Chapter 48
Skin Integrity and Wound Care
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Scientific Knowledge Base:
Skin
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Dermal-epidermal junction
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Epidermis
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Separates dermis and epidermis
Top layer of skin
Dermis
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Inner layer of the skin
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Pressure Ulcers
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Pressure ulcer
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Pressure sore, decubitus ulcer, or bed sore
Pathogenesis
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Pressure intensity
Blanching
Pressure duration
Tissue tolerance
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Risk Factors for Pressure Ulcer
Development
Impaired sensory
perception
Alterations in LOC
Impaired mobility
Shear
Friction
Moisture
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Classification of Pressure Ulcers
Stage I
Stage II
Intact skin with nonblanchable
redness
Partial-thickness skin loss
involving epidermis, dermis, or
both
Stage III
Stage IV
Full-thickness tissue loss with
visible fat
Full-thickness tissue loss with
exposed bone, muscle, or
tendon
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Wounds
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Classification
Wound healing
Repair
Complications
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Nursing Knowledge Base
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Prediction and prevention of pressure
ulcers
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Norton Scale
• Physical and mental condition, activity, mobility, and
continence
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Braden Scale
• Sensory perception, moisture, activity, mobility, nutrition,
and friction and shear
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Factors Influencing Pressure Ulcer
Formation and Wound Healing
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Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds
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Assessment
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Skin
Presence of ulcers
Mobility
Nutrition and fluid status
Pain
Existing wounds, appearance, character
Wound culture
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Nursing Diagnosis and Planning
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The assessment will reveal important
information regarding the client’s status.
Use NANDA-I–approved diagnoses.
Write client goals and outcomes specific to
the client’s needs.
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Implementation
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Health promotion
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Topical skin care
• Protect bony prominences, skin barriers for incontinence.
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Positioning
• Turn every 1 to 2 hours as indicated.
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Support surfaces
• Decrease the amount of pressure exerted over bony
prominences.
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Acute Care
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Wound management
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Debridement
• Mechanical, autolytical, chemical, or surgical/sharp
 Nutrition
 Client education
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Dressings
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Dry or moist
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Hydrocolloid
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Protects the wound from surface contamination
Hydrogel
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Gauze
Maintains a moist surface to support healing
Wound V.A.C.
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Uses negative pressure to support healing
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Dressings
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Changing
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Securing
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Know type of dressing, placement of drains, and
equipment needed.
Tape, ties, or binders
Comfort measures
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Carefully remove tape.
Gently cleanse the wound.
Administer analgesics before dressing change.
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Wound Cleansing
Cleansing
Irrigation
Apply noncytotoxic solution.
Removes exudates, use sterile
technique with 35-ml syringe
and 19-gauge needle
Suture Care
Drainage Evacuation
Consult health care facility
policy.
Portable units that exert a
safe, constant, low-pressure
vacuum to remove and collect
drainage
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Bandages and Binders
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Bandages
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Rolled gauze, elasticized knit, elastic webbing,
flannel, and muslin
Binder application
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Breast, abdominal, sling
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Heat and Cold Therapy
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Assessment for temperature tolerance
Bodily responses to heat and cold
Factors influencing heat and cold
tolerance
Education
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Evaluation
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Nursing interventions for reducing and
treating pressure ulcers need to be
evaluated to determine if the client has
met the identified outcomes or goals.
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