Skin & Wound Care Primer

Introduction

Skin breakdown can be unfairly equated with poor nursing care. However, an aging patient population requires a new look at the skin’s capability. These facts show the importance of learning more:

  • 15% of hospital patients have pressure ulcers.1
  • 25% of hospitalized patients have perineal dermatitis.2
  • 15% of diabetics develop at least one foot ulcer.3
  • Healing of venous ulcers takes 9to 24 months to heal and recursin 60% of cases. 3
  • 8% of those over 70 have peripheral arterial disease, the primary cause of arterial ulcers.3

Skin vulnerabilities change throughout life. Age-specific examples are the diaper rash of babies, the acne of adolescence, and skin cancers cropping up after middle-age. This course focuses on the geriatric population. Normal skin changes associated with aging are:

  • Drying of skin due to decline in sweat and sebaceous gland function.
  • Thinning of the epidermis, dermis, and subcutaneous fat layer.
  • Increase in vulnerability to ultraviolet rays and infection.
  • Emergence of age spots, wrinkles and skin growths.
  • Decrease in vitamin D production.
  • Increase in capillary fragility
  • Delayed wound healing.
  • Decrease in blood flow.
  • Loss of elasticity.3, 4, 5, 6

The magnitude of these natural changes increases with time. The percentage of older adults with skin infections, for example, rises with age.7Contributing factors are:

  • Functional decline in all systems, especially the immunological and cardiovascular systems.
  • Increased vulnerability to accidents from co-morbidities and polypharmacy.
  • Accumulation of lifelong exposure to the sun.
  • Increasing likelihood that chronic infections will to go undetected and therefore, untreated.

Skin Repair

The skin heals in three phases:

  1. Inflammation.

After the formation of a clot, the inflammatory response lasts about five days. It is characterized by pain, warmth, redness, swelling and exudate.

  1. Proliferation.

This generally takes weeks. Partial-thickness wounds regenerate; whereas full-thickness wounds heal with scar formation. During this phase epithelialization, granulation, collagen synthesis, and revascularization occur. New cells migrate from the edges to the center of the wound, creating a new matrix.

  1. Maturation.

This phase takes anywhere from three weeks to two years. Fibers remodel, resulting in contracted, stronger tissue.3, 5, 6

Chronic wounds are those that do not heal within six weeks. Most often these are pressure ulcers and vascular ulcers of the lower extremities. The majority take up to six months to heal. Some may take years to heal, andthen are likely to reoccur.8, 9

The inflammatory phase of healing is prolonged in chronic wounds.6 The size of the wound may increase over time, edges may look irregular, exudate and necrotic tissue may be present, and tissue destruction may extend under the skin into the surrounding area, a phenomenon known as undermining and/or tunneling.5

Several factors can underlie a diminished healing capacity:

  • Obesity.
  • Incontinence.
  • Immobility.
  • Chronic pain.
  • Malnutrition.
  • Cigarette smoking.
  • Immunosuppression.
  • Poor diabetic control.
  • Scratching due to intolerable itching.
  • Inadequate oxygenation and/or tissue perfusion.
  • Failure to increase calories and protein needed to heal wounds, infections, and injuries.
  • Wound damage from excessive moisture or dryness; mechanical trauma, pressure, friction; and/or radiation.

Skin Problems

Dermatitis

Dermatitis shows up where skin is irritated. It is commonin body folds, especially in the perineal area. Post-menopausal women have diminished estrogen that creates atrophy of vaginal and vulvar tissues. Pruritis often initiates unconscious scratching that leads to infection. More than half of nursing home residents are incontinent of urine and/or feces.10, 11Incontinence irritates and inflames the whole area, extending to the buttocks. Antiseptics, soaps and topical ointments may further aggravate the condition.

Infection

Infection can occur in several ways:

  • Skin integrity is lost through scratching, injury, ulceration, or insertion of an invasive device.
  • Skin is colonized with MRSA (methicillin-resistant staph aureus).
  • Immune function weakens and dormant viruses become activated.
  • Unhealthy skin supports a chronic or recurring fungal infection.4, 7, 12

Skin Tears

Skin tears occur when aging skin becomes vulnerably paper-thin. Older adults are also increasingly accident-prone from cognitive impairment, diminished perceptual ability, gait and balance problems, and dizziness. The prevalence of senile purpura and xerosis causes skin to tear more easily.4Older skin tears easily when adhesive dressings are hastily removed.

