stratum corneum
the thin outermost layer of the epidermis which allows for evaporation of water and permits absorption of certain topical medications
dermis
inner layer of the skin
protects underlying muscles bones and organs
pressure ulcers
localized injury to the skin and underlying tissue, usually over a body prominence as a result of pressure combination with shear and/or friction
What patients are at risk for pressure ulcers?
any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition
Pressure Ulcer: Pathogenesis (3 Factors)
- Pressure Intensity
- Pressure Duration
- Tissue Tolerance
Tissue ischemia
occurs when the normal capillary pressure and the vessel is occluded for prolonged periods of time.
What happens if a patient cannot respond to the discomfort of ischemia?
tissue ischemia and tissue death result
Hyperemia
redness over a pressure point from a prolonged position
Pressure Intensity includes
- hyperemia
- blanching
- non-blanchable hyperemia
blanching
pressing into a hyperemic area and having the affected skin turn white in color (lighter skinned individuals)
non-blanchable hyperemia
deep tissue damage is probable (stage 1 pressure ulcer)
pressure duration
either low pressure over a prolonged period of time OR intensity pressure over a short period
Common locations for pressure ulcer formation in a supine position
- occiput
- scapula
- sacrum
- heels
Common locations for pressure ulcer formation in a lateral position
- ear,
- acromion process
- elbow
- trochanter
- medial & lateral condyle
- medial & lateral malleolus
- heels
Common locations for pressure ulcer formation in a prone position
- elbow
- ear, cheek, nose
- breasts (female)
- genitalia (male)
- iliac crest
- patella
- toes
Tissue Tolerance
the ability of the tissue to endure pressure
Tissue Tolerance is dependent on
- integrity of the tissue and supporting structures
- extrinsic factors of shear, friction and moisture
- nutritional status
- age
- hydration
- low blood pressure
Risk Factors for the formation of pressure ulcers
- impaired sensory perception
- impaired mobility
- alteration in LOC
- shear
- friction
- moisture
impaired sensory perception include
pain and pressure
alterations in LOC include
confusion, aphasia, coma
shear
- gravity pulling the bony skeleton towards the foot of the bed while the skin remains against the sheets.
- outer layers of the skin may appear intact.
friction
force of two surfaces moving across one another
Unstageable/Unclassified Pressure Wound
- until the slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) is removed, a pressure wound cannot be staged.
- however it is most likely a Stage III or IV
What wounds are staged?
- only pressure wounds are staged.
- diabetic ulcers and stasis ulcers are not staged!
Deep tissue injury
- purple or maroon in color
- localized area of discolored intact skin or blood filled blister
A deep tissue injury may
- be preceded by tissue that is painful, firm, mushy, boggy, warm or cooler to the touch
- be difficult to detect in dark skin
Granulation Tissue
- red
- moist
- composed of new blood vessels
- progression toward healing
Slough
- stringy substance attached to a wound bed
- requires debriding
Eschar
- black, brown, tan, or necrotic tissue
- must be debrided
Exudate
- wound drainage
- describe amount, color, consistency and odor
Wound classification systems enable the nurse to do what?
understand the risks associated with a wound and implications for healing
Wound Classification Systems describe:
- state of skin integrity
- cause of the wound
- severity or extent of tissue injury or damage
- cleanliness
- descriptive qualities of wound tissue (i.e color)
Wound Classification
classified by the amount of tissue loss
Wound Classification includes
- Partial Thickness Wounds
2. Full Thickness Wounds
Partial Thickness Wounds
- involves only a partial loss of skin layers (epidermis, superficial dermal layer).
- healing is by regeneration
Partial Thickness Wound Characteristics
- shallow in depth
- moist
- painful with red wound base
Full Thickness Wounds
- involves total loss of the skin layers (epidermis and dermis)
- heals by forming new tissue.
Full Thickness Wound Characteristics
- depth varies
- extends into the subcutaneous layer
Process of Wound Repair includes
- primary intention
2. secondary intention
Primary Intention
- skin edges are approximated (surgical incisions)
- risk for infection is low
- healing occurs quickly w/ minimal scar formation
Secondary Intention
- involves loss of tissue (burn, pressure ulcer, severe laceration)
- wound is left open until it becomes filled by scar tissue
Healing of partial thickness wounds involve what 3 components?
- inflammatory response
- epithelial proliferation and migration
- reestablishment of the epidermal layers
epithelial proliferation and migration
- starts at the wound edges and the epidermal cells
- allows for quick resurfacing
- epithelial cells begin to migrate across the wound bed soon after wound occurs
reestablishment of the epidermal layers
- left open to air: resurfaces in 6-7 days
- keep moist: resurfaces in 4 (ish) days: epidermal cells only migrate across a moist surface
Healing of full thickness wounds involve what 4 phases?
- hemostasis phase
- inflammatory phase
- proliferative phase
- maturation or remodeling phase
Hemostasis Phase
blood vessels constrict and platelets gather to stop bleeding
Inflammatory Phase
include mast cells, neutrophils and monocytes
function of neutrophils
ingests bacteria and small debris
function of monocytes
transforms into macrophages -> cleans the wound of bacteria, dead cells and debris by phagocytosis
function of mast cells
secretes histamine -> vasodilation -> WBCs to damaged tissues = localized edema, redness, warmth, throbbing
Proliferative Phase
-lasts 3-24 days
Main activities of the Proliferative Phase include
- filling of the wound with granulation tissue
- contraction of the wound
- resurfacing of the wound by epithelialization (fibroblasts synthesize collagen providing strength and structural integrity to a wound)
In a clean wound, what happens during the Proliferative Phase?
