Skin Integrity, Pressure Ulcers & Wound Care

Four classifications for how wounds heal

1. Regeneration: In epidermal wounds. No scar. (superficial). New skin formation that cannot be distinguished from old skin. 2. Primary Intention 3. Secondary Intention 4. Tertiary Intention

Phases of Wound Healing

1.Inflammatory 2.Proliferation (Regeneration) 3.Maturation (Remodeling)

Sanguineous

active bleeding

Granulation

red, moist tissue -progressing toward healing

Norton Scale

5 risk factors: physical condition, mental condition, activity, mobility , and continence -Score 5-20; low score greater risk (14 or less)

Serous

clear, watery, straw colored

Eschar

necrotic tissue -tan, brown, black in wound bed

Pressure Intensity

When pressure exceeds normal capillary pressure, vessels occlude and tissue ischemia develops, tissue may be damaged or tissue death may result

Secondary Intention

-edges not close together -drainage might be necessary -necrotic tissue decombosed and escapes -cavity fills with granulation tissue -scarring greater ex:pressure ulcer extensive tissue loss. Pressure ulcers, or a wound that prevents approximation (edges coming together). Wounds heal by granulation so they heal from inner layer out. Surface area fills with granulation tissue. Center is granulation tissue. Heal slower, more prone to infection. More scar tissue than primary.

Primary Intention

-wound surgically made -Skin edges close together -Minimal scarring -starts during inflammatory phase occurs in wounds with minimal tissue loss. Clean laceration or surgical incision. These types of wounds are well approximated. Short phase of tissue repair. Meaning inflammation resolves quickly, minimal connective tissue repair required. They leave a minimal scar. Steri strips, sutures, staples. Surgical glue.

Inflammation Phase

Begins Immediately -swelling/edema -erythema(redness) -increased heat -pain -possible loss of function Cleansing phase. Lasts 1-5 days and involves these two processes: Hemostasis: vessels localized to where the area is at are constricting to limit blood loss. Clotting mechanisms are activated and a clot is formed. Inflammation: localized reaction to cell injury. All the WBC's come to the site, pain, heat, redness, swelling. Phagocytosis occurs during this. A scab is formed. This stage protects body from infection

Maturation Phase

Begins in 2nd-3rd week and continues until wound is totally healed. Epithelialization phase. Epithelial cells actually grow into the wound and seal it- which is called epithelialization. Continues until wound is completely healed. Collagen fibers that were formed during proliferation phase are strengthened to form scar tissue. Scar tissue is only 8% as strong as original tissue

Skin/Wound related labs

CBC: for WBC count Protein/Albumin: any nutritional deficiencies Biopsy: to help with diagnosis, tells us what cell types we are dealing with Culture: tells us what organisms we are dealing with Would culture: to determine the infecting agent (staph, strep, etc.) Bone scan: We do this for our deep stage 4 pressure wounds. To make sure there is no osteomyelitis going on.

Nutrition

Calories:cell energy Protein:collagen formation, wound remodeling, immun function Vitamin C:capillary wall integrity, fibroblast func. antioxident Vitamin A:epithelialization, wound closure, inflammatory response Vitamin E:no known role, antioxident Zinc:collagen formation, protein synthesis, cell membrane Fluid:Essentail Fluid envir. for all cell function

Factors that impact wound healing

Collagen synthesis slows as we age. Nutrition status: need protein, vitamins, zinc. Medications: steroids inhibit the immune response since they are an anti-inflammatory. Obesity: poor circulation impacts ability to heal, more adipose tissue the worse the circulation. Smoking: impedes everything, nicotine causes vasoconstriction so that it leads to cellular hypoxia. Chronic conditions: Diabetes: decreased collagen synthesis, slow capillary growth, reduction in circulation.

Proliferative Phase

Days 5-21 granulation phase -macrophages clear wound -new capillary to provide oxygen and nutrients -deep pink tissue -begins to close -possible scarring Cells migrate to the wound to form collagen. New blood and lymph develop from the existing capillaries at the edge of the wound, which results in the formation of granulation tissue..

Other treatments for wounds

Dressing changes Whirlpool treatment Nutritional support, pt's require 1500 cals per day for wound healing. Electrical stimulation to promote frenulation and increases blood tissue growth? Hyperbaric oxygenation therapy, raises tissue concentration but very costly Surgery

Fistula

Fistula is an abnormal passage that is connected two cavities or cavities in skin. Often result from infection, formation of an abscess, poor wound healing, or disease complications. Fixed surgically. RF:infection and fluid and electrolyte imbalance

Complications of wound healing

Hemorrhage: Caused by suture failure, infection, trauma from tubes or drains. Bleeding that begins AFTER hemostasis occurs. Can be internal or external. Pt's are at greatest risk of hemorrhage 24-48hrs after surgery. Infection: I: Induration F: Fever E: Erythema E: Edema D: Drainage O: Odor Local infection: can be green Systemic infection: eleveated WBC, fever, malaise, can lead to sepsis.

Braden Scale

Most commonly used. Based on nursing home risk factors. 6 subscales. Total score ranges from 6 - 23. Lower score indicates higher risk for pressure ulcer development. Cutoff score is at 18. TABLE 48-4

Stage 2 PU

Partial-thickness skin loss involving epidermis, dermis, or both presenting as a shallow open ulcer with a red pink wound bed without slough -Abrasion blister or shallow crater broken skin, superficial. Partial thickness, may go as deep as dermis. Typically can be characterized as shallow crater, blistjer, etc. can be red to pink in the wound bed..