Skin Cancers

Life-long exposure to ultraviolet radiation is the cause of over 90% of non-melanoma skin cancers, affecting almost half of Americans over 65.13Actinic keratosis,pre-cancerous lesions, are commonly seen on sun-exposed areas of the head, neck and upper body. Among cancerous lesions, most are basal cell carcinomas. They are slow growing and curable if detected early. Squamous cell carcinoma is seen in people who have had chronic sun exposure. Melanomas are life-threatening because of their tendency to metastasize. The occurrence of skin cancer among North Americans is:

  • One in five for basal cell carcinoma.
  • One in twenty for squamous cell carcinoma.
  • One in sixty for melanomas.14

Ulcers

Pressure ulcers occur over bony prominences subject to pressure and/or friction. They may go undetected until development penetrates the surface skin. The skin over a healed ulceris likely to breakdown again because scarring weakens the tissue.15 Skin integrity deteriorates in just a few hours, making prevention of pressure ulcers a critical task. Pressure ulcers can occur when:

  • Patients are in surgeries lasting over three hours.
  • Patients are immobile due to spinal cord injuries or strokes.
  • Patients are recovering from hip fractures.
  • Patients do not move because of pain.
  • Devices assert continual pressure on skin.
  • Patients on bed-rest are dehydrated or malnourished.16, 17

Diabetic ulcers are due to neuropathy which occurs in 2/3of diabetics within 5-10 years after diagnosis.3; 17 Normal protective sensation in the feet is lost and structural changes occur that contribute to injuries. Ulcers develop from either a single trauma, repetitive damage from improper shoes, or bath water that is too hot.18

Arterial ulcers occur when peripheral artery disease becomes severe. This can stem from atherosclerosis, blood clots, vasculitis, or Raynaud’s disease. Critical limb ischemia eventually creates full-thickness ulceration that turns gangrenous and necessitates amputation if untreated.19

Venous ulcers develop from deep vein thrombosis, faulty valves, and/or inadequate calf muscle pumping function.

Burns

Most burn injuries in older adults come from scalding accidents. The prognosis for survival is poor in older adults. The percent of full-thickness injury is higher in older peoplebecause their skin is more susceptible. Full-thickness burns require surgery, a high risk for traumatized, older, and frail people.20

Skin Assessments

Inspecting the skin, hair, and nails isroutine for nurses. Skin changes can occur within a few hours, making frequent re-inspection a preventive measure. Visual assessments include:

  • Color: redness, pallor, cyanosis, jaundice.

In darker skinned people, inflammation may not look red but the inflamed area may be firmer than surrounding tissue. A halogen light can show skin hue differences between the affected area and the surrounding skin.21

  • Texture: smooth, rough, or cracked.
  • Moisture: dry, or covered in sweat.
  • Temperature.
  • Edema of the body part, rated from one to four if pitting and/or measured by taking a limb circumference.
  • Turgor.
  • Exudate.
  • Hemorrhage.
  • Lesions.

Before choosing terms to describe lesions, wounds have to be palpated and measured, and distribution patternsdetermined. Basic terms used to describe lesions are:

  • Macule.
  • Papule.
  • Patch.
  • Plaque or scale.
  • Wheal.
  • Nodule.
  • Vesicle.
  • Pustule.
  • Cyst.
  • Scar.
  • Abrasion.
  • Tear.
  • Fissure.
  • Burn.
  • Ulcer.

It may be difficult for nurses to make an accurate assessment of skin wounds. Current guidelines recommend that facilities choose terms, tools, and perimeters that staffwill agree to use consistently. Whereas accuracy of assessment is crucial for determining initial treatment, the goal of daily wound measurement is to identify change as an evaluation of treatment.22

An assessment begins with:

  1. Differentiating between superficial, partial-thickness, and full-thickness wounds.

A typical sunburn is a superficial wound. A second degree burn is a partial-thickness wound. It is red, painful, swollen, and blistered.The wound base of a partial-thickness wound is bright or pearly pink with red “islets”. A full-thickness wound has extensive damage and necrotic tissue. Its wound base is beefy red but the wound may have black eschar, yellow slough, or white margins indicating maceration.

  1. Estimating the wound size.

There are three ways to do this: take a two-dimensional measurement, take a three-dimensional measurement, or calculate the total surface area.

