Health Safety: Ch 32, Skin Integrity and Wound Care

Taylor's Fundamentals of Nursing
Chapter 32, Skin Integrity and Wound Care

Anatomy and Physiology of Integument

Structures of Skin

• Epidermis- top layer
• Dermis- second layer, nerves, hair follicles, glands, blood vessels
• Subcutaneous tissue- underlying layer that anchors the skin layers to the underlying tissues of the body. Stores fat for energy, insulates body for heat, provides cushioning for protection

Functions of Skin and Mucous Membranes

Protection

• acts as barrier to microorganisms, water, UV light
• protects against infection
• decreases injury to underlying tissues
• prevents loss of moisture

Temperature Regulation

• evaporation of moisture draws heat from skin
• blood vessels dilate to dissipate heat
• blood vessels constrict to limit heat loss

Psychosocial

• major contributor to self esteem
• important role in identification and communication

Sensation

• nerve endings provide sense of touch, pain, pressure, and temp
• sensory impulses from skin send messages to brain and spinal cord

Vitamin D Production

• precursor for Vit D is present in skin

Immunological

• breach in surface of skin triggers immune responses

Absorption

• substance, such as meds, can be absorbed though skin for local and systemic effects

Elimination

• water, electrolytes, and nitrogenous wastes are excreted in small amounts in sweat

Types and Causes of Wounds

• Incision: cutting or sharp instrument;wound edges in close approximation and are aligned
• Contusion: blunt instrument, overlaying skin remains intact, with injury to underlying soft tissue;possible resultant bruising and/or hematoma
• Abrasion: friction; rubbing or scraping epidermal layers on the skin; top ayer of skin abraded
• Laceration: tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, ofter with loose flaps of skin and tissue
• Puncture: blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental
• Penetrating: foreign object entering skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissue
• Avulsion: tearing a structure from a normal anatomic position; possible damage to blood vessels, nerves, and other structures
• Microbial: secretion of endotoxins or release of endotoxins by living organisms
• Chemical: toxic agents such as drugs, acids, alcohols, metals, and substances releases from cellular necrosis
• Thermal: high or low temps; cellular necrosis as a possible result
• Irradiation: ultraviolet or radiation exposure
• Pressure Ulcers: compromised circulation secondary to pressure or pressure combined with friction
• Venous Ulcers: injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
• Arterial Ulcers: injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombus
• Diabetic Ulcers: injury and underlying diabetic neuropathy, peripheral arterial disease,  diabetic foot structure

Wound Classification

 There are many different classifications of wounds.

Intentional Wounds and Unintentional Wounds

• an intentional wound is the result of a planned invasive therapeutic procedure or treatment
• from surgery, IV therapy, lumbar puncture, etc
• the edges are clean
• bleeding is usually controlled
• risk for infection is decreased, healing is facilitated (bc the wound was created with sterile supplies and skin preparation)
• an unintentional wound is accidental
• trauma, accidents, stabbing, gunshot, burns
• wound edges are usually jagged
• multiple traumas are common
• bleeding is uncontrolled
• high risk for infection and longer healing time

Open and Closed Wounds

• Open Wound: 
• occurs from intentional or unintentional trauma
• skins surface is broken
• increased risk for infection and delayed healing
• Closed Wound
• results from blow, force, or strain
• skin surface not broken
• soft tissue is damaged
• internal injury and hemorrhage may occur

Acute and Chronic Wounds

• Acute Wounds
• ie surgical incisions
• heal in days to weeks
• wound edges are well approximated (edges meet close to skin surface)
• risk of infection is lessened
• usually move through healing phase without difficulty
• Chronic Wounds
• remain in the inflammatory stage of healing
• includes any wound that does not heal along the expected continuum
• ie wounds related to venous insufficiency and pressure ulcers

