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CHAPTER 32 Skin Integrity & Wound Healing
Assessing Mobility and Activity Level Patients who have some degree of immobility are at a higher risk for developing pressure injury and should be closely monitored to detect early signs of the formation of pressure-related wounds. See Chapter 29 for more details about physical activity and immobility.
measure wound depth, gently insert a sterile cotton-tip applicator into the deepest part of the wound. Measure the applicator from the tip in the wound bed to the skin level. Serial photographs with grids showing the wound’s dimensions, especially if the wound has an irregular border, are useful for documenting the baseline and wound healing (European Pressure Ulcer Advisory Panel [EPUAP] et al., 2019). Undermining or Tunneling Assess the wound edges for any undermining or tunneling. Pay close attention to any tissue that appears to have a separation in either tissue type or plane because tunnels may frequently be found. Measure the depth and location of any undermining or tunneling using the face of a clock as a guide. Periwound Examine the skin surrounding the wound. Skin discoloration may indicate a hematoma or additional injury to the surrounding tissue. Look for the following conditions: ■ Maceration is caused by excessive moisture from pooled drainage on intact skin for periods of time or when a moist dressing is inappropriately applied, is left on too long, or overlaps onto healthy skin. The skin may appear pale and wrinkled (“pruned”) and may flake and peel. ■ Undermining (tunneling) will produce a boggy feel around the wound. ■ Crepitus is gas trapped under the skin. If you palpate the surrounding skin and feel a crackling sensation, this is crepitus. Crepitus may be due to air leaking from the lung in a chest wound or may also indicate the presence of gas-producing bacteria. ■ Erythema , swelling, or other signs of irritation indi- cate that the surrounding tissue is in jeopardy. ■ Epibole is closed or rolled wound edges. Examine wound edges for epithelial tissue and contraction. Epibole may indicate that epithelial cells have moved down and rolled under the wound edges. The edges tend to be lighter in color than surrounding tissue and may feel indurated (hardened). Once the cells reach the wound bed, they will stall wound healing. ■ Slough, which is often soft, stringy, and pale yellow or gray, is moist necrotic tissue that needs to be removed from the wound bed. ■ Eschar (also known as an unstageable pressure injury ) is dry necrotic tissue that appears thick, hard, and black or brown in the wound bed. Extent and Type of Tissue in the Wound Base Assessment of the types of tissue and their amounts can give you an idea of the severity of the wound, treatment options, and/or healing of the wound. Table 32-4 outlines different types of tissue you might see in a wound bed. ■ Key Point: Viable (living) tissue must be distinguished from nonviable tissue.
Think Like a Nurse 32-4: Clinical Judgment in Action
Review the Braden scale (see Focused Assessment, Braden Scale for Predicting Pressure Sore Risk in Volume 2).Apply this risk assessment scale to Mr. Harmon (Meet Your Patient). ■ What additional information, if any, do you need to complete these assessments? ■ Calculate a Braden score based on Mr. Harmon’s risk factors if he had also been incontinent of urine twice that day. Assessing Treated Wounds All wounds require a focused assessment. Assessment frequency depends on the condition of the wound, the work setting, the patient’s overall condition and under- lying disease process, the type of wound, and the type of treatment used for the wound. If you are providing wound care, you will assess the wound with every treat- ment (Table 32-3). For a wound assessment summary,
See Chapter 32, Focused Assessment, Physical Examination: Wound Assessment, in Volume 2.
Location Describe the wound location in anatomi- cal terms. For example, describe an incision from car- diac surgery as a midsternal incision extending from the manubrium to the xiphoid process. An accurate descrip- tion of the location is important because: ■ Location influences the rate of healing. Wounds in highly vascular regions, such as the scalp or hands, heal more rapidly than wounds in less vascular regions, such as the abdomen or a heel. ■ Location affects movement. Wounds that can be readily stabilized heal more rapidly than those in areas that are affected by the constant stress of movement. ■ Location can give you clues to the wound etiology. A wound over a bony prominence could be related to pressure, whereas one on the bottom of the foot could be a diabetic foot ulcer. Type of Wound Is it an acute wound? If the wound is sutured, examine the closure. Are the wound edges approximated (together)? Is there tension on any aspect of the wound? Are the stitches intact? Or is this a chronic wound? Size Place the patient in a neutral position to mea- sure the wound. Variations in positioning can distort soft tissue, causing you to obtain a larger or smaller measurement. Use a consistent method to measure the length, width, and depth of the wound in centimeters. To
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