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CHAPTER 32 Skin Integrity & Wound Healing
tactile sense. They are therefore more prone to skin breakdown. ■ Patients with diminished sensation are less able to sense a hot surface and more likely to suffer a burn. A cut or wound in an area with limited sensation may go unnoticed and therefore untreated. They are also unable to feel pressure in an affected area. As a result, they may not shift position to relieve pressure over bony prominences or be aware that footwear or cloth- ing are constricting. ■ Patients with impaired cognition (i.e., Alzheimer disease, dementia, altered level of consciousness) are at higher risk for pressure injury because they are not aware of the need to reposition. Cognitive impairment can be subtle and difficult to recognize. Talk to your patients’ families or caregivers and review the patient’s health history so that the plan of care can be adjusted. Impaired Circulation The vascular system brings oxygen-rich blood to the tis- sues and removes metabolic waste products. ■ Impaired arterial circulation restricts activity, produces pain, and leads to muscle atrophy and thin tissue that can lead to tissue death. ■ Impaired venous circulation results in engorged tissues containing high levels of metabolic waste products that make the tissue susceptible to edema, ulceration, and breakdown. Both forms of circulatory impairment interfere with tissue metabolism and delay wound healing. Key Point: Circulatory impairment is one of the main causes of chronic wounds. Medications Any medication that causes pruritus (itching), derma- toses (rashes), photosensitivity, alopecia (hair loss), or pigmentation changes can result in changes that impair skin integrity or delay healing (Fig. 32-2). The following are examples: ■ Blood pressure medications decrease the amount of pres- sure required to occlude blood flow to an area, creat- ing a risk for ischemia. ■ Anti-inflammatory medications, such as over-the-counter (OTC) NSAIDs and steroids (e.g., prednisone), inhibit wound healing. ■ Anticoagulants (e.g., heparin, warfarin) can lead to extravasation of blood into subcutaneous tissue. As a result, even minimal pressure or injury can cause a hematoma (large bruise) . ■ Chemotherapeutic agents (e.g., methotrexate) delay wound healing as a result of toxicity to rapidly grow- ing cells. ■ Certain antibiotics, psychotherapeutic drugs, and chemo- therapy agents increase sensitivity to sunlight, increas- ing the risk for sunburn.
FIGURE 32-2 Skin reaction to medication.
■ Certain antibiotic, antifungal, anticonvulsant, and psy- chotherapeutic drugs can trigger a severe rash and skin peeling (known as Stevens-Johnson syndrome ). ■ Several herbal products, such as those containing laven- der and tea tree oil, cleanse but dry out the skin. Moisture on the Skin Excessive exposure to moisture leads to maceration (softening of the skin) and increases the likelihood of skin breakdown. Incontinence and fever are the most common sources of moisture. Bowel incontinence is particularly troublesome because feces contain diges- tive enzymes and microorganisms that can readily lead to excoriation (denuding) of superficial skin layers. This can lead to moisture-associated skin damage (MASD), dermatitis (inflammation of the skin), pressure injury, and infection. Fever Fever leads to sweating, which can cause skin macer- ation if ongoing. Fever also increases the metabolic rate, thereby raising the tissue demand for oxygen. An increased oxygen demand is especially difficult to meet if there is circulatory impairment or pressure-induced tissue compression. Contamination or Infection ■ Contamination of a wound refers to the presence of microorganisms in the wound. Key Point: All chronic wounds are considered contaminated. ■ Colonization occurs as microorganisms begin to increase in number but are causing no harm. Wounds
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