Skin Integrity and Wound Care

Teresa V. Hurley, MSN, RN

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

Wounds
What are wounds ?
Break in skin or mucous membranes

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

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

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

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

Pressure Ulcer Stages

Stage II: Superficial
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

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

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

Pressure Ulcer Assessment

Wound Dimensions (L, W, D) Wound Deterioration
Skin surrounding ulcer
Redness, warmth, edema

Exudate
Amount, color, consistency, odor

Wound Healing
Primary Intention
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

Wound Healing
Inflammatory Response
Serum and RBCs 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

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

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

Wound Assessment
Wound Closure
Staples Sutures Steri-strips

Drains
Penrose Hemovac or Jackson Pratt exert low pressure

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

Heat and Cold Therapies

Heat
Vasodilation
Increases blood flow Nutrient delivery Removal of waste Decreases venous congestion

Blood Viscosity Decreased

leuokocytes antibiotics

Heat and Cold Applications

Heat
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

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

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

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

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

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

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

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