1. skin integrity and wound care
NURS 101
skin integrity and wound care

2. Integumentary system Skin Hair Nails Epidermis Dermis
Subcutaneous layer
Hair
Nails

3. skin Largest organ of body 15% of adult body weight
Protects against disease carrying organisms
Sensory organ for pain, temp, touch
Synthesizes vitamin D
Regulates temperature
Maintains fluid balance

4. Health History Medications Soap, shampoo, detergent
Itching or burning sensations
Changes in skin after certain foods
History of hives, asthma, allergies, excema
Occupation
New pets, plants

5. Physical assessment Inspection Well lit room, use penlight if needed
Color, lesions, vascularity, condition of nails
Condition of hair (head and body, lashes)
Texture, color, distribution
Moist or dry appearance

6. Skin color alterations
Pallor
Jaundice
Cyanosis
Erythema
Brown-tan

7. Physical assessment Palpation Wear gloves to palpate rash or lesions
Mobility, turgor
Texture of skin and nails
Temperature, moist or dry

8. Diagnostic studies Skin biopsy Woods’ light exam Description:
Nursing implications
Woods’ light exam

9. Older Adults’ skin Reduced elasticity….easily torn
Concomitant med conditions and polypharmacy interfere with wound healing
Attachment between dermis and epidermis becomes flattened, allowing mechanical tears(tape)
Diminished inflammatory response, poor wound healing
Dimished subcutaneous padding over bony prominences
Poor nutrition is a risk factor for breakdown and pressure ulcers
See chart 60-1 in Hinkle and Cheever

10. Pressure ulcers
Impaired skin integrity related to unrelieved, prolonged pressure.
AKA pressure sores, decubitus ulcer, bedsore
Localized injury to skin and underlying tissue, usually over a bony prominence
Pressure interferes with blood flow, cellular metabolism, results in tissue ischemia and ultimately tissue death

11. Risks for pressure ulcers
Decreased mobility
Decreased sensory perception
Altered level of consciousness
Fecal or urinary incontinence
Poor nutrition

12. Staging a pressure ulcer
Assessment descriptions
To evaluate wound healing, plan interventions, evaluate progress
Staging describes the depth of tissue destroyed
Necrotic tissue must be removed for proper staging and assessment
Staging I-IV… can stage up but not down

13. Stage I Red, nonblanchable skin. Intact
Warmth, edema, hardness, or pain may be present
Dark pigmented skin may not “blanche”
“at risk”

14. Stage II Partial thickness skin loss Blister Or shallow, open ulcer
Without slough or bruising
Not related to tears, burns, excoriation

15. Stage III Full thickness skin loss Fat is visible
Bone, tendon, muscle not visible
Slough may be present
May be tunnelling

16. Stage IV Full thickness tissue loss Bone, muscle, or tendon is exposed
Undermining and tunnelling common
Slough or eschar present

17. Preventing pressure ulcers
Avoid prolonged pressure
Maximize nutrition
Keep skin clean and dry
Use skin protectant/defriction ointment
Daily assessments
Document changes
Educate patients

18. Treating pressure ulcers
Easier to prevent than to treat!!!!
Avoid rubbing area
Keep clean and dry
Barrier ointment
Irrigate open ulcers with SALINE
Dressing per facility or wound nurse recommendation (may be moist or dry)

19. Braden scale table 48-3 Sensory perception 1-4 Moisture 1-4
Activity 1-4
Mobility 1-4
Nutrition 1-4 (usual intake pattern)
Friction and shear 1-3
The lower the number, the greater the risk

20. Wound classifications
acute
chronic
Trauma, surgical incision
Proceeds through orderly and timely reparitive process
Edges are clean and intact
Easily cleaned and repaired
Fails to proceed through an orderly and timely process
Does produce anatomical and functional integrity
Chronic inflammation, vascular compromise, repetitive insults to tissue
Continued exposure to insult impedes healing
Wound classifications

21. Healing processes
Primary intention; edges are closed, risk of infection low. minimal scar formation
Secondary intention: involves loss of tissue. Wound is left open until filled with scar tissue. Longer to heal, more risk of infection
Tertiary intention: delayed closure of wound for several days . Resolve infection before closing

23. Process of wound repair (partial thickness)
Tissue trauma causes inflammatory response
Epithelial cells begin to regenerate
Epithelial proliferation and migration start at the wound edges, migrate across wound bed
Migration requires a moist surface

24. Process of wound repair (full thickness)
Hemostasis- blood vessels constrict, platelets gather. Fibrin matrix formed for cellular repair
Inflammatory phase- damaged cells secrete histamine, causing vasodilation of surrounding capillaries and exudation of serum and WBCs into damaged tissue. Redness, warmth, edema
Proliferative phase- construction of new blood vessels, fill wound with granulation tissue, resurface with epithelial cells. New collagen
Remodeling- maturation of cells. Collagen continues to reorganize. Scar tissue may be lighter or darker than surrounding skin.

25. Impairment of healing
Age
Anemia
Hypoproteinemia
Zinc deficiency

26. Complications of wound healing
Hemorrhage
Infection
Dehiscience
Evisceration

27. Nutrition and wound healing
Calories
Protein
Vit C
Vit A
Vit E
Zinc
Fluid

28. Wound terminology
Abrasion
Avulsion
Incision
Laceration
Puncture
Ulcer

29. Assessing wounds
Do not remove dressing without order unless you suspect complications
Analgesia if needed 30 mins prior
Edges: approximated? Clean?
Presence of exudate? Color, odor?
Wound base description?
Erythema? Edema?
Surrounding skin??

30. More assessment data Serum albumin level White blood cell count
Wound culture, gram stain results
Vital signs
Palpation of periwound skin

31. Assessing drainage
Amount (scant, small, moderate, copious, saturated dressing)
Weigh the dressing if needed for exact measure
Record output from drain
Serous, sanguinous, serosanguinous, purulent

32. drains Change dressings with caution to avoid dislodging drains
Yes, Penrose drains are supposed to have that safety pin.
Nurses may “pull” drains with surgeon’s orders
Empty receptacle as needed, at least q shift
Make sure suction and drainage continue, “strip” tubing with order only.

33. Wound closures

34. Collaborate with Physicians and surgeons Physical therapists
Wound/ostomy nurse
Dieticians