Chapter 31
Skin Integrity and Wound Care
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Functions of the Skin
• Protection
• Body temperature regulation
• Psychosocial
• Sensation
• Vitamin D production
• Immunologic
• Absorption
• Elimination
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Question
Tell whether the following statement is true or false.
Blood vessels in the skin dilate to dissipate heat.
A. True
B. False
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Answer
Answer: A. True
Rationale: Blood vessels in the skin dilate to dissipate
heat.
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Cross-Section of Normal Skin
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Factors Affecting the Skin
• Unbroken and healthy skin and mucous membranes
defend against harmful agents.
• Resistance to injury is affected by age, amount of
underlying tissues, and illness.
• Adequately nourished and hydrated body cells are
resistant to injury.
• Adequate circulation is necessary to maintain cell life.
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Developmental Considerations
• In children younger than 2 years, the skin is thinner and
weaker than it is in adults.
• An infant’s skin and mucous membranes are easily
injured and subject to infection; a child’s skin becomes
increasingly resistant to injury and infection.
• The structure of the skin changes as a person ages; the
maturation of epidermal cells is prolonged, leading to
thin, easily damaged skin.
• Circulation and collagen formation are impaired, leading
to decreased elasticity and increased risk for tissue
damage from pressure.
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Causes of Skin Alterations
• Very thin and very obese people are more susceptible to
skin injury.
– Fluid loss during illness causes dehydration.
– Skin appears loose and flabby.
• Excessive perspiration during illness predisposes skin to
breakdown.
• Jaundice causes yellowish, itchy skin.
• Diseases of the skin, such as eczema and psoriasis, may
cause lesions that require special care.
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Types of Wounds
• Intentional or unintentional
• Open or closed
• Acute or chronic
• Partial thickness, full thickness, complex
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Question
Which type of wound is caused by a blunt instrument
that causes injury to underlying soft tissue with the
overlying skin remaining intact?
A. Contusion
B. Abrasion
C. Laceration
D. Avulsion
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Answer
Answer: A. Contusion
Rationale: A contusion is caused by a blunt instrument
and may result in bruising or hematoma. An abrasion is
the rubbing or scraping of epidermal layers of skin. A
laceration is the tearing of skin and tissue with a blunt or
irregular instrument. Avulsion is the tearing of a
structure from normal anatomic position.
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Principles of Wound Healing
• Intact skin is the first line of defense against
microorganisms.
• Careful hand hygiene is used in caring for a wound.
• The body responds systematically to trauma of any of its
parts.
• An adequate blood supply is essential for normal body
response to injury.
• Normal healing is promoted when the wound is free of
foreign material.
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Principles of Wound Healing (cont.)
• The extent of damage and the person’s state of health
affect wound healing.
• Response to wound is more effective if proper nutrition is
maintained.
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Phases of Wound Healing
• Hemostasis
• Inflammatory
• Proliferation
• Maturation
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Question
In phase of wound healing is new tissue built to fill the
wound space, primarily through the action of fibroblasts?
A. Hemostasis
B. Inflammatory phase
C. Proliferation phase
D. Maturation phase
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Answer
Answer: C. Proliferation phase
Rationale: In the proliferation phase, granulation tissue
is formed to fill the wound. In hemostasis, involved blood
vessels constrict and blood clotting begins. In the
inflammatory phase, white blood cells move to the
wound. In the maturation phase, collagen is remodeled,
forming a scar.
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Hemostasis
• Occurs immediately after initial injury
• Involved blood vessels constrict and blood clotting
begins.
• Exudate is formed, causing swelling and pain.
• Increased perfusion results in heat and redness.
• Platelets stimulate other cells to migrate to the injury to
participate in other phases of healing.
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Inflammatory Phase
• Follows hemostasis and lasts about 4 to 6 days
• White blood cells move to the wound.
• Macrophages enter the wound area and remain for an
extended period.
• They ingest debris and release growth factors that attract
fibroblasts to fill in the wound.
• The patient has a generalized body response.
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Proliferation Phase
• Begins within 2 to 3 days of injury and may last up to 2
to 3 weeks
• New tissue is built to fill the wound space through the
action of fibroblasts.
• Capillaries grow across the wound.
• A thin layer of epithelial cells forms across the wound.
• Granulation tissue forms a foundation for scar tissue
development.
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Maturation Phase
• Final stage of healing; begins about 3 weeks to 6 months
after injury
• Collagen is remodeled.
• New collagen tissue is deposited.
• Scar becomes a flat, thin, white line.
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Local Factors Affecting Wound Healing
• Desiccation (dehydration)
• Maceration (overhydration)
• Trauma
• Edema
• Infection
• Excessive bleeding
• Necrosis (death of tissue)
• Presence of biofilm (thick grouping of microorganisms)
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Systemic Factors Affecting Wound Healing
• Age: children and healthy adults heal more rapidly
• Circulation and oxygenation: adequate blood flow is
essential
• Nutritional status: healing requires adequate nutrition
• Wound condition: specific condition of the wound affects
healing
• Health status: corticosteroid drugs and postoperative
radiation therapy delay healing
• Immunosuppression
• Medication use
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Wound Complications
• Infection
• Hemorrhage
• Dehiscence and evisceration
• Fistula formation
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Question
Which wound complication is caused by overhydration
related to urinary and fecal incontinence?
