Chapter 48: Skin integrity and Wound care

PRESSURE ULCERS
- Stage 3: Full-Thickness skin loss
o Subcutaneous fat may be visible; but bone, tendon and muscle are NOT exposed
o Slough may be present but does not obscure depth of tissue loss
o MAY include undermining and tunneling
- Stage 4: Full-thickness tissue loss
o Exposed bone, tendon or muscle, subcutaneous fat may be visible
o Slough or eschar may be present
o Often includes undermining and tunneling
- Unstageable/Unclassified: Full-thickness skin or tissue loss- depth unknown
o Actual depth of an ulcer is completely obscured by slough and/or eschar in the
wound bed
o Until enough slough and/or eschar are removed to expose the base of a wound,
the true depth cannot be determined
- Suspected Deep-tissue injury- depth unknown
o Purple or maroon localized are of discolored intact skin or a blood-filled blister
caused by damage of underlying soft tissue from pressure and/or shear
o Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or
cooler temperature as compared to adjacent tissue
- Measuring the length and width as well as depth = indicator for wound healing progress

WOUND CLASSIFICATIONS
- Wound: disruption of the integrity and function of tissues in the body
PROCESS OF WOUND HEALING
- Partial-thickness wounds: involve only epidermis and superficial dermal layers
o Shallow in depth, moist and painful
o Wound base generally appears red
o Heals by REGENERATION
- Full-thickness wounds: involve total loss of the skin layers (epidermis and dermis)
o Extends into subcutaneous layer
o Heals by FORMING NEW TISSUE (longer healing process)
- Primary intention
o Includes 3 phases: initial phase, granulation phase, maturation phase and scar
contraction
o Wound that is closed
o Caused by surgical incision; wound that is sutured or stapled
o Healing occurs by epitheliazation; heals quickly with minimal scar formation
- Secondary intention
o Wounds that occur from trauma, ulceration and infection have large amounts of
exudate and wide, irregular wound margins with extensive tissue loss
o Edges cannot be approximated
o Results in more debris, cells, and exudate = must be cleaned away
 o Difference between secondary and primary is that there is greater defect in
secondary and gaping wound edges
o Wound is left open until it becomes filled by scar tissue
- Tertiary intention
o Wounds that are contaminated and require observation for signs of
inflammation
o Closure of wound is delayed until risk of infection is resolved
o Delayed primary intention due to delayed suturing of the wound
o Occurs whne a contaminated wound is left open and sutured closed after
infection is controlled
WOUND REPAIR
- Partial-thickness: heals by regeneration because epidermis regenerates
o Ex.) Scrape or abrasion
- Full-thickness: extend into dermis and heal by scar formation because deeper structures
do not regenerate
o Ex.) Pressure ulcers
- Partial-thickness wound repair
o Inflammatory response: beneficial. Collagen appears as early as the second day
and is the main component of scar tissue
 Clean wound; inflammatory phase establishes a clean wound bed
 This phase is prolonged if too little inflammation occurs (cancer or after
steroids) or too much inflammation (competition for available nutrients)
o Proliferative phase: Begins and lasts from 3 – 24 days
 Main activities: filling of a wound with granulation tissue, wound
contraction and wound resurfacing by epitheliazation
 Vascular bed is reestablished (granulation tissue), area is filled with
replacement tissue (collagen, contraction and granulation tissue), and the
surface is repaired (epitheliazation)
 Impairment of healing during this stage usually results from systemic
factors = age, anemia, hypoproteinemia, zinc deficiency
o Maturation: final stage of healing
 Sometimes takes place for more than a year
 Collagen scar continues to reorganize and gain strength for several
months
 Healed wound usually does not have the tensile strength of the tissue it
replaces
COMPLICATIONS OF WOUND HEALING
HEMORRHAGE
- Bleeding from a wound site
- Normal during and immediately after initial trauma
o Hemostasis occurs within several minutes unless large blood vessels are involved
or a patient has poor clotting function
o Surgical wounds = risk of hemorrhage is great during first 24-48 hours after
surgery or injury
INFECTION
- Erythema, increased amount of wound drainage, change in the appearance of the
wound drainage (thick, color change, presence of odor), periwound warmth/pain or
edema
- Pt may have a fever and increased WBC
- Bacterial infections inhibit wound healing
- Contaminated or traumatic wounds show signs of infection early, within 2-3 days
- Surgical wound infection usually does not develop until 4-5 day postop
- Edges of the wound will appear inflamed
- If drainage is present, it is odorous and purulent = yellow, green or brown color
o Types of wound drainage
 Serous: clear, watery plasma
 Purulent: thick, yellow, green, tan or brown
 Serosanguineous: pale, pink, watery, mixture of clear and red fluid
 Sanguineous: bright red, indicates active bleeding
DEHISCENCE
- When an incision fails to heal properly, the layers of skin and tissue separate
- This occurs most commonly before collagen formation (3-11 days after surgery)
- Partial or total separation of wound layers
- Patient who is at risk for poor wound healing (poor nutritional status, infection) is at risk
- Obese patients have a higher risk of wound dehiscence because of constant strain
placed on their wounds and the poor healing qualities of fat tissue
- Can happen in abdominal surgical wounds and occurs after a sudden strain such as
coughing, vomiting, sitting up in bed
- When there is an increase in serosanguineous drainage from a wound in the first few
days after surgery, be alert for potential for dehiscence
EVISCERATION
- Total separation of wound layers
- Protrusions of visceral organs through a wound opening
- Emergency!
- Requires surgical repair
- Place sterile gauze soaked in sterile saline over extruding tissues to reduce chances of
bacterial invasion and drying of the tissues
- Immediately place damp sterile gauze over the site, contact surgical team, do not allow
patient anything by mouth, observe for s/s of shock, prepare patient for emergency
surgery

