Chapter 48: Skin Integrity and Wound Care

Importance of Skin

• Largest organ, protective barrier, sensory organ
• Synthesizes vitamin D

Nursing Responsibilities

• Assessing and monitoring skin integrity
• Identifying patient risks for skin problems
• Planning, implementing, and evaluating interventions

Age-related Skin Changes

• Reduced elasticity, decreased collagen
• Thinning of underlying muscle and tissues
• Flattened attachment between epidermis and dermis

Medical Conditions and Wound Healing

• Diminished inflammatory response due to aging
• Slow epithelialization and wound healing

Pressure Injuries

• Terms: pressure injury, pressure ulcer, decubitus ulcer, bed sore
• Caused by prolonged pressure, often over bony prominences
• Stage 1 to 4 detailed

Factors Affecting Pressure Injury Development

• Intrinsic Factors: Tissue integrity, supporting structures
• Extrinsic Factors: Shear, friction, moisture
• Systemic Factors: Nutrition, hydration, blood pressure, aging

Risk Factors for Pressure Ulcers

• Altered sensory perception
• Inability to change positions independently
• Comatose, confused, expressive aphasia
• Shearing force and friction
• Moisture presence

Pressure Injury Staging

• Stage 1: Non-blanchable erythema
• Stage 2: Partial thickness skin loss
• Stage 3: Full thickness skin loss
• Stage 4: Full thickness skin and tissue loss
• Deep Tissue Injury: Persistent non-blanchable deep red or maroon discoloration
• Unstageable Pressure Injury: Obscured by sloth or eschar

Wound Healing Intention Types

• Primary Intention: Wound edges approximated, minimal scarring
• Secondary Intention: Wound edges not approximated, granulation tissue formation
• Tertiary Intention: Wound left open then approximated

Wound Repair Phases

• Partial Thickness: Inflammatory response, epithelial proliferation
• Full Thickness: Hemostasis, inflammatory, proliferative, maturation

Hemostasis and Inflammatory Phase

• Control blood loss, bacterial control
• Releases histamine causing vasodilation and WBC movement

Proliferative and Maturation Phase

• New blood vessel formation, granulation tissue
• Wound contraction and epithelialization

Wound Healing Complications

• Hemorrhage: Normal post-trauma
• Infection: Prolongs inflammation
• Dehiscence: Separation of wound layers
• Evisceration: Protrusion of visceral organs

Preventing Pressure Injuries

• Appropriate nutrition, adequate oxygenation
• Regular repositioning and turning

Wound Assessment

• Tissue type, amount, appearance
• Drainage types: serous, purulent, serosanguinous, sanguinous

Wound Dressings

• Protect wound, aid hemostasis, promote healing
• Types: gauze, hydrocolloid, hydrogel

Heat and Cold Therapy

• Heat: Improves blood flow, muscle relaxation
• Cold: Reduces swelling, muscle tension

Evaluation and Teaching

• Evaluate nutritional status
• Involve family in wound care education

Conclusion

• Holistic approach to wound care
• Ensure proper nutrition, teaching, and management for patient recovery.