Chapter 36

Skin Integrity and Wound Healing

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Normal Structures and Function of Healthy Skin

The skin is the body’s largest organ and the primary defense against pathogenic invasion.

The skin also contributes to temperature regulation, prevents loss of internal fluids, and provides sensory awareness.

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Normal Structures and Function of Healthy Skin

Epidermis• Outermost layer of the skin• Primary function is to maintain a barrier

against loss of internal fluids and pathogenic invasion.

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Normal Structures and Function of Healthy Skin

Dermal-Epidermal Junction• Anatomic point at which the epidermis

connects with the dermis• Characterized by interdigitating connections

that provide resistance to superficial skin injury.

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Normal Structures and Function of Healthy Skin

Dermis• Innermost layer of the skin• Nourishes the basal layer of the epidermis.• Provides sensory awareness.• Contributes to temperature regulation.• Composed primarily of collagen and elastin

fibers.

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Normal Structures and Function of Healthy Skin

Hypodermis (Subcutaneous layer)• Consists primarily of adipose tissue and

connective tissue.• Critical role of providing “padding” and even

weight distribution over bony prominences.

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Normal Structures and Function of Healthy Skin

Fascia/Muscle Layer• Fascia is a thin layer of connective tissue

covering the muscle.• Muscle layer is composed of contractile

fibers that control position and movement.• Muscle layer is the most metabolically active

layer of the skin and soft tissues.• Muscle layer is most vulnerable to ischemic

damage.

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Normal Structures and Function of Healthy Skin

Changes Across the Lifespan• Neonates and Infants• Elderly Adults

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Strategies to Maintain Healthy Skin

Nutrition and Hydration Bathing and Lubrication Managing Pruritic Skin

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Strategies to Maintain Healthy Skin

Common Skin Lesions• Bacterial Infections• Fungal Infections• Viral Infections

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Strategies to Maintain Healthy Skin

Inflammatory Conditions Cutaneous Malignancies

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Pressure Ulcer Formation

A pressure ulcer is an area of skin and tissue loss caused by prolonged or excessive soft tissue pressure.

Results in skin breakdown. Increasingly common problem among

clients in all health care settings.

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Pressure Ulcer Formation

Pathology of Pressure Ulcers• Tunneling• Friction• Maceration

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Pressure Ulcer Formation

Assessment• Use of a research-based risk assessment

tool to screen all non-ambulatory clients- Braden scale- Norton scale

• Nonblanching erythema• Induration with palpation• Extensive tissue damage

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Pressure Ulcer Formation

Assessment• Etiologic Risk Factors• Prolonged or High-Intensity Pressure• Shear Force• Compromised Tissue Tolerance

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Pressure Ulcer Formation

Nursing Diagnosis• Impaired Skin Integrity Related to

Pressure/Shear Injury

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Outcome Identification and Planning

Individualized outcomes are based on the client’s overall physical condition, the stage of the wound, and the client’s risk factors.

Client teaching is an integral part of the planning process.

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Implementation

Pressure ulcers can be prevented through a variety of measures.

Early identification of high-risk individuals and contributing factors decrease the possibility of pressure ulcer formation.

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Implementation

Appropriate Use and Selection of Support Surfaces• A variety of support surfaces for bed and

chair are designed to reduce interface pressures or to constantly change the pressure points.

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Implementation

Measures to Control Moisture and Maceration

Nutritional and Fluid Support Routine Skin Assessment Management for Shear Force Avoidance of Massage of Tissue at Risk

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Evaluation

Physical signs of healing and the status of the pressure ulcer

Client’s adaptation to the altered skin integrity

Each intervention should be evaluated for its effectiveness.

Plan of care is revised to reflect most beneficial actions.

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Wound Healing

Definitions and Classifications of Wounds• Acute • Chronic

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Wound Healing

Definitions and Classifications of Wounds• Partial-thickness wounds involve partial loss

of the skin layers but do not involve the deeper tissues.

• Full-thickness wounds involve total loss of the epidermis and dermis with extension into the subcutaneous tissue and possibly the muscle.

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Wound Healing

Partial-Thickness Wound Repair• Brief inflammatory phase• Epithelial cell proliferation and migration• Vertical migration• Collagen synthesis (formation of new

connective tissue)

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Wound Healing

Full-Thickness Wound Repair• Inflammatory phase

- Control bleeding- Establish clean wound bed- Release of growth factors- Inflammatory response

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Wound Healing

Full-Thickness Wound Repair• Proliferative phase

- Granulation tissue- Epithelialization- Contraction

• Maturation phase (remodeling phase)- 3 months to 2 years- Hypertrophic scarring (keloid formation)

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Wound Management

Identify and address etiologic factors. Establish appropriate goals. Provide systemic support and topical

therapy.