PREDICTION AND PREVENTION OF PRESSURE ULCERS

RISK ASSESSMENT
- Braden Scale: most widely used risk assessment tool for pressure ulcers
o However has shown insufficient predictive validity and poor accuracy in
discriminating intensive care patients at risk for developing pressure ulcers
o 6 subscales:
  Sensory perception: ability to respond meaningfully to pressure-related
discomfort
 Moisture: degree to which skin is exposed to moisture
 Activity
 Mobility
 Nutrition
 Friction and shear
o Total scores ranges from 6-23
 Lower score = higher risk for pressure ulcer development
 Cutoff score for onset pressure ulcer risk in general adult population = 18
PREVENTION
- Medicare and Medicaid = no additional reimbursement for care related to stage 3 and 4
pressure ulcers
FACTORS INFLUENCING PRESSURE ULCER FORMATION AND WOUND HEALING
- Nutrition: 1500 kcal/day for nutritional maintenance
o Wound healing = proteins, vitamins (A and C), and the trace minerals zinc and
copper
o Cals = energy source
o Serum proteins = biochemical indicators of malnutrition (albumin)
- Tissue perfusion: O2 fuels cellular functions
o PVD = risk for poor tissue perfusion because of poor circulation
- Infection: Prolongs inflammatory phase, delays collagen synthesis, prevents
epitheliazation, increases the production of cytokine = leads to additional tissue
destruction
o Presence of purulent drainage; change in odor, volume or character of drainage;
redness in surrounding tissues; fever; pain
- Age: Decrease in functioning of the macrophage = delayed inflammatory response,
delayed collagen synthesis and slower epithelization
- Psychosocial impact of wounds: body image changes = great stress on adaptive
mechanisms

