Skin Integrity and Wound Care

The skin is the largest organ in the body and serves a variety of important functions in maintaing health and protecting the individual from injury. Impaired skin integrity is not a frequent problem for most healthy people but is a threat to older people, to clients with restricted mobility, chronic illnesses, or trauma, and those undergoing invasive health care procedures.

Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds. The appearance of the skin and skin integrity are influenced by internal factors such as genetics, age, and the underlying health of the individuals as well as external factors such as activity.

A wound: disruption in the continuity of cells. Wound healing is the restoration of that continuity.

  Effects of wound:• Loss of all or part of organ functioning• Sympathetic stress response• Hemorrhage and blood clotting• Bacterial contamination• Death of cells

Types of wounds

Body wounds are either intentional or unintentional. Intentional trauma occurs during therapy e.g., operations or venipuncture, removing tumor. Unintentional wounds are accidental; e.g. a person may fracture an arm in an automobile collision. If the tissues are traumatized without a break in the skin, the wound is closed. The wound is open when the skin or mucous membrane surface is broken.

Wounds may be described according to how they are acquired:-

- Incision wounds: Sharp instrument ''open, deep or shallow''.

– Contusion wounds: blow from a blunt instrument '' closed, skin appears ecchymosed (bruised)''.

– Puncture wounds: penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional ''open wounds''.

– Lacerated wounds: tissue torn apart, often from accident ''open, edges are often jagged''.

– Abrasion wounds: Surface scrape ''open, involving the skin''.

– Penetrating wounds: penetrating the skin and underlying tissues.

'' Open wound ''.

Types of wounds according to degree of wound contamination:-

1. Clean wounds: uninfected wounds in which minimal

inflammation is encountered.

2. Clean – contaminated wounds: surgical wounds in

which the respiratory, alimentary, genital or urinary tract has been entered. No evidence of infection.

3. Contaminated wounds: open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Show evidence of inflammation.

4. Dirty or infected wounds: containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.

Pressure Ulcer

Pressure Ulcers were previously called decubitus ulcers, pressure sores, or bedsores.It is any lesions caused by unrelieved pressure that result in damage to underlying tissues.

Etiology of pressure ulcers

Pressure ulcers are due to localized ischemia, a deficiency in the blood supply to the tissue. The tissue is compressed between two hard surfaces, usually the surface between the bed and the skeleton, when the blood cannot reach the tissue, the cells are deprived of oxygen and nutrients, waste products of metabolism accumulate in the cells, and the tissue consequently dies. Prolonged, unrelieved pressure also damages the small blood vessels.

After the skin has been compressed, it appears pale, as if the blood had been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush called reactive hyperthermia. The flush is due to vasodilatation, a process in which extra blood supply to compensate for the preceding period of impeded blood flow.

stage III pressure ulcer

Risk factors• Friction and Shearing

Two other factors frequently act in conjunction with pressure to produce pressure ulcers:

Friction: is a force acting parallel to the skin surface, such as sheets rubbing against skin create friction. Friction can abrade the skin, that is, remove the superficial layers, making it more prone to breakdown.

Shearing force: combination of friction and pressure. It occurs commonly when the a client assumes a Fowler’s position. In this position, the body tends to slide downward toward the foot of the bed. This downward movement is transmitted to the sacral bone and the deep tissues . At the same time, the skin over the sacrum tends not to move because of the adherence between the skin and the bed linens. The skin and superficial tissues are thus relatively unmoving in relation to the bed surface, whereas the deeper tissues are firmly attached to the skeleton and move downward. This causes a shearing force in the area where the deeper tissues and the superficial tissues meet. and the superficial tissues meet. The force damages the blood vessels and tissues in this area.

Shearing forces can occur when a patient is moved carelessly or slides down in bed.

• Immobility Refers to a reduction in the amount and control of

movement a person has. Such as paralysis, extreme weakness, pain.

• Inadequate nutrition It causes weight loss, muscle atrophy, and loss of

subcutaneous tissue. These three reduce the padding between the skin and the bones. More specifically, inadequate intake of protein, carbohydrates, fluids, and vitamin C.

