Alterations in Physical
Integrity
Types of Wounds
Wound: disruption of normal anatomical
structure and FX that results from
pathological processes beginning
internally or externally to the involved
organ(s). (p. 1551)
Classification of Wounds
Intentional vs. Unintentional
Intentional:
Usually the result of
therapy. Occur under
aseptic conditions.
Wound edges: usually
smooth/clean
Unintentional:
Occurs unexpectedly.
Occurs under unsterile
conditions.
Wound edges:
sometimes jagged.
Open vs. Closed
Open:
Involves a break in the
skin or mucous
membranes.
Wound edges are not
closed.
If drainage system in
place, it is an open
system.
Closed
Involves no break in skin
integrity.
Wound edges are
closed.
If drainage system is in
place, it is a closed
system.
Acquisition
Incision: Wound made with a Puncture/Perforating:
sharp instrument.
Penetrating wound in which
a foreign object enters/exits
an internal organ.
Contusion:
Laceration: Tearing apart of
Closed wound caused by a tissues. Wound has irregular
edges.
blow to the body by blunt
object.
Abrasion:
Superficial wound.
Scraping, rubbing of skin’s
surface.
Penetrating:
Wound involving a break in
epidermal skin layer, as well
as dermis and deeper
tissues or organs.
Contamination
Clean wounds: Closed
surgical wound not entering
GI, respiratory, genital,
uninfected urinary tract, or
oropharyngeal cavity.
Contaminated wounds
Open, traumatic, accidental
wound.
Surgical wound involving a
break in aseptic technique.
Clean-contaminated
wounds:
Surgical wound entering GI,
respiratory, genital,
uninfected urinary tract, or
oropharyngeal cavity under
controlled conditions.
Dirty or infected wounds:
Any wound that does not
properly heal and grows
organisms.
Old traumatic wound,
surgical incision into a area
infected.
 Acute: Wound that proceeds through an
orderly and timely reparative process.
 Chronic: Wound that fails to proceed
through an orderly and timely reparative
process.
 Superficial: Wound that involves only
epidermal layer of skin.
Stages of Wound Healing
Regeneration: The process of tissue
renewal
 Defensive stage (Inflammatory
Phase/Reaction) (hemostasis,
inflammation, cell migration &
epithelialization)
Reconstructive stage
(Proliferative Phase/Regeneration)
 Filling in of the wound with new connective
or granulation tissue
 the closing of the top of the wound by
epitheliazation.
Maturative stage
(Maturation Phase /Remodeling)
May take more than a year.
Collagen scar continues to reorganize and
gain strength for several months.
Usu. scar tissue has fewer pigmented cells
and has a lighter color than normal skin.
Classification of Wound Healing
Primary Intention




Wounds that heal with little tissue loss.
The skin wedges are approximated.
Risk of infection is low.
Healing occurs quickly:
drainage stops by day 3 of closure,
wound is epitheliazed by day 4,
inflammation is present up to day 5,
healing edge is present by day 9.
Classification of Wound Healing
Secondary Intention
Wound edges do not approximate.
Wound is left open until it becomes filled by scar
tissue.
Chance of infection is greater.Inflammatory phase
is often chronic
Wound filled with granulation tissue (a form of
connective tissue that has a more abundant
blood supply than collagen.
Scarring is greater.
Classification of Wound Healing
Tertiary Intention
There is a time delay between the time of the
injury and the approximation of the wound
edges.
Attempt by surgeon to allow for effective drainage
and cleansing of a clean-contaminated or
contaminated wound.
Not closed until all evidence of edema and wound
debris has been removed.
Dressing is used to protect.
Wound Drainage
Serous: Clear, watery
Sanguineous: Hemorrhagic. Specify color.
Serosanguinous: pink to light red in color. Thinner
than sanguineous.
Purulent: thick drainage that is often yellow-green
in color.
Factors affecting Wound Healing
Compromised host
Stress
Nutrition
Patient teaching
Obesity
Hospital in-patient “time”
Medications
(immunosuppressants)
Blood sugar
Factors Inhibiting Wound Healing: Elderly
Diminished epidermal cell After age of 50 cell renewal
time is increased by one
activity
third. Epithelial cell renewal
takes 30 or more days for
the elderly. SLOWS
Healing…
Atrophy and Thinning of
both skin layers
Both layers are thinner and
flatter. The thinning of the
epidermis reduces the skin’s
natural barriers.