NURSING PROCESS – ASSESSMENT

- Assess on admission and on regular basis
- Identify factors that may delay healing
- Assess the patient’s perception of what is occurring with the wound-healing
interventions
- Nursing assessment questions
o Sensation: tingling? Skin sensitivity to heat/cold?
o Mobility: is movement painful? Can you change position easily?
o Continence: problems or accidents leaking urine or stool? What help do you
need whne using the toilet? How often do you use toilet?
o Presence of wound: cause? When? Tetanus shot?
- Skin
o High risk patients have skin assessments every 4 hours
 o Assessment for tissue pressure damage includes visual and tactile inspection of
skin
o Hyperemia = gently palpate the reddened tissue; blanchable?
o Blanchable erythema = disappears within several hours
o Nonblanchable = indicates structural damage to capillary bed; indication for
stage 1 pressure ulcer
o UNDRESS AND TURN
- Pressure ulcers
o Predictive measures: Braden scale
o Mobility: muscle tone and strength. Inadequate ROM to move independently to
a more protective position. Assess activity tolerance. MUST assess mobility as
part of baseline data
o Nutritional status: within 24 hours of admission. Malnutrition is a risk factor for
pressure ulcer formation. Weigh patient and perform this measure more often
for at risk patients. Loss of 5% of usual weight, weight less than 90% of ideal
body weight and a decrease of 10 lbs in a brief period = signs of actual/potential
nutritional problems.
o Body fluids: Saliva and serosanguineous drainage = not as caustic to the skin.
Urine/bile/stool/ascetic fluid and purulent wound exudate = moderate risk for
skin breakdown. Gastric and pancreatic drainage = highest risk for skin
breakdown
o Pain: maintain adequate pain control for patient’s willingness and abil8ity to
increase mobility
- Wounds
o Important to initially obtain information regarding the cause and history of the
wound, treatment, wound description and response to therapy
o Emergency setting
 ABC’s
 Inspect wound for bleeding; for foreign bodies or contaminant material;
size and depth of wound;
 Use disposable wound-measuring device to measure width and
length
 Measure depth by using a cotton tipped applicator in wound bed
 Determine when pt last received tetanus toxoid injection
 Necessary if patient has not had one in 10 years
o Stable setting
 Consider analgesic at least 30 minutes before exposing a wound
o Wound appearance
o Character of wound drainage:
 Note amount, color, odor and consistency
 Weigh dressing and compare it with the weight of the same dressing that
is clean and dry
 General rule is that 1 g of drainage equals 1 mL of volume of
drainage
 o Drains
 Some drains are sutured in place
 Penrose drain: lies under a dressing; wound will heal from inside out
o Wound palpation
 Lightly press the wound edges, detecting areas of tenderness or drainage
 If pressure causes fluid to be expressed, note character of drainage
 Extreme tenderness = infection
o Wound cultures
 If purulent or suspicious looking drainage, may need a cuture
 Clean wound with NS first to remove skin flora
 Culturette
 Gold standard of wound culture = tissue biopsy
WOUND MEASUREMENTS
- Made in cm
- First measurement = head to toe
- Second = side to side
- 3rd = depth
- If there is any tunneling (when cotton tipped applicator is placed in wound, there is
movement) or undermining (when cotton tipped applicator is placed in wound, there is
a lip around the wound) this is charted with respect to clock

