Skin Integrity and Wound Care Study Guide
 Pressure Ulcers
 = Impaired skin integrity caused by unrelieved pressure resulting in damage to underlying tissue
 Risk Factors:
 Decreased mobility, incontinence, poor nutrition, decreased sensory perception, impaired mental
awareness
 Over 1 million persons/year develop pressure ulcers
 Development of Pressure Ulcers
 localized tissue ________________ (obstructed blood flow):
 If pressure relieved in a short time: Reactive hyperemia (capillaries dilate but blanchable hyperemia;
no tissue loss if pressure relieved)
 Nonblanchable hyperemia: indicates tissue damage; first stage of pressure ulcer development but
reversible if pressure relieved and tissue protected
 Contributing Factors to Pressure Ulcer Development
 Shear
 tissue is caught between 2 hard surfaces (bed and bony skeleton) causing obstructed blood supply to
deep tissues
 Ex: When HOB elevated, gravity pulls skeleton down but skin does not move against sheets
 Friction: 2 surfaces rubbing against each other (heels and elbows most at risk)
 Contributing Factors to Pressure Ulcer Development
 Moisture (incontinence, perspiration, wound drainage)
 Poor nutrition
 Serum hypoalbuminemia (less than 3g) results in tissue edema; blood supply is decreased and waste
products remain
 _____________: extreme thinness; loss of adipose tissue to protect bony prominences
 Infection and fever: increase metabolic rate which makes hypoxic tissue more susceptible
 Age: loss of skin thickness and increased skin tears
 Wound Classification
 Stage 1: nonblanchable erythema
 Stage 2: partial thickness skin loss
 Blister, abrasion, shallow crater
 Stage 3: Full thickness skin loss
 Deep crater, loss of subcutaneous tissue
 Stage 4 = Stage 3 plus tissue necrosis or damage to muscle, bone or supporting structures
 Wound Healing Process
 Primary Intention: edges are _______________ Ex: surgical incision
 Secondary Intention: edges not approximated so healing occurs gradually
 Layer of granulation tissue
 Ex: Pressure ulcers
 Longer repair time, greater scarring, increased risk of infection
 Tertiary intention: edges heal by secondary then primary
 Phases of Wound Healing
 Inflammatory: initiated immediately
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 Hemostasis: cessation of bleeding and white blood cells brought to the site.
 Epitheliazation or Granulation (best in moist environment; cells migrate from edges)
 If full thickness wound: collagen is synthesized (whitish protein) and wound contracts
 Granulation tissue: capillary network: fragile, bleeds easily
 Remodeling phase up to one year in full thickness wounds; reorganizes collagen
 Factors affecting wound healing
 Age (slower, increased risk of infection)
 Nutrition
 Infection (prolongs healing)
 Obesity (less blood supply)
 Extent of wound
 Tissue perfusion
 Smoking
 Immunosuppression
 Diabetes mellitus
 (impaired perfusion, increased risk of infection)
 Wound stress
 Complications of Wound Healing
 Excessive bleeding: external or internal
 Internal = ______________________ (collection of blood underneath tissues)
 Risk greatest during first 48 hours
 In emergency: apply pressure, monitor VS while MD is called
 Infection
 Locally: Redness, warmth, tenderness, purulent drainage
 If systemic: fever, malaise or increased WBC
 Confirmed by wound culture
 If traumatic wound, appears in 2-3 days; Surgical wound: 4-5 days
 Dehiscence: partial or total rupture of wound
 Increased risk if obese or sudden strain
 Can occur 3-11 days after injury; suspect if serosanguineous drainage increases
 Evisceration: protrusion of internal contents after dehiscence
 Risk factors: Obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing,
vomiting, dehydration
 If occurs: cover with large sterile dressings soaked in saline, pt lies in bed with knees bent while
surgeon notified
 Fistulas: abnormal opening between 2 areas
 Assessment: Predicting and Preventing Pressure Ulcers
 Risk Assessment Tools: ____________________
 lower the number, the higher the risk
 16 or below: “at risk”; 9 or below: “high risk”
 Assess:
 on admission (to document existing lesions)
 daily for patients at high risk
 Specific actors assessed: sensory perception, moisture, activity, nutrition, friction and shear
 Skin & Pressure Ulcer Assessment
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 Assess all areas of skin from head to toe
 Baseline: patient’s normal skin characteristics and any actual or potential areas of breakdown
 Especially: heels, sacrum, elbows, occiput
 Reassess daily for high risk patients
 Document the assessment
 If you notice hyperemia:
 Check if blanchable or nonblanchable; document:
 Location, size, color,
 Recheck in 1 hour; if still there: document & check for induration which indicates progressive
tissue damage
 If wound exists, perform wound assessment
 Wound assessment
 Anatomic location, size, approximation of wound edges, presence of exudate, condition of underlying
tissue, signs of infection
 If drains are present: (used if large amounts of drainage expected)
 Security of drain
 Character and amount of drainage
 If surgical wound:
 Pain assessment and effect on mobility
 If dressing still present from surgery, surgeon usually performs 1st dressing change; assess the
dressing for character and amount of drainage
 After 1st dressing change: assess if staples, sutures, glue present; if edges are approximated; any
signs of infection, dehiscence or evisceration; character and amount of drainage
 Types of Wound Drainage
 Serous: clear portion of blood, watery
 Ex: blister from burn
 Purulent: thick yellow, green
 Odor often present
 Sanguineous: fresh bleeding
 Serosanguineous: clear/pink with blood streaks
 Ex: surgical incisions
 Potential Nursing Diagnoses
 Risk for Impaired Skin Integrity
 Impaired Skin Integrity
 Risk for Infection
 Pain
 Imbalanced Nutrition
 Impaired Physical Mobility
