1 Wound Care: Part I Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract Although many types of wounds are easily treated, some require specialized expertise in order to resolve or treat the primary cause and to prevent additional wounds. Clinicians who opt to specialize in wound care provide an important skillset to patients suffering from chronic or acute injury, disease, or medical treatment. Often, a holistic approach is adopted, with coordination of health team efforts to ensure that all aspects of a patient's health are considered during the course of initial and ongoing wound care management. Wound care clinicians also serve as a resource to prepare the patient to continue care at home.
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Wound Care:
Part I
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and medical
author. He graduated from Ross University
School of Medicine and has completed his
clinical clerkship training in various teaching
hospitals throughout New York, including King’s County Hospital Center and Brookdale
Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and
has served as a test prep tutor and instructor for Kaplan. He has developed several medical
courses and curricula for a variety of educational institutions. Dr. Jouria has also served on
multiple levels in the academic field including faculty member and Department Chair. Dr.
Jouria continues to serves as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also developed several
continuing medical education courses covering various topics in clinical medicine. Recently,
Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &
Physiology.
Abstract
Although many types of wounds are easily treated, some require specialized
expertise in order to resolve or treat the primary cause and to prevent
additional wounds. Clinicians who opt to specialize in wound care provide an
important skillset to patients suffering from chronic or acute injury, disease,
or medical treatment. Often, a holistic approach is adopted, with
coordination of health team efforts to ensure that all aspects of a patient's
health are considered during the course of initial and ongoing wound care
management. Wound care clinicians also serve as a resource to prepare the
patient to continue care at home.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Statement of Learning Need
As wound care is a rapidly advancing field, continuing education is necessary
to ensure that clinicians caring for patients with wounds stay on top of the
latest treatment techniques and strategies to achieve wound healing.
Certification in the field of wound care is available for clinicians wanting to
specialize in their area of practice to best; causes of skin breakdown, types
of wounds, treatment of acute and chronic wounds and, importantly, wound
prevention, are all key areas for clinicians to commit to continuous learning
and practice improvement.
Course Purpose
To provide clinicians with knowledge of wound risk, and phases of wound
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development and healing.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
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1. Tertiary intention involves the process of:
a. wound closure done by applying physical measures to close a wound.
b. initially leaving the wound open to partial healing. c. leaving a wound open to heal through production of new granulation
tissue to fill in the wound base. d. None of the above.
2. A nurse must continue to monitor a surgical wound
a. regardless of the type of surgical wound.
b. when a wound is closed with sutures. c. only if there is an open wound
d. Answers a and b.
3. True or False: venous insufficiency is a condition that develops when the veins are unable to return blood to the heart at a
normal rate and the blood collects in the lower extremities.
a. True.
b. False.
4. Surgical wound drains
a. must be emptied on a regular basis to ensure that they work properly. b. may cause damage to wound tissues.
c. prevent wound infections caused by drainage accumulation. d. All of the above.
5. When a nurse must administer medications intravenously, he or
she should be aware that
a. medications known as vesicants are safe because they do not cause
tissue damage to the skin. b. it is preferable to administer medications intravenously because they
cannot accidentally infiltrate into the skin tissues. c. some medications, when administered intravenously, can cause
significant wounds if accidentally infiltrated into the skin and tissues. d. extravasation does not develop if medications are administered
intravenously.
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Introduction
Wound care is a specialized form of nursing that requires thorough
knowledge of the skin and its potential for breakdown and ulceration. A
nurse who provides wound care on a regular basis must have the skills to
perform various procedures and to provide treatment to patients of different
backgrounds. Wounds can develop through a number of sources, including
chronic disease, injury or trauma, cancer, or through surgical procedures.
Appropriate care and treatment of wounds requires experience and
understanding of the complex needs of the diverse patient populations who
develop wounds, as well as those methods that will support the best
outcomes for these patients.
Causes Of Wounds
The skin is the largest organ of the body and provides a significant amount
of protection for internal structures from damaging pathogens and
environmental factors that can cause internal injuries. There are times,
though, when the skin breaks down and its damaged areas are unable to
perform their normal functions. When a skin wound develops, the skin
requires time and extra care for healing, particularly when the wound is
deep or extensive. There are multiple causes of wounds, which can occur on
any area of the body covered by skin.