Planimetry calculates the size of a wound in cm2 by multiplying length and width of the actual wound, a tracing, or a photo.

Some wounds are irregular in shape and have tunnels beneath the surface of surrounding skin. To get a three-dimensionalmeasurement an applicator has to be inserted to read depth and direction of the wound and its tunnels. Another way is to create molds made with alginate or pour fluid into the wound to determine volume.

Total surface area of a wound such as a burn can be estimated through either the Rule of Nines or, more accurately, with a Lund and Bower Chart that takes age-related differences of body proportions into consideration. (R)

  1. Determining between critically colonized and infected wounds.

Chronic wounds are typically colonized with many different microbes. A microbial count can be obtained by swabbing the wound or having a biopsy done. Clinical signs may differentiate a poorly healing wound from an infected wound. Both critically colonized and infected wounds have clear yellow or straw-colored exudates. They may both have a foul smell and be expanding in size. However, the critically colonized wound will show red granulation tissue and the infected wound will generate an inflammatory response including increased temperature.23, 24

Tests that determine the healing capacity for wounds are:

  • Tests of blood flow and tissue oxygenation.

CBC: RBCs, WBCs, hemoglobin, hematocrit, platelet count, and mean corpuscular volume.

TcPO2(transcutaneous oxygen): Less than 20 mmHg indicates an inability to heal.

ABI (ankle-brachial index): calculation is derived from the ratio between pressure at the ankle and pressure in the arm. Severe ischemia is indicated when the measurement is less than 0.5. Elevations above the normal of 0.9 to 1.1 occur when calcification is present.25

A handheld Doppler ultrasound is used to take an ABI . Doppler ultrasound is also used for color duplex imaging that can identify occlusions and restrictions in veins and arteries.

  • Nutritional status.

More than 15% loss of usual body weight is significant. Obesity is also a marker for poor healing capacity, due to diminished tissue perfusion.

Significantly poor healing capacity is indicated in these values:

A prealbumin level under 9 mg/dl.

An albumin level under 2.7g/dl.

A transferrin level under 149 mg/dl.

A total lymphocyte count under 1200 mm3. 3

  • Neuropathy.

The Semmes-Weinstein monofilament test assesses the protective function of nerves in diabetics.

  • Glucose control.

A fasting blood glucose over 400 mg/dl shows lack of homeostasis.

An Hb A1c (glycosylated hemoglobin) over 8% shows poor long-term diabetic control.

  • Bacterial status of wound.

A microbial count of over 100,000 cfu (colony forming units) indicates infection that will prevent healing. However, some bacteria such as streptococcus will prevent healing even with a smaller number of colonies. Wound cultures and sensitivities may be necessary to direct treatment.

Specific Assessments

Skin cancer

Skin cancer is suspectedwhen there is a visible change in the skin. Skin cancer is usually painless but may bleed regularly. The change may be a new growth or an old growth that starts to change in appearance. Although diagnosis of skin cancer is made by biopsy, a preliminary differentiation may be attempted by appearances:

  • Actinic keratosis: reddened, scaly papules, often in clusters.
  • Basal cell carcinoma: superficial, smooth, pigmented nodules or papules.
  • Squamous cell carcinoma: scaly, red papules, often concurrent

with actinic keratosis.

  • Melanoma: varied appearances but follows the ABCDE rule:

A: asymmetrical

B: borders are irregular

C: colors are multiple within same lesion

D: diameter over 6mm.

E: evolving/changing lesion5, 14

Skin tears

Skin is easily torn in the geriatric population and may go unnoticed by the patient. A tear may be mistaken as a pressure ulcer if it occurs over a pressure point (B-D). The Payne-Martin System is helpful in classifying tears for documentation purposes:

I: A flap-type tear without tissue loss.

II: A tear with scant to moderate tissue loss.

III: A tear with complete tissue loss.4

Skin infections

Differentiation between common diseases is often made by clinical signs and symptoms.