 Assess factors that contribute to diagnosis and these become focus of your interventions
 Planning: Goals
 Prevent skin breakdown
 Reduce impaired skin integrity
 Promote wound healing
 Implementing
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 Support Wound Healing
 Nutrition: Adequate Protein (may need supplements), Vits C, A, B1, B5, Zinc
 Fluids: 2500 ml/day if not contraindicated
 Promote good rest
 Prevent Infection
 Systemic support
 Oxygen
 Blood sugar control
 Consider meds (Prednisone delays healing)
 Topical skin care
 Assess daily; pay attention to bony prominences; do not massage red areas
 Use mild cleansing agent
 Examine for dryness, cracking
 Use a good moisturizer like Eucerin
 Examine for edema and moisture
 If incontinent:
 Use moisture-barrier product to protect
 Use zinc oxide barrier paste if already irritated
 Treat incontinence
 Consider fecal incontinence collector
 If use diapers or underpads, selct those that wick moisture away from skin; do not leave on for
extended periods
 Positioning
 Reposition immobile patient at least every 2 hours
 If patient can reposition self, teach to shift weight every 15 minutes
 If sitting: use gel or air cushion
 Reduce shear by:
 Keeping HOB below 30 degree angle
 Use assistive devices when turning or transferring
 Use 30 degree lateral position (Fig 35-9)
 KEEP _______________ OFF BED
 Support Surfaces
 Heel protectors, chair pillow, foam overlay mattresses, static air and low air loss mattresses,
specialty beds (air fluidized and kinetic)
 Wound Healing Principles
 Control or eliminate causative factors
 Pressure, shear, friction, moisture
 Provide systemic support
 Nutritional and fluid support
 Control of factors affecting wound healing (oxygen, blood sugar control)
 Maintain wound environment
 Prevent and manage infection
 Cleanse wound
 Remove nonviable tissue (debridement)
 Manage drainage/exudate
 Eliminate dead space
 Control odor
 Protect wound
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 Provide moist wound environment while protecting surrounding tissue
 Stable Wound Environment
 Control infection: assess and consult for wound culture and antibiotics
 Cleanse at each dressing change to promote removal of debris and bacteria
 If necrotic: consult for debridement
 Maintain moist wound environment without macerating surrounding tissue
 Appropriate dressing selection
 Eliminate dead space
 Treating Pressure Ulcers
 Use _____________ Color Code
 Red = developing granulation tissue: protect
 Yellow = “slough”
 cleanse to remove nonviable tissue
 Black = thick necrotic tissue
 debride (sharp, mechanical (wet to dry dsg), chemical, autolytic)
 Selecting Dressings
 Gauze: beware of maceration
 Transparent (Tegaderm):
 Often used to secure other dressings: can observe wound
 Impermeable to water & bacteria; allow oxygen in
 Hydrocolloids (Duoderm, Tegasorb):
 For pressure wounds with light drainage (but not infected)
 Absorbs; moist env without maceration; Protects; waterproof;
 Can be left on for several days
 Research: superior to gauze in wound healing
 Hydrogels: promote moisture
 Polyurethane Foams (Lyofoam, Allevyn)
 Absorbs exudate, must be taped/sealed
 Alginates (Algiderm): seaweed
 Absorbs up to 20x weight in exudate, requires second dsg
 Turns into gel – easily washed away
 Traditional dressings: wet to dry
 For Pressure Ulcers: for Mechanical Debridement only
 Question: What color wound would this include?
 Problems with these dressings:
 Maceration of surrounding skin
 Removes good granulation tissue
 Excessive moisture promotes bacterial growth
 Advocate for your patient and request a better dressing selection!
 Cleaning Wounds (agency protocol)
 Irrigation tray
Plexipulse irrigation
 Sterile or clean technique (agency protocol)
 Wound Irrigation and Packing
 Wound Vac
 Airtight seal; removes drainage
 Securing dressings
 Tape: ___________ tape is less irritating
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Apply skin barrier around wound
Montgomery ties avoid repeated removal of tape; can also place Duoderm around edges of wound
then tape to Duoderm to protect the skin
Binders can be applied over top for more protection
Remember pain management!!
 May need analgesics __________ mins before dressing change
 Evaluation
 Should see improvements in pressure ulcers within 1-2 weeks
 Improvement includes:
 Resolution of periwound redness in 1 week
 50% reduction of wound dimensions in 2 weeks
 Reduction in volume of exudate
 Decreased pain intensity during dressing changes
 If no improvement:
 Re-evaluate factors contributing to impaired healing
 Re-evaluate Dressing selection
 Also evaluate patient and family’s need for education and support services and initiate referral process
 Heat and Cold Application
 Local application of heat causes _____________: increases blood flow, bringing oxygen, nutrients,
antibodies and leukocytes
 Disadv: may result in edema
 Uses: musculoskeletal
 Local Effects of Cold: vasoconstriction, limits swelling and bleeding
 Uses: sports injuries (strains, sprains, fractures)
 Prolonged use: impairs circulation
 Implementing
 Precautions for heat/cold: Avoid if: neurosensory impairment, impaired mental status, impaired
circulation, immed. after surgery, open wounds
 Remember: Adaptation of Thermal Receptors: increased tolerance over time
 Heat: use for about 20 minutes, max 1 hour; beyond that, body causes vasoconstriction
 Cold: max effect when skin @ 60F, else body causes vasodilation (usually about 20 minutes)
 Applying Heat and Cold
 Dry heat: hot water bottle, heating pad
 Moist heat: compresses, soaks, sitz baths
 Dry cold: cold pack, ice
 Moist cold: compresses, cool sponge bath
 Guidelines: ID contraindications, assess skin, return in ______ mins to reassess, remove at designated
time, examine area and response
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