Skin Integrity and
Wounds
Sandra S. Jones, MSN, RN, CNE
1
Types of
Wound
Healing
 Primary
 Secondary
 Tertiary
2
 Primary Intention: The wounds’ dermal edges are re-approximated
and held together e.g., with sutures, staples, steri-strips or surgical
glue.
 This reduces tissue loss. Wound edges are well approximated.
Wound
Healing by
Primary
Intention
3
 Secondary Intention: A wound that involves area of tissue loss; it
is left open until it becomes filled by scar tissue. Doctors will leave
the wound to heal naturally in these cases; but takes longer to heal
and greater chance of infection
Healing by
Secondary
Intention
 More common for wounds that have a rounder edge, cover
uneven surfaces, or are on surfaces of the body where movement
makes stitches or other closure methods impossible.
 Secondary wound healing relies on the body’s own healing
mechanisms.
4
 Tertiary wound healing, or healing by delayed primary closure,
occurs when there is a need to delay the wound-closing process.
Wound
Healing by
Tertiary
Intention
 This could be necessary if a doctor fears that an infectious agent
may be trapped in a wound by closing it. In these cases, the
wound may be allowed to drain or wait for the effects of other
therapies to take place before closing the wound.
5
Phases of
Wound
Healing
6
 STOP THE BLEEDING!
 Reduced blood flow
PHASES:
Hemostasis
(Day 1)
 Initial vasoconstriction (5-10
minutes); then vasodilation
(persistent)
 ADP (Adenosine Diphosphate) leaks
from damaged tissue, attracting
platelets.
 Platelet aggregation initiates the
clotting cascade- platelet plug is
formed; bleeding is stopped
 Inflammation initiation
7
 PREVENTS INFECTION, BEGINNING
OF FRAMEWORK FOR NEW BLOOD
VESSEL GROWTH
PHASES:
Inflammatory
(Days 1-4)
 Increased vascular permeability
 Inflammatory cells enter wound–
(Inflammatory cells = lymphocytes,
neutrophils, monocytes)
 Secretion of cytokines and growth
factors into the wound
 Activation of the migrating cells
8
Inflammatory
Phase
9
 PULLS THE WOUND CLOSED
PHASES:
Proliferative
(Day 4-21) )
 Fibroblasts lay a collagen scaffold
 Keratinocytes migrate over the
scaffold
 M1 > M2 macrophage polarization
 Angiogenesis occurs
10
Proliferative
Phase
Re-epithelialization
11
Proliferative
Phase
12
Proliferative
Phase
13
 FINAL PROPER TISSUE, SCAR IS
ESTABLISHED
PHASES:
Remodeling/
Maturation
(Day 21–
2 years)
 Macrophages recede
 Fibroblasts continue to remodel
collagen in the scar, improving
pliability and appearance
 Smaller vascular tissue aggregates
into larger vessels
 There is a reduction of the scar
14
PHASES:
Remodeling/
Maturation
15
 During wound healing the body needs:
Factors that
Affect
Wound Healing:
Nutrition







More calories
Protein
Fluid
Vitamin A
Vitamin C
Zinc
Copper
 Inadequate nutrition impede the normal processes that
allow progression through stages of wound healing
 Malnutrition is related to decreased wound tensile
strength and increased infection rates
 Serum Albumin proteins are biochemical indicators of
malnutrition– most frequently measured.
 Prealbumin is the most accurate – gives more current
nutritional status
16
Nutritional
Support for
Wound
Healing
17
Factors that
Affect
Wound Healing:
Tissue Perfusion
 Tissue Perfusion: Availability of oxygen to cells in the wound area
is an important factor to the healing process. Oxygen plays a
critical role in the formation of collagen, growth of new capillaries
and the control of infection.
 Clinical interventions to maintain perfusion and oxygen supply
include:




Fluid volume assessments
Pulmonary hygiene regimens
Postoperative position changes
Ambulation
18
 Studies have shown that infection triggers the body’s immune
response, causing inflammation and tissue damage, as well as slowing
the healing process.