Injury
An injury is an event that causes damage to the body. Injuries may cause
various types of wounds, from small and minor tears in the skin to large
openings that expose underlying tissue and organs. The type of wound that
results from an injury depends on the mechanism of injury that incurred the
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trauma. Wounds caused by injuries may include incisions, lacerations,
abrasions, bites, penetrating wounds, and burns.
A nurse may care for a wound caused by an injury at different stages of its
healing. A trauma nurse may care for a patient who is being seen in the
emergency department just after a gunshot wound and the nurse must work
to stabilize the patient and the wound to prevent hemorrhage. Alternatively,
a nurse who works in a rehabilitation unit may care for a patient who is
slowly recovering from a significant burn wound, providing debridement and
dressing changes on a regular basis. Both types of wounds occurred because
of injuries, but they are cared for in different stages.
Management of wounds caused by injuries involves assessment of the size
and depth of the wound, understanding the mechanism of injury, ensuring
there are no other factors involved that would complicate the wound, such
as the presence of foreign objects or other injuries around the wound,
managing the patient’s pain, and preventing other complications associated
with the wound, such as bleeding or infection.
Disease
Chronic disease can impair skin and tissue integrity, causing wounds that
may be slow to heal. Certain diseases impact the circulatory system, which
causes skin breakdown when the peripheral tissues do not receive enough
oxygen. Examples of diseases that can cause wounds include venous
insufficiency and diabetes.
Other types of wounds may occur from diseases that cause skin breakdown
after exposure to substances or environmental stimuli. Some diseases cause
wounds when they impact patient mobility and activity levels, increasing the
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risk of skin breakdown from pressure sores and poor circulation. Finally,
some diseases cause growths within the body that ultimately lead to
external wounds. An example of this situation might be a cancerous tumor
that grows under the skin and then causes a wound on the skin surface,
known as a fungating wound.
In addition to treating the wound caused by a disease process, a significant
part of the nurse’s work when caring for a wound patient is to also manage
the underlying disease. This includes administration of medications,
providing treatment or therapy for the disease, and educating the client
about his or her condition. When a wound has developed as a result of a
disease, the nurse must work to help the patient control the disease
symptoms to prevent the wound from occurring again in the future.
Medical Treatment
Medical treatments and procedures can cause wounds. The wound may heal
rapidly or it may need more time to heal. Surgical incisions are one of the
most common types of wounds that occur because of medical treatments,
although other procedures, such as radiation therapy or the administration
of certain kinds of medications, can also cause sores or burns on the skin
that must be monitored and treated.
The process of wound healing may vary depending on the method of
intention used to close the wound. Wounds are healed by intention, which is
categorized into three different stages and is based on the type of wound,
the amount of debris present or if the wound is contaminated, and the
mechanisms of the cause of the wound.
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Primary intention is a method of wound closure that is done by applying
physical measures to close a wound. A wound may be closed by primary
intention by applying sutures, staples, or medical-grade glue to approximate
the wound edges and bring them together for healing. Primary intention is
most often used with linear wounds, such as when closing a surgical incision.
As the wound edges grow together to form a scar, the resulting tissue is
typically as strong as the surrounding, undamaged tissue.
Secondary intention involves leaving a wound open to heal through
production of new granulation tissue to fill in the wound base. Eventually,
the wound edges will heal and result in a scar, although this process
typically takes months longer than a wound healed by primary intention.
When the wound has completely healed, the scar tissue covering the wound
is not as strong as the surrounding tissue; it is thought that it reaches
approximately 80 percent of its previous strength as that of surrounding,
undamaged tissue once a wound has healed by secondary intention.21
Examples of wounds that may heal by secondary intention include wounds
that develop from pressure ulcers, venous ulcers, and diabetic ulcers.
Tertiary intention involves the process of initially leaving the wound open to
partial healing. The application of sutures, staples, or glue, to bring the
edges together, closes the wound after a period of time. These types of
wounds initially develop some scar tissue as they heal. After the wound
edges are brought together, the scar may become stronger than when the
wound was healing through secondary intention.21 Tertiary intention may be
performed in a case when there is an extensive wound that is contaminated
and needs to be cleaned and debrided for a period before surgically closing
the wound.