Diabetic Foot Ulcers

Results from narrowing of arteries, delayed healing, and tissue necrosis Often painless Occur mainly on plantar surface, ball of foot, or toes Usually painless due to neuropathy. Usually deep with even margins. Macerated (skin is wasting away).

Wound Classification

Status of skin integrity:open or closed; acute or chronic Cause: intentional or unintentional Depth: partial thickness or full thickness Severity: superficial, penetrating or perforating Cleanliness: clean, clean-contaminated, contaminated, infected, colonized Descriptive qualities: laceration, abrasion, puncture wound, contusion

Slough

Stingy tissue attached to wound bed which is tissues that must be removed before healing can proceed -yellow, tan, gray, green, brown

Tertiary Intention

They are left open to heal by secondary intention until no signs of infection or edema. Star. We then close the wound and closed by primary intention. Usually caused by a traumatic injury of some sort. Could be caused by surgery involving a non sterol body cavity. Debris and exudate removed throughout the day. Prone to infection. Strict aseptic technique must be used. They have less scarring than secondary since they are eventually closed by primary. Wounds with high risk for infection

Pressure Ulcers

Tissue compression restricts blood flow to skin Results in tissue anoxia & cell death. If the pressure over a capillary exceeds normal capillary pressure, this is when ischemia occurs. Complications: Most common complication: Recurrence. Cellulitis is a complication of a pressure ulcer Chronic infection Osteomylitis Sacrum is most susceptiable to pressure ulcer To treat and prevent: Mobilize your PT ROM exercises Reposition Q2hrs Encourage proper nutrition and fluid intake Keep skin clean and dry Keep linens dry and free from wrinkles Heel floaters and cushions Focus on prevention High protein, mineral and vitamin supplements

What is undermining? What is tunneling?

Undermining: this is basically a lip or pocket of the wound. Occurs in one or more directions. Tunneling: extends in one direction only. Results in dead space. Puts the pt at risk for abscess formation.

Classification of pressure ulcers

Unstageable wounds: Covered in eschar (necrotic tissue usually black or brown).. Cannot be staged because we don't know how deep it is. Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss involving epidermis, dermis, or both Stage 3: Full-thickness tissue loss with visable fat Stage 4: Full-thickness tissue loss with exposed bone, muscle, or tendon

Wound Vacuum-Assisted Closure (VAC)

Uses negative pressure and suction to remove drainage and speed up the healing process. Cut sponge to fill the wound or crater. All fluid removed is documented as output.

Venous Ulcers

Venous insufficiency Typically on lower legs, below calf First appears as dark red or purplish skin Very slow to heal Venous stasis ulcers are somewhere between 80-90% are venous ulcers. Wounds that develop from venous insufficiency. Caused by venous pooling, veins don't move blood back to the heart. Often the atrial valves aren't working very well. Causes fluid to seep into the surrounding tissue. Below calf known as medial malleolus line. Surrounding skin is red or brown. Unknown why they develop. The borders are irregular. Wound is usually shallow. Typically have significant amounts of drainage. Surrounding skin often discolored. Minimal pain. STAR skin temperature and pulses are normal. Just for venous ulcers. Painful with irregular borders. We treat these with compression. Pulse should be normal

Evisceration

Wound evisceration: total separation, where the intestines come out of the wound. Medical emergency. Cover the wound with sterile saline soaked towels. We must reduce drying of the intestines. NPO, and monitor for shock. EMERGENCY Causes can be: poor nutrition, poor suturing technique, obesity (lower blood supply available), straining for BM, infection, coughing excessively. Avoid heavy lifting, avoid straining with bowel movement. Give them stool softeners.

Adhesions

bands of scar tissue between or around in GI tract or in Lungs, between lugns and plura of lungs. Can cause abdominal or chest pain. Can interfere with bowel or lung function. Number one cause for small bowel obstruction post surgery.

Purulent

yellow, green, tan, brown

Stage 3 PU

full thickness tissue loss involving damage or necrosis of subcutaneous tissue (deep crater) Bone tendon or muscle not exposed. Slough may be present but doesn't obscure the depth of the tissue loss. -Undermining and tunneling Full thickness skin loss, sub cutaneous tissue is damaged or necrotic. Much deeper. Extends to but not past the faschia (tissue over the muscle). No bone or muscle is exposed. May have undermining and tunneling.

Stage 4 PU

full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. -Undermining and tunneling full thickness loss. Extensive destruction of tissue, typically necrotic. Damage to muscle and bone and all supporting structures around it. Often tendons and bone exposed. Often develops sinus tracts (also called tunneling).

Stage 1 PU

intact skin with nonblanchable redness of a localized area usually over a boney prominence changes in skin sensation, may complain of pain or itching, maybe warm or cool. Consistency is boggy or firm. Skin is intact and nonblanchable redness

Serosanguineous

pale, red, watery -mixture of clear and red fluid

Arterial ulcer

poor circulation of blood due to arterial sclerosis. Typically arterial sclerosis is the cause. On the leg, usually on heels, toes and feet as well as the lateral malleoli line. Base is usually pretty red. Typically yellow, brown, gray or black in color. Tend to have regular borders. Very painful. Tissues are not getting oxygenated. Surrounding skin is shiny, thin, dry and COOL to the touch. Often involve hair loss. Will develop delayed capillary refill on the extremity with the ulcer.

Dehiscence

rupture of one or moore layers of wound. Meaning the wound edges have separated. Usually occur in the inflammatory phase. This is when stitches rupture open. Pt will complain of feeling a pop or a tear. We will apply a sterile dressing over the wound. We will also contain the surgeon for further orders. Causes are infection, obesity, straining, heavy lifting, coughing. Splinting is coughing while holding chest.

Abrasion

superficial wound, considered partial thickness