SKIN CARE AND WOUND

PREVENTION
By: Karen C. Lyon, PhD, APRN, ACNS, NEA
Presented by: Wanda Butaud RN, BSN, WOCN
Spring 2015

Student Learning Outcomes

Differentiate categories of chronic wounds in
terms of predisposing factors, anatomic location
and wound characteristics
Describe assessment parameters for venous
ulcers, diabetic leg/foot ulcers and pressure ulcers
Describe wound care management strategies
including appropriate primary and secondary
dressings, compression, offloading, biologic
dressings and bed surfaces
http://guidelines.gov/content.aspx?id=24492

Chronic Wound Prevalence in US

Over 6.5 million patients with chronic wounds in US
One half of these are pressure sores
80% of patients with pressure sores are over
65 years of age
85% of paraplegics will develop a pressure
sore
63% of pressure sores are present at hospital
admission
Over $25 billion spent annually on treatment

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC281019
2/
http://www.justice.gov/opa/pr/2003/June/03_civ_386.

A wound is a disruption of
normal anatomic structure and
function that is usually inclusive
of the skin.

Wound healing should result in

restoration of

Anatomic continuity
Function

A
C
U
T
E

VS.
C
H
R
O
N
I
C

Shear
Shear is caused by tissue layers sliding
against each other. This results in
disruption or angulation of blood
vessels, usually at the fascia level
Purple areas on sacrum and heels
Ulcers start deep and work outward
Irregularly shaped
Undermined

Moisture
Excessive moisture causes
maceration which acts as a factor in
skin breakdown
Incontinence
Wound drainage
Excessive sweating

Nutritional Compromise
Altered skin integrity
Delayed wound healing
Decreased resistance to infection
Nutritional supplements
Feeding tubes
Anabolic steroids

Contributing Factors
Activity and mobility
Loss of sensation
Age
Disease states
Previous ulcers
Medications

Granulation Tissue
Formation
KEY Cells
Macrophages
Fibroblasts
Endothelial Cells

KEY Elements
Macrophage derived
- PDGF
- TGF-
- FGF-2 (bFGF)

MMPs
- Cell migration

Reference:
Reference: Monaco
Monaco JL,
JL, Lawrence TL. Acute wound healing; an overview.
overview. Clinics
Clinics in
in Plastic
Plastic Surgery 30
30 (2003):
(2003): 1-12.
1-12.

Reepithelialization

Keratinocyte
Keratinocyte Proliferation
Proliferation

Keratinocyte
Keratinocyte Migration
Migration

Relevant
Relevant Growth
Growth Factors
Factors

Keratins
Keratins

Chronic wounds have failed to

proceed through an orderly and
timely process to produce anatomic
and functional integrity, or proceeded
through the repair process without
establishing a sustained anatomic
and functional result.
Lazarus GS et al. Arch Dermatol 1994.

Chronic is actually a misnomer:

It

is not as much an issue of time as it is

condition of the wound
What we are really talking about is wound
healing failure which may be identifiable
almost at the time of injury

Local factors affecting wound

healing:
Ischemia
Infection
Edema
Scarring
Radiation

injury

Topical

steroids
Local toxins
Trauma, pressure
Foreign bodies
Local malignancy

Systemic factors affecting wound

healing:
Diabetes mellitus
Tobacco use
Renal failure
Nutritional
deficiencies
Hereditary disorders
Alcohol use
Distant malignancy
Systemic infections

Connective tissue
disease
Immunological
disorders
Chemotherapeutic
agents
Extremes of age
Systemic steroids
Hepatic failure

Age associated differences in cellular

proliferation
11000
10000

NumberofCells

9000
8000
7000
6000

NB

5000

YA

4000

OA

3000
2000
1000
0

10

11

12

13

Day

(Buras and Buras, Harvard Medical School, MGH, Boston)

Decreased cellular proliferation with diabetes

35

30

#CellsX104

25

20

15

Diabetic

10

NonDiabetic
5

Days

(Buras and Buras, Harvard Medical School, MGH, Boston)

PRESSURE ULCER DEFINITION

A PRESSURE ULCER IS:

Any lesion caused by unrelieved pressure
Results in damage to underlying tissue
Located over bony prominences

Pathophysiology
External pressure impedes local
blood flow to skin (20mmHg),
muscle
Muscle and subcutaneous tissue
more susceptible to injury than
skin
Necrosis generally over bony
prominence
Loss of skin moisture

Pressure Ulcers

Stage 2

Stage 1
Stage 3

Stage 4

Heel
8%

Posterior
Calf

Sacrum
23%

Elbow Scapula Back of

3%
5%
head
Spinous
1%
processes
1%

Dorsum of
foot and
ankle

Knee Thigh
6%

Iliac
crest 4%

Anterior Cheek
Chest
and ear
Acromion
process

Points of Pressure
Lateral Position

Malleolus 7%

Medial and
lateral
condyles

Greater trochanter
15%

Ribs

Ear

Points of Pressure
Sitting Position

Scapula

Popliteal

Plantar surface of
foot

Sacrum & coccyx

Ischial tuberosity 24%

Heel

Braden Scale

http://education.woundcarestrategies.com/colopla
st/resources/BradenScale.pdf

Pathophysiology
Prolonged venous hypertension
Valvular incompetence, DVT, calf
muscle dysfunction
Enlarged dermal capillaries, reduced
capillary number, microvascular
thrombosis, increased permeability of
microlymphatics
WBC sequestration,
ischemic/reperfusion injury

Venous Leg Ulcers

Pathophysiology

Sensory, motor, autonomic

neuropathy
Low resistance to infection with
attenuated inflammatory response
impaired chemotaxis, inefficient
bacterial killing
Perivascular localization of
albumin
Large vessel arterial occlusive
disease
Peripheral A-V shunting

Diabetic Wounds/Amputations

Wagner Diabetic Wound Grading

Scale

http://www.medicalcriteria.com/site/index.ph
p?option=com_content&view=article&id=114%3Ad
btfoot&catid=49%3Adiabetes&Itemid=80&lang=en

Table 1. Suggested Technique for the

Management of Chronic Wounds

Wound cleansing

Yes

Clean

Supplies (Includes
solutions and dressing
supplies)
Normal saline solution or
commercially prepared
wound cleanser - sterile;
maintain as clean per
care setting policy*

Routine dressing
change without
debridement

Yes

Clean

Sterile; maintain as clean Sterile; maintain as clean

per care setting policy*
per care setting policy

Dressing change
with mechanical,
chemical, or
enzymatic
debridement

Yes

Clean

Sterile; maintain as clean Sterile; maintain as clean

per care setting policy*
per care setting policy

Dressing change
with sharp,
conservative
bedside
debridement

Yes

Sterile

Sterile

Sterile

Intervention

Handwashing Gloves

Instruments
Irrigation with sterile device;
maintain as clean per care
setting policy

* "Maintain clean as per care setting policy" means that each care setting must address the parameters
for maintenance,
such as expiration
dates for supplies,
consideration of
cost, and correct
interpretation of
the manufacturer's

Farrow Wraps

NURSING IMPLICATIONS

Nutritional

Skin care

Pressure relief/reduction
Risk assessment

Support
Outcomes

Early
Education
Treatment

Documentation
Tracking