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As a wound heals, it goes through a series of stages in which the tissue that
was broken down comes back together to form a scar. A wound that is small
may heal relatively quickly and without complications. Alternatively, a very
deep wound, one that is contaminated, or a wound in a patient who has an
underlying chronic disease that is poorly controlled, may take much longer
to heal. The stages of wound healing include the following.
Inflammatory phase
Bleeding that may be present initially stops when the blood starts to clot. As
the blood clots dry, they form a scab, which is a combination of old blood
and wound exudate. The body’s immune system responds to the wound by
causing inflammation. In the first hours or days after the wound has
developed, it may become red, swollen, and tender to the touch. White
blood cells are sent to the wound site and there is increased blood flow to
provide oxygen. There may be exudate production at this stage.
Proliferative phase
Granulation tissue begins to form in the wound bed and angiogenesis, the
process of creating new blood vessels, takes place under the skin. The
wound edges begin to come together as the cells migrate during
epithelialization. This stage lasts anywhere from a few days to several weeks
after the wound has developed.
Remodeling phase
Collagen formation builds strength in the wound bed; the wound has “filled
in” with epithelial tissue, although it is not as strong as the surrounding
tissue. The remodeling phase may occur for months or years after a wound
has developed.102
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Wound Types
Wounds are typically classified as being either chronic or acute wounds,
depending on how the wound has formed and the mechanism of injury
causing the wound. Chronic wounds are those that develop after tissue
damage has been ongoing. Examples of chronic wounds include wounds that
develop due to arterial insufficiency, diabetic ulcers, pressure sores, and
wounds that occur from venous insufficiency. The period of time that it takes
to develop a chronic wound may be weeks to months, but the point that
differentiates chronic wounds from acute wounds is that chronic wounds
develop over some period of time.
Alternatively, acute wounds are those that occur after injury to the skin
leads to damage and bleeding. Examples of types of acute wounds include
wounds from burns or trauma, and surgical wounds in which an incision is
made and the surgeon closes the wound with sutures or staples. The type of
wound that occurs, whether it is acute or chronic, typically affects one or
more layers of the skin, and may extend enough to impact the subcutaneous
fat, underlying tendons and ligaments, or may even affect the bones and
organs under the skin.
The outermost layer of skin, the epidermis, consists of layers of cells that
are continuously pushed upward toward the skin surface where they are
eventually sloughed from the body. The lowest layer of the epidermis is a
row of cells known as germinative cells; these cells divide continuously to
form keratinocytes, which are the cells that make up a majority of the
epidermis. Keratinocytes form from the germinative layer of cells and then
slowly proceed toward the outside edge of the epidermis. As they move,
they become filled with keratin, which is a fibrous protein that provides
structure. Once the keratinocytes reach the outermost layer of the
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epidermis, they die. They are not removed immediately, but instead remain
as the surface of the skin where they provide protection against
environmental components that could otherwise invade the body.
When a wound occurs, part of the healing process involves producing new
skin cells from the germinative cells of the epidermis that are near the
wound edges. The epidermis is a very thin outer layer and covers the lower
dermal layer. Because it is so thin, the epidermis does not contain hair
follicles, blood vessels, or sweat glands, although hairs will protrude from
where they are formed in the dermis and extend through the epidermis to
the skin surface. When a wound occurs that is very superficial and only
affects the epidermis, the wound typically heals quickly and with little
scarring, as the body is able to produce new skin cells from nearby
germinative cells.
Deeper wounds may affect the dermis, the skin layer that lies below the
epidermis. The dermis is thicker than the epidermis and it mostly consists of
connective tissue. The dermal layer contains many structures, including
blood vessels, hair follicles and nerve endings, as well as other cells that
take part in inflammatory processes when a wound occurs. The dermis is
much tougher than the epidermis because of its composition. The lower
levels of this layer contain collagen fibers that provide strength for the skin
and that take part in wound healing and scar formation.
