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Course: Fundamentals of Nursing�Topic: Skin Integrity and Wound Healing

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Module Goals

Learners will be able to:

Identify risk factors leading to impaired skin integrity.
Explain the pathogenesis of pressure injury.
Discuss the different stages of pressure injury.
Describe the process of wound healing, including primary and secondary intention and complications.
Apply the nursing process to the care of a client with impaired skin integrity.

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Impaired Skin Integrity

Impaired skin integrity

“Altered epidermis/or dermis” (Herdman & Kamitsuru, 2017).

Impaired skin integrity can evolve to impaired tissue integrity where deeper layers are affected.

“Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” (Herdman & Kamitsuru, 2017).

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Impaired Skin Integrity Risk Factors

Impaired circulation and impaired oxygenation

A lack of blood perfusion to the skin impacts wound healing.
Impaired circulation can impact delivery of necessary oxygen, clotting factors, and nutrients needed for healthy skin.

Impaired immune system

Stress, hospitalizations, and medications can impair wound healing and immune system.

Smoking

Alters inflammatory process of wound healing.
Increases risk of infection and chances of poor wound healing.

Ernstmeyer & Christman, 2021

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Impaired Skin Integrity Risk Factors

Age

Skin becomes less elastic and thinner as one ages, leading to chance of injury.
Older adults have an altered inflammatory response that can impact wound healing.

Obesity

Increased risk of yeast and fungal infections in folds of skin.

Diabetes

Leads to both wound development and slow wound healing.

Poor nutrition

Skin needs nutrients to keep healthy and promote wound healing.

Vitamin A, Vitamin C, Vitamin D, Vitamin E, selenium, copper, and zinc.

Ernstmeyer & Christman, 2021

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Case Study

Upon admission assessment of V.B., a 66 year old male, you are conducting a health history interview. V.B. indicates that he is a current smoker, smoking 1 pack of cigarettes a day, as well as a daily drinker of alcohol. V.B. mentions he works 10 hours a day, 6 days a week, at his job and gets little sleep. Additionally, he was recently diagnosed with Type 2 Diabetes Mellitus. When stating why he was seeking care, he states that there is an open wound on his left heel that has been present for 4 weeks and not healing. What lifestyle factors and comorbidities does V.B. have that can delay the wound from healing appropriately? Describe why the identified factors can affect his wound.

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What is a Pressure Injury

Ernstmeyer & Christman, 2021

Previously known as a pressure ulcer
Now identified as a pressure injury because a pressure injury can occur without the formation of an ulcer.
Defined as:

“Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear” (Ernstmeyer & Christman, 2021).

Staged when assessed.

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Shear and Friction

Shear

When layers of tissue cause blood vessels to stretch and break while passing through the subcutaneous tissue when the layers move atop of each other.
Outermost layer of skin and the underlying tissues move in opposition, causing the capillaries to stretch and then tear, resulting in decreased blood flow and delivery of oxygen to tissues resulting in a pressure injury.

Friction

Movement of skin against a hard object.
Friction creates heat, which then can remove the outermost layer of skin resulting in damage of integrity.

Ernstmeyer & Christman, 2021

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Staging of Pressure Injury

Ernstmeyer & Christman, 2021

Based upon the skin damage to the pressure injury.
Staged as stages 1 through 4

Stage 1 is least amount of skin damage progressing to Stage 4 with the most damage to skin integrity and underlying structures.

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Stage 1 Characteristics

Ernstmeyer & Christman, 2021

Intact skin
Localized area that has been subjected to pressure for a substantial amount of time resulting in nonblanchable erythema.

Nonblanchable erythema: an area of skin that is reddened that does not turn white when pressed upon.

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Stage 2 Characteristics

Ernstmeyer & Christman, 2021

Partial-thickness skin loss
Exposed dermis
Visible wound bed
May look like an intact or ruptured blister

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Terminology Seen in Stage 3 and Stage 4

Undermining

When there is a pocket underneath the skin due to wound edge erosion.

