8.3 Integumentary Disorders & Wound Care

Skin Assessment Basics

Assess skin systematically with inspection and palpation: color (erythema, pallor, cyanosis, jaundice), moisture, temperature, texture, mobility, and turgor — skin that remains tented after pinching suggests dehydration; in older adults, test over the sternum or forehead because age-related elasticity loss makes hand turgor unreliable. Document lesions by configuration, distribution, and morphology (macule, papule, vesicle, pustule, ulcer).

ABCDE melanoma screening

• A — Asymmetry: one half does not match the other
• B — Border: irregular, notched, or blurred edges
• C — Color: variegated — multiple shades of brown, black, blue, or red
• D — Diameter: greater than 6 mm (pencil eraser), though melanomas can be smaller
• E — Evolving: any change in size, shape, color, or symptoms (itching, bleeding)

Teach sun-protective behaviors (broad-spectrum SPF 30+, avoiding peak UV hours, no tanning beds) and monthly self-examination. Risk factors include fair skin, blistering sunburns, family history, and immunosuppression.

Pressure Injuries: Staging

Pressure injuries result from sustained pressure, shear, and friction, most often over bony prominences (sacrum, heels, ischium, trochanters). Prevention — repositioning at least every 2 hours, moisture management, nutrition, and pressure-redistribution surfaces — is the highest-yield intervention.

Note: staging never reverses — a healing Stage 3 is documented as a "healing Stage 3," not a Stage 2.

Wound Healing

Phases

1. Hemostasis: immediate vasoconstriction and clot formation.
2. Inflammatory (days 1-4): neutrophils then macrophages clear debris; expect redness, warmth, swelling, and drainage — this is normal healing, not necessarily infection.
3. Proliferative (days 4-21): fibroblasts lay collagen; granulation tissue (beefy red, moist) fills the defect and epithelial cells migrate across. Pale, friable, or dusky granulation signals a problem.
4. Maturation/remodeling (up to 2 years): collagen reorganizes; scar regains only about 80% of original tensile strength.

Healing is impaired by diabetes, poor perfusion, malnutrition (protein, vitamin C, zinc deficiency), corticosteroids, smoking, advanced age, obesity, and infection.

Closure intentions

• Primary intention: clean edges approximated (surgical incision, sutures); minimal scarring, lowest infection risk.
• Secondary intention: wound left open to heal by granulation and contraction from the bottom up (pressure injuries, dehisced wounds); longer healing, more scar, higher infection risk.
• Tertiary intention (delayed primary closure): wound left open for several days (contaminated wounds) then surgically closed once infection risk passes.

Wound Care Principles

• Debridement removes necrotic tissue: sharp/surgical (fastest; needed for eschar and infected wounds), enzymatic (topical agents dissolve slough), autolytic (occlusive dressings let the body's own enzymes work — never on infected wounds), and mechanical (wet-to-dry gauze, which is nonselective and removes healthy tissue too).
• Dressing selection by exudate: alginate (from seaweed) absorbs heavy drainage; hydrocolloid for light-moderate exudate and autolytic debridement; foam for moderate-heavy drainage and cushioning; transparent film for Stage 1 or IV sites; gauze for packing tunnels (keep the wound bed moist — moist wounds heal faster).
• Negative pressure wound therapy (wound vac): applies controlled suction to remove exudate, reduce edema, and promote granulation; the foam dressing is changed every 48-72 hours; avoid over exposed vessels or organs without protective layers.
• Document wound measurements (length x width x depth in centimeters), tunneling/undermining (clock-face notation), drainage type and amount, and peri-wound skin.

Burns

Depth and extent

Burns are classified as superficial (epidermis only — sunburn-type), superficial partial-thickness (blisters, moist, very painful), deep partial-thickness, and full-thickness (dry, leathery, white or charred, painless because nerve endings are destroyed). Extent in adults is estimated with the Rule of Nines:

Emergent phase priorities

1. Airway first. Singed nasal hairs, facial burns, sooty sputum, or hoarseness indicate inhalation injury — intubate EARLY, before edema closes the airway.
2. Fluid resuscitation with the Parkland formula: 4 mL x weight (kg) x %TBSA = total Lactated Ringer's for the first 24 hours. Give half in the first 8 hours from the time of the burn (not arrival), and the second half over the next 16 hours. LR is preferred because large volumes of normal saline cause hyperchloremic acidosis.
3. Monitor adequacy by urine output: target 30-50 mL/hr in adults (0.5 mL/kg/hr). Titrate the infusion to output — the formula is a starting estimate.
4. Escharotomy: circumferential full-thickness burns form inelastic eschar. On the chest this restricts ventilation; on extremities it cuts off perfusion (absent distal pulses, tightness). An escharotomy — a longitudinal incision through the eschar — restores movement or blood flow. Watch also for compartment syndrome.
5. Pain control with IV opioids, tetanus prophylaxis, and prevent hypothermia (burn patients lose thermoregulation — keep the room warm).

Cellulitis vs Necrotizing Fasciitis

Surgical Site Infection Prevention

Evidence-based bundle: administer prophylactic antibiotics within 60 minutes before incision (within 120 minutes for vancomycin/fluoroquinolones); remove hair with clippers, not razors (razors create microabrasions); chlorhexidine skin prep; maintain normothermia and perioperative glucose control; strict sterile technique and hand hygiene; and patient education on not touching the incision and recognizing infection signs (fever, increasing pain, purulent drainage, wound edge separation).