Below the dermis is the subcutaneous tissue, which consists of fat and other
components, including blood vessels, nerves, and lymph channels. The
subcutaneous tissue is covered by fascia, a membrane of connective tissue
that provides protection. The subcutaneous tissue covers underlying
structures such as bone and muscle, however, the thickness of
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subcutaneous tissue layers varies between locations. Some areas, such as
those of the abdomen or upper thigh, naturally contain more fat tissue when
compared to other areas. The organs and muscles underneath the
subcutaneous tissue also have their own protective membranes. Depending
on the wound and the mechanism of injury, the wound can extend down into
the subcutaneous tissue and can expose underlying muscles or bone. There
are many different mechanisms that can produce wounds, whether by
disease processes, through acute injury to the tissue, or through ongoing
factors that contribute to skin breakdown over time.
Pressure Ulcers
A pressure ulcer develops in an area that becomes ischemic because
increased pressure on the skin and underlying tissues prevents adequate
blood flow to the area. Pressure ulcers can develop almost anywhere on the
body where excessive pressure impairs blood flow, but they are most
common on areas that cover bony prominences. The most likely areas where
pressure ulcers develop include the sacrum, the heels, the ear, and the
coccyx.3 Pressure ulcers used to be referred to as decubitus ulcers or
bedsores; however, these terms do not necessarily reflect a comprehensive
mechanism of injury. For instance, a person who is not confined to bed may
still develop a pressure ulcer. The term “pressure ulcer” is more consistent in
defining the means of injury that occurs with this type of wound.
Increased pressure over an area of skin causes compression of the blood
vessels that normally supply oxygenated blood to the skin, subcutaneous
tissue, and underlying fascia. When the blood vessels are constricted in this
manner, blood flow to these sites slows and the distal areas do not receive
adequate oxygen or nutrients that are so needed to maintain healthy skin.
Further, venous return is also slowed, and blood is unable to adequately flow
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away from these areas and back toward the heart because of vessel
compression. As a result, metabolic wastes, which are normally carried away
from the area as part of venous return, instead accumulate in the affected
area. This causes a negative cycle as the increased build up of metabolic
wastes causes vasodilation of surrounding blood vessels, followed by edema,
and further compression of the blood vessels supplying the area.
After a period of time in which blood flow is restricted, tissue ischemia
develops whereby the tissues fed by the compressed blood vessels no longer
have enough oxygen to survive and cell death occurs. This cell death then
contributes to skin breakdown and the affected person develops a pressure
ulcer.
Regular wound assessment is required to determine the depth and extent of
the wound, as well as whether treatment measures are being effective in
healing the wound. The nurse should note the location, size, and appearance
of the wound to better determine the degree of damage. The National
Pressure Ulcer Advisory Panel (NPUAP) has defined several classifications of
pressure ulcers according to the depth of tissue involvement and the extent
of damage. By understanding the stages of pressure ulcers, the nurse can
assess a wound and better understand how it is staged. By staging the
wound, the provider then has a guide for the best form of wound
management.
Stage I
In stage I the skin is still intact but does not blanch when pressed. The skin
appears red, which does not resolve with time or position changes. It may
more likely appear over a bony prominence. In a person with dark skin, the
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area may not be red or even noticeable except that the affected skin
appears as a different color when compared to the surrounding skin.
Normally, an area of skin may turn red after a short period of pressure; this
situation is known as reactive hyperemia. The process occurs when the body
increases blood flow to the compressed area to make up for temporary
oxygen deprivation.8 With reactive hyperemia, the skin becomes red and
appears flushed. However, this typically resolves quickly with position
changes and as blood flow resumes to its normal pattern.3 An area of
redness can be considered a stage I ulcer if the redness does not resolve
and the area does not blanch.
Stage II
The skin is broken in Stage II but the wound is typically confined to the
epidermis. The skin appears red and blisters filled with serous fluid may be
present; blisters may have broken, resulting in shallow wounds that ooze.
The base of the wound may appear pink or red and slough may or may not
be present.
