Outer, avascular layer

Forms hair, nails, and some glands

Outermost layer - stratum corneum is continuously shed (desquamation)

Cells: Keratinocytes, melanocytes

Tough connective tissue layer

Supports and nourishes the epidermis

Contains vessels, nerves, lymphatic vessels

Cell: fibroblast

There is probably full dermal loss. 

The Dermis contains sweat glands (which moisturize the wound) and is heavily vascularized (which would contribute to a deep red color). 

If the wound lacks moisture and color, it is likely that the dermal layer has been destroyed.

Cosmetic

Protective Barier

Water Balance

Temperature regulation

Vitamin production

Protection:

Protects from physical and chemical injury

• Evaporative fluidloss
• Vascular responses to heat/cold
• Maintain fluid within tissue compartments
• Well moistureized skin = essential to healthy skin.
• Avoid DRY or WET skin.

Patients with neuropathy, aging patients

Skin sensation declines with age

Diabetics at risk because of neuropathy = decreased skin sensation

Which soap (of those listed) is most optimal for bathing patients to maintain skin health?

1. Ivory Soap
2. Dove soap
3. Dial soap
4. Zest

Benefit: Proivdes quick and rapid kill of topical microbes

Risk: Very drying and may be damaging to epidermis

Color

Vascularity

Turgor

Mobility

Presence/absence of lesions, rashes, wounds

Condition of hair and nails

Medical history (including medications)

Nutrition history/status

They are hard on fibroblasts. 

Steroids make skin weak and likely to tear easily.

They decrease skin integrity

Surgical

Vascular

Pressure

Traumatic

By anatomic location AND orientation.

"Top" of wound towards the head

"Bottom" of wound towards feet

yellow, green, tan

thick

Granulation tissue. 

It indicates progress to health/healing

Pale red/dry = less healthy

Slough

• Yellow stringy substance attached to wound bed
• Usually must be removed before wound can heal
• Not necessarily a bad part of wound healing, sometimes just a byproduct (dead white cells)
• Pay attention to it as wound heals

Brown or black

Indicates dead tissue

Must be removed for wound to heal

Intact

Erythema

Macerated

Blistered

Indurated

A patient is complaining of increased pain at the wound site.  The wound has increased drainage but it is not foul smelling.  The RN suspects:

1. Foreign body in the wound
2. Ineffective pain management
3. Possible wound infection
4. Nerve regeneration in the wound bed

3: Possible wound infection. 

Pain at localized site in the wound bed is in early indicator of infection.

• Fever, elevated WBC count
• Increased amount and type of wound drainage
• Heat at wound site
• Regression of wound healing
• May send specimen for C & S
• PAIN - often underestimated by healthcare professionals.  Always ask about it!

Factors Affecting Integumentary function and wound healing:

Circulation

• Lack of perfusion, blood volume, or vessel patency contribute to poor circulation.
• LE ulcers often develop because of venous and/or arterial insufficiency
• Without vascularity, we can't heal a wound

Factors affecting integumentary function and wound healing:

Nutrition

Vasoconstrictors will decrease vascular activity. 

Without vascularity, we can't heal a wound.

Wound bed is "beefy red"

Wound heals from edges (contracts)

Decreasing pain, but patient may have more pain when wound is open (nerve endings)

Free of signs/symptoms of infection

What is the primary difference between a wound and a pressure ulcer?

1. Treatment interventions
2. Etiology
3. Infection Risks
4. There are no differences

2: etiology

A pressure ulcer is caused by excessive pressure over a bony prominence. 

Wounds and pressure ulcers may have the same treatment interventions and infection risks

"Pressure" contribution to pressure ulcers

Compresses underlying tissue and small blood vessels against the surface below.

Pressure is exerted vertically.

Tissues become ischemic and die

Friction: Resistance created when one surface moves horizontally against another (i.e., pulling a patient along bed linen).

Shear: occurs when one of layer of tissue slides horizontally over another, deforming and destroying blood flow.  (i.e., when HOB is raised greater than 30 degrees).

They both require the addition of pressure from a surface to cause the tissue injury

- Intensity and duration pressure and

- the ability of the skin and supporting tissues to tolerate pain.

• Sensory perception
• ability to respond meaningfully to pressure-related discomfort
• Moisture
• degree to which skin is exposed to moisture
• Activity
• degree of physical activity
• Mobility
• ability to change body position
• Nutrition
• usual food intake pattern
• Friction and Shear

• Advanced age
• cognitive deficits
• chronic illness (diabetes millitus, peripheral vascular disease)
• immobility
• poor nutrition (under/overweight)
• medications (steroids, anti-hypertensives, sedatives)
• Arterial pressure

• Pressure
• Friction
• Humidity
• Shear Force

• Deep Tissue Injury (DTI)
• Stage I
• Stage II
• Stage III
• Stage IV
• Unstageable

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Darkly bigmented skin may not have visible blanching, its color may differ from the surrounding area

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

May also present as an intact or open/ruptured serum-filled blister

Full thickness tissue loss.  Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.

Slough may be present but does not obscure the depth of tissue loss. 

May include undermining and tunneling

Full thickness tissue loss with exposed bone, tendon, or muscle. 

Slough or eschar may be present on some parts of the wound bed.

Often include undermining and tunneling

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. 

This area may be preceeded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue