SKIN INTEGRITY AND WOUND CARE
Degree of wound contamination:
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Clean Wounds are uninfected wounds in which there is minimal inflammation and the
respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are
primarily closed wounds
Clean-contaminated wounds are surgical wounds in which the respiratory, gastrointestinal,
genital, and urinary tract has been entered. Such wounds show no evidence of infection
Contaminated Wounds include open, fresh, accidental wounds and surgical wounds involving
major break in sterile technique or a large amount of spillage from the gastrointestinal tract.
Contaminated wounds show evidence of inflammation.
Dirty or infected wound include wounds containing dead tissue and wounds with evidence of a
clinical infection, such as purulent drainage.
TYPES OF WOUNDS
TYPE
CUASE
Incision
Sharp instrument (e.g., knife or
scalpel)
Contusion
Blow from a blunt instrument
Abrasion
Surface scrape, either
unintentional (e.g., scraped knee
from a fall)
Penetration of the skin and often
the underlying tissues by a sharp
instrument, either intentional or
unintentional
Tissues torn apart, often from
accidents (e.g., with machinery)
Penetration of the skin and the
underlying tissues, usually
unintentional (e.g., from a bullet
or metal fragments)
Puncture
Laceration
Penetrating wound
DESCRIPTION AND
CHARACTERISTICS
Open wound; deep or shallow;
once the edges have been sealed
together as a part of treatment
or healing, the incision becomes
a closed wound.
closed wound, skin appears
ecchymotic
Open wound involving the skin
Open wound
Open wound; edges are often
jagged
Open wound
CLASSIFYING WOUNDS BY DEPTH
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Partial Thickness confined to the skin, that is, the dermis and epidermis; heal by regeneration
Full thickness involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and
bone; require connective tissue repair
PRESSURE ULCERS
 Consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result
of force alone or combination movement.
 Previously called decubitus ulcers, pressure sores or bedsores
ETIOLOGY OF PRESSURE ULCERS
Pressure ulcers are due to localized ischemia, a deficiency in the blood supply to the tissue
Prolonged, unrelieved pressure also damages the small blood vessels.
When pressure is relieved, the skin takes on a red flush, called reactive hyperemia. The flush is due to
vasodilation, a process in which extra blood floods to the area to compensate for the preceding period
of impeded blood flow.
RISK FACTORS
Friction and shearing
 FRICTION is a force acting parallel to the skin surface.
 SHEARING FORCE is a combination of friction and pressure.
Immobility
 Refers to a reduction in the amount and control of movement a person has.
 Paralysis, extreme weakness, pain or any cause of decreased activity can hinder a person’s
ability to change positions independently and relieve the pressure, even if the person can
perceive the pressure.
Inadequate Nutrition
 Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of
subcutaneous tissue.
 Hypoproteinemia, due to either inadequate intake or abnormal loss, predisposes the client to
dependent edema
 Edema makes skin more prone to injury by decreasing its elasticity, resilience, and vitality.
Fecal and Urinary Incontinence
 Moisture from incontinence promotes skin maceration and makes the epidermis more easily
eroded and susceptible to injury.
 Digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute to skin
excoriation
Decreased mental status
Diminished sensation
Excessive body heat
Advanced age
Chronic medical conditions
Other factors
STAGES OF PRESSURE ULCERS
A. STAGE 1 – nonblanchable erythema signaling potential ulceration
B. STAGE 2 – partial-thickness skin loss involving the epidermis and possibly the dermis
C. STAGE 3 – full-thickness skin loss involving damage or necrosis subcutaneous tissue that may
extend down to, but not through, underlying fascia.
D. STAGE 4 – thickness skin loss with tissue necrosis or damage to muscle, bone or supporting
structures, such as tendon or joint capsule
WOUND HEALING
 Referred to as regeneration (renewal) of tissues.
TYPES OF WOUND HEALING
The types of healing are influenced by the amount of tissue loss.
Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there
is minimal or tissue loss; it is characterized by the formation of minimal granulation tissue and scarring.
It is also called primary union or first intention healing.
A wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should
not be approximated, heals by secondary intention healing.
Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and
are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention. Also called
delayed primary intention.
PHASES OF WOUND HEALING
INFLAMMATORY PHASE
 Begins immediately after injury and lasts 3 to 6 days. Two major processes occur during this
phase: hemostasis and phagocytosis.
 Hemostasis results from vasoconstriction of the larger blood vessels in the affected area,
retraction of injured blood vessels, the deposition of fibrin and the formation of blood clots in
the area.
 A scab may also form on the surface of the wound. Consisting of clots and dead and dying tissue,
this scab serves to aid hemostasis and inhibit contamination of the wound by microorganisms.
Below the scab, epithelial cells migrate into the wound from the edges. The epithelial cells serve
as a barrier between the body and the environment, preventing the entry of microorganisms.
 The inflammatory phase also involves vascular and cellular responses intended to remove any
foreign substances and dead and dying tissues.
 During cell migration, leukocytes move into the interstitial space. These are placed about 24
hours after injury by macrophages. These macrophages engulf microorganisms and cellular
debris by a process known as phagocytosis.
PROLIFERATIVE PHASE
 The second phase in healing, extends from day 3 to 4 to about day 21 postinjury.
 Fibroblasts which migrate into the wound starting about 24 hours after injury, begin to
synthesize collagen.
 Collagen is a whitish protein substance that adds tensile strength of the wound.
 Capillaries grow across the wound, increasing the blood supply. Fibroblasts move from the
bloodstream into the wound, depositing fibrin. As the capillary network develops, the tissue
becomes a translucent red color. This tissue, called granulation tissue, is fragile and bleeds
easily.
MATURATION PHASE
 Begins on about day 21 and can extend 1 or 2 years after the injury.
 Fibroblasts continue to synthesize collagen.
 The wound is remodelled and contracted. The scar becomes stronger but the repaired area is
never as strong as the original tissue.
TYPES OF WOUND EXUDATE
Exudate – is material, such as fluid and cells, that has escaped from blood vessels during the
inflammatory process and is deposited in tissue or on tissue surfaces.
3 major types:
1. Serous Exudate – consists chiefly of serum derived from blood and the serous membranes of
the body, such as the peritoneum. It looks watery and has few cells
2. Purulent exudate – thicker than serous exudate because of the presence of pus, which consist
of leukