Skin and Wound Care
Skin Integrity, Impairments, and Interventions
Carolinas Rehabilitation
This self-directed learning module contains information
you are expected to know in order to provide quality
care to the rehab client and to be better prepared as a
rehabilitation professional.
Target Audience: All RNs and LPNs on all teams
Ancillary personnel as appropriate
Contents
Instructions ........................................................2
Learning Objectives...........................................2
Module Content .................................................3
Job Aid ..............................................................11
Posttest .............................................................12-13
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The material in this module is an introduction to important general information. After
completing this module, contact your Manager or Skin and Wound Care Specialist to
obtain additional information specific to your unit.
•
Read this module.
•
If you have any questions about the material, ask your Manager or Skin and
Wound Care Specialists.
•
Complete the online post test for this module.
•
The Job Aid on page 10 may be used as a quick reference guide.
•
Completion of this module will be recorded under My Learning in PeopleLink.
Learning Objectives:
When you finish this module, you will be able to:
•
Identify layers of the skin and its major purpose
•
State benefits of good circulation
•
Identify physiological and mechanical factors affecting skin integrity
•
Identify components of an assessment of patient at risk for impaired skin
integrity
•
State the expected outcomes related to potential impaired skin integrity
•
Identify nursing interventions used to maintain skin integrity for pressure
ulcers
•
Identify six stages of National Pressure Ulcer Advisory Panel (NPUAP)
staging guidelines for pressure ulcers
•
Describe necessary documentation related to wound healing
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I. Overview
Preserving and restoring skin is a major focus of professional nursing because
patients present with multiple risk factors and major disruptions in health.
Recovery can be seriously impeded when pressure ulcers develop. In 1994
AHCPR (Agency for Health Care Policy and Research) published a set of practice
guidelines based on extensive critique of research literature and expert review.
Rehab professionals need to be skilled in maintaining intact skin and in identifying
and treating pressure ulcer problems. The rehab professional’s major concern in
skin care is to prevent and when necessary, heal pressure wounds. All wounds
should be treated with appropriate care techniques and dressings as necessary.
II. Anatomy and Function of the Skin
The epidermis is the outermost layer of skin that protects deeper layers and is
constantly being replaced by newer cells from the dermis. It protects against
ultraviolet radiation and environmental antigens. It protects the body from injury,
retains moisture and excretes waste products. It also assists in regulating body
temperature. The dermal layer contains fibrous connective tissue and allows for
elasticity of the skin. It permits motion and supports healing. The subcutaneous
layer (hypodermis) contains sweat glands, oil glands, and hair follicles. It provides
blood supply to the skin and contains neuron receptors for touch, pain, and
vasomotor response. It is sustained by a layer of fat.
Circulation provides nutrients, oxygenation, and moisture. It promotes healing
through increased blood supply, phagocytosis, and tissue rebuilding. It also
provides support and healing in response to tissue load damage. The nerve
supply provides response to environment and supports homeostasis.
III. Risk Factors for Loss of Skin Integrity
Physiological factors affecting skin integrity include altered metabolic states that
increase the body’s need for nutrients and may cause cellular level impairment.
Other factors putting skin at risk include underlying medical issues like diabetes or
renal disease. Low serum protein albumin or hemoglobin identifies impairment of
the body’s cellular rebuilding activity. Impaired circulation from peripheral
neuropathies (sensory changes), anemia, atherosclerosis, or hypertension can
impact a body’s skin integrity. Prolonged pressure and immobility (motor
changes), can lead to pressure ulcer formation. Neurological injuries can result in
impaired sensation, resulting in inability to perceive the need to move the body.
Medications can suppress the immune response. Other risk factors include
smoking, poor nutrition, and incontinence. Increased age can impact skin integrity
because elderly people have diminished effectiveness of skin protection, slowed
healing ability and are more likely to have comorbidities and mobility problems.
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Mechanical factors affecting skin integrity include sustained pressure, especially
over bony prominences, as well as shearing, which are the movement of muscle,
subcutaneous, and fat tissues downward while compressing against bony
skeleton. The epidermis does not slide. This may happen when a patient is sitting
up in bed and slides down in response to gravity. Mechanical rubbing of tissue
across a rough surface (this occurs with incomplete lifting or dragging a patient to
pull up in bed) is called friction.
Body moisture from incontinence, diuresis or sweating, especially in the skin folds
of an obese patient can affect skin integrity. Also particular problems associated
with stomas, medical devices, incorrect fit prostheses, brace, or compression
stockings can impact the skin integrity.
Psychosocial factors that can affect skin integrity include nonconformance with
recommended health practices, substance abuse, impaired cognitive or intellectual
ability, depression and social isolation, particularly when the patient needs
assistance in daily care.