  • Shingles: skin manifestations preceded by tingling, numbness and burning. Within days, clusters of blisters occur, embedded in a rash. This appears in a line on one side of the trunk. It progresses to plaques and pustules.
  • Cellulitis: a red, warm, hardened, tender area. Borders are not sharply demarcated. The WBC count is elevated.
  • Impetigo: an inflamed patch that progresses to clusters of rupturing blisters filled with honey-colored liquid.12

Perineal dermatitis

This is characterized by redness over a diffuse area. It may extend from groin to buttocks to thighs. There may be erosion of superficial skin layers, scaling, blisters, or weeping. If the condition continues, secondary infection commonly occurs, usually from fungi. The patient complains of discomfort, itching, pain and burning.2, 10

Perineal dermatitis can be caused by allergic reactions, contact with irritants in laundry soaps, or skin cleansing and moisturizing products. Most often it is associated with incontinence. Risk assessment toolsidentify patients needing preventive measures. However, use of the tools is problematic because of the frequent need forre-assessment. A re-assessmentis needed after each perineal cleaning, as often as every two hours. Clinical experts recommend using a simple three question check:

  • Is the skin color or firmness different from that of the surrounding area?
  • Is the skin blistered or weeping?
  • Is the area causing pain or itching?11

Diabetic ulcers

Assessment includes observation, popliteal and pedal pulse checking, and classification of the wound according to severity.

Diabetic ulcers usually occur on the ball of the foot, on top of the toes, or under the heel. The ulcer can be shallow, or deep with undermining. The edges will be even and the bed will show granular, red tissue. The foot will be warm and there will be slight to moderate drainage.3, 18, 26

The University of Texas Diabetic Foot Classification System is a useful tool:6

Stage / Grade 0 / Grade I / Grade II / Grade III
A / Epithelialized / Superficial wound
↓ / Wound penetrating to tendon or capsule
↓ / Wound penetrating to bone or joint
↓
B / Infected
C / Ischemic
D / Infected + ischemic

Another useful tool is the Wagner Grading System:6

Grade
0 / Pre-ulcerative lesion
Healed ulcers
Bone deformity
1 / Superficial ulcer
2 / Wound penetrating through subcutaneous tissue
3 / Osteitis, abscess, or osteomyelitis
4 / Gangrene of digit
5 / Gangrene of foot

Vascular ulcers

Venous ulcers typically occur in the lower legs, between the ankle and mid-calf area. They are flat, shallow wounds with irregular edges and a beefy color. There is firm edema and moderate to heavy drainage. The skin around the wound is dry, thin, and scaly, with visibly dilated superficial veins. The patient complains of minimal to severe pain. This lessens when the affected leg is elevated and increases when resting at night.

3, 8, 18

Some diagnostic tests for patients with venous ulcers are:

  • ABI checks for arterial insufficiency, present in 25% of patients with venous disease. If arterial insufficiency is found, it contradicts compression therapy as a treatment for venous disease.
  • Contrast venogram rules out deep vein thrombosis (DVT).
  • Doppler ultrasound studies check for venous reflux, obstructions and restrictions.
  • Venous cuff pressure readings below the knee can be obtained by air or a photoelectrode. They rule out DVT, check for venous reflux and calf muscle pump ability, and assess the severity of the disease.3, 6

Arterial ulcers tend to occur in the distal part of the leg, on the sides of the feet, at the ankle, between the toes or on their tips, or places subject to trauma or constant rubbing. They are small, round, wounds that looks “punched out”. They may be shallow or deep but have even, smooth edges and pale wound beds. Drainage is minimal. The patient complains of severe pain that worsens when the leg is elevated and lessens when the leg is lowered. The surrounding skin is thin, shiny, cyanotic, dry and cold. 3, 18, 19

Clinical assessments of arterial ulcers include:

  • The pain history.

How and where did the pain start?

How long does the pain last? (Is there intermittent claudication?)

Has the pain progressed to another location, for example from the calf to across the foot?

  • Perfusion test.

Check capillary refill by observing skin temperature and color upon elevating and lowering the leg.

  • Pulse checks.

Take the dorsalis, posterior tibial, bilaterial femoral and poplilteal pulses.19, 25

Diagnostic tests are:

  • ABI identifies arterial insufficiency.
  • Segmental cuff pressure readings (high thigh, low thigh, below knee and above ankle) confirm arterial insufficiency or identify calcification of arteries.
  • Toe pressures identify poor healing potential.
  • Doppler ultrasound studies measure blood flow and determine the severity of arterial disease. These include skin perfusion pressure study, waveform analysis, and color duplex imaging.
  • TcPO2 identifies micro-vascular insufficiency/perfusion problems.
  • MRA identifies and rates the severity of arterial obstruction.
  • Angiography is the gold standard for diagnosis of arterial disease. The test is associated with risks but is necessary beforerevascularization procedures.3, 6

Pressure ulcers