Skin Integrity and Wound Care Teresa V Hurley

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 RBC’s 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 o 2 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?