Factors that
Affect
Wound Healing:
Infection
 Bacteria can enter wounds and form biofilms. They release chemicals
that prevent immune cells from killing these bacteria and delay
wound healing.
 Fibroblast proliferation was depressed at the wound edges
 Small vessel angiogenesis was increased in areas of abscess
formation, but larger vessels were commonly blocked by thrombus or
distorted by inflamed tissue.
 Indicators of Wound Infection:






Redness
Swelling
Purulent exudate
Smell
Pain
Systemic illness
19
Factors that
Affect
Wound Healing:
Aging
 Age-related differences in wound healing have been clearly
documented.
 They have a slower healing process
 All phases of wound healing are affected
 Inflammatory response and proliferative stage are delayed or
decreased
 Remodeling occurs, but to a lesser degree
 The collagen formed is qualitatively different
 Diseases that affect wound healing are more prevalent in the elderly
and have a greater adverse effect than in the young
20
Factors that
Affect
Wound Healing:
Psychosocial
Impact of
Wounds
 Psychological impact for patients with wounds can be significant
 Adverse psychological effects frequently occur when there are
permanent changes in the body’s structure or function
 Anxiety, depression, and stress can adversely affect the wound
healing process
21
Complications
of Wound
Healing:
HEMORRHAGE
 Internal bleeding is considered a leading
cause of trauma-associated mortality
globally.
 If untreated, severe or chronic
hemorrhaging might lead to organ
failure, seizures, coma, external bleeding
and eventually death.
 Wound hematoma, a collection of blood
and clot in the wound, is a common
wound complication and is usually
caused by inadequate hemostasis.
22
 Wound infection is the 2nd most common health-care associated
infection
 Risk Factors:
Complications
of Wound
Healing:
INFECTION






Hyperglycemia
Smoking
Untreated peripheral vascular disease
Obesity
Age
Emergency surgery
 Signs and Symptoms of Wound Infection
 Erythema
 Increased amount of wound drainage
 Change in appearance of wound drainage (thick, color change,
presence of odor)
 Periwound warmth, pain, or edema
 Increased temp and WBC count
23
 Dehiscence: Unintentional reopening of a surgical wound, either
internally or externally. Usually happens within 2 weeks of surgery
and following abdominal or cardiothoracic procedures.
 Prevention of Dehiscence (Teaching to patient):
Complications
of Wound
Healing:
DEHISCENCE
 Don’t lift anything >10 pounds
 Be extremely cautious in the first 2 weeks of recovery – walk around
to avoid blood clots or pneumonia (but don’t push for much more
than this)
 Start slightly with rigorous physical activity at your own pace after 24 weeks
 After about 2 months, start pushing a little more, but listen to your
body
Treatment of Dehiscence:
• Always report dehiscence
to your surgeon
• Cover the incision with
sterile/clean dressing until
you receive further
instructions from surgeon.
24
Complications
of Wound
Healing:
EVISCERATION
 Evisceration: A rare, but severe surgical
complication where the surgical
incision opens (dehiscence) and
abdominal organs then protrude or
come out of the incision (evisceration)
 Treatment of Evisceration:
 Cover the wound with sterile dressing
moistened with warm sterile saline
 Doctor will probably order antibiotics
and pain medication
 Surgery will be necessary to remove
any dead tissue and repair the wound
25
 Old terminology =
‘Pressure ulcer’, ‘bed sore’, or ‘decubitus ulcer’
Pressure Injury
 Pressure Injury: Localized damage to the skin and/or underlying
soft tissue usually over a bony prominence or related to a medical
or other device.
 The injury may present as intact or an open ulcer and may be
painful
 The injury occurs as a result of intense and/or prolonged pressure
or pressure in combination with shear.
(Edsburg et al., 2016)
 95% of all pressure ulcers are preventable!