Tunneling

Occurs when there are tunnels underneath the surface of the skin that can twist and turn .

Slough

Soft, moist, yellow inflammatory exudate.

Eschar

Dead tissue that is dark brown or black, thick, dry, and leathery in appearance.

Ernstmeyer & Christman, 2021

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Stage 3 Characteristics

Ernstmeyer & Christman, 2021

Full-thickness loss of tissue with underlying fat visible
Not exposed:

Ligaments
Muscle
Cartilage
Tendon
Bone

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Stage 4 Characteristics

Ernstmeyer & Christman, 2021

Full-thickness tissue loss
Exposure of one or more structures:

Ligament
Tendon
Cartilage
Muscle
Bone

A bone infection, osteomyelitis, may occur

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Unstageable Pressure Injury

Ernstmeyer & Christman, 2021

Full-thickness skin loss and tissue loss.
Stage unable to be determined due to lack of visibility under slough and/or eschar.

In each image, eschar is located on the left side (dark color) and slough is located on the right side (yellow/tan color).

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Deep Tissue Pressure Injury

Ernstmeyer & Christman, 2021

Area of tissue that is persistently nonblanchable.
Color of tissue: maroon, deep red, or purple.
May show a wound bed dark in color or a blood-filled blister.
Occurs from significant and/or intense prolonged pressure in addition to shear forces located at the interface of a bone and muscle.
May heal to show a large tissue injury or may heal without any tissue loss.

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Critical Thinking Question

Describe the difference between a Stage 3 pressure injury and a Stage 4 pressure injury.

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Wound Healing - Primary Intention

Ernstmeyer & Christman, 2021

A wound is closed for healing
Techniques used to close the wound:

Staples
Glue
Sutures

Wound heals underneath the closure
Approximated edges

Closed edges
Examples: closed surgical incision, clean edge laceration

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Wound Healing - Secondary Intention

Ernstmeyer & Christman, 2021

Edges of a wound cannot be brought together to heal
Wounds heal from the bottom up by first producing granulation tissue
Examples:

Pressure injury
Skin tear

Higher risk of infection due to not be approximated

Protect from contamination to prevent infection

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Wound Healing - Tertiary Intention

A healing wound that must remain open or was reopened.

A severe infection may indicate reopening of a wound.

The wound is later approximated after the infection has been treated.

Ernstmeyer & Christman, 2021

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Complications of Wound Healing

Ernstmeyer & Christman, 2021

Infection
Delayed wound healing
Development of hematoma
Venous ulcer
Dehiscence
Occurs when the edges of a surgical wound separates
Evisceration

When abdominal surgical scar separates and there is a protrusion of abdominal organs and escape the incision
Severe, rare

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Nursing Process Application

Gather both subjective and objective data through assessment.
Assessment of a wound if present.
Lab work if applicable.
Use of Braden Scale to assess skill breakdown risk.

Look for detail of Braden scale for predicting Pressure Sore Risk: https://wtcs.pressbooks.pub/app/uploads/sites/31/2020/12/pasted-image-0-2.png

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Subjective Health Assessment

Subjective

Ask client:

Any current wounds or skin issues (itching, rashes) and associated pain.

If chronic wound, assess comorbidities that can affect wound healing

Obesity, inadequate nutrition, stress, diabetes, alcohol, medication use, smoking.
Impact of quality of life.
Routine in dressing changes, pain, odor, medication side effects, activity level.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Objective Health Assessment

Objective:

Perform thorough skin assessment on admission to seek any current, present wounds.
Perform Braden scale to assess risk of skin breakdown.
Continue skin assessments throughout stay to prevent new breakdown.
Turn client if prolonged periods in beds or ambulate client.