Stage III
In state III the wound is deep enough that it extends through the epidermis
and into the dermis. A stage III pressure wound is considered a full-
thickness wound; however, this stage of wound does not affect the
underlying muscle, tendons, or bone. The subcutaneous fat under the dermis
may be seen in some areas where there are greater amounts of fat. Slough
may or may not be present at the base of the wound, which may make it
difficult to determine depth. Stage III wounds can have tunneling, in which a
hole or tunnel progresses deeper into surrounding tissue. If a second wound
is nearby, tunneling may connect the two wounds.8
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Undermining may also be present at this stage, which occurs when the
edges of the wound at the surface cover more of the wound than is present
at the base. When undermining is present, the wound is actually larger than
it appears at the surface.
Stage IV
Stage IV pressure ulcer is a full-thickness wound that extends from the
epidermis into the dermis and subcutaneous tissue and exposes underlying
bones, muscles, or tendons. In areas where there is less subcutaneous fat
and cartilage is present instead, such as on the nose or the ear, the
exposure of underlying cartilage classifies the wound as a stage IV pressure
ulcer.3 Tunneling and undermining may also be present with this stage of
wound.
In addition to the standard categories of wounds based on the depth of the
affected tissue and the exposure of underlying structures, there are other
classifications of pressure wounds that consider those injuries whose
measurements or depth are not obvious and apparent.
Deep Tissue Injury
In a deep tissue injury (DTI) the skin may or may not be broken but there is
significant bruising that appears as blue or purplish skin with bruising that
extends down into lower layers of skin. The appearance of the wound may
also look like that of a blood-filled blister. The texture of the skin with a deep
tissue injury can vary; some patients have skin that feels warmer than
surrounding tissue, while others have cooler skin. The skin texture may feel
firm or it may be mushy. Some patients have intense pain while others do
not.
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Deep tissue injury occurs in an area that has been injured by shear forces. It
can be difficult to determine how deep the injury is and if it extends down
past the dermal layer. A DTI can be difficult to assess in a patient with dark
skin. As the injury heals, it may become an ulcer with open skin on the
surface or it may resolve under the skin.
Kennedy Terminal Ulcer
Another type of ulcer, termed the Kennedy Terminal Ulcer, is a specific type
of skin breakdown that may occur hours, weeks, or months before death in a
terminal patient. This type of terminal ulcer typically develops among
patients who are nearing death and who are cared for in long-term care
situations. The skin takes on a purple, red, or yellow appearance and the
wound may be shaped like a pear or a butterfly.3,4 The most common
location where the ulcer develops is on the sacrum, although it can show up
on any part of the skin. This type of ulcer may be more commonly seen by
caregivers who work in long-term care facilities or among those who work in
critical care units who receive patient transfers from long-term care facilities.
A Kennedy terminal ulcer may develop rapidly through the process of skin
breakdown as the patient nears death. As Margaret Falconio-West of Medline
best explained, when a person nears death, organ failure becomes an issue
and is often a cause of death. It stands to reason, then, that the skin, the
largest organ of the body, may also fail, leading to skin breakdown
associated with a Kennedy terminal ulcer.4
Unstageable Wound
The unstageable type of wound is not obvious as far as its depth is
concerned. The clinician may not be able to classify the wound based on its
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appearance and further measurements are often required. The base of the
wound is usually covered with slough or eschar, which makes the depth of
the wound difficult to determine.
Several other terms that describe wound tissue may be identified as
characteristics of wounds; these elements may be present in pressure ulcers
or in wounds that have developed as a result of other reasons. Eschar is
used to describe necrotic tissue that has developed within a wound. Eschar
is dead skin that is often tough and thick; it may have a similar appearance
to a scab but it is not the same. Eschar is what must be removed with
debridement. Without removal of eschar, would healing can be significantly
delayed.
Slough is another component of the wound that may develop alongside
eschar, but it has an appearance that is different. Slough is also a collection
of necrotic tissue, but unlike eschar, it is typically moist, crusty, or crumbly.
It is typically white, yellow, or cream colored and it is thought to contain
dead leukocytes, bacteria, dead skin, fibrin, and wound exudate.22 Slough
must be removed during debridement in order to promote wound healing, as
the body typically cannot get rid of slough on its own and it may accumulate,
harboring bacteria and preventing growth of normal, new skin tissue.
