Skin integrity and Wound
care
Fall semester
2014
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Skin integrity
• Intact skin: presence of normal skin layers
uninterrupted by wounds.
• Impaired skin integrity is a threat to:
-
Elders
Client with restricted mobility
Chronic illness
Trauma
Those undergoing invasive health care procedure
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Skin integrity
• The skin is the body’s largest organ and the
primary defense against pathogenic invasion.
• The skin also contributes to temperature regulation,
prevents loss of internal fluids, and provides
sensory awareness.
• The appearance of skin and skin integrity are
influenced by:
- Internal factors( genetics, age and status of person’s
health, malnutrition)
- External ( activity, sun and medications as AB and
chemotherapy, corticosteroids)
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Types of wound
• Intentional: trauma occurs during
therapy as operation, vein puncture and
tumor excision
• Unintentional: are accidental as fracture
from car accident
and
 Closed: tissue trauma without a break in
the skin
 Open: when the skin or mucous
membrane surface is broken
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Types of the wound according to the way they
acquired
1. Incision: sharp instrument (open wound;
deep or shallow)
2. Contusion: blow from a blunt instrument
(closed wound, skin appears ecchymotic
(bruised) because of damaged blood
vessels)
3. Abrasion: surface scrape, either
unintentional (e.g., scraped knee from a
fall) or intentional (e.g., dermal abrasion
to remove pockmarks) (open wound
involving the skin)
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3. Puncture: penetration of the
skin &often the underlying
tissue by a sharp instrument,
either intentional or
unintentional (open wound)
4. Laceration: tissue torn a part,
often from accident( e.g., with
machinery) (open wound; edges
are often jagged)
5. Penetrating wound:
penetration of the skin & the
underlying tissue, usually
unintentional (e.g., from bullet
or metal fragments) (open
wound)
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Wound description according to degree
of contamination
Clean wound: are uninfected wound in which minimal inflammation is
encountered and the respiratory, genital, urinary tract are not entered.
Clean wound are primarily closed wound
Clean-contaminated wounds: are surgical wounds in which respiratory,
alimentary, genital or urinary tract has been entered, such wounds
show no evidence of infection (high risk of infection)
Contaminated wounds: include open, fresh, accidental wounds &
surgical wounds involving a major break in sterile technique there is
an evidence of inflammation
Dirty or infected wounds: wounds containing dead tissue & wounds
with evidence of a clinical infection, such as purulent drainage (old,
accidental wounds)
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Wound classification according to
the depth of the wound
1. Partial thickness: confined to the skin, that is, the dermis
and epidermis; heal by regeneration
2. Full thickness: involving the dermis, epidermis,
subcutaneous tissue, &possibly muscle &bone; require
connective tissue repair
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Pressure ulcers
• Also called bedsores , pressure sores or
decubitus ulcers: injury to skin (usually
over a bony prominence) caused by
unrelieved pressure.
• Etiology:
– Tissue is compressed between two surfaces
a deficiency
in blood supply to these tissues
the cells are deprived of
O2 and nutrient (pale) + waste products accumulates in cells
tissues die
localized ischemia.
(when pressure is relieved, the skin takes on a bright red flush called
reactive hyperemia due to vasodilation. Reactive hyperemia lasts ½ - ¾ as
long as the duration of impeded blood flow to the area)
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Risk Factors for Pressure Ulcers
• Friction and shearing:
– Friction: is a force acting parallel to the skin
surface (sheets rubbing against skin create
friction).
– Shearing forces: is the combination of friction
& pressure. It occurs commonly when a client
assumes a sitting position.
• Immobility no control to change
position
• Inadequate nutrition: causes wt. loss,
muscle atrophy, loss of SC in which
decrease the amount of padding
between skin and bone. (diet low in
protein, CHO, vit c, fluids, zinc)
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• Fecal & urinary incontinence: promotes skin maceration (tissue
softened by prolonged wetting or soaking)
• Decrease mental status: pt. with reduced level of awareness
unconscious or heavily sedative are less able to respond to pain
perception.
• Diminished sensation paralysis, stroke, reduce ability to respond to
heat or cold sensation
• Excessive body heat: fever increase BMR thus increase the cell
need for o2 especially in the pressure area, fever with infection may
affect the body ability to deal with the compressed area.
• Advanced age: aging process brings a lot of skin changes (loss of
body mass, pain perception, thinning of epidermis, alteration in
venous and arterial flow…)
• Chronic disease (CVD, DM.) compromise O2 delivery and delay
healing
• Other factors: Poor lifting technique, incorrect positioning,
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repeated injections.
