Skin Integrity and Wound Care
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Transcript Skin Integrity and Wound Care
Jeanne Lowe PhD, RN, CWCN
VA HSR&D Center of Excellence
Objectives:
•Describe skin function and structure
•Discuss normal phases of healing
•Identify factors that can interfere with normal healing
•Describe basics of wound assessment
•Discuss different categories of wound dressings
2
Functions of the Skin
Protection
Thermoregulation
Sensation
Metabolism
Communication
3
Skin Structure
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
4
Factors Contributing to Impaired
Skin Integrity
Circulation
Systemic Diseases
Nutrition
Trauma
Condition of the
Excessive Exposure
Epidermis
Allergies
Infections
Mechanical Forces
Friction
Shearing
Pressure
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Phases of Wound Healing
Hemostasis and Inflammation
Platelets release
vasoactive substance
causing permeability
enzymes that attract
leukocytes
growth hormones that
influence fibroblasts
Wound develops
erythema and edema
Phases of Wound Healing
Wound “clean up”
Neutrophils arrive
Phagocytosis
Macrophages appear
within 3-4 days
Phagocytosis
Release of enzymes
that trigger fibroblast
response
Stimulate
angiogenesis
Wound Repair
Regeneration of injured cells by cells of same type
(i.e. Epidermis, bone)
Replacement by fibrous tissue (fibroplasia, scar
formation)
Epithelialization
Fibroplasia (Proliferation)
Occurs within the granulation tissue
framework (new blood vessels and loose
collagen)
Proliferation of fibroblasts at site of injury
Growth factors
Cytokines
Wound Healing
Granulation = Collagen and Capillaries
Surgical Wound
Intentional injury that disrupts blood vessels and
causes clotting and cascade of events that leads to
wound closure within 2 to 4 weeks
History of Surgery
18th Century surgeons were
apprentices of barbers and
butchers
Primary Closure
Patient Risk Factors for Post-Surgical Wound
Complications
Obesity
Diabetes
Immunosuppression
Cardiovascular disease
Smoking
Cancer
Previous surgery
Malnutrition
Surgical Wounds: Complications
Hemorrhage
Hematomas
Infection
Dehiscence
Evisceration
Fistula
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Incision Healing Time
Epithelial resurfacing complete at 2-3 days
No tensile strength, but impenetrable to bacteria
“Healing ridge” 5-9 days
Lack of ridge = interventions to reduce incisional strain
Most dehiscences occur 5-8 days post-op, and
about half are associated with infection
Incision Care
Cover with dry sterile dressing 24 to 48
hours, then open to air
Gently wash between sutures/staples to
remove crusts
Report persistent pain, bleeding, erythema,
wound edge separation or cloudy drainage
Wound Closure Aids
Steri-strip
Montgomery straps
Medical Staples
Sutures
22
Steri-Strips
23
Montgomery Straps
24
Medical Staples
25
Suture/Staple Removal
Usually removed 7-10 days post-op
Incisions over areas with tension up to two
weeks
If concerned about incision dehiscence:
Remove every other one
Steri-strip
Wound Dehiscence
Fascial or Cutaneous
disruption
Heavy bacterial load
Long time-lapse since
wounding
Crushed or ischemic
tissue – severe
contused avulsion
injury
Sustained high-level
steroid therapy
Secondary Intention
(includes chronic wounds)
Large tissue defect
More inflammation
More granulation tissue
Wound contraction - myofibroblasts
Factors Inhibiting Wound Healing
Medication
Cortisone, and epinephrine
Malnutrition
Protein & calories
Vitamin & mineral deficits
Zinc, Vitamin A, Vitamin C, Vitamin E
Dehydration
Edema
Perfusion
Chronic illness & other conditions
i.e. diabetes, CHF, immobility
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Principles of Wound Care
Keep wound moist
Manage drainage
Fill deep wounds
Control bacterial load
Protect wound from trauma
Assess healing
Keep Wounds Moist
Select dressings that
maintain moisture.
Minimize time that
wounds are open to air.
Add moisture to wound
bed?
Manage Drainage
Maceration makes skin
more fragile.
Excessive drainage
requires nursing time.
Fill Dead Space
Fill wound with
dressing
Be careful not to
over-fill (no rocks)
Control Bacterial Load
Take time to wash or
irrigate wounds to
decrease bacterial load.
No need to scrub!
Protect From Trauma
Be gentle to skin
Use non-stick
dressings
Minimize tape
But . . .
Remember to protect yourself from splash
Assess
Know what is under
the dressing
Know typical healing
pattern
Size matters
Document
Document findings
Location
Size (length / width / depth)
Wound base
Drainage
Surrounding skin
Systemic infection
What we’re doing
Wound Documentation:
Wound Base Descriptors
Granulation tissue
Red, cobblestone/beefy.
Only in full thickness
wounds
Epithelial tissue
Regrowth of epidermis
Pink or pearly
Smooth, shiny
Wound Documentation:
Wound Base Descriptors
Slough
Necrotic/avascular tissue.
Moist.
Can be white, yellow, tan, or
green.
Eschar
Necrotic/avascular.
Black or brown
Hard or soft.
Often leathery adherent tissue.
Wound Healing Basics
Wounds do best in moist environment
not too wet, not too dry
Loosely pack when needed
tight packing → injury to wound bed.
Protect peri-wound skin
No Sting Barrier
Cleanse/irrigate before assessment
Pre-medicate for pain prior to dressing changes
If culture is needed
cleanse wound thoroughly prior to swabbing
swab in area of granulation/viable tissue if present.