IV. Assessment of Patients at Risk for Impaired Skin Integrity
Components of an assessment should include the underlying medical conditions of
the patient, as well as nutritional status. Labs such as albumin and prealbumin,
hemoglobin, white blood count should be reviewed. Assess circulatory support
and presence of neurological injury, bladder and bowel function and body
moisture. Also assess a patient’s sensory-perceptual ability, mobility, activity and
exercise, and ability to position his or her body. Assess whether a patient is at risk
for pressure, shearing and friction, which may occur in the course of bedside care.
Note the patient’s age. Elderly patients are at particular risk for developing
pressure ulcers as they are most likely to have substantive problems in all of these
categories.
The Braden Scale is used to predict the patient’s risk for skin breakdown. The
Braden scale contains six weighted elements, grade from 1 (very poor) to 4
(excellent) and summed across all elements for a total score for individual’s status.
A score of 18 or less should prompt specific interventions to maintain or restore
skin integrity. Scoring should be repeated every day. Interventions should be
documented daily and from shift to shift based upon the score.
V. Expected Patient Outcomes Related to Potential Impaired Skin
Integrity
The expected outcomes are intact skin and demonstrated self-care measures in
the management of skin integrity.
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VI. Interventions to Maintain Skin Integrity
Ensure good nutritional support and use supplements if needed. Patients should
be turned and repositioned frequently. In bed, the patient should be repositioned
every 2 hours. In the wheelchair or seated position, patients should be encouraged
to reposition every 30 minutes to hourly. Clinicians should use good lifting, transfer,
and turning techniques. Cushion bony prominences and protect skin against
friction and shearing. Position the patient with adequate support and increase the
patient’s efforts toward mobility and activity. Use of positioning devices or devices
to offload bony prominences should be employed for those at risk of skin
breakdown from pressure, friction and shear. Care for the skin by inspecting each
shift. Cleanse skin at regular intervals and use a mild cleansing agent to preserve
the neutral pH of skin. Apply emollients to help retain or maintain skin moisture.
Avoid massaging bony prominences to avoid increased tissue damage. Minimize
exposure to incontinence, perspiration, or wound drainage by using wicking
materials to draw moisture away from the skin, using topical agents as protective
barriers, and instituting bladder and bowel training regimes whenever possible.
Teach patients about the importance of self-care in nutrition, management of tissue
loads, and general skin care.
VI. Normal Phases of Wound Healing
There are only two ways for soft tissue to heal. One is by regeneration, the other is
by scar formation also known as granulation. Epidermal cells regenerate, dermal
cells may regenerate depending on the depth. The hypodermis and muscle do no
regenerate, they rely on scar formation. A wound can be acute (occurring suddenly
such as trauma or surgically) or chronic (wounds that are acute and do not heal or
happen by other means of skin breakdown. The first phase of wound healing
includes vascular supply and wound stabilization (i.e., the wound bleeds and then
clots). The next phase involves inflammation of the tissue with influx of
phagocytes to remove dead tissue. Following this phase is proliferation of fibrin
and formation of a loose matrix within the wound, which supports additional tissue
formation and retention. The last phase is maturation of the wound when the fibrin
matrix evolves into intact skin. Wound healing is the orderly process of tissue
closure. Various descriptors are used for the different phases. Some texts identify
the phases as defensive, proliferative, epithelialization and maturation. Others
identify them as coagulation, inflammatory, proliferative, and remodeling stages.
The stages overlap in a continuum and vary based upon whether or not the wound
involves partial thickness or full thickness tissue destruction.
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VII. Essential Elements for Planning Nursing Care for Pressure Ulcers
and Expected Patient Outcomes
Nutritional support needs to provide sufficient protein to produce serum albumin
values of > 3.5, and the patient’s weight will be > 80% of ideal. Protein stores
require several weeks of intensive therapy to demonstrate a rise in serum albumin.
Prealbumin testing shows a rise in 3-5 days. Nurses should consult a Dietician to
assist in managing adequate nutritional intake. Management of tissue loads
includes resting skin surfaces and positioning to provide adequate protection for
the tissue load to be encouraged in healing and to prevent further loss. Fluid intake
needs to be monitored especially if a wound is draining. Another essential element
is care of the ulcer itself. Ulcer care will promote wound cleansing and healing.
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Response to treatment may be slow due to underlying vascular damage,
comorbidities, and immobility.