Weakening in the
epidermis and dermis
attachment.
The epidermis can slide –
precipitates skin tears.
Factors Inhibiting Wound Healing: Elderly
Impaired immune
function of skin cells
Increases the risk of
infection
Hypodermics is
decreased (insulator of
the skin)
Little subcutaneous padding
over bony prominences.
More at risk for skin
breakdown and heat
stroke.
Decreased skin turgor
Greater risk for shearing and
tearing injuries.
Loss in the amt. of
collagen
Complications of Wound Healing
 Hemorrhage
 Dehiscence
 Evisceration
 Infection
 Fistulas
Nursing Process for Wound
Management
Untreated Wounds – basic first aide
Treated Wounds – prescribed per M.D. or
wound care nurse.
Wound Care Protocol
Wound Assessment
 Appearance
 Drainage (penrose, J-P drain, Hemovac)
 Swelling & Induration
 Pain
 Temperature
Sequential signs of primary wound
healing:
 Absence of bleeding
 Inflammation
 Granulation tissue
 Scar formation
 Reduction in scar size
Lab Data
WBC
Hgb, Hct
BUN, Albumin
Wound cultures
MD promotes wound healing
RN provides:
 Ongoing wound assessment
 Aseptic wound care according to MD
specifications
 Documentation of wound status
 Keeps MD apprised of wound status as
appro.
To promote healing/prevent complications…
 Adequate nutrition
 Prevent wound stress/trauma
vomiting
coughing
abdominal distention
 Prevent wound infection
Factors Affecting Wound Care
 Type of wound
 Size
 Drainage/exudate
 Open vs. closed
 Wound location
 MD orders
 Presence of complications
Drain management
 Open vs. closed
 Monitor drainage
 Universal precautions, aseptic technique
Penrose Drain
Open Drainage System
Jackson Pratt Drain
Close Drainage system
Hemovacs
Drainage
Collection Bag
(T-tubes)
Close Drainage System
Sutures….
Staples….
Hot/cold applications
Pressure ulcer
Pressure sore, Decubitus Ulcer
 Epidermis:
Stratum corneum
stratum basale
 Dermis
Tissue Ischemia: local absence of blood
flow/major reduction in blood flow
Blanching: Normal red tones of lightskinned client are absent. Does not occur
in clients with darkly pigmented skin.
Darkly pigmented skin: Skin that remains
unchanged (does not blanch) when
pressure is applied over a boney
prominence – irrespective of the client’s
race or ethnicity.
Normal Reactive Hyperemia: Visible effect
of localized vasodilatation, the body’s
normal response to lack of blood flow to
the underlying tissue. Area blanches with
fingertip pressure. Lasts less than 1 hour.
Abnormal reactive hyperemia: Excessive
vasodilatation and induration in response
to pressure. The skin appears bright pink
to red. Lasts more than 1 hour to 2 weeks
after the removal of the pressure. Does
not blanch.
Characteristics of Intact Dark Skin that might
alert nurses to the potential for pressure
ulcers (p. 1546)
Color
Temperature
Touch
Appearance
Risk Factors for Skin Breakdown
Impaired Sensory input
Impaired motor fx
Alteration in LOC
Orthopedic devices
Any equipment
Contributing Factors
Shearing Force
Obesity
Friction
Infection
Edema
Impaired peripheral
circulation
Anemia
Age (elderly)
Cachexia
Nutrition
Evaluation Tools
Classification of Pressure Ulcers
I
Nonblanchable erythema of the intact skin.
II
Partial-thickness skin loss involving
epidermis and /or dermis.
III
Full-thickness skin loss involving damage
or necrosis of subcutaneous tissue that
may extend down to but not through
underlying fascia.
IV
Full-thickness skin loss with extensive
destruction; tissue necrosis; or damage to
muscle, bone, or supporting structures.
Stage I
(no skin loss)
Stage I
(no skin loss)
Stage II
(Shallow crater – involves epidermis and/or dermis)
Stage II
Shallow crater – involves epidermis and/or dermis)
Stage III
(Full thickness involving damage/necrosis of subc. Tissue.
Does not extend down through underlying fascia)
Stage III or IV
Four Stages of Ulcers