SKIN INTEGRITY AND WOUND CAREBY: Nelson Munthali Dip/RN

objectives

By the end of this presentation students should be able to:

Describe factors affecting skin integrity Identify clients at risk of pressure ulcers Describe the four stages of pressure ulcer

development Differentiate primary and secondary wound

healing

Describe the three phases of wound healing

The skin is the largest organ in the body and it serves a number of functions including: protection, thermoregulation

To protect the skin and manage wounds effectively, the nurse must understand factors affecting skin integrity, the physiology of wound healing and specific measures that promote optimal skin conditions

SKIN INTEGRITY

Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds

The appearance of skin and skin integrity are influenced by internal factors such as age, genetics and underlying health of the individual as well as external factors such as activity.

Many chronic illnesses and their treatments affect skin integrity

People with impaired peripheral arterial circulation may have skin on the legs that damages so easily

WOUND

A wound is a break in the skin integrity TYPES OF WOUNDS Accidental wounds: occur when the skin is

exposed to extremes in temperature, exposure to chemicals, excessive pressure, trauma and radiation

Common accidental wounds are abrasions, lacerations and puncture wounds

abrasions

An abrasion is caused when the skin rubs against a hard surface . Friction scrapes away the epithelial layer of the skin, exposing the epidermal or dermal layer

LACERATION: Is an open wound or cut. Most lacerations affect only the upper layers of the skin and subcutaneous tissues, but permanent damage may occur if there is injury to internal structures such as muscles, tendons, blood vessels or nerves.

Accidents involving auto mobiles , machinery or knives may result in lacerations

Puncture wounds

It is created when tissue is penetrated by a sharp pointed instrument like nails, pins

SURGICAL WOUNDS: They are intentional wounds that vary from simple to superficial to deep.

Classification of Wounds • 1) Clean Wound: – Operative incisional wounds that follow

nonpenetrating (blunt) trauma.

• 2) Clean/Contaminated Wound:

uninfected wounds in which no or minimal inflammation is encountered but the respiratory, gastrointestinal, genital, and/or urinary tract have been entered.

• 3) Contaminated Wound:

open, traumatic wounds or surgical wounds involving a

major break in sterile technique that show evidence of

inflammation.

4) Infected Wound:

old, traumatic wounds containing dead tissue and

wounds with evidence of a clinical infection (e.g.,

purulent drainage

The severity of the wound determines the time for healing, the degree of pain and the probability of wound complication.

OSTOMIES: Are surgical openings in the abdominal wall that allow part of the intestine to open onto the skin.

STASIS DERMATITIS: Is caused by impairment of venous return secondary to varicose veins. Pooling of blood leads to oedema, vasodilatation and plasma extravasation all of which may result in dermatitis

PRESSURE SORES

Pressure sores are also called decubitus ulcers or bed sores. They occur when capillary blood flow to the skin is impaired.

These ulcers occur primarily as a result of unequal distribution of pressure over certain parts of the body. Because of decreased blood flow , the supply of nutrients and oxygen to the skin and underlying tissues is impaired. This causes cells to die and decompose and form an ulcer

Pressure sore

ULCER STAGING

Stage 1: involves inflammation and reddening of the skin. Any breakdown present during this stage involves only the epidermis. Usually stage 1 ulcers are reversible if pressure is relieved

STAGE II. Ulcer appears as a shallow crater or a blister. It involves the dermis and can penetrate to the subcutaneous layer.

Stage III

Ulcer involves destruction of subcutaneous layer and capillary beds. The ulcer is not painful but may have foul smelling yellow or green drainage.

Stage III ulcer may require months to heal. STAGE IV: Involves extensive damage to underlying

structures and may extend to the bone. On the skin surface , the wound may appear small but beneath the skin, the tunnels extend away from the opening. They are usually necrotic and have foul smelling drainage

At the edges the ulcer may develop a leathery black crust(eschar) which may eventually cover the ulcer. Infectious complications such as osteomylitis are common.

RISK FACTORS

Factors causing ulcer formation include: increased pressure and decreased tissue tolerance.

Pressure can be increased by decreased mobility, decreased activity and decreased sensory/ perceptual ability.

Extrinsic factors that decrease tissue tolerance and increase the likelihood of pressure sore development are: moisture, friction, shearing force. Other contributing factors are: age, malnutrition.

ALTERED NUTRITIONAL STATUS This increases the risk of pressure sore

development because inadequately nourished cells are easily damaged. Severely malnourished patients experience weight loss, decreased subcutaneous tissue, and decreased muscle mass. This limit the amount of padding between skin and underlying bone, aggravating the effects of pressure over bony prominences.

