Skin Integrity and Wound Healing
Possible nursing diagnoses
risk for impaired skin integrity
impaired skin integrity
impaired tissue integrity
risk for impaired tissue integrity
risk for infection
disturbed body image
altered epidermis and/ord dermis
at risk for skin being adversely altered
invasion of body structure
destruction of skin layers (dermis)
disruption of skin surface (epidermis)
damage to mucous membrane, corneal, integumentary, or subcutaneous tissue
damaged or destroyed tissue
stage 3 and 4 pressure injuries
Phases of wound healing
inflammatory phase - cleansing
1-5 days
proliferation phase - granulation
hemostasis and inflammation
5-21 days
fibroblasts fill and strengthening wound forming collagen
epithelial cells grow into wound seal over the wound - epithelialization - pink pearls in wound base
smooth and velvety in texture
granulation
an active process that fills the wound with new tissue, collagen by the fibroblasts and new blood vessels
pink-red in color
granulation tissue becomes scar tissue
maturation
epithelialization - remodeling
day 21 up to 2 years
after wound has closed continues
next 3-6 months
collagen fibers broken down and remodel into scar tissue
tensile strength reaches 70-80%
max strength 10-12 weeks
Acute wounds
short duration
heals without complications through 3 phases of wound healing
Chronic wounds
a wound fails to heal normally - months to years
healing interrupted or stalled due to infection, ischemia, or edema
includes pressure injuries, arterial venous, or diabetic ulcers
heal slowly due to co morbities
Types of healing
primary intention
edges are well approximated - closed
surgical incision
secondary intention
damage preventing wound edges to approximate
granulation occurs
can not be closed
tertiary intention
delayed closure
initially allowed to close with secondary intention
strict aseptic technique prone to infection
Related factors
temperature: hyperthermia, hypothermia
chemical: incontinence
mechanical
immobility
radiation
medications
extremities of age
Extrinsic factors
friction
pressure exerted by two surfaces moving across one another
shearing
when a portion of the skin remains stationary and the underlying tissue shifts, resulting in diminished blood supply to the skin and consequent tissue damage
moisture
incontinence, diaphoresis, etc
excess moisture softens connective tissue leading to erosion of the epidermis
moist skin is 5 times as likely to develop pressure ulcers
Intrinsic factors
nutrition - obesity/emaciation
age
altered circulation, sensation
underlying health status
immunological deficit
Expected client outcomes
regains integrity of skin surfaces
reports altered sensation / pain
states plan to heal skin and prevent re-injury
describes specific measures to heal and care for skin lesions
Pressure ulcer / pressure injury
any lesion caused by unrelieved pressure resulting in damage to underlying tissue
located over bony prominences
stage I-IV, unstageable, deep tissue injury
stage I
nonblanchable erythema, intact skin
make be difficult to detect in clients with dark skin tones
stage II
partial thickness loss of dermis
epidermis, dermis or both - superficial, abrasion, blister, shallow crater
no slough
stage III
full thickness skin loss, may include undermining or tunneling
deep crater
adipose tissue present
stage IV
full thickness skin loss, with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures, undermining, sinus tracts
unstageable
full thickness loss
base is covered with slough and or eschar
deep tissue injury
due to damage from shearing or friction
maroon or purple localized area
evolves quickly and deeply
difficult to treat