Factors contributing to pressure ulcers
Other factors may contribute to development of pressure ulcers, putting
some populations of patients at higher risk. Immobility is a prime cause of
development, as the inability to move or change positions to relieve pressure
on an affected area results in sustained periods of time in which affected
blood vessels are compressed. Patients who have excess moisture on their
skin, whether from such factors as sweating or poor hygiene, are at
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increased risk, particularly when the skin has become ischemic from too
much pressure. The excess moisture on the skin causes the surface skin to
become softer and more prone to breakdown.
Older adults are a population at high risk, not only because of their
increased instances of immobility, but also because of body changes
associated with aging. Many older adults have less subcutaneous fat under
the surface of the skin, which results in less protection from epidermal
injury. Older adults also have thinner skin as a result of aging, which often
becomes dry and less elastic due to decreased action of collagen and elastin
within the skin’s structure. These effects of aging cause the skin to heal
much more slowly when a wound occurs. Further, some older adults suffer
from sensory changes that result in diminished sensation in the extremities
and distal tissues. These older adults may be less likely to perceive when
tissue damage is happening because they cannot feel it immediately.
Obese patients are also at higher risk of skin breakdown due to pressure
ulcers and tissue ischemia. Patients who are obese have more weight
applied to certain areas when lying in different positions. A person who is
obese may have extra skin folds that can retain moisture and can be difficult
to clean. The skin in these folds may break down more easily when moisture
remains between the folds or skin folds rub on bed sheets or linens, causing
small abrasions on the surface of the skin.
Various other factors, both extrinsic and intrinsic, can impact the risk of
developing pressure ulcers. Extrinsic factors include such elements as:
Friction and shear
Level of moisture
Irritating substances on the skin
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The environment that prevents movement or turning to relieve
pressure
Alternatively, intrinsic factors are part of the patient; some intrinsic factors
can be changed, while others cannot. Intrinsic factors that affect wound
development include:
Age
Circulation status
Personal habits that affect skin integrity (smoking, diet, alcohol
consumption)
Body temperature
Use of some medications (steroids, vasoactive drugs)
Weight
History of injury or disability
Assessment tools and rating scales
Multiple rating scales are available to assess patient risk for development of
pressure ulcers. In the United States, the Braden scale is one of the most
common tools used to assess whether particular patients are at risk of skin
breakdown or if the skin is no longer intact. The nurse may use the Braden
scale when performing a patient assessment. The results are given scores
based on factors such as the patient’s levels of sensory perception, moisture
content of the skin, nutrition levels, and mobility. The lower the score, given
with the Braden scale, the higher the risk for skin breakdown.
Assessment tools may be used on any patient who may be at risk of
pressure ulcers; although, not all patients may need intervention for
pressure ulcer prevention, it is always better to provide more care to prevent
ulcers than to avoid interventions because a patient is believed to be at low
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risk. Increased nursing care and interventions for prevention of pressure
ulcers has been shown to decrease pressure ulcer development, regardless
of the patient’s level of risk.3
Arterial Insufficiency
Arterial insufficiency refers to decreased and inadequate blood flow to
tissues and organs. When a patient has arterial insufficiency, he or she is at
increased risk of developing ulcers when the skin and underlying tissues
become ischemic from lack of blood flow. Arterial insufficiency ulcers most
commonly affect the lower extremities, including the legs and feet. As blood
flow diminishes, the cells are starved for oxygen and tissue ischemia
develops. Without correction of adequate blood flow, the skin becomes
necrotic and starts to break down, forming a wound.
Arterial insufficiency can develop through various causes and it may occur
suddenly or it can develop gradually. A sudden cause of arterial insufficiency
may result from trauma or injury to a part of the body that disrupts blood
flow to the extremities. Alternatively, chronic arterial insufficiency may
develop over time due to atherosclerosis.9
According to Hess, author of an arterial ulcer checklist in the journal
Advances in Skin and Wound Care, several conditions are associated with
arterial insufficiency and patients with these illnesses are more likely to
suffer from blood flow abnormalities and wounds that develop from arterial
insufficiency. Examples include thrombosis of any cause, vasculitis,