BASIC HUMAN NEEDS
ALTERATIONS IN
SKIN INTEGRITY
PRESSURE ULCERS
Donna M Penn RN MSN CNE
Skin Integrity





Skin/Integumentary system is the body’s largest
organ, 1/6th of TBW
Protects against disease causing organisms
Sensory organ for temp, pain, touch
Synthesizes Vitamin D
Injury to skin poses a risk to safety and triggers a
complex healing process
Normal Integument




2 principle layers in relation to wound healing
Epidermis
Dermis
Separated by basement membrane
Epidermis






Outer layer has several layers within it
Stratum Corneum
Stratum Lucidem
Stratum Granulosum
Stratum Spinosum
Basal cell layer
Dermis




Inner layer of skin
Provides tensile strength & mechanical support
& protection to underlying muscle, bones, and
organs
Contains mostly connective tissue
Also includes blood vessels, nerves, sensory
nerve cells, lymphatics, collagen
Skin Functions

Epidermis-functions to re-surface wounds &
restore the barrier against bacteria

Dermis-functions to restore structural integritycollagen& physical properties of skin
Pressure Ulcers

New NPUAP terminology (2007)

A pressure ulcer is a localized injury to the skin
and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure
in combination with shear and/or friction.
A number of contributing factors are also
associated with pressure ulcers

Pressure Ulcers



Tissues receive oxygen and nutrients and
eliminates metabolic wastes via the blood
Any factor that interferes with this affects
cellular metabolism and cell life
Pressure affects cellular metabolism by
decreasing or stopping tissue circulation
resulting in tissue ischemia
Causes of Pressure Ulcers

Pressure > ischemia > edema > inflammation >
small vessel thrombosis > cell death

Shear – trauma caused by tissue layers sliding
across each other, results in disruption or
angulation of blood vessels
Pressure Ulcer Contributing Factors





Friction
Poor Nutrition
Incontinence
Moisture
Co-existing Medical Conditions
Pressure



Tissue damage occurs when pressure exerted on
the capillaries is high enough to close the
capillaries
Capillary closing pressure is the pressure needed
to close the capillary > 32 mmHg
After a period of ischemia light toned skin
undergoes 2 hyperemic changes
Hyperemia


Normal Reactive Hyperemia-visible effect of
localized vasodilatation (REDNESS) area will
blanch with fingertip pressure and redness lasts
less than 1 hour
Abnormal Reactive Hyperemia-excessive
vasodilatation and induration (edema) in
response to pressure. Skin appears bright pinkred. Lasts 1 hour to 2 weeks
Risk Factors for Pressure Ulcer
Development

Impaired Sensory Input

Impaired Motor Function

Altered Level of Consciousness

Orthopedic Devices
Pathogenesis of Pressure Ulcers

Intensity of pressure and capillary closing
pressure

Duration and sustenance of pressure

Tissue Tolerance
Pathogenesis of Pressure Ulcers



Bony prominences are most at risk (sacrum,
heels, elbows, lateral malleoli, greater trochanter,
ischial tuberosities
Pressure ulcer forms as a result of time/pressure
relationship
Greater the pressure and duration of pressure,
the greater the incidence of ulcer formation
Pathogenesis of Pressure Ulcers



Skin and subcutaneous tissue can withstand
some pressure
Tissue will over time become hypoxic and
ischemic injury will occur
If the pressure is above 32mmHg and remains
unrelieved to the point of tissue hypoxia, the
vessel will collapse and thrombose
Pathogenesis of Pressure Ulcers


If circulation is restored before this critical
point, circulation to tissue is restored (Reactive
Hyperemia)
Skin has a greater ability to tolerate ischemia
than does muscle, hence true pressure ulcers
begin at bone with pressure related to muscle
ischemia eventually coming through to
epidermis (Shear injury) Sacrum and heels most
susceptible
Pressure Ulcer Staging





Depth of destroyed tissue
Does not indicate healing
Ulcer covered by necrotic tissue or eschar
cannot be staged until debrided
NPUAP system used most clinically
Other staging systems exist
Stage 1 Pressure Ulcer




Intact skin with non-blanchable redness of a
localized area usually over a bony prominence.
Darkly pigmented skin may not have blanching:
its color may differ from the surrounding area
The area may be painful, firm, soft, warmer or
cooler as compared to adjacent tissue.
Stage I may be difficult to detect in individuals
with darker skin tones
Stage I Treatment

Off-load pressure

Transparent film dressing

Hydrocolloid dressing

Moisture barrier
Stage 2 Pressure Ulcer



Partial thickness skin loss involving the
epidermis and/or dermis.
The ulcer is superficial and presents clinically as
an abrasion, blister, or shallow open ulcer
Presents as shiny or shallow ulcer (red/pink
wound bed) without slough or bruising. This
stage should not be used to describe skin tears,
tape burns, perineal dermatitis, maceration or
excoriation
Stage II Treatment




Hydrocolloid dressing: dressing of choice in
minimally draining stage 2 ulcer
Absorptive dressings (Foam) draining wounds
Hydrogel: Healing wounds
Off-load pressure
Stage III




Full thickness skin loss involving damage or
necrosis to subcutaneous tissue that may extend
down to, but not through underlying fascia
Ulcer presents as a deep crater with or without
undermining or tunneling of adjacent tissue
Slough tissue may be present but does not
obscure the depth of tissue loss
Depth varies by anatomical location
Stage III Treatment






Requires physician order for Stage III or IV
Draining vs. Non-draining
Necrotic vs. Granulating
Draining wounds-Absorptive dressings
Granulating wounds-Hydrogel
Necrotic wounds-Require debridement
(Chemical. Mechanical, Autolytic, Sharp)
Stage IV





