Understanding Skin Integrity and Wound Care

Sep 20, 2024

Foundations of Nursing: Skin Integrity and Wound Care

Overview

  • Skin is the largest organ, providing protective barrier and sensory functions.
  • Synthesizes vitamin D.
  • Injury to skin increases safety risks.

Wound Healing

  • Complex process influenced by systemic and local factors.
  • Involves cellular and biochemical processes.

Skin Structure

  • Epidermis: Outer layer with several sub-layers.
    • Stratum Corneum: Outermost layer, protects underlying tissues.
  • Dermis: Inner layer, contains connective tissue and supports skin structure.

Pressure Injury

  • Previously known as pressure ulcer, decubitus ulcer, bedsore.
  • Caused by unrelieved, prolonged pressure.
  • Localized damage usually over bony prominences.
  • Factors: Microclimate, nutrition, perfusion, comorbidities, condition of soft tissue.
  • Risk Factors: Decreased mobility, sensory perception, incontinence, malnutrition.

Pressure Injury Staging

  • Stage 1: Non-blanchable erythema.
  • Stage 2: Partial-thickness skin loss.
  • Stage 3: Full-thickness skin loss with visible fat.
  • Stage 4: Full-thickness tissue loss exposing bone/muscle.
  • Unstageable: Covered by slough/eschar.
  • Deep Tissue Injury: Persistent non-blanchable deep red/maroon/purple discoloration.

Case Study: Mr. Omar Ahmed

  • 76 y/o with pneumonia, previous coronary artery surgery, hypertension, type 2 diabetes.
  • Risks: Limited mobility, weight loss, potential for pressure injuries.

Factors Influencing Pressure Injury Development

  • Shear Force: Sliding movement damaging tissues.
  • Friction: Affects epidermis, causing superficial loss.
  • Moisture: Increases risk by softening skin.

Assessment and Management

  • Tools: Braden Scale for risk assessment.
  • Nutritional Support: Essential for wound healing.
  • Positioning: To relieve pressure, 30-degree lateral position.

Wound Classification

  • Open vs Closed Wounds: Skin integrity difference.
  • Healing by Intention:
    • Primary Intention: Edges approximated, minimal scar.
    • Secondary Intention: Open until scar fills, risk of infection.
    • Tertiary Intention: Left open, closed after infection clears.

Wound Healing Phases

  1. Hemostasis: Blood vessels constrict, clot forms.
  2. Inflammatory: Histamine released, capillary dilation.
  3. Proliferative: New tissue forms.
  4. Remodeling: Scar tissue forms.

Nursing Diagnosis and Care Planning

  • Impaired skin integrity, risk assessment, wound care management.
  • Set SMART goals to track progress.

Interventions

  • Proper cleaning, moist environment, non-cytotoxic solutions.
  • Use dressings, support surfaces, and repositioning to manage wounds.

Education and Safety

  • Educate patients and caregivers on wound care.
  • Use heat and cold therapy carefully.
  • Evaluate outcomes based on wound healing progress.