- vascular bed is reestablished (granulation tissue)
- the area is filled with replacement tissue (collagen, contraction, and granulation tissue)
- surface is repaired (epithelialization)
Impairment in wound healing during the proliferative stage is usually related to
age, anemia, hypoproteinemia and zinc deficiency.
Maturation or Remodeling Phase
- maturation, the final stage of healing
- may take place over a year
What are some complications of wound healing?
- hemorrhage
- infection
- dehiscence
- evisceration
dehiscence
total or partial separation of wound layers
evisceration
protrusion of visceral organs
How does fatty tissue effect wound closure?
contains poor blood supply which can be a challenge in wound closure due to the extra pressure on the incision
What is the major nursing priority related to caring for pressure ulcers?
PREVENTION.
- important indicator of nursing quality
- use of a standardized tool is essential.
Braden Scale
widely used risk assessment tool composed of 6 subscales
What are the 6 subscales of the Braden Scale?
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction/shear
Very high risk on Braden Scale is a score of
9 or less
High risk on Braden Scale is total score of
10-12
Moderate risk on Braden scale is a total score of
13-14
Mild risk on Braden Scale is a total score of
15-18
No risk on Braden Scale is a total score of
19-23
Factors Influencing Pressure Ulcer Formation
- Nutrition
- Tissue Perfusion
- Infection
- Age
Nutrition
- 1500 cal/day
- protein (for the formation of collagen)
- vitamins (A and C)
- trace minerals (zinc and copper)
Tissue Perfusion
adequate amounts of oxygenated blood
How does infection affect wound healing?
- prolongs inflammatory phase
- delays collagen synthesis
- prevents epithelialization
- increases production of proinflammatory cytokines (leads to more tissue destruction)
Psychosocial Impact of Wounds
- body image changes
- self-concept (scars, drains, odor from drainage, temporary or permanent prosthetic devices)
Nursing Process: Assessment
- skin
- predictive instrument for pressure ulcer risk (braden scale)
- mobility
- nutritional status
- body fluids (moisture)
- pain
- wound
Wounds are usually assessed under what 2 conditions?
- at the time of injury before treatment
2. after therapy
Wound Characteristics Include
- appearance
- wound drainage and character
- drains
- wound closures: staples, steri-strips, dermabond
- need for wound cultures: aerobic and anaerobic
Nursing Process: Diagnosis
- Risk for infection
- Imbalanced Nutrition
- Acute or Chronic Pain
- Impaired Physical Mobility
- Impaired Skin Integrity
- Risk for Impaired Skin -Integrity
- Ineffective Peripheral Tissue Perfusion
Acute Wound
requires immediate intervention
Chronic Wound
the patient’s hygiene may be more important
Preventative Practices:
- skin care practices (clean, dry, moisturized)
- elimination of shear
- positioning/movement
Major Nursing Priority
promotion of wound healing
Prevention of Wounds
- skin care and management of incontinence
- positioning
- mechanical loading and support devices (proper positioning and use of therapeutic surfaces/beds)
- education
No single device eliminates the
effects of pressure on the skin
Acute Care Management
- documentation
- wound management
Documentation of Wounds
- photo documentation to establish baseline then periodically to track healing (or lack of healing)
- may be performed by the RN or wound ostomy RN according to hospital policy
Wound Management
maintain a healthy wound environment
Maintaining a healthy wound environment
- Prevent and manage infection
- Clean the wound *only with noncytotoxic wound cleaners
- Remove nonviable tissue. (debridement)
- Maintain a moist environment
- Eliminate dead space
- Control odor
- Eliminate/minimize pain
- Protect the wound and periwound skin
Debridement
removal of nonviable necrotic tissue
Debridement includes
- mechanical debridement
- autolytic debridement
- chemical debridement
- surgical debridement
mechanical debridement
wet to dry saline gauze, wound irrigation, whirlpool treatments
autolytic debridement
- synthetic dressings to allow eschar to be self-digested by the action of enzymes.
- hydrocolloid dressings, transparent film
chemical debridement
topical enzyme preparation: dakin’s solution, sterile maggots
surgical debridement
using a scalpel, scissors or other sharp instrument
Nursing Process: Collaboration
-utilize resources: interdisciplinary health care professionals
Collaboration: Interdisciplinary health care professionals
- Health care provider
- Wound care nurse specialist
- Physical therapist
- Occupational therapist
- Nutritionist
- Case Manager
- Pharmacist
Nursing Process: Dressings
- follow institutional policy and procedure
- consider medicating the patient 30” before a dressing change
- wound vac
- hot and cold packs
Nursing Process: Evaluation
- response to nursing therapies
- was the goal reached?
- was the etiology of the skin impairment addressed? pressure, friction, shear, moisture
- photo documentation
excessive exudate may be a sign of
infection
Characteristics of Secondary Intention
- takes longer to heal
- increased risk for infection
- increased scarring
- severe scarring may lead to loss of tissue function