IMPLEMENTATION
- 3 major areas of nursing interventions for prevention of pressure ulcers
o Skin care and management of incontinence
 Avoid soap and hot water
 Use cleansers with nonionic surfactants that are gentle to the skin
 Make sure skin is completely dry
 Apply moisturizer to keep epidermis well lubricated but not
oversaturated
 Incontinent episode = gently clean area, dry, apply thick layer of moisture
barrier to exposed areas
 Bowel incontinence = proper diet and meds
 Urinary = behavioral techniques, medication and surgery = timed voiding
 Use absorbent apds and garments
o Mechanical loading and support devices, which includes proper positioning and
the use of therapeutic surfaces
 Elevating HOB to 30 degrees or less
 30 degree lateral position
 Shift weight every 15 minutes while sitting
 Sit on foam/gel/air cushion
 Rigid and donut shaped = reduce blood supply
 Never massage reddened areas
o Education
ACUTE CARE
- Management of pressure ulcers
o Acute wounds = assess every 8 hours
o Evaluate the wound with every dressing change, usually not more than 1 time
per day
- Wound management
o Clean pressure ulcers only with noncytotoxic wound cleaners like normal saline
or commercial wound cleaners
o Irrigation: common method of delivering a wound-cleansing solution to wound.
Debrides cecrotic tissue with pressure that can remove debris from wound bed
without damaging healthy tissue
 Use 19 gauge angiocatheter and 35 ml syringe that delivers saline to a
pressure ulcer at 8 psi
o Debridement: removal of nonviable, necrotic tissue
 Removal of necrotic tissue is necessary to rid the wound of a source of
infection, enable visualization of the wound bed and provide a clean base
necessary for healing
 During debridement, some normal wound observations include:
 Increase in wound exudate, odor and size
 Administer an ordered analgesic 30 minutes before debridement
 Methods
 Mechanical
o Wound irrigation and whirlpool treatments
 Autolytic
o Removal of dead tissue via lysis of necrotic tissue by the
WBCs and nautral enzymes of body. Use dressings that
support moisture at the wound surface. If wound base is
dry, use a dressing that adds moisture. If there is excessive
exudate, use a dressing that absorbs the excessive
moisture while maintaining moisture at the wound bed =
transparent film and hydrocolloid dressings
 Chemical
o Use of topical enzyme preparation, Dakin’s solution or
sterile maggots. Dakin’s solution breaks down and loosens
dead tissue in a wound. Apply solution to gauze and apply
to wound. Sterile maggots ingest dead tissue
o Requires HCP order
 Sharp/surgical
o Removal of devitalized tissue with scalpel, scissors or other
sharp instrument. Usually performed by physicians.
Quickest method of debridement. Usually indicated when
patient has signs of sepsis or cellulitis
 Moist environment supports the movement of epithelial cells and
facilitates wound closure
  Excessive exudate/drainage = supports bacterial growth, macerates the
periwound skin and slows healing process
- Protecting a wound from further injury
o Place a folded thin blanket or pillow over abdominal wound
o Light but firm pressure over wound when coughin
o Wear an abdominal binder
- Education
- Nutritional status
o If patient’s oral intake is inadequate, enteral nutrition is likely choice
o 30-35 calories/kg
o Increased caloric intake helps replace subcutaneous tissue
o Vitamin C = collagen synthesis, capillary wall integrity, fibroblast function and
immunological function
o Pt can lose as much as 50 g of protein per day from an open, high exudative
pressure ulcer
o Recommended intake of protein = 0.8 g/kg/day
 Need 1.8 g/kg/day for ehaling
o Maintain Hb 12g/100 mL
FIRST AID FOR WOUNDS
- Dressings
o Mechanically debride the wound using a saline moist-to-dry dressing
 When wounds such as a necrotic wound require debriding, a moist to dry
dressing technique can be considered
 You place the moist dressing (contact) over wound bed, cover with a
clean gauze and allow the contact layer to dry
 Contact dressing is allowed to dry so it stick sto underlying tissue and
debrides the wound during removal
 Nonselective
 Recommended for debridement in a necrotic wound
- Minimize periwound skin breakdown by keeping skin clean and dry and reduing the use
of tape
- Moist wound base facilitates the movement of epitheliazation
TYPES OF DRESSINGS
- To avoid causing damage to the periwound skin, it is important that the dressing
technique that yo use to treat pressure ulcers and other wounds is not excessively moist
- Gauze sponges: absorbent and especially useful in wounds to wick away wound exudate
o 4x4 size most common
o Can be saturated with solutions and used to clean and pack a wound
o Unfolding dressing allows easy wicking action
o Purpose = provide moisture to wound yet allow wound drainage to be wicked
into dry cover gauze pad
- Self-adhesive transparent film
o Traps moisture over a wound, providing a moist environment
 o Transparent film dressing ideal for small superficial wounds such as stage 1
pressure ulcer or partial-thickness wound
o Use film dressing as a secondary dressing and for autolytic debridement of small
wounds
o Advantages
 Adheres to undamaged skin
 Serves as a barrier to external fluids and bacteria but till allows the
wound surface to breathe because oxygen passes through transparent
dressing
 Promotes a moist environment that speeds epithelial cell growth
 Can be removed without damaging underlying tissues
 Permits viewing a wound
 Does not require a secondary dressing
- Hydrocolloid dressings
o Dressings with complex formulations of colloids and adhesive components
o Adhesive and occlusive
o Wound contact layer of this dressing forms a gel as wound exudate is absorbed
and maintains a moist healing environemtn
o Support healing in clean granulating wounds and autolytically debride necrotic
wounds
o Functions
 Absorbs drainage through the use of exudate absorbers in the dressing
 Maintains wound moisture
 Slowly liquefies necrotic debris
 Impermeable to bacteria and other contaminants
 Self-adhesive and molds well
 Acts as preventive dressing for high-friction areas
 May be left in place for 3-5 days, minimizing skin trauma and disruption
of healing
o Useful in shallow-to-moderately deep dermal ulcers
o Cannot absorb amount of drainage from heavily drainage wounds
o Contraindicated for use in full-thickness and infected wounds
o Most leave a residue in the wound bed that is easy to confuse with purulent
drainage
- Hydrogel dressings
o Gauze or sheet dressings impregnated with water or glycerin-based amorphous
gel
o Hydrates wounds and absorbs small amounts of exudate
o For partial-thickness and full-thickness, deep wounds with some exudate,
necrotic wounds, burns and radiation damaged skin
o They can be very useful in wounds because they are soothing and do not adhere
to wound bed
o Disadvantage = require secondary dressing and you must take care to prevent
periwound maceration
 o Come in a sheet dressing or tube; squirt gel directly into wound base
o Advantages
 Soothing and can reduce wound pain
 Provides moist environment
 Debrides necrotic tissue (by softening)
 Does not adhere to the wound base and is easy to remove
- Foam dressings
o Large amounts of exudate and those that need packing
o Used around drainage tubes to absorb drainage
- Calcium alginate
o Manufactured from seaweed and come in sheet and rope form
o Aglinate forms a soft gel when in contact with wound fluid
o Highly absorbent
o For wounds with an excessive amount of drainage and don’t cause trauma when
removed
o DO NOT USE THESE IN DRY WOUNDS and they require a secondary dressing