26
 Impaired Sensory Perception – Unable to feel when a part of body
undergoes increased, prolonged pressure or pain
Risk Factors
for
Pressure Injury
Formation
 Decreased Mobility – Unable to turn themselves independently
(Spinal cord injury)
 Alteration in Level of Consciousness – Those who are comatose,
confused, or disoriented, inability to verbalize
 Shear/Friction – when HOB is elevated
 Moisture – Presence and duration of moisture on the skin
increases the risk of pressure injury. Moisture reduces the
resistance of the skin to other physical factors such as pressure,
friction or shear
27
SHEAR AND FRICTION
Risk Factors
for
Pressure Injury
Formation
Shear
Friction
28
(coccyx)
Areas High
Risk for
Pressure Injury
Formation
(trochanter)
Bony Prominences (areas where bones are close to the skin surface)
In bed, bony prominences can be padded with foam or pillows to help
keep them free of pressure and skin-to-skin contact
29
 Pressure injury prevention and treatment products are readily
available. At a minimum, this includes: -
Pressure Injury
Prevention






Skin moisture barrier products
Appropriate incontinence containment products/bedding
Pressure redistribution mattresses
Heel offloading devices
Pillows or wedges for repositioning
Repositioning slings/sheets to use with ceiling lifts
30
Staging of
Pressure
Injury
STAGE I: Nonblanchable
erythema of intact skin
31
Staging of
Pressure Injury
STAGE 2: Partial-thickness
with exposed dermis
Skin loss involving the
epidermis and/or dermis.
The ulcer is superficial and
presents clinically as an
abrasion, blister or
shallow crater.
32
Staging of
Pressure Injury
STAGE 3: Full-thickness
skin loss
Skin loss involving
damage or necrosis of
subcutaneous tissue
that may extend down
to, but not through, the
underlying fascia.
33
Staging of
Pressure Injury
STAGE 4: Full-thickness
skin and tissue loss
skin loss with extensive
destruction, tissue
necrosis or damage to
muscle, bone, or
supporting structures
(for example tendon or
joint capsule).
34
Staging of
Pressure
Injury
Unstageable
Obscured fullthickness skin and
tissue loss
 Necrotic tissue must be removed before a
wound can be accurately staged
 If the initial assessment is of a granulating
wound bed, it is not clinically accurate to stage
the wound due to not seeing the depth of
tissue injury
ageable
Do
not reverse stage.
This is clinically
inaccurate b/c this
implies deeper tissue
layers heal by
regeneration instead of
granulation formation.
35
Staging of
Pressure
Injury
Deep Tissue Pressure Injury: Persistent
nonblanchable deep red, maroon or purple
discoloration.
Deep-Tissue
Pressure Injury
36
ASSESSMENT:
• Assess the patient’s perception of proposed wound
treatment
 Assess at initiation of care and at least once/shift
 Use visual and tactile inspection
NURSING
PROCESS
 Look at any medical devices that may apply
pressure to the skin
 Pay particular attention to bony prominences, next
to or around medical devices, under casts, traction,
braces, etc.
 Be alert for hyperemia (increased blood flow)
 Determine if wound is causing pain – pre-medicate
before dressing change
37
ASSESSMENT:
• Wound assessment:
• Wound Location
• Stage/Classification of Wound -- Assess the type of tissue in the
wound base (viable vs. nonviable)
NURSING
PROCESS
• Granulation tissue – red, moist tissue composed of new blood
vessels, the presence of which indicates progression toward
healing
• Slough – Soft yellow or white tissue of a stringy consistency
attached to the wound bed.
• Eschar – black, brown, tan or necrotic tissue
• Measure the wound (length, width, and depth)
• Presence of undermining, sinus tracts, or tunneling
• Exudate (Amount, color, consistency, odor of drainage –
excessive exudate indicates infection
• Wound pain
• Examine the skin around the wound (Periwound) for redness,
warmth, signs of maceration
38
Granulation Tissue
39
Slough
40
Eschar
41
Wound Measurement:
First measure length: Widest point (head to toe)
Then measure width: Widest point (laterally)
Depth: Insert a sterile cotton-tip applicator in the deepest part of the wound,
marking the skin level with your finger.