ALTERED MENTAL STATUS

Can occur when patients are confused, comatose or if one is taking medications that alter normal cognitive process. When this occurs, patients are less aware of pressure build up and not reposition themselves as needed to prevent ulceration.

MOISTURE Moisture can predispose the skin to breakdown. Skin

which is continuously exposed to moisture becomes macerated. Incontinence often causes the patient to lie in urine or faeces.

FRICTION

Occurs when two surfaces rub together. When the skin rubs against a hard surface such as beddings, small abrasions may occur.

SHEARING FORCE: Occurs when tissue layers move on each other causing stretching of blood vessels

COMMON LOCATIONS

Pressure sores usually develop over bony prominences where body weight is distributed over a small area with inadequate padding. When in supine, the greatest points of pressure are back of the skull, the elbows, the sacrum, the coccyx and heels. When sitting, the greatest points of pressure are the ischial tuberosities and the sacrum

Wound healing

When the skin is wounded, a type of healing by replacement occurs.

PHASES OF WOUND HEALING

Defensive phase

It is also known as inflammatory or exudative phase. The body responds to the wound by setting up defenses against further invasion

It involve combined forces of hemostasis, inflammation and cell migration to control bleeding, seal the wound , and protect the wound from bacterial contamination.

hemostasis

Is the process to stop bleeding, and is the first step in defensive phase. It occurs as a result of vasoconstriction of injured vessels, platelet aggregation and clot formation, deposition of fibrin which forms a matrix for cellular repair.

The inflammatory response is the next step in defensive phase. The venules dilate, capillaries open and there is increased vascular permeability to plasma. Symptoms may include : pain, redness, swelling and warmth.

Reconstructive phase

The reconstructive or proliferative phase begins on the third or fourth day after injury. In this phase, which lasts about two weeks, the fibroblasts multiply and form a network for migrating cells. Collagen synthesis is the major event at this phase.

MATURATION PHASE

The maturation or modeling phase which completes healing process begins about three weeks after the injury and may last up to two years. The number of fibroblasts decreases and collagen synthesis stabilises .

TYPES OF WOUND HEALING

Wounds heal differently depending on whether or not tissue loss has occurred.

HEALING BY FIRST INTETION Wounds with minimal tissue loss such as clean

surgical incision, shallow structured wounds heal by first intention (approach each other ) rapidly . Granulation tissue is not visible and scarring is generally minimal. Infection risk is lower when wounds heal by first intention.

Healing by second intention

Wounds with tissue loss such as deep lacerations, burns and decubitus ulcers have that do not rapidly approximate

HEALING BY THIRD INTENTION

Healing by third intention occurs when a wound is closed at a later stage after wound surfaces have already started granulating. This may happen when a deep wound is not sutured.

FACTORS AFFECTING WOUND HEALING

There are many factors that can affect wound healing:

Nutrition: nutritional defincies retard wound healing by pronging the exudative phase and inhibiting collagen synthesis. Patients with protein deficient are more likely to develop infections

Circulation of oxygen: blood circulation to the involved wound and oxygenation of the tissues greatly influence wound healing. Wound healing is slowed when there is reduced cellular blood flow and that is the reason for prolonged healing in bed sores.

Immune cellular function

Immunosupression delays wound healing. Any underlying condition that lowers immune function will lead to delayed wound healing. There are also drugs that affect the immune system like corticosteroids which would lead to delay in wound healing. Chemotherapy and radiation retard wound healing.

DRUGS: A number of drugs in addition to those that affect the immune response alters wound healing

Oral anticoagulants given to decrease the chance of thrombus formation increase chances of bleeding

stress

Physical and emotional stress triggers the release of catecholamines. They cause blood vessels to constrict, decreasing blood flow to the wound.

Local factors Usually, a surgical incision made using

strict aseptic technique heals faster

COMPLICATIONS OF WOUND HEALING Delayed wound healing can cause a number of

complications which includes: hemorrhage, hematoma formation, infection, dehiscence, evisceration and fistula

Hemorrhage: after initial trauma, bleeding is expected, but within several minutes hemostasis occurs. However, when large blood vessels are cut or patient has poor clotting ability, bleeding may continue. Bleeding may occur internally or externally.

hematoma

Hematoma is a localised collection of blood appears as a swelling or mass underneath the skin surface and often has a bluish color.

Infection: a break in the skin creates a port of entry for microorganisms.

Dehiscence and evisceration

Dehiscence is total or partial disruption of the wound edges. As wound edges separate an increase in drainage occurs.

Evisceration is protrusion of viscera through a wound opening. It can follow dehiscence if the wound is not closed.

fistula

A fistula is an abnormal tube like passageway that forms between two organs or from one organ to the outside of the body. Normal wound healing promotes tissue closure, thus preventing abnormal communication between organs of the body.