• Fecal and urinary incontinence Moisture from incontinence promotes skin

maceration, (tissue softened by prolonged wetting or soaking), digestive enzymes in feces contribute in excoriation (area of loss of the superficial layers of the skin) which cause irritation to skin, harbor microorganisms.

 

• Decreased mental status Individual with a reduced level of awareness for

example, Unconscious, or heavily sedated, they are less able to organize and respond to pain associated to prolonged pressure.

 

• Diminished sensation

Paralysis, stroke, loss of consciousness may cause loss of sensation in a body area. loss of sensations reduce person’s ability to respond to trauma, to injuries heat and cold, and to the tingling (pins and needles) that signals loss of circulation. Sensory loss also impairs the body’s ability to recognize and provide healing mechanisms for a wound.

•  Excessive body heat

Increased body temperature increase metabolism, increase cell need for oxygen.

 

• Advanced age

Due to changes in body mechanisms such as loss of lean body mass, decreased strength and elasticity, diminished pain perception, increased dryness due to a decrease in the amount of oil produced by the sebaceous.

• Chronic medical conditions D/M, cardio vascular diseases are risk for skin breakdown

and delayed healing. These conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.

 • Other factors Poor lifting techniques, incorrect positioning, repeating

injection at the same area, incorrect application of pressure relieving devices.

 

Stages of pressure ulcers• Stage 1:- red color and the skin don’t return to

normal color even the pressure is released.• Stage 2 :- redness accompanied by blisters or

shallow break in the skin• Stage 3 :- break in the skin extending to the

subcutaneous tissue• Stage 4:- ulcer involves loss of all skin layers

exposing muscle and bone.

Risk assessment tools

Several risk assessment tools are available that provide the nurse with systematic means of identifying clients at high risk for pressure ulcers.

- Braden scale for predicting pressure sore risk.

- Norton’s pressure area risk assessment form scale.

Wound Healing

Healing is a quality of living tissue , it is also referred to as regeneration (renewal) of tissues.

Healing can be considered in terms of types of healing and phases of healing

Types of Wound Healing There are two types of healing, influenced by the

amount of tissue loss.

1- Primary intention healingOccurs where the tissue surfaces have been

approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. It is also called primary union or first intention healing.

e.g. closed surgical incision

Primary intention healing is healing of a wound where the wound edges heal directly touching each other.

2- Secondary intention healing

It is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated. e.g., pressure ulcer.

 

Secondary intention healing differs from primary intention healing in three ways:-

1- The repair time is longer

2- Scarring is greater

3- Susceptibility to infection is greater

Phases of wound healingInflammatory phase: is initiated immediately

after injury and last 3 to 6 days. Two major processes occur during this phase:• Hemostasis• Phagocytosis

Hemostasis (the cessation of bleeding) results from vasoconstriction of the larger blood vessels in the affected area, deposition of fibrin (connective tissue) and the formation of blood clots in the area. The blood clots, formed from blood platelets, provide a matrix of fibrin that becomes the framework for cell repair.

The inflammatory phase also involves vascular and cellular responses to remove any foreign substances and dead and dying tissues. The area appears reddened and edematous. After 24 hours post injury, large macrophages enter the area these macrophages engulf microorganisms and cellular debris by a process known as phagocytosis.The macrophages also secrete angiogenesis factors which stimulate the formation of epithelial buds at the end of injured vessels, leads to reanastomosis.

This phase include mildly elevated temperature, leukocytosis, and generalized malaise.

Proliferative phase: extends from day 3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue cells), which migrate into the wound begin to synthesize collagen (whitish protein), these substance adds tensile strength, this decreases the chance that wound open again. Capillaries grow across the wound, ↑ the blood supply. Fibroblasts move from the bloodstream into wound, depositing fibrin , the tissue becomes a translucent red color. This tissue , called granulation tissues , is fragile and bleeds easily.

Maturation (Remodeling phase): begins about day 21 and can extend 1 or 2 years after the injury. During maturation, the wound is remodeled and contracted. The scar becomes stronger but the repaired area is never as strong as the original tissue.

Hand abrasion

Approximate days since injury

0 2 17 30

Types of wound exudate

Exudate: - is material such as fluid and cells that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.