42
Undermining: Destruction of the underlying tissue surrounding
some or all of the wound margins; may extend in one or many
directions underneath the wound edges.
Tunneling: A narrow opening or passageway that can extend in any direction
through soft tissue and result in dead space with potential of abscess formation.
Also known as sinus tract
43
ASSESSMENT:
• Wound Cultures – Collection of specimen of
purulent or suspicious-looking drainage is
present.
NURSING
PROCESS
•Never collect the specimen
from old drainage
•Clean the wound first with
normal saline to remove skin
flora
•Gold standard of wound
culture is wound biopsy – must
be done by HCP or wound care
specialist
44
ASSESSMENT:
NURSING
PROCESS
• Maceration: softening and
breaking down of skin
resulting from prolonged
exposure to moisture
45
PROBLEM STATEMENT:
Impaired Skin Integrity
Risk for Impaired Skin Integrity
NURSING
PROCESS
Additional Nursing Diagnoses related to
Impaired Skin Integrity
Risk for Infection
Acute or Chronic Pain
Impaired Mobility
Impaired Peripheral Tissue Perfusion
46
PLANNING (Goals and Outcomes):
An appropriate GOAL for a patient with a wound:
NURSING
PROCESS
Wound will progress toward healing within a twoweek period AEB:
 Increase in percentage of granulation tissue
 No further skin breakdown
 Increase in caloric intake by 10%
47
IMPLEMENTATION
HEALTH PROMOTION:
NURSING
PROCESS
Nutrition – Cleveland Clinic (2017) recommends:
• Protein (5-8 servings daily
• Whole grains (5 servings daily)
• Vegetables (2 servings daily)
• Fruit (3 servings daily)
• Dairy (3 servings daily)
48
IMPLEMENTATION
HEALTH PROMOTION:
NURSING
PROCESS
Prevention of Pressure Injuries –
Three major areas of nursing interventions for
prevention of pressure injury:
• Skin care and management of incontinence
• Mechanical loading and support devices
• Education
49
IMPLEMENTATION
Topical Skin Care and Incontinence
Maintenance:
NURSING
PROCESS
• Use cleaners with nonionic
surfactants that are gentle to the
skin
• Make sure skin is completely dry
• Apply moisturizer, but don’t
oversaturate
50
Moisture
Balance
Protective Ointment which is petroleum-based, provides excellent
barrier that seals out excess moisture in the case of diarrhea. It
contains emollients to moisturize and is non-sensitizing and
fragrance free.
51
IMPLEMENTATION
Topical Skin Care and
Incontinence Maintenance:
NURSING
PROCESS
• Control, contain or correct
incontinence, perspiration or
wound drainage
• Diarrhea – gently clean the area,
dry and apply thick layer of
moisture barrier
52
IMPLEMENTATION
Positioning
• Repositioning (turning at least every 2
hours—some patients require more often)
NURSING
PROCESS
• Reduces or relieves pressure at the interface
between bony prominence and support
surface (bed or chair)
• Limits the amount of time the tissue is
exposed to pressure
• “Rule of 30”
• HOB elevated no more than 30°
• 30° lateral incline
53
NURSING
PROCESS
• “Repositioning patients at
risk for pressure ulcers
every three hours at night
using the 30° tilt reduces
the incidence of pressure
ulcers more than usual
care.”
• Citation: Moore, et al.
(2012)
54
IMPLEMENTATION
Positioning
• “Floating Heels” – Patient’s heels should be
positioned in such a way as to remove all contact
between the heel and the bed
NURSING
PROCESS
55
IMPLEMENTATION
Positioning Tips:
• To prevent shear and friction injuries, use a transfer device
to lift rather than drag the patient when changing positions.