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Wound Management

Assessment• Location, dimensions and depth• Stage of the wound• Status of wound bed (eschar, slough)• Exudate• Status of wound edges (flat, red, moist,

closed)• Status of surrounding skin• Pain

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Assessment

Factors Affecting Wound Healing• Perfusion and Oxygenation• Nutritional Status• Diabetes Mellitus• Corticosteroids• Aging

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Assessment

Laboratory Data• Cultures of wound drainage• Elevated WBC count• Decreased leukocyte• Albumin

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Nursing Diagnoses

Impaired Tissue Integrity Risk for Infection Pain Disturbed Body Image Deficient Knowledge (wound care)

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Outcome Identification and Planning

Targeted outcomes are based on client’s identified needs and individualized on basis of client’s condition.

Focus is on promoting wound healing, preventing infection, and educating the client.

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Implementation

Systemic Support Measures• Tissue perfusion and oxygenation• Nutritional support• Glucose levels within normal limits• Compensation for chronic steroid intake

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Implementation

Topical Therapy• Wound cleansing• Dressing selection• Debridement of necrotic tissue

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Implementation

Topical Therapy• Monitor drainage of wounds

- Penrose drains- Jackson-Pratt drains- Hemovac drains

• Maintenance of open proliferative wound edges

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Drainage Systems: Closed System

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Drainage Systems: Tube and Reservoir System

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Evaluation

Achievement or Maintenance of Skin Integrity• Wound healing• Prevention of infection• Client education

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Management Guidelines for Specific Wounds

Abrasions and Lacerations Surgical Incisions Skin Tears

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Types of Wounds

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Management Guidelines for Specific Wounds

Lower Extremity Ulcers• Venous ulcers• Arterial ulcers• Neuropathic ulcers• Atypical ulcers

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Management Guidelines for Specific Wounds

Burns• Thermal, chemical, or electrical causes• Epidermal burns• Superficial partial-thickness burns• Deep partial-thickness burns• Full-thickness burns

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Contusions, Strains, and Sprains: Management Guidelines

Contusions are bruises of the soft tissues with no break in the skin surface.

Contusions resolve spontaneously and require no active management.

Application of ice for 24 hours following injury can reduce the amount of edema and bruising.

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Contusions, Strains, and Sprains: Management Guidelines

Strains represent “stretch” injuries of muscles, tendons, or ligaments.

Application of ice for 24 hours to reduce swelling and bleeding, elevation to reduce swelling, use of an elastic wrap or sling, and aspirin or acetaminophen as needed.

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Contusions, Strains, and Sprains: Management Guidelines

First- and second-degree sprains involve trauma to ligaments, tendons, or bones around a joint.

Caused by twisting or pulling forces. Nonsteroidal anti-inflammatory drugs,

ice, elastic wrap or sling, and restricted activity until symptoms resolve

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Contusions, Strains, and Sprains: Management Guidelines

Third-degree sprains represent a more serious injury.

Characterized by separation of tendons and ligaments from their bony attachments.

Produce severe bleeding, swelling, pain, and loss of function.

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Contusions, Strains, and Sprains: Management Guidelines

Management of Third-Degree Strains• Rest• Crutch to prevent weight bearing during

ambulation• Ice for 24 to 72 hours• Compression with an elastic wrap• Soft cast or sling• Elevation

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Contusions, Strains, and Sprains: Management Guidelines

Management of Third-Degree Sprains• Narcotic analgesics for severe pain• Restricted mobility for up to 3 weeks• Surgery may be required for reattachment or

removal of torn tendons and ligaments.• Potential for developing post-traumatic

arthritis

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Administer Heat and Cold Therapy

Heat and cold therapies require nursing care that assesses both the vasoconstriction and vasodilation of an individual.

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Administer Heat and Cold Therapy

Conditions that necessitate precautions in the use of heat and cold applications:• Neurosensory impairment• Impaired mental status• Impaired circulation• Open wounds, broken skin, scar formation,

edema

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Administer Heat and Cold Therapy

Heat Therapy• Promotes vasodilation• Decreases blood viscosity• Increases tissue metabolism• Increases capillary permeability• Reduces muscle tension

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Administer Heat and Cold Therapy

Cold Therapy• Promotes vasoconstriction• Increases blood viscosity• Decreases tissue metabolism• Local anesthetic effect• Decreases muscle tension