Wound Healing

• the healing process fills the gap caused by tissue destruction, restoring the structural integrity of  the damaged tissue through the orderly release of growth factors and chemical mediators
• these substances help to increase the blood supply to the damaged area, wall off an remove cellular and foreign debris, and initiate cellular development
• normally occurs without assistance
• wound repair occurs by primary, secondary, or tertiary intention
• Primary Intention:
• wounds healed by primary intention are well approximated (the edges are close together)
• intentional wounds such as those made by surgical incision, with minimal tissue loss,  that are well approximated sutured edges, heal by primary intention
• Secondary Intention:
• large, open, wounds such as from burns or trauma
• require tissue replacement and are often contaminated
• if a wound that is healing by primary intention becomes infected it then heals by secondary intention
• take longer to heal and form more scar tissue
• Tertiary Intention (delayed primary)
• wounds that are left open for several days to allow edema or infection to resolve r exudate to drain, and are then closed

Phases of Wound Healing

• four phases
• hemostasis
• inflammation
• proliferation
• maturation
• Hemostasis:
• occurs immediately after initial injury
• blood vessels constrict and blood clotting begins via platelet activation
• after a brief period of constriction, the same vessels dilate and capillary permeability increases allowing plasma and nutrients to leak into the area forming a liquid called an exudate
• accumulation of exudate causes swelling and pain
• increased perfusion results in heat and redness
• platelets release substances that stimulate other cells to migrate to the injury to help heal
• Inflammatory Phase:
• follows hemostasis and lasts about 4-6 days
• leukocytes and macrophages migrate to wound
• leukocytes arrive first and ingest bacteria and cellular debris
• macrophages arrive after about 24hrs
• they ingest bacteria and release growth factors necessary for new cells and blood vessels
• growth factors attract fibroblasts that help fill in the wound
• Acute inflammation is characterized by pain, heat redness and swelling
• during inflammatory phase pt has a generalized body response, including a mildly elated temp, leukocytosis, and generalized malaise
• Proliferation Phase
• also known as fibroblastic or regenerative phase
• lasts for several weeks
• new tissue is built to dil in the wound space
• granulation tissue form base for scar development
• it is highly vascular, red, and bleeds easily
• granulation tissue is not visible in wounds that heal by first intention
• systemic symptoms disappear 
• adequate nutrition and oxygenation, as well as prevention of strain on suture line, are important
• wounds that heal by secondary intention eventually follow the same process but take longer and form more scar tissue
• Maturation Phase:
• final stage
• begins about three weeks after injury
• possibly continuing for months or years
• collagen continues to be deposited
• scar is an avascular collagen tissue that does not sweat, grow hair, or tan

Factors Affecting Wound Healing

Local Factors

• Pressure
• disrupts blood supply to wound area
• Desiccation
• the process of drying up
• cells dehydrate in a dry environment
•  wounds that are kept moist (not wet) and hydrated heal better
• Maceration
• over hydrated of cells related to urinary and fecal incontinence can lead to impaired skin integrity
• damage is related to 
• moisture
•  changes in pH of skin
• overgrowth of bacteria and infection of skin
• erosion of skin from friction on moist skin
• Trauma
• repeated trauma to wound results in delayed healing or inability to heal
• Edema
• edema at wound site interferes with blood supply to the area
• results in inadequate supply of oxygen and nutrients
• Infection
• bacteria in a wound increases stress on the body
• toxins produced by bacteria and released when bacteria die interfere with healing and cause cell death
• Necrosis
• dead tissues delay healing
• appears as slough, moist, yellow, stringy tissue
• removal must occur for healing to take place

Systemic Factors

• Age
• binding between layers of skin causes layers to separate easily during inflammatory phase placing infants and small children at risk for impaired skin integrity
• epidermal stripping, such as with tape removal, can cause layers to separate
• Circulation and Oxygenation
• blood flow delivers nutrients and oxygen and removes local toxins, bacteria and other debris
• Nutritional Status
• wound healing requires adequate proteins, carbs, fats, minerals
• need calories and protein to rebuild tissues
• Vitamin A, C, and Zinc
• Medications and Health Status
• pts on corticosteroids or receiving radiation have delayed healing and wound complications
• steroids decrease the inflammatory process, by which delaying healing