Ernstmeyer & Christman, 2021

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Wound Assessment

Ernstmeyer & Christman, 2021

Type
Location
Size
Degree (Stage)
Color of wound base
Presence of drainage
Patency of tubes or drains if present
Signs of infection
Wound edges
Pain

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Type: Examples include skin tear, abrasion, burn, surgical incision, pressure injury

Location: Document as accurate and precisely as possible

Size: Wound should be measured upon initial assessment and then at regular intervals to assess if the wound is growing or shrinking. If there is tunneling present, measuring the depth should be done with a sterile cotton-tip applicator.

Degree: Stage of pressure injury

Color of wound base: Is there healthy tissue (pink)? Is there unhealthy tissue (slough, eschar, necrotic tissue, dark red)?

Presence of drainage: Document color of drainage, consistency of drainage, and amount of drainage. If there are dressing changes, all these points should be documented again. Generally described as: none, scant, minimal, moderate, or copious amount of drainage. The drainage should be described as: sanguineous (wound exhibits fresh bleeding), serous (plasma exudate that is thin, watery, and clear), serosanguinous (a combination of serous drainage and sanguineous drainage), or purulent (thick, opaque exudate ranging in color from yellow, green, tan, or brown). Sanguineous, serous, and serosanguinous exudate can all be considered normal while purulent is never normal and should be reported to a provider if there is new presence of purulent drainage.

Tube and Drain Patency: Not applicable in all situations. Ensure patency and document any drainage in tubes or drain.

Signs of infection: Signs may be redness, the area warm to the touch, any tenderness, swelling, or pain, purulent drainage, the client exhibits a fever, or labs show increased white blood cells

Wound edges: Aside from the wound itself, the surrounding edges of the wound should be assessed and looked for signs of any infection or maceration surrounding the wound.

Pain: assess for pain.

(Ernstmeyer & Christman, 2021)

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Lab Work

Ernstmeyer & Christman, 2021

If a wound is not healing, lab work may assist in determining factors delaying the healing process.
Abnormal lab values that may show association with any delayed wound healings.

Hemoglobin
White blood cells
Platelets
Albumin
Blood glucose or hemoglobin A1C
Serum BUN (blood urea nitrogen) and creatinine
Wound culture

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Hemoglobin: If hemoglobin is low, this shows that there is a decreased amount of oxygen being delivered to the wound therefore delaying healing/

White blood cells: If elevated, this indicates an infection.

Platelets: If low, wound healing may be delayed because platelets assist in creation of granulation tissue that is an important part of the healing process.

Albumin: If albumin is lower than normal, this indicates a low count of protein. Adequate protein levels are important for wound healing.

Blood glucose or hemoglobin A1C: If this is elevated, this indicates diabetes in poor control which is a disease process that impacts adequate and timely wound healing.

Serum BUN and creatinine: An elevated level of BUN and creatinine show poor kidney function. BUN specifically impacts wound healing.

Wound culture: A positive wound culture shows an infection that is present within the wound. A culture should also show the amount and type of bacteria that is present. With this information, the appropriate antibiotic is selected to treat the infection and assisting in the healing of the wound.

(Ernstmeyer & Christman, 2021)

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What would the nurse do? -- Part 1

At the nurse’s shift change assessment, the nurse performs a thorough head to toe assessment, including a wound assessment. The nurse documents the following: wound located on the client’s right hip, the wound’s edges are warm to the touch, the open wound is 3mm wide with no tunneling, and a scant amount of purulent drainage is present. After comparing their assessment with the previous assessment in the client’s chart, the nurse notices that there was no mention of the wound edges being warm to the touch and no drainage was present. What are the nurse’s next steps? What orders should the nurse anticipate?

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What would the nurse do? -- Part 2

After the nurse receives the lab results back, the nurse finds the following:

Positive wound culture
Increased white blood cell count
Increased A1C

What would the nurse anticipate to perform next?

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Reference:

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/chapter/10-1-integumentary-introduction/

Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (11th ed.). Thieme Publishers. pp. 404, 406, 407, 412, 413.

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