VIII. General Nursing Interventions for Pressure Ulcers
Interventions include promoting increased protein intake, vitamin C and zinc
supplement, and adequate hydration, as appropriate. Patients should be kept off
of the wound as much as possible and turned and repositioned at least every 2
hours using sheets to lift (not dragging the patient). Use positioning pillows to
maintain pressure relief; consider using pressure-redistributing devices (e.g., air
mattresses, heel lift boots). Encourage mobility. Skin should be kept clean, dry,
and lubricated. Linens should be changed promptly after any episodes of bladder
or bowel incontinence. Use a moisture barrier for added protection. Provide
consistent, timely treatments and document progress. Pressure ulcers become
visible quickly, worsen quickly, and heal slowly. Focus treatment approaches on
the whole person and the environment; pressure ulcers tend to be multivariant in
cause.
Pressure ulcers should be assessed and reassessed using standard staging
guidelines. Pressure ulcers are staged according to depth, characteristics of
wound bed, and potential involvement of deep fascia. NPUAP guidelines note that
the identification of Stage I redness may be problematic in individuals with darkly
pigmented skin. A reliable system for assessment should be developed. Pressure
ulcers are staged I through IV, plus deep tissue injury (DTI), and unstageable
ulcers.
•
Stage I includes non-blanchable erythema of intact skin of a localized area
over a bony prominence. The wound may present with warmth, edema,
induration, or hardness of soft tissues surrounding the pressure point.
•
Stage II is partial thickness skin loss of dermis and presents as a shallow
open ulcer with a red pink wound bed, without slough. May also present as
an intact or open- ruptured serum-filled blister.
•
Stage III is full thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon or muscle are not exposed. Slough may be present, but does
not obscure the depth of tissue loss. May include undermining or tunneling.
•
Stage IV is full thickness tissue loss with exposed bone, tendon or muscle.
Slough may be present on some parts of the wound bed. Undermining and
sinus tracts may be present and should be assessed for depth and
direction.
•
DTI is a purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or
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shear. The area may be preceded by tissue that is painful, firm, mushy,
boggy, warmer, or cooler as compared to adjacent tissue.
•
Unstageable ulcers have full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar
(tan, brown or black) in the wound bed.
IX. Nursing Interventions for Pressure Ulcers (See Skin and Wound
Care Protocol for details)
Stage I
•
•
Provide pressure redistribution for reddened areas where skin is still
intact
Protect the skin with protective barrier lotion if necessary
Stage II
• Keep the wound moist and clean to promote healing
• Use hydrogel ointments, hydrocolloid dressings or transparent absorbent
dressings if recommended
• During dressing changes, gently and thoroughly cleanse the wound
using either normal saline or a wound cleanser
• Adjust frequency of dressing changes to allow assessment of
improvement without disruption of fibroblastic activity and the inadvertent
entry of additional pathogens into the wound. In the absence of
symptoms of active infection, changing the dressing every 2-3 days may
be sufficient
Stage III
• Clean the wound first, as Stage III wounds usually have slough or
drainage and may have sinus tracts and undermining
• Gently, but thoroughly pack the ulcer and apply a secondary dressing,
as ordered.
• Use hydrophyllic foam dressings, calcium alginates, hydrofibers or or
other advanced dressing selections as ordered. If a wound is more than
0.5 cm deep, it will usually need to be packed or have gauze loosely
fluffed into the wound bed to wick the dead spaces. When using
nonselective debridement (e.g., normal saline wet-to-dry dressings), take
care to lessen the loss of new granulating tissue.
• Protect periulcer area from maceration
• Change dressings according to amount of drainage absorbed; irrigate
ulcer with each dressing change, as ordered.
• Decrease frequency of dressing changes as drainage slowly decreases.
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•
Use dressings, as ordered, that keep the wound base moist to promote
healing
Stage IV
• Regularly cleanse and pack the wound, which may extend into bone,
tendon, and muscle, until a clean epithelializing base is obtained (see
interventions for Stage III). Stage IV wounds often require surgical
closure with grafts or flaps once a clean base is obtained. Consider that
wounds with exposed bone may have osteomyelitis (bone infection) and
may need antibiotics.
DTI
• Provide pressure redistribution for affected areas
• Protect the skin with protective barrier lotion if necessary
• Monitor these areas frequently for changes or further breakdown
• Apply and change dressings as ordered
• DO NOT apply hydrocolloid dressings to these areas
Unstageable
• MD, NP, CWOCN or trained PT may debride the wound if eschar (i.e., a
black scab within the wound, generally at the base) is present. This is
done through surgical sharp debridement. Topical debriding enzymes
such as Collagenase (Santyl) may be used.
• In some situations an eschar cap may be left intact as the body’s natural
protection from infection.
• Apply and change dressings as ordered.
Appropriate skin care products should be utilized based on staging of the wound
and the goals of treatment as well as the cost effectiveness of the product.