Never culture dressing!
Product Selection
Frequency of change
Ease of procedure
Caregiver ability
Availability of products
Cost/reimbursement factors
Dressing Purposes:
To absorb drainage
To prevent contamination
To prevent mechanical injury to the wound
To help maintain pressure to prevent
excessive bleeding
To provide a moist wound environment
To provide comfort
Topical Wound Care Products
Alginates/Fiber Gelling Dressings
Antimicrobials
Collagen
Contact Layers
Foams
Gauze & Impregnated Gauze
Hydrocolloid
Hydrogels (Amorphous)
Skin Sealants
Topical Debriders
Negative Pressure Therapy
Compression Therapy
Gauze Packing
(Kerlix, Nu-gauze, 4 x 4s)
description - inexpensive,
user dependent
indications - to fill deep
defects to maintain moisture
and absorb exudate, may
be soaked with antibiotic
solution
considerations - pack lightly,
may cause surrounding
wound maceration, may
traumatize wound if allowed
to dry
Contact Layer Dressings
(Greasy gauzes, N-terface, Adaptic, Xeroform, Mepitel)
description - nonadherent,
prevents trauma and
permits exudate to “pass
through” pores of dressing
for absorption by a
secondary dressing,
inexpensive
indications - superficial
wounds with minimal to
moderate exudate
contraindications - if goal is
to “clean up” wound
Hydrocolloids
(Duoderm, Comfeel)
description - absorbs
exudate, maintains
moisture, insulates, protects
from secondary infection,
non-permeable
indications - or superficial
wounds with minimal to
moderate drainage
contraindications - infected
wounds
Typically changed every
3 - 5 days
Polyurethane Foam
(Mepilex,Biatain, LyoFoam)
description - nonadherent
foam, absorbs exudate,
insulates, variable protection
from environmental
contaminants (outer layer water
proof or water-repellent)
indications - superficial
weeping wounds, cover for
deep (packed) wounds
leave on for 3 - 5 days or change
when cover-layer is at least
50% saturated
Hydrogels
(solid gel sheets or amorphous gel)
description - nonadhesive,
maintains moisture, protects wound
and allows visualization, nonabsorptive
indications - superficial wounds with
minimal drainage; amorphous gel
may be buttered on semi-dry red
wound before applying moist
dressing; good dressing for arterial
ulcers
contraindications - heavily
exudating wounds
Alginates / Fiber Gel
(Kaltostat, Sorbsan, Medifil, Aquacel)
description - applied to
wound dry but forms gel
with absorption of exudate
indications - heavily
exudating wounds to allow
daily or QOD dressing
changes
contraindications - minimally
exudating wounds (it will
stick to wound and
dehydrate)
Moisture Barriers
Barriers are products
that wick away
moisture from skin
Contain
Zinc oxide
Dimethicone
Petrolatum
Polymer
(i.e. SensiCare,
Proshield, Perineal
wipes, No Sting)
Compression Therapy
(Profore, SurePress, Jobst, Isotoner)
description – Single or multilayer compression bandage or
stocking usually applied over
primary dressing
indications – management and
treatment of venous leg ulcers.
Can be left on for up to one
week.
contraindications – do not use
on patients with ABI <0.8 or on
diabetic patients with advanced
small vessel disease
Tapes and Adhesives
Consider
gentleness to skin
Consider cost
Consider job to be
done
Clinical Interventions
Monitor skin at every visit
Evaluate type of skin care practices
Assess patient and/or caregiver ability
Minimize exposure of skin to moisture from
incontinence, perspiration, or drainage
Evaluate need for specialty mattresses or
seating cushions
Assess nutritional status
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Nutritional Deficits
Determine barriers to the patient
eating sufficient quantities of quality
food
Nutritionist consult?
Diabetes education?
Moisture and incontinence
Minimize exposure to moisture and soiling
Use briefs and underpads to wick away
moisture from skin
Teach patients & caregivers to cleanse skin
at the time of soiling
Urine & feces very caustic
Use barrier cream as necessary
Pressure Ulcer Prevention
Assess for risk factors: immobility, moisture
& incontinence, inadequate nutrition,
impaired sensation or perception,
decreased activity, exposure to friction &
shear
Incorporate risk assessment into plan of
care
Monitor patient’s skin at each visit
Document Evaluation
Is the skin intact?
Is the wound healing? Did the interventions work
or not?
If no progress at two-week assessment, time to
change interventions
If yes, do you want to continue?
If no, how do you want to revise?
Does patient understand risk factors and wound
care plan?
Case Studies
89-year-old male with hx of COPD with chronic
steroid use. Uses 2 L O2 at home and smokes 1/2
pack cigarettes a day. Hx. Includes DM, depression,
and prostate cancer.
Presents to your clinic with right forearm wound after
scraping arm against wheelchair.
How do we optimize healing?
Case Studies
49-year-old male with hx of IV heroin use. Smokes 2
packs cigarettes a day. Hx also includes Hep C,
depression, and hypertension.
Presents to your clinic with fever, chills, and right
lower limb wound that he has had for months.
Case Studies
46 year-old female admitted to hospital for elective
surgery to remove renal growth. Morbidly obese,
uses 2 L O2 at home, smokes 2 packs a day. Hx
includes DM, depression, sleep apnea. Rarely gets
out of bed at home (able to walk w/ assistance to
bathroom).
Suspected deep tissue injury to sacrum present on
admission. Wound surgically debrided.
Warning . . .
What do you see?
Make sure there are no hidden surprises
Questions?