Stages of Pressure Ulcer Formation
• Stage I: non-blanchable
erythema of intact skin
signaling potential
ulceration
• Stage II: partial-thickness
skin loss involving
epidermis and possibly
dermis
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Stages of Pressure Ulcer Formation
• Stage III: full-thickness
skin loss involving
damage or necrosis of
subcutaneous tissue
• Stage IV: full-thickness
skin loss with tissue
necrosis or damage to
muscle, bone, or
supporting structures
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Wound Healing
• Healing is a quality of living tissue, it is also called regeneration
(renewal) of tissues.
1- Primary Intention (primary union or 1st intension healing): occur
when tissue surface have been approximated (closed), and there
is minimal or no tissue loss, characterized by Formulation of
minimal granulation and scarring (surgical incision)
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2- Secondary intention healing: Extensive wound, involves
tissue loss, the edges cannot or should not be approximated
such (as pressure ulcer)
The difference between 2nd and 1st intention healing:
- The repair time is longer
- Scarring greater
- Susceptibility to infection greater
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3- Tertiary Intention Healing
(Delayed Primary Intention): wound left open for 35 days to allow edema or infection to resolve or
exudates to drain and then closed with suture
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Phases of Wound Healing
• It is the same for all wound but the rate of
healing depend on:
- Type of healing
- Location and size of wound
- Client health status
Phases of wound healing:
• Inflammatory Phase
• Proliferative Phase
• Maturation Phase
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Inflammatory Phase
• Immediately after injury; lasts 3 to 6 days. 2
processes occur during this phase:
• Hemostasis (cessation of bleeding): results from
vasoconstriction of larger vessels in affected area, retraction of
injured blood vessels, the deposition of fibrin (connective tissue) and
the formation of blood clots which provide a matrix of fibrin that
becomes the framework for cell repair.
• Phagocytosis: leukocytes (neutrophils) move into
interstitial space. Theses are replaced by
macrophages which engulf microorganisms and
cellular debris.
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Proliferative Phase
• From post injury day 3 or 4 until day 21
Fibroblasts in wound start to synthesize collagen
(a whitish protein substance adds strength to
wound
Capillaries grow across wound increasing Bld
supply and fibrin deposits in wound .
The capillary network develops tissue becomes
red color called granulation tissue.
Epithelization: proliferation of epithelial tissue
over the granulation, if failed dried plasma
proteins and dead cells formed eschar
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Maturation Phase
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•
•
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From day 21 until 1 or 2 years post injury
Fibroblasts continue to produce collagen
Remodeling of the wound occur
Scar formation occur which is strong
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Types of wound exudates
• Exudate: is a fluid that are escaped from blood during
inflammatory process and deposited in the tissue or in the
tissue surface. 3 types:
A- Serous Exudate: consist of serum (clear protein of blood)
derived from blood &serous membrane of body (watery&
has few cells) (e.g., fluid in the blister from burn)
B- Purulent exudate: is thicker, presence of pus (leukocytes,
dead tissue debris,& dead and living bacteria) blue,
green, or yellow color depend on causative agents
C- Sanguineous (hemorrhagic) exudate: large amount of
RBC indicate damage to capillaries (in open wounds, may
be bright( fresh bleeding) or dark (old bleeding
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Mixed Exudate
• Serosanguineous
– Clear and blood-tinged drainage, commonly seen
in surgical incision
• Purosanguineous
– Pus and blood, commonly seen in new wound that
is infected
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Complications of Wound Healing
Hemorrhage: (massive bleeding) due to removal of clot,
slipped stitch, erosion of blood vessel, risks increase in
the 1st 48hr’s after surgery
- Internal ( swelling and distension under skin, may called
hematoma, if it large may cause compression in the
blood vessels)
- External (blood appear under dressing or escape. So
apply sterile pressure dressing + check V/S)
Infection: impaired skin healing, become apparent 2-11
day post operative, cause change in wound color, pain,
exudate, fever, increase WBC’s, hotness, tenderness and
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redness, foul odor
Dehiscence: Partial or total rupturing of
sutured wound, occur 4-5 day post op.
Evisceration: Protrusion of the intestines
through the incision.
Risk factors including: obesity, poor nutrition,
multiple trauma, excessive coughing and
sneezing, sudden straining and dehydration, it
is managed by (large sterile dressing soaked in
N|S, place pt in bed with knee bent, then notify
doctor
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Factors Affecting Wound Healing
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Age: Young, Adult, or Elderly
Nutritional status: diet. Obesity
Lifestyle: Exercise, smoking, poor hygiene
Medications: anti-inflammatory drugs
(steroids, aspirin) prolong use of
antibiotics.
