Skin Integrity and Wound Care
The skin is the largest organ in the body and serves a variety of important functions in maintaing health and protecting the individual from injury. Impaired skin integrity is not a frequent problem for most healthy people but is a threat to older people, to clients with restricted mobility, chronic illnesses, or trauma, and those undergoing invasive health care procedures.
Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds. The appearance of the skin and skin integrity are influenced by internal factors such as genetics, age, and the underlying health of the individuals as well as external factors such as activity.
A wound: disruption in the continuity of cells. Wound healing is the restoration of that continuity.
Effects of wound: Loss of all or part of organ functioning Sympathetic stress response Hemorrhage and blood clotting Bacterial contamination Death of cells
Types of wounds
Body wounds are either intentional or unintentional. Intentional trauma occurs during therapy e.g., operations or venipuncture, removing tumor. Unintentional wounds are accidental; e.g. a person may fracture an arm in an automobile collision. If the tissues are traumatized without a break in the skin, the wound is closed. The wound is open when the skin or mucous membrane surface is broken.
Wounds may be described according to how they are acquired:- Incision wounds: Sharp instrument ''open, deep or shallow''. Contusion wounds: blow from a blunt instrument '' closed, skin appears ecchymosed (bruised)''. Puncture wounds: penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional ''open wounds''. Lacerated wounds: tissue torn apart, often from accident ''open, edges are often jagged''. Abrasion wounds: Surface scrape ''open, involving the skin''. Penetrating wounds: penetrating the skin and underlying tissues. '' Open wound ''.
Types of wounds according to degree of wound contamination:1. Clean wounds: uninfected wounds in which minimal inflammation is encountered. 2. Clean contaminated wounds: surgical wounds in which the respiratory, alimentary, genital or urinary tract has been entered. No evidence of infection.
3. Contaminated wounds: open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Show evidence of inflammation.
4. Dirty or infected wounds: containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.
Pressure Ulcer
Pressure Ulcers were previously called decubitus ulcers, pressure sores, or bedsores. It is any lesions caused by unrelieved pressure that result in damage to underlying tissues.
Etiology of pressure ulcers
Pressure ulcers are due to localized ischemia, a deficiency in the blood supply to the tissue. The tissue is compressed between two hard surfaces, usually the surface between the bed and the skeleton, when the blood cannot reach the tissue, the cells are deprived of oxygen and nutrients, waste products of metabolism accumulate in the cells, and the tissue consequently dies. Prolonged, unrelieved pressure also damages the small blood vessels.
After the skin has been compressed, it appears pale, as if the blood had been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush called reactive hyperthermia. The flush is due to vasodilatation, a process in which extra blood supply to compensate for the preceding period of impeded blood flow.
stage III pressure ulcer
Risk factors
Friction and Shearing Two other factors frequently act in conjunction with pressure to produce pressure ulcers: Friction: is a force acting parallel to the skin surface, such as sheets rubbing against skin create friction. Friction can abrade the skin, that is, remove the superficial layers, making it more prone to breakdown.
Shearing force: combination of friction and pressure. It occurs commonly when the a client assumes a Fowlers position. In this position, the body tends to slide downward toward the foot of the bed. This downward movement is transmitted to the sacral bone and the deep tissues . At the same time, the skin over the sacrum tends not to move because of the adherence between the skin and the bed linens. The skin and superficial tissues are thus relatively unmoving in relation to the bed surface, whereas the deeper tissues are firmly attached to the skeleton and move downward. This causes a shearing force in the area where the deeper tissues and the superficial tissues meet. and the superficial tissues meet. The force damages the blood vessels and tissues in this area.
Shearing forces can occur when a patient is moved carelessly or slides down in bed.
Immobility Refers to a reduction in the amount and control of movement a person has. Such as paralysis, extreme weakness, pain. Inadequate nutrition It causes weight loss, muscle atrophy, and loss of subcutaneous tissue. These three reduce the padding between the skin and the bones. More specifically, inadequate intake of protein, carbohydrates, fluids, and vitamin C.
Fecal and urinary incontinence
Moisture from incontinence promotes skin maceration, (tissue softened by prolonged wetting or soaking), digestive enzymes in feces contribute in excoriation (area of loss of the superficial layers of the skin) which cause irritation to skin, harbor microorganisms.
Decreased mental status
Individual with a reduced level of awareness for example, Unconscious, or heavily sedated, they are less able to organize and respond to pain associated to prolonged pressure.
Diminished sensation Paralysis, stroke, loss of consciousness may cause loss of sensation in a body area. loss of sensations reduce persons ability to respond to trauma, to injuries heat and cold, and to the tingling (pins and needles) that signals loss of circulation. Sensory loss also impairs the bodys ability to recognize and provide healing mechanisms for a wound. Excessive body heat Increased body temperature increase metabolism, increase cell need for oxygen.
Advanced age Due to changes in body mechanisms such as loss of lean body mass, decreased strength and elasticity, diminished pain perception, increased dryness due to a decrease in the amount of oil produced by the sebaceous.
Chronic medical conditions D/M, cardio vascular diseases are risk for skin breakdown and delayed healing. These conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.
Other factors Poor lifting techniques, incorrect positioning, repeating injection at the same area, incorrect application of pressure relieving devices.
Stages of pressure ulcers Stage 1:- red color and the skin dont return to normal color even the pressure is released. Stage 2 :- redness accompanied by blisters or shallow break in the skin Stage 3 :- break in the skin extending to the subcutaneous tissue Stage 4:- ulcer involves loss of all skin layers exposing muscle and bone.
Thanks