Wound Complications

• Infection
• the risk of infection is increased for any surgical procedure involving the intestines because the risk of contamination from fecal matter is high
• symptoms usually occur with 2-7 days after injury and surgery
• often patient is home
• Symptoms include:
• purulent drainage
• pain 
• redness
• swelling
• increased temp
• increased WBC
• can lead to other complications:
• osteomyelitis (bone infection)
• sepsis
• Hemorrhage
• may occur from slipped suture, dislodged clot, erosion of blood vessel
• check dressing and frequently, an then no less than q8h
• if bleeding occurs, apply pressure
• Dehiscence and Evisceration 
• most serious post op wound complications
• Dehiscence is the partial or total separation of wound layers as a result of excessive strain on wounds that are not healed
• Evisceration is the most serious complication of dehiscence
• the wound completely separates
• protrusion of viscera through incisional area
• patients at greeatest risk are
• obese or malnourished
• smokers
• use anticoagulants
• have infected wounds
• have excessive coughing, vomiting, or straining (note straining, not voiding)
• an increased flow of fluid post op days 4 and 5 are a sign of impending dehiscence
• if dehiscence occurs:
• cover wound with sterile towels with normal saline
• notify physician
• once dehiscence occurs it is managed like any open wound
• it is a medical emergency
• place pt in low fowlers position
• Fistula Formation
• an abnormal passage from an internal organ to another
• can be created intentionally or by infection or pressure

PRESSURE ULCERS

• pressure ulcer is a wound with a a localized area of tissue necrosis
• may be acute or chronic
• underlying cause is pressure
• costly in terms of pt discomfort, disfigurement, decreased quality of life, and health care expenditures
• Result from combination of factors:
• aging skin
• chronic illness
• immobility
• malnutrition
• fecal and urinary incontinence
• altered level of conscious
• certain populations (spinal cord injuries, brain injuries, neuromuscular disorders)

Factors in Pressure Ulcer Development

• Two mechanism contribute to pressure ulcer development
• external pressure that compresses blood vessels
• friction and shearing forces that injure blood vessels and abrade the top layer of skin
• External Pressure
• usually occurs over bony prominences
• insufficient circultaion deprives tissue of oxygen and nutrients and leads to ischemia, hypoxia, edema, inflammation, and necrosis
• may form in as little as 1-2 hours if pt has not been repositioned
• pts with casts or supports stocking need additional assessment of circulation
• Friction and shear
• pts who are pulled, rather than lifted, when being moved are at risk for shearing 
• may also affect a pt who is sitting in bed but slides down
• Risk factors for pressure ulcer development:
• dehydration
• incontinence
• skin hygiene
• diabetes mellitus
• deminished pain awareness
• factures
• hx of corticosteroid therapy
• immunosuppression
• multisystem trauma
• poor circulation
• previous pressure ulcers
• significant obesity or thinness

Pressre Ulcer Staging:

• Stage 1
• intact skin
• nonblancheable redness of localized area, usually over bony prominence
• darkly pigmented skin may not have visible blanching
• may be painful, firm, soft, warmer, or cooler, compared to surrounding tissue
• may be difficult to detect in dark skinned persons
• may identify pat as "at risk"
• Stage 2
• hallow open ulcer
• red pink wound bed
• partial thickness loss of dermis
• without slough or bruising
• Stage 3
• full thickness tissue loss
• subq fat may be visible
• bone, tendon, muscle not exposed or palpable
• Stage 4
• full thickness tissue loss with exposed nine, tendon, or muscle
• slough or eschar may be present
• Unstageabe
• stable, dry, adherent, intact eschar on heels serves as the body's natural cover and should not be removed
• When to assess skin:
• acute care setting: on admission, then reassessed at least every 48 hours or if the patients condition changes. Reassess stable patients in the ICU daily. Reassess unstable patients in ICU q shift
• long term care setting: an admission, the q48h for the first week, weekly for the first month, followed by monthly to quarterly. More frequently if pts status changes.
• homecare: on admission, and then with each visit
• Norton and Braden scale can be used to assess for risk
• Lab values that indicate risk for ulcers
• Albumin <3 .2="" 3.5-5="" li="" normal="">
• Prealbumin <19 16-40="" li="" normal="">
• body weight decrease of >15%

Evaluation of Existing Ulcer

• location of any lesion or ulcer
• identification of the stage
• size: length, width, depth; presence of undermining
• color and type of wound tissue
• presence of abnormal pathways such as a sinus tract or tunneling
• visible necrotic tissue or slough
• presence of an exudate or drainage
• presence of odor
• presence of absence of granulation tissue
• evidence of epithelialization
• periwound skin condition