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CHAPTER 32 Skin Integrity & Wound Healing
➤ A stage 1 pressure injury is an area of persistent red- ness and does not blanch. ➤ A stage 2 pressure injury involves partial-thickness skin loss of the epidermis, dermis, or both. ➤ A stage 3 pressure injury is characterized by full- thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater. ➤ A stage 4 pressure injury involves full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or support structures. Undermining and sinus tracts (blind tracts under- neath the epidermis) are common. ➤ Extrinsic factors leading to pressure injuries are those that alter the skin and tissue integrity and blood sup- ply (e.g., aging, low blood pressure, neurological injury, poor nutrition, edema, and fever). ➤ Extrinsic factors include friction and shearing and exposure to moisture and pressure. ➤ Not all lower extremity ulcers are related to pressure. Some are caused by poor perfusion, such as venous stasis ulcers, diabetic foot ulcers, and arterial ulcers. ➤ An eschar is a black leathery covering of necrotic tis- sue. An ulcer covered by an eschar cannot be classi- fied because it is impossible to determine the depth. ➤ The Braden, Norton, and PUSH scales evaluate risk for problems with skin integrity. ➤ When assessing a wound, note the following: the type of wound, the color of the wound and surrounding
skin, the condition of the wound bed, drainage and odor, and the level of pain associated with the wound or wound care. ➤ Prevention of pressure injury includes skin care, nutri- tion, turning and positioning, using therapeutic mat- tresses and cushions, and patient/family teaching. ➤ Five types of debridement are used: sharp, mechan- ical, enzymatic, autolytic, and biotherapy (maggot debridement). ➤ Wound care therapies to promote healing might include negative pressure wound therapy, electrical stimulation, tissue growth factors, ultrasound, bioen- gineered skin substitutes, and surgical options. ➤ Primary dressings are ones that are placed in the wound bed and have contact with the wound. A sec- ondary dressing covers or holds a primary dressing in place. Many dressings can act as both. ➤ Types of wound dressings are absorption, alginate, antimicrobial, collagen, gauze, foam dressings, hydro- colloid, hydrogel, skin sealants, and moisture barriers. ➤ Ideal wound irrigation pressures range from 4 psi to 15 psi. Current recommendations are to use a 35-mL syringe attached to a 19-gauge angiocatheter. This will deliver the solution at approximately 8 psi. ➤ Heat application promotes vasodilation, increases tissue metabolism, increases capillary permeability, reduces blood viscosity, and reduces muscle tension. ➤ The application of cold causes vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, and decreased muscle tension.
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