Full thickness skin loss with extensive destruction,
tissue necrosis or damage to muscle, bone , or
supporting structures (tendons, joint)
Undermining and tunneling are often associated with
Stage IV ulcers
Slough or eschar may be present in some on some parts
of the wound bed
Depth of wound varies by anatomical location
Exposed bone or tendon is visible or directly palpable
Unstagable Wounds
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,
black) in the wound bed
The true depth of the wound cannot be
determined until slough or eschar is removed,
therefore stage cannot be determined.
Stable eschars serve as the body’s natural
biological cover and should not be removed
Deep Tissue Injury




Purple or maroon localized area of discolored
intact or blood filled blister due to the damage
of underlying soft tissue from pressure or shear.
The area may be preceded by tissue that is
painful, firm, mushy, boggy, warmer or cooler as
compared to adjacent tissue
May be difficult to detect with darker skin tones
Evolution may include a thin blister over a dark
wound bed
Staging by Color

Black

Yellow

Pink/Red

Mixture of colors
Process of Wound Healing

Primary Intention

Secondary Intention
Healing by Primary Intention

Inflammatory (Reaction)

Proliferative (Regeneration)

Maturation (Re-modeling)
Healing by Secondary Intention






Healing takes longer
Wounds drain more fluids
Inflammation phase is prolonged, chronic
Wound becomes filled with fragile granulation
tissue rather than collagen
Wound Contraction takes place
More susceptible to infection
Complications of Wound Healing





Hemorrhage
Infection (Nosocomial)
Dehiscence
Evisceration
Fistula Formation
Risk Assessment for Pressure Ulcers






Identify at risk population
Norton Scale
Gosnell Scale
Braden Scale- most uses clinically, includes 6
subscales (sensory perception, moisture, activity,
mobility, nutrition, friction & shear
6-23 score, <18 at risk in hospitalized patients
Refer to P&P pg. 1496-1497 for Braden Scale
Factors Affecting Pressure Ulcer
Formation








Shearing force
Friction
Moisture
Tissue Tolerance Factors
Nutrition
Infection
Impaired Peripheral Circulation
Age
Factors that Impair Wound Healing









Age
Malnutrition
Obesity
Impaired oxygenation
Smoking
Diabetes (blood glucose level)
Drugs
Radiation
Wound Stress
Nursing Process
Assessment





Predictive measures-Risk assessment tools
Skin assessment- any areas susceptible to
pressure sources, (NG, oxygen tubes, casts,
bony prominences)
Tactile Assessment-Blanching red areas
Assess mobility
Assess nutritional status
Wound Assessment






Location, Size, Stage
Wound drainage
Wound bed, tissue type
Wound edges
Periwound skin
Presence of undermining, tunneling
Wound Assessment




Anatomical location
Stage-NPUAP staging
Staging is for pressure ulcers only, other wounds
are classified as partial or full thickness
Size- Measure length, width, depth in
centimeters
Wound Assessment





Drainage
Amount, color, consistency, odor
Scant, moderate, large
Serous, serosanguinous, purulent, yellow, brown,
green, clear
Odor to wound may be indicative of infection
Wound Assessment
Tissue Type






When describing wound bed include % of each
tissue type (50% slough, 50% granulation)
Necrotic tissue-nonviable
Eschar- dry, leathery, black or brown
Slough- stringy, cheesy, loose, yellow, tan
Granulation- healthy, viable pink to beefy red
Epithelialization-occurs along wound edges or
as islands inside wound bed, pale pink
resurfacing of wound
Wound Assessment
Periwound Area

Erythema-may mean infection

Maceration-Whitish, wrinkled appearance
Indicates presence of excessive moisture


Rash- Macular or papular, may indicate fungal
infection
Wound Assessment
Presence of Undermining/Tunneling
Document location and depth
 Use hands of clock as descriptor
 Measure with cotton tipped applicator

Staging Limitations



Difficult to identify stage I in dark skinned
patients
Unable to stage when obscured by eschar
Reverse Staging/Downstaging
Nursing Process
Diagnosis

You tell me!!!!!
Nursing Process
Planning








Preventing pressure ulcers-early identification of those
at risk (Braden, Norton, Gosnell scales)
Prevention protocols by hospital
Positioning
Hygiene and skin care (incontinence care)
Support surfaces
Nutritional support
Prevent friction and shear
Education
Nursing Process
Acute Care Implementation








Management of Pressure Ulcers
Culturing wound
Cleansing wound
Debridment of wound
Moist Wound Healing
Dressing selection
Nutritional support
Off-load pressure
Wound Dressing Selection










Goal: Promote moist wound healing
Transparent dressing
Hydrocolloid
Hydrogel
Calcium alginate
Foam dressing
Silver/Antimicrobial
Collagen dressing
Biological dressing (Regranex)
Negative pressure wound therapy (VAC)
Practice Scenario



The nurse is assessing a bedridden client when a
large erythemic area is noted on the client’s
sacrum. In addition, the center of the injury
looks like an abrasion with a shallow center.
The nurse would classify this ulcer as:
How will the nurse treat this type of pressure
ulcer?
What risk factors could have contributed to this
patient developing a pressure ulcer?
Practice Question





A nurse is working in a geriatric screening clinic.
The nurse would expect that the skin of the
normal elderly client will demonstrate which of
the following characteristics?
A. Dehydration causing skin to swell.
B. Moist skin turgor.
C. Skin turgor showing a loss of elasticity
D. Overhydration causing skin to wrinkle.
Practice Question





The nurse decides to treat a Stage II pressure
ulcer with a hydrocolloid dressing. The nurse
recognizes that the dressing will promote which
type of wound debridement?
A. Sharp
B. Autolytic
C. Chemical
D. Mechanical