DRESSINGS BY PRESSURE ULCER STAGE

STAGE 1
- Intact
o No dressing
o Allows visual assessment
o Resolves slowly without epidermal loss over 7-14 days
o Turning schedule; support hydration and nutrition
STAGE 2
- Clean
- Composite film
o Limits shear
o Heals through reepithelialization
- Hydrocolloid
o Change when seal of dressing breaks. Max wear time = 7 days
- Hydrogel
o Provides moist environment
STAGE 3
- Clean
- Hydrocolloid
o Must change when seal of dressing breaks; max wear time = 7 days
o Heals through granulation and reepitheliazation
- Hydrogel covered with foam dressing
o Applied over wound to protect and absorb moisture
- Calcium alginate
o Used with significant exudate; must cover with secondary dressing
- Gauze
 o Used with NS or other prescribed solution; must unfold to make contact with
wound
STAGE 4
- Clean
- Hydrogel covered with foam dressing
- Calcium alginate
- Gauze
UNSTAGEABLE
- Wound with eschar
- Adherent film
o Facilitates softening of eschar
o Eschar lifts at edges as debridement progresses
- Gauze plus ordered solution
o Delivers solution and softens eschar
- Enzymes
o Facilitates debridement
- None
o If eschar is dry and intact. No dressing used. Eschar acts as a physiological coer
o May be indicated in heel eschar treatment

