, and depth
Bleeding
Foreign bodies
Associated injuries
Last tetanus toxoid injection
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31. Assessment Data Treated wounds Appearance Size Drainage
Presence of swelling
Pain
Status of drains or tubes
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32. Click here to view a video on pressure ulcers.
Pressure Ulcers Video
Click here to view a video on pressure ulcers.
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33. 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
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34. 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
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35. Figure Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

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

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

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

39. Assessment of Laboratory Data
Leukocyte count
Hemoglobin level
Blood coagulation studies
Serum protein analysis
Albumin level
Results of wound culture and sensitivities
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40. Nursing Diagnoses Risk for Impaired Skin Integrity
Impaired Tissue Integrity
Risk for Infection
Pain
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41. 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
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42. Measures to Prevent Pressure Ulcers
Providing nutrition
Maintaining skin hygiene
Avoiding skin trauma
Providing supportive devices
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43. Providing Nutrition
Maintain fluid intake of at least 2500 mL per day unless contraindicated, sufficient protein, vitamins C, A, B1, B5, and zinc.
Dietary consultation and nutritional supplements should be considered for nutritionally compromised clients.
Weight should be monitored as should lab data monitoring e.g. lymphocyte count, protein (especially albumin), and hemoglobin levels.
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44. Maintaining Skin Hygiene
Use mild cleansing agents that do not disrupt the skin’s “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.
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45. Avoiding Skin Trauma Smooth, firm surfaces Semi-Fowler’s position
Frequent weight shifts
Exercise and ambulation
Lifting devices
Reposition q 2 hours
Turning schedule
Avoid the use of baby powder and cornstarch which create harmful abrasive grit and are a respiratory hazard
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46. Providing Supportive Devices
Mattresses
Beds
Wedges, pillows
Miscellaneous devices
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47. Figure 36-6 Heel protector. (Courtesy of Gaymar Industries, Inc.)

48. Figure 36-7 Alternating pressure mattress (Ease).

49. Figure 36-8 Low-air-loss bed.

50. Figure Low-air-loss and air-fluidized combo bed (Clinitron/Rite Hite). (Courtesy of Hill-Rom Services, Inc. Reprinted with permission. All rights reserved.)

51. 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
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52. RYB Color Guide for Wound Care
Red (protect)
Yellow (cleanse)
Black (debride)
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53. Red wounds
Need to be protected to avoid disturbance to regenerating tissue. The nurse protects the wound by gentle cleansing, covering periwound skin with alcohol-free barrier film, filling dead space with hydrogel or alginate, covering the wound with an appropriate dressing such as transparent film, hydrocolloid dressing, or a clear absorbent acrylic dressing, and changing the dressing as infrequently as possible.

54. Yellow wounds
are characterized primarily by liquid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection.

55. The nurse cleanses yellow wounds to remove nonviable tissue
The nurse cleanses yellow wounds to remove nonviable tissue. Methods used may include applying moist-to- moist normal saline dressings, irrigating the wound, using absorbent dressing materials such as impregnated hydrogel or alginate dressings, and consulting with the primary care provider about the need for a topical antimicrobial to minimize bacterial growth.

56. Black wounds
are covered by thick necrotic tissue or eschar. They require debridement (removal of dead tissue). Debridement may be achieved in four different ways: sharp, mechanical, chemical, autolytic, and use of fly larvae (maggots). Once eschar is removed, the wound is treated as yellow, then red.

57. Promoting Wound Healing
Fluid intake
Protein, vitamin, and zinc intake
Dietary consult
Nutritional supplements
Monitor weight/lab values
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58. Controlling wound infection
Prevent entry of microorganisms
Prevent transmission of pathogens
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59. Types of Wound Dressings
Transparent film
Impregnated nonadherent
Hydrocolloids
Clear absorbent acrylic
Hydrogel
Polyurethane foam
Alginate
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60. 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.

61. Impregnated nonadherent dressings
are used to cover, soothe, and protect partial- and full-thickness wounds without exudate.

62. 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.

63. 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.

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

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

66. 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.

67. Types of Bandages Gauze Elasticized Binders 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
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68. 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.

69. Figure Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

70. Figure (continued) Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

71. Figure (continued) Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over a joint at a right angle to the direction the joint moves.

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

73. Figure 36-13 Vacuum-assisted closure (VAC) system for wounds.

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

75. Figure 36-15 Applying spiral turns.

76. Figure 36-16 Applying spiral reverse turns.

77. Figure 36-17 Starting a recurrent bandage.

78. Figure 36-18 Completing a recurrent bandage.

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

80. Figure 36-20 Large arm sling.

81. Figure 36-20 (continued) Large arm sling.

82. Figure 36-21 A straight abdominal binder.

83. Obtaining a Wound Specimen
A culturette tube for a wound specimen.
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84. Irrigating a Wound Skill 36-2
Irrigating an open wound.
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