 There are three major types of exudates:-

1- Serous exudate

Consist chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum. It looks watery and has few cells.

e.g fluid in a blister from a burn.

 

2- Purulent exudate

Is thicker than serous because of the presence of pus (leukocyte, dead tissue debris, dead and living bacteria). The process of pus formation is referred to as suppuration; bacteria that produce pus are called pyogenic bacteria. Purulent exudates vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

3- Sanguineous (hemorrhagic) exudates consist of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma .

Mixed types of exudates likeSerosanguineous ( consisting of clear and blood

tinged drainage) purosanguineous (consisting of pus and blood )

Complications of wound healing 1- HemorrhageHemorrhage is abnormal massive bleeding; internal

hemorrhage may be detected by swelling or distention in the wound. Hematoma, a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise).

The nurse should know the location of the pt’s incision to inspect the site of operation for bleeding at intervals for the first 48 hours, not less than Q 8hours. Any undue amount of bleeding should be reported, additional sterile dressing, fluid replacement, may need surgical interventions.

Occurs in slipped sutures, dislodged clot, infection, erosion of blood vessels by a foreign

2- InfectionStaphylococcus aurous, E. coli, Aerobacter

aerogenes and pseudomonas aeroginosa. The main important area of prevention lies on aseptic techniques in wound care, cleanliness and environmental disinfection are important. The symptoms appear within 36-48 hours.

The temperature and pulse increase, wound become tender, swollen, and warm. Nursing intervention will be through the use of warm antiseptic solutions to flush the wound. Take culture at site of operation. Specific antibiotics. A wound can be infected with microorganisms at the time of injury, during surgery, or postoperatively.

3- Dehiscence with possible Evisceration

Dehiscence: partial or total rupturing of sutured wound. Evisceration: the protrusion of the internal viscera

through an incision area. A number of risk factors including obesity , malnutrition, multiple trauma, failure of suturing, coughing, vomiting, and straining, dehydration . Wound dehiscence is more likely to occur 4 to 5 days postoperatively.

Sudden straining , such as coughing or sneezing, may precede dehiscence. The client may feel " something has given away “. When dehiscence or evisceration of a wound occurs, the wound should be supported by large sterile dressing moistures with sterile saline. Place the client in bed with knees bent to decrease pull on the incision. The surgeon is notified at once.

 

Factors affecting wound healing

Developmental considerations: Children and healthy adults heal more rapidly than elders, who are more likely to have chronic diseases that hinder healing.

 Nutrition : clients require a diet rich in protein, carbohydrates ,

lipids , vitamins A and vitamins C, and minerals such as iron, zinc, and copper . Obese clients (large amount of subcutaneous and fat tissues) these tissues have less blood supply and this lead to slow wound healing, so they are more prone to infection. Also in peripheral vascular disorders, cardio vascular disorders, hypertension, or D\M, anemic, chronic respiratory disorders and smoke people.

 

Wound condition: large, contaminated, infected wounds that retain foreign bodies, healing slowly. Some wounds fail to heal.

 Lifestyle : e.g exercise, smoking  Medications: anti-inflammatory drugs (e.g.,

steroids and aspirin) and antineoplastic agents interfere with healing. Also prolonged use of an antibiotics .

Nursing management1- Assessing- Assessment of skin integrity - Nursing history and physical assessment - Assessment of wounds Untreated wounds Treated wounds Pressure ulcers Laboratory data2- Diagnosing3- Planning4- implementing

Nursing intervention for maintaining skin integrity and wound care involve:

1- Supporting wound healing

The 4 major areas in which nurses can help clients develop optimal conditions for wound healing are

- Moist wound healing

The dressing and frequency of change should support moist wound bed conditions. Wound beds that are too dry or disturbed too often fail to heal.

- Nutrition and fluids

Clients should be assisted to take in at least 2500ml of fluids a day unless it is contraindication, also the nurse should ensure that clients receive sufficient protein, vitamins C,A,B1 and B5, and Zinc.

- Preventing infection

There are two main aspects to controlling wound infection: preventing micro. From entering the wound, and preventing the transmission of bloodborne pathogens to or from the client to others.

- Positioning

To promote wound healing, clients must be positioned to keep pressure off the wound. Changes of position and transfers can be accomplished without shear or friction damage, also the client should be assisted to be as mobile as possible because activity enhances circulation.