• Contamination or infection
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Nursing Process: Assessment
• Nursing history
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Review of systems
Skin diseases
Previous bruising
General skin condition
Skin lesions
Usual healing of sores
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• Inspection and palpation
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Skin color distribution
Skin turgor
Presence of edema
Characteristics of any skin lesions
Particular attention paid to areas that are most likely to break down
• Untreated wounds
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Location
Extent of tissue damage
Wound length, width, and depth
Bleeding
Foreign bodies
Associated injuries
Last tetanus toxoid injection
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• Treated wounds
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Appearance
Size
Drainage
Presence of swelling
Pain
Status of drains or tubes
• Pressure Ulcers
– Location of the ulcer related to a bony prominence
– Size of ulcer in centimeters including length (head to toe), width
(side to side), and depth
– Stage of the ulcer
– Color of the wound bed
– Location of necrosis or eschar
– Condition of the wound margins
– Integrity of surrounding skin
– Clinical signs of infection
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Laboratory Data:
Leukocyte count: decrease LEUKOCTE COUNT delay
healing increase risk for infection.
Hemoglobin level: Low Hgb poor O2 delivery to tissue
Blood coagulation: prolonged coagulation times result in
severe bleeding, while hypercoagulability lead to
intravascular clotting and decrease bld supply to the wound
Serum protein indicates nutritional status (for rebuilding
cells). Albumin if less than 3.5 g/dl increase risk for
infection and delay healing
Wound culture: confirm or rule out presences of infection
Sensitivity tests: to select the apropriate AB
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Nursing Diagnoses (NANDA)
• Risk for Impaired Skin Integrity: applies to pressure ulcers
and wounds extending through the epidermis but not
through the dermis.
• Impaired Skin Integrity: altered epiderms and/or dermis
• Impaired Tissue Integrity: applies to pressure ulcers and
wounds extending into SC tissues, muscles, or bones.
• Risk for Infection: with severe skin impairment, pt is
immunosuppressed
• Pain: RT nerve involvement within the tissue impairment
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Goals in Planning Client Care
• Risk for Impaired Skin Integrity
– Maintain skin integrity
– Avoid or reduce risk factors
• Impaired Skin Integrity
– Progressive wound healing
– Regain intact skin
• Client and family education
– Assess and treat existing wound
– Prevention of pressure ulcers
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Implementation
• Supporting wound healing : maintain moist wound
healing, nutrition and fluid, preventing infection and
positioning
• Preventing pressure ulcer
• Treating pressure ulcer :RYB (Protect (cover) red,
cleanse yellow, and debride black)
• Dressing wound
• Cleaning wound
• Supporting and immobilizing wound
• Heat and cold application
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Dressing wound
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Purposes:
To protect the wound from mechanical injury
To protect the wound from infection
To maintain moist wound healing
To absorb drainage
To prevent hemorrhage
To splint or immobilize the wound
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Types of Wound Dressings
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Transparent film
Impregnated no adherent
Hydrocolloids
Clear absorbent acrylic
Hydrogel
Polyurethane foam
Alginate
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Types of Bandages
• Gauze
– Restrain dressings on wounds
– Bandage hands and feet
• Elasticized
– Provide pressure to an area
– Improve venous circulation in legs
• Binders
– Support large areas of body
• Triangular arm sling; straight abdominal binder
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Heat and cold application
• Heat and cold are applied for local and
systemic effects.
• Local Effects of Heat
– Vasodilation & increase bld flow bringing O2,
nutrients, antibodies & leukocytes.
– Increases capillary permeability (may result in
edema)
– Often used for musculoskeletal problems.
– Produces sedative effect
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• Local effects of cold
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Vasoconstriction
Decreases capillary permeability
Decreases cellular metabolism
Slows bacterial growth
Decreases inflammation
Local anesthetic effect by slowing nerve
conduction rate and blocking nerve impulses
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Contraindication of heat and cold
application
Neurosensory function of the patient.
Impaired mental status: need monitoring to
ensure safety.
Impaired circulation: risk for tissue damage
Immediately after injury or surgery: heat
increases bleeding and swelling
Open wound: cold decreases blood flow to
the wound thus inhibit healing.
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Methods for Applying
Dry and Moist Heat
• Dry heat
– Hot water bottle
– Aquathermia pad
– Disposable heat pack
– Electric pad
• Moist heat
– Compress
– Hot pack
– Soak
– Sitz bath
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Methods for Applying Dry
and Moist Cold
• Dry cold
– Cold pack
– Ice bag
– Ice glove
– Ice collar
• Moist cold
– Compress
– Cooling sponge bath
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