NURSING
PROCESS
• High-risk patients who can sit in chairs should be limited to
2 hours or less; in addition, teach the patient to shift their
weight every 15 minutes; use air, foam, or gel cushion
56
IMPLEMENTATION
Support Surfaces
NURSING
PROCESS
• “Specialized devices for pressure redistribution
designed for management of tissue loads,
microclimate, and/or other therapeutic functions (i.e.
any mattress, integrated bed system, mattress
replacement, overly, seat cushion.” (EPUAP, NPLIAP
2019a)
57
IMPLEMENTATION
Support Surfaces
• Category One
• Static overlays and
mattresses
• Foam, air, gel
NURSING
PROCESS
• Category Two
• Alternating pressure and air
flotation
• Category Three
• Air fluidized
• Low air loss bed/mattress
58
IMPLEMENTATION
Acute Care
• Acute wounds require close monitoring (every 4-8 hrs.)
• Chronic wound assessment is less frequently
• Wound Management:
NURSING
PROCESS
• Goal is – maintenance of a physiological local wound
environment.
•
•
•
•
•
•
•
•
Prevent/Manage Infection
Clean the wound
Remove nonviable tissue
Maintain wound in a moist environment
Eliminate dead space
Control odor
Eliminate or minimize pain
Protect the wound and periwound skin
59
IMPLEMENTATION
Wound Management
• To help prevent infection, clean
wound with noncytotoxic wound
cleanser
NURSING
PROCESS
• Wound Irrigation – cleans and
debrides necrotic tissue (use 19
gauge catheter with 35 mL syringe
– delivers saline at 8 psi)
60
IMPLEMENTATION
Wound Management - Debridement
• Debridement is the removal of nonviable, necrotic tissue
• Methods of Debridement:
NURSING
PROCESS
•
•
•
•
Autolytic
Mechanical
Chemical
Sharp/Surgical
61
Autolytic Debridement: Removal of dead tissue via lysis or necrotic tissue by WBCs and
natural enzymes of the body
• Accomplished with specialized dressing
• If wound bed is dry, use a dressing that adds moisture
• If there is excessive exudate, use a dressing that absorbs the excessive moisture
Films for Autolytic Debridement
Hydrogel Dressings
for Autolytic Debridement
62
Chemical Debridement: Use of topical enzyme preparations that induce
changes in the substrate, resulting in the breakdown of necrotic tissue
(Dakin’s Solution, or sterile maggots)
Dakin’s Solution for Chemical Debridement
Collagenase – Enzymatic Debridement
63
Debridement with Sterile Maggots
64
Sharp/Surgical Debridement: Removal of devitalized tissue with a scalpel, scissors or other sharp
instrument. Physicians, or specially trained Wound Care Nurse are allowed to perform this task.
65
Mechanical Debridement: Involves high-pressure wound irrigation, pulsatile high-pressure lavage,
and whirlpools.
66
IMPLEMENTATION
Wound Management: Dressings
Purposes of Dressings
• Protects a wound from microorganism contamination
• Aids in hemostasis
NURSING
PROCESS
• Promotes healing by absorbing drainage and debriding
wound
• Supports or splints a wound site
• Promotes thermal insulation of a wound surface
• Provides a moist environment
67
IMPLEMENTATION
Wound Management: Dressings for Pressure
Injuries
NURSING
PROCESS
Type of Dressing is based on the stage of the
pressure injury, types of tissue in the wound, and
the function of the dressing
Gauze sponges (oldest and most common)
• Absorbent and wick away wound exudate
• Gauze can be saturated with solutions to clean and
pack a wound
68
IMPLEMENTATION
Wound Management:
Packing a Wound
• Be aware of the reason for packing the
wound (debridement or absorbing
exudate)
NURSING
PROCESS
• Check physician’s order (gauze, solution,
frequency)
• Measure wound
• Technique is usually “clean” (not sterile)
– but use sterile dressing supplies
• Saturate gauze with solution, wring out,
unfold and lightly pack into wound
• Cover wound and packed gauze with a
secondary dressing
69
EVALUATION:
The outcomes selected for the patient in the
plan of care are the milestones you hope to
achieve to meet the goals of care.
NURSING
PROCESS
GOAL
Wound will progress toward healing
within a two-week period AEB:
OUTCOMES
 Increase in percentage of granulation tissue
 No further skin breakdown
 Increase in caloric intake by 10%
70
THE END
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