ROM, turning schedule are important for independent clients.

2- Preventing pressure ulcers

To reduce the likelihood of pressure ulcer in all clients, the nurse employs a variety of preventive measures:-

- Providing nutrition

The diet should be similar to that which supports wound healing adequate intake of calories, protein, vitamins, and iron.

Monitor Wt. regularly to help assess nutritional status. Pertinent lab work ( lymphocyte count, protein , hemoglobin).

- Maintaining skin hygiene

- Avoiding skin trauma

- Providing supportive devices.

3- Treating Pressure ulcers

- The RYB color code

This concept is based on the color of an open wound – red, yellow, or black (RYB) rather than the depth or sixe of a wound. The goals of wound care are to protect (cover)red, cleanse yellow, and debride black.

Wounds that are red are usually in the late regeneration phase of tissue repair. They need to be protected to avoid disturbance to regenerating tissue. The nurse protects red wounds by (a) gentle cleansing,(b) protecting periwound skin with alcohol – free barrier film, © filling dead space with hydrogel or alginate, (d) covering with an appropriate dressing such as transparent film, hydrocolloid dressing, (e) changing the dressing as infrequently as possible.

Yellow wounds are characterized by liquid to semiliquid that is often accompanied by purulent drainage or previous infection. Methods may include applying moist to moist normal saline dressings, irrigating the wound, using absorbent dressing.

Black wounds are covered with thick necrotic tissue. Black wounds reqiure debridement. Removal of nonviable tissue from a wound must occur before the wound can be staged or heal.

Debridement may be achieved in four different ways: Sharp debridement, a scalpel or scissors is used to separate and remove dead tissue. Mechanical debridement through scrubbing force or mist to moist dressings. Chemical debridement collagenase enzyme agents such as papain – urea. A utolytic debridement , dressing that contain wound moisture, such as hydrocolloid and clear absorbent dressings.

• Recently, the use of fly LARVAE/MAGGOTS

4- Dressing wounds

Purposes for applying dressings Page 922

- Types of dressings

Types of dressing used depends on

- location, size, type of the wound

- Amount of exudate

- Whether the wound requires debridement or is infected

- Frequency, ease or difficulty of dressing application, and cost

5- Cleaning wounds

Wound cleaning involves the removal of debris

( i.e., foreign materials, necrotic tissue, bacteria).

- Wound irrigation and packing

One example is vacuum assisted closure

See file

6- Supporting and immobilizing wounds

Bandages: strip of cloth used to wrap some part of the body

Binders : is a type of bandage designed for a specific body part.

Bandages and binders serve various purposes:

• Support a wound

• Immobilizing a wound

• Applying pressure

• Securing a dressing

• Retaining warmth

7- Heat and cold applications

Heat and cold are applied for systemic and local effects.

Local effect of heat:

• Sedative effect to relief pain and aches

• Vasodilatation and increase blood flow to the affected area

• Bringing oxygen and nutrients, antibodies, and leukocytes

• Promote soft tissue healing

• It is often used for clients with musculoskeletal problems such as arthritis.

Disadvantages:

• Increase capillary permeability which cause edema

Local effect of Cold:

• Vasoconstriction, which decrease the blood supply and nutrients to the affected area.

• Decrease cellular metabolism

• Decrease removal of wastes

• Prolonged exposure to cold results impaired circulation, cell deprivation, and subsequent cell damage

Advantages:

• Slow bacterial growth, decrease inflammation

• Local anesthetic effect

Systemic effects of cold and heat:

Heat applied to a localized body area, or large body area, it may cause excessive vasodilatation, drop in blood pressure, fainting, especially for those with pulmonary and cardiac problems.

Cold application cause vasoconstriction, increase in blood pressure. Shivering is the body response to cold.

For all local applications of heat and cold, the nurse need to follow these guidelines:

• Client’s ability to tolerate the therapy

• Contraindication of treatment such as bleeding

• Explain the application to client

• Assess skin area

• Ask the client to report any discomfort

• Return to the client after 15 minutes

• Remove the equipment at the designed time

• Examine the area and record the result

See box 36-4 page 933

Thanks