1. Skin Integrity and Wound Care Dr James Pelletier The Swain Department of Nursing The Citadel

2. Functions of the Skin Protection Body temperature regulation Psychosocial Sensation Vitamin D production Immunologic Absorption Elimination

3. Cross-Section of Normal Skin Need to know this anatomy.

4. Factors Affecting the Skin -Unbroken and healthy skin and mucous membranes defend against harmful agents. -Resistance to injury is affected by age, amount of underlying tissues, and illness. -Adequately nourished and hydrated body cells are resistant to injury. - Adequate circulation is necessary to maintain cell life.

5. Developmental Considerations -In children younger than 2 years, the skin is thinner and weaker than it is in adults. -An infant’s skin and mucous membranes are easily injured and subject to infection; a child’s skin becomes increasingly resistant to injury and infection. -The structure of the skin changes as a person ages; the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

6. Causes of Skin Alterations - Very thin and very obese people are more susceptible to skin injury. Fluid loss during illness causes dehydration. Skin appears loose and flabby. Obese: skin on skin fiction; cause abscess on the skin, sweat more, more bacteria - Excessive perspiration during illness predisposes skin to breakdown. -Jaundice causes yellowish, itchy skin leading to scratching and possible injury. -Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care.

7. Types of Wounds Intentional(surgery, catheters) or unintentional Open (SKIN IS COMPLIMINE) or closed ( HEMATOMA, bruise) Acute( sudden) or chronic ( don’t go through normal healing process) Partial thickness, full thickness, complex Know “Types of Wounds” Table 31-3

8. Principles of Wound Healing - Intact skin is the first line of defense against microorganisms. - Careful hand hygiene is used in caring for a wound. - The body responds systematically to trauma of any of its parts. -An adequate blood supply is essential for normal body response to injury. -Normal healing is promoted when the wound is free of foreign material.

9. Principles of Wound Healing (cont.) -The extent of damage and the person’s state of health affect wound healing. - Response to wound is more effective if proper nutrition is maintained.

10. Wound repair occurs by primary intention( normal, nice and neat cut, only leave nice thin scar), secondary intention(we can not sew them together, it must fill in cause a big scar), or tertiary intention: Wounds healed by primary intention are well approximated (skin edges tightly together). Wounds healed by secondary intention have edges that are not well approximated. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed : when it start to fill in you can sew them in. Know this

14. Phases of Wound Healing - Hemostasis: - Inflammatory - Proliferation - Maturation

15. Hemostasis -immediately after the initial injury. -involved blood vessels constrict and blood clotting begins through platelet activation and clustering -these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate( plasma and RBC)

16. Inflammatory Phase Follows hemostasis and lasts about 4 to 6 days White blood cells move to the wound. Macrophages enter the wound area and remain for an extended period. They ingest debris and release growth factors that attract fibroblasts to fill in the wound.

17. Proliferation Phase Begins within 2 to 3 days of injury and may last up to 2 to 3 weeks New tissue is built to fill the wound space through the action of fibroblasts. Capillaries grow across the wound. A thin layer of epithelial cells forms across the wound. Granulation tissue forms a foundation for scar tissue development.

18. Maturation Phase Final stage of healing; begins about 3 weeks to 6 months after injury Collagen is remodeled. New collagen tissue is deposited. Scar becomes a flat, thin, white line.

19. Local Factors Affecting Wound Healing Pressure: old people skin thinner easily to get bruise Desiccation (dehydration) Maceration (over hydration) Trauma Edema Infection Excessive bleeding Necrosis (death of tissue)

20. Pressure -disrupts the blood supply to the wound area -persistent or excessive pressure interferes with blood flow to the tissue and delays healing Desiccation( burn pt) -Cells dehydrate and die in a dry environment -This cell death causes a crust to form over the wound site and delays healing -Wounds that are kept moist (not wet) and hydrated experience enhanced epidermal cell migration, which supports epithelialization

21. Maceration -breakdown of skin resulting from prolonged exposure to moisture -damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin. Trauma -Repeated trauma to a wound area results in delayed healing or the inability to heal Edema - Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.

22. Infection -infection requires large amounts of energy be spent by the immune system -toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death Excessive Bleeding -results in large clots: need to go in take the clot out -this increases the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. -accumulated blood is an excellent place for growth of bacteria and promotes infection

23. Necrosis -Dead tissue present in the wound delays healing -Slough—moist, yellow, stringy tissue -Eschar appears as dry, black, leathery tissue -Healing wound will not take place with necrotic tissue in the wound (surgical, autolytic( chemical), maggots).

24. Systemic Factors Affecting Wound Healing Age: children and healthy adults heal more rapidly Circulation and oxygenation: adequate blood flow is essential Nutritional status: healing requires adequate nutrition Wound condition: specific condition of the wound affects healing Health status: corticosteroid drugs and postoperative radiation therapy delay healing Immunosuppression

25. Wound Complications Infection Hemorrhage Dehiscence and evisceration Fistula formation

26. Infection -Symptoms of wound infection usually become apparent within 2 to 7 days after the injury or surgery -often, the patient is at home -Symptoms of infection include purulent drainage; increased drainage, pain, redness, and swelling in and around the wound; increased body temperature; and increased white blood cell count

27. Hemorrhage Hemorrhage may occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain.

28. Wound Dehiscence and Evisceration Dehiscence (A) is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Evisceration (B) is the most serious complication of dehiscence Risk Factors: -Obesity -Malnourished -Smoking -Anticoagulant use -Infected wounds -Excessive coughing, vomiting, or straining

29. Fistula Formation -A fistula is an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another. -may be created purposefully (arteriovenous fistula is created surgically to provide circulatory access for kidney dialysis) -often the result of infection that has developed into an abscess -accumulated fluid applies pressure to surrounding tissues, leading to the formation of the unnatural passage.

30. Factors Affecting Pressure Ulcer Development Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders

31. Mechanisms in Pressure Ulcer Development External pressure compressing blood vessels-The major predisposing factor for a pressure ulcer is exter- nal pressure applied over an area, which results in occluded blood capillaries and poor circulation to tissues. Friction or shearing forces tearing or injuring blood vessels-A patient who lies on wrinkled sheets is likely to sustain tissue dam- age as a result of friction.

33. Stages of Pressure Ulcers Stage I: non-blanchable erythema of intact skin Stage II: partial-thickness skin loss Stage III: full-thickness skin loss; not involving underlying fascia Stage IV: full-thickness skin loss with extensive destruction Unstageable: base of ulcer covered by slough and/or eschar in wound bed

35. The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria -Sensory perception -Moisture -Activity -Mobility -Nutrition -Friction and Shear Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23

36. Skin Assessment -on admission -reassessed at least every 24 hours or if the patient’s condition changes -reassess stable patients in intensive care units daily -reassess unstable patients every shift -long-term care setting: On admission, then reassess weekly for 4 weeks, then quarterly and whenever the resident’s condition changes -home health care: On admission, then reassess at every visit

37. Measurement of a Pressure Ulcer Size of wound Depth of wound Presence of undermining, tunneling, or sinus tract Review Guidelines for Nursing Care 31-1 “Measuring Wounds and Pressure Ulcers”

38. Assessment of Wound Drainage Serous- is composed primarily of the clear, serous portion of the blood and from serous mem- branes. Serous drainage is clear and watery. Sanguineous-consists of large numbers of red blood cells and looks like blood. Serosanguineous- is a mixture of serum and red blood cells. It is light pink to blood tinged Purulent-white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green)

39. Type of Drainage Systems Open systems Penrose drain Closed systems Jackson-Pratt (JP) drain Hemovac drain