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CHAPTER 32 Skin Integrity & Wound Healing

EXAMPLE CLIENT CONDITION: Pressure Injury—cont’d

Physical Findings When ischemia first occurs, the skin over the area is pale and cool. When pressure is relieved (by turning the patient), vasodilation occurs, extra blood goes to the area, and the area flushes bright red (reactive hyperemia). If the redness does not disappear quickly, tissue damage has occurred. Inspecting Skin Daily 1. Begin skin care with regular assessment of the skin for appearance, temperature, texture, and color. 2. Ensure adequate light to detect subtle, early skin changes. 3. Check pressure points for erythema, ten- derness, or edema (see Fig. 32-11). 4. Instruct caregivers on how to detect early signs of skin problems. 5. Look for skin breakdown under breasts, in abdominal folds, and where there is skin- to-skin contact in patients with obesity. Assessing for and Evaluating Pressure Injury • The Braden scale rates sensory perception, moisture, activity, mobility, nutrition, friction, and shear. The lower the score, the more likely the patient will develop a pressure injury. The Braden Q is for children. • Impaired Skin Integrity, Actual or Risk for • Impaired Tissue Integrity, Actual or Risk for Adjunctive Wound Care Therapies • Surgery. Excision and débridement, skin graft, drains, and flaps close wounds and promote healing. • Electrical Stimulation. Stimulates cellular growth through development of fibroblasts and new collagen; increases blood flow and tissue oxygenation. • Hyperbaric Oxygen Therapy (HBOT). High oxygen under pressure accelerates healing. HBOT also enhances white blood cell activity to improve healing. • Tissue Growth Factors. Naturally occurring proteins that cause specific cells to grow and replicate; platelet- derived growth factor for chronic wound healing for diabetic and other nonhealing wounds; used for clean wounds without necrotic tissue and that have good blood supply.

RECOGNIZING CUES

Go to Chapter 32, Focused Assessment: The Braden Scale for Predicting Pressure Sore Risk Assessment Scale, in Volume 2.

• The Norton scale assesses risk based on the patient’s physical condition, mental state, activity, mobility, and incontinence. The lower the score, the higher the risk is for pressure injury. See Chapter 32, Focused Assessment: Norton Pressure Sore Risk Assessment Scale , in Volume 2. • The PUSH tool reports the progression of a pressure injury. Surface area, exudate, and type of wound tissue are scored and totaled. As the injured area heals, the total score falls. See Chapter 32, Focused Assessment:

PUSH Tool for Evaluation of Pressure Injuries , in Volume 2.

• Infection, Actual or Risk for • Pain • Altered Body Image

ANALYZING CUES/ DIAGNOSING

COLLABORATING

• Ultrasound. Sound waves that pass into tissue cause vibration and heat. This stimulates movement of fluid within and between cells, aids in debridement, and increases cell metabolism. • Bioengineered Skin Substitutes. Aid in temporary or permanent closure of partial- and full-thickness wounds. Made of human epidermis or dermis, animal cells, or synthetic material. • Nitric Oxide (NO). Enhances wound healing by improving circulation to the wound bed. Additionally, NO promotes the growth of fibroblasts and collagen for repair of skin and tissue. NO has high antibacterial effects and thus decreases infection (Saidkhani et al., 2016). • Maggot Therapy. More precise débridement method because irradiated maggots eat only necrotic tissue.

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