PACKING A WOUND
- First step is to assess size, depth and shape
o Determines size and type of dressing used to pack wound
- Dressing needcs to be flexible and in contact with entrie wound surface
- Alginate used for packing
- Gauze = saturate with solution, wring, unfold and lightly pack
- Entire wound surface needs to be in ctonact with part of the moist gauze dressing
- Don’t pack a wound too tightly
o Overpacking = causes pressure on the wound bed tissue
o Pack wound only until packing material reaches the surface of the wound
o Should not extend higher than wound surface
o Packing that overlaps = maceration of skin surrounding wound
- Negative-pressure wound therapy/vacuum-assisted closure
o Subatmospheric (negative) pressure to wound through suction to facilitate
healing and collect wound healing
o Device that helps in wound closure by apply8ing localized negative pressure to
draw edges of a wound together
o Supports wound healing by edema reduction and fluid removal, macro
deformation and wound contraction, and micro deformation and mechanical
stretch perfusion
o Angiogenesis, granulation tissue formation and reduction in bacterial bioburden
o Treats acute and chronic wounds
o Wear time for dressing = 24 hours – 5 days
o As wound heals, granulation tissue lines its surface
 o Enhances adherence of split thickness skin grafts
o Airtight seal mut be maintained

DRAINAGE EVACUATION
- Convenient portable units that connect to tubular drains lying within a wound bed and
exert a safe, constant, low pressure vacuum to remove and collect drainage
o Evacuator collects drainage
o Assess for volume and character every shift
HYPERBARIC OXYGEN
- Delivers 100% o2
- 30-40 treatments m-f
- About 2 hours
- Can be very successful
BANDAGES AND BINDERS
- Use tape, ties or secondary dressing to secure a dressing
- Strips of tape are used to secure dressings
o Nonallergenic paper and silincone tapes = minimize irritation
o Ensure it adheres to several inches of skin on both sides
o Press tape gently making sure to exert pressure away froun wound
o Remoce = loosen ends and gently pull the outer end parallel ith the skin surface
toward wound. Apply light traction to skin away from the wound as tape is
loosened and removed
- Montgomery ties = reusable

BANDAGES AND BINDERS

- Creates pressure over a body part
- Immobilize body part
- Support wound
- Reduce/prevent edema
- Secure splint
- Secure dressings
- Binders = bandages made of large pieces of material to fit a specific body part. Most are
elastic or cotton
PRINCIPLES FOR APPLYING BANDAGES AND BINDERS
- Inspect skin for abrasions, edema, discoloration or exposed wound edges
- Covering exposed wounds or open abrasions with a dressing
- Assessing the condition of underlying dressings and changing if soiled
- Assessing the skin of underlying areas that will be distal to bandage for signs of
circulatory impairment to provide a means for comparing changes in circulation after
application
- Nurse who applies a bandage loosens and readjusts as necessary
- Need HCP before loosening or removing bandage applied by HCP
- Feels relatively firm or tight
- Replace any soiled bandage
Binder application
- Binders = designed for the body part to be supported
- Most common = abdominal
o Supports large abdominal incisions vulnerable to tension or stress as patient
moves or coughs
o Secure with safety pins or Velcro strips
- Slings: support arms with muscular sprains or fractures
o Patient lies supine during application
o Bend affected arm, bringing forearm straight across chest
o Base of triangle under wrist and the point of triangle at elbow
o Tie ends at side of neck
o Fold loose material at elbow evenlow around elbow then pin to secure
o Always support the lower arm and hand at a levelabove the elbow to prevent
formation of dependent edema
- Roll bandage application: Secure or support dressings over irregularly shaped body
parts

HEAT AND COLD THERAPY

- Assessment for temperature tolerance
o Skin assessment. Neuro function testing for sensation . assess mental status and
LOC
o Do not cover an active area of bleeding with warm application = bleeding
conditinues
o Do not use warm for patient who has an acute, localized inflammation such as
appendicitis
o Don’t use if CV roblems
o Cold = don’t use if already edematous. Impaired circulation. Neuropathy.
Shivering
- Bodily responses to heat and cold
- Check patient and skin every 20 minutes. Observe for excess redness, pain, tingling