X. Documentation of Wound Healing
1.
2.
3.
4.
5.
6.
7.
Describe location, diameter, and depth of the wound in centimeters; use measuring
guide for accuracy.
Describe wound base (e.g., color, presence or absence of moisture, slough, eschar)
Evaluate undermining or sinus tract formation by gently probing the wound with
sterile gauze swabs to determine the true size of the wound
Note evidence of pain, induration, or inflammation and remember that redness,
hardness, or discoloration around pressure areas that have poor blood supply (e.g.,
heels, sacrum) can mask major tissue necrosis behind apparently intact skin
Include present and planned treatment regimen
Take pictures of the wound for baseline and repeat at periodic interval (generally
every week) until the wound is healed.
Document pressure ulcers that are healing by retaining the label of the original stage
with “healing” added; do not revert back to lesser staging as the wound heals
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References:
National Pressure Ulcer Advisory Panel, 2007. www.npuap.org
Wound, Ostomy, and Continence Nurses Society (2003). Guideline for prevention and
management of pressure ulcers. Mount Laurel, NJ: Author.
Association of Rehabilitation Nurses (2001). Professional rehabilitation nursing manual.
Glenview, IL: Author.
Emory University WOCNEC Skin and Wound Module. September 2006, 6th edition.
Institute of Medicine. (1991). Disability in America: Toward a national agenda for
prevention. Washington, D.C.: National Academy Press.
Jacelon, Cynthia. (Ed.). (2011). The Specialty Practice of Rehabilitation Nursing: A Core
Curriculum (6th ed.). Glenview, IL: Association of Rehabilitation Nurses.
Mumma, C.M., & Nelson, A. (2002). Theory and practice models for rehabilitation nursing.
In S.P. Hoeman (Ed.,). Rehabilitation nursing: Process, application, & outcomes
(3rd ed., pp.32). St. Louis: Mosby.
Smith. Sandra.F, 2008. Clinical Nursing Skills 7th edition Upper Saddle River, N.J.
Pearson Prentice Hall.
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JOB AID
•
The outermost layer of the skin is the epidermis and protects deeper layers and
it the first defense to protect skin breakdown.
•
The dermal layer allows for elasticity of the skin
•
The subcutaneous layer contains sweat glands, oil glands, and hair follicles and
provides blood supply to the skin as well as receptors for touch and pain
•
Circulation promotes healing
•
Pressures ulcers are affected by sensory and motor changes
•
Nutrition is important in wound healing
•
Mechanical factors affecting skin integrity include sustained pressure and
shearing
•
There are six stages of pressure ulcers
•
Documentation is important. Describe location, diameter and depth of wound,
wound base, and undermining
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Posttest
Name: _____________________________________________
Date: ______________________________________________
Circle the correct answer.
1. There are multiple factors that contribute to the formation of pressure ulcers.
These factors include:
a.
b.
c.
d.
Sensory changes
Motor changes
Poor nutrition
All of the above
2. Which of the following forces causes pressure ulcers?
a.
b.
c.
d.
Direct pressure
Shearing forces
Laziness
A and B
3. Wound healing is a multiple step process that includes the following phases:
a. The defensive phase, proliferative phase, epithelialization phase, and maturation
phase
b. The defensive phase and maturation phase
c. A never-ending process
d. The proliferative phase only
4. Stage 3 of the NPUAP staging guidelines is:
a. Full-thickness skin loss: damage or necrosis of subcutaneous tissue, may extend
down to but not through underlying fascia; presents as a deep crater with or
without undermining of adjacent tissue
b. Partial thickness: epidermis, dermis, or both affected; superficial ulcer, presents
clinically as an abrasion, blister, or shallow crater
c. Nonblanchable erythema of intact skin: dark-skinned persons may show
discoloration or darkening, warmth, edema, induration, and hardness
d. Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to
muscle, bone, or support structures; with or without undermining/tracts
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5. When determining which skin care product should be utilized on a wound, one
must look at all of the following EXCEPT the:
a. Stage of the pressure ulcer
b. Client’s insistence that a certain product should be used despite its
appropriateness.
c. Goals for treatment of the pressure ulcer
d. Cost effectiveness of the product
6. The anatomy of the skin includes:
a.
b.
c.
d.
Epidermis
Dermal layer
Subcutaneous layer (hypodermis)
All of the above
7. According to guidelines, which of the following solutions should be used for
routine wound cleansing?
a.
b.
c.
d.
Dakin’s solution or Anasept spray
Normal saline solution or wound cleanser
Povidone-iodine
Hydrogen peroxide
 Carolinas HealthCare System
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