A. Necrosis
B. Edema
C. Desiccation
D. Maceration
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Answer
Answer: D. Maceration
Rationale: Maceration is caused by overhydration related
to incontinence that causes impaired skin integrity.
Necrosis is dead tissue present in the wound that delays
healing. Edema is swelling at a wound site that interferes
with blood supply to the area. Desiccation is the process
in which the cells dehydrate and die.
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Wound Dehiscence and Evisceration
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Psychological Effects of Wounds
• Pain
• Anxiety
• Fear
• Impact on activities of daily living
• Change in body image
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Factors Affecting Pressure
Ulcer Development
• Aging skin
• Chronic illnesses
• Immobility
• Malnutrition
• Fecal and urinary incontinence
• Altered level of consciousness
• Spinal cord and brain injuries
• Neuromuscular disorders
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Mechanisms in Pressure
Ulcer Development
• External pressure compressing blood vessels
• Friction or shearing forces tearing or injuring blood
vessels
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Stages of Pressure Ulcers
• Stage I: nonblanchable erythema of intact skin
• Stage II: partial-thickness skin loss
• Stage III: full-thickness skin loss; not involving
underlying fascia
• Stage IV: full-thickness skin loss with extensive
destruction
• Unstageable: base of ulcer covered by slough and/or
eschar in wound bed
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Measurement of a Pressure Ulcer
• Size of wound
• Depth of wound
• Presence of undermining, tunneling, or sinus tract
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Pressure Ulcer Scale for Healing (PUSH)
PUSH Tool 3.0
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Question
Tell whether the following statement is true or false.
A stage III pressure ulcer requires débridement through
wet-to-dry dressings, surgical intervention, or proteolytic
enzymes.
A. True
B. False
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Answer
Answer: A. True
Rationale: A sétage III pressure ulcer requires
débridement through wet-to-dry dressings, surgical
intervention, or proteolytic enzymes.
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Cleaning a Pressure Ulcer
• Clean with each dressing change.
• Use careful, gentle motions to minimize trauma.
• Use 0.9% normal saline solution to irrigate and clean the
ulcer.
• Report any drainage or necrotic tissue.
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Assessment of Wound Drainage
• Serous
• Sanguineous
• Serosanguineous
• Purulent
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Wound Assessment
• Inspection for sight and smell
• Palpation for appearance, drainage, and pain
– Serous drainage
– Sanguineous drainage
– Serosanguineous drainage
– Purulent drainage
• Sutures, drains or tubes, and manifestation of
complications
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Purposes of Wound Dressings
• Provide physical, psychological, and aesthetic comfort
• Remove necrotic tissue
• Prevent, eliminate, or control infection
• Absorb drainage
• Maintain a moist wound environment
• Protect wound from further injury
• Protect skin surrounding wound
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Presence of Infection
• Wound is swollen.
• Wound is deep red in color.
• Wound feels hot on palpation.
• Drainage is increased and possibly purulent.
• Foul odor may be noted.
• Wound edges may be separated, with dehiscence
present.
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Types of Wound Dressings
• Telfa
• Gauze dressings
• Transparent dressings
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Types of Bandages
• Roller bandages
• Circular turn
• Spiral turn
• Figure-of-eight turn
• Recurrent-stump bandage
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Types of Binders
• Straight: used for chest and abdomen
• T-binder: used for rectum, perineum, and groin area
• Sling: used to support an arm
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Type of Drainage Systems
• Open systems
– Penrose drain
• Closed systems
– Jackson-Pratt drain
– Hemovac drain
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Penrose Drain
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Jackson-Pratt Drain
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Color Classification of Open Wounds
• R = red—protect
• Y = yellow—cleanse
• B = black—débride
• Mixed wound—contains components of RY&B wounds
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Pressure Ulcer Assessment
• Risk assessment
• Mobility
• Nutritional status
• Moisture and incontinence
• Appearance of existing pressure ulcer
• Pain assessment
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Topics for Home Health Care Teaching
• Supplies
• Infection prevention
• Wound healing
• Appearance of the skin/recent changes
• Activity/mobility
• Nutrition
• Pain
• Elimination
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Factors Affecting the Response
to Hot and Cold Treatments
• Method and duration of application
• Degree of heat and cold applied
• Patient’s age and physical condition
• Amount of body surface covered by the application
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Effects of Applying Heat
• Dilates peripheral blood vessels
• Increases tissue metabolism
• Reduces blood viscosity and increases capillary
permeability
• Reduces muscle tension
• Helps relieve pain
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Effects of Applying Cold
• Constructs peripheral blood vessels
• Reduces muscle spasms
• Promotes comfort
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Devices to Apply Heat
• Hot water bags or bottles
• Electric heating pads
• Aquathermia pads
• Hot packs
• Warm, moist compresses
• Sitz baths
• Warm soaks
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Devices to Apply Cold
• Ice bags
• Cold packs
• Hypothermia blankets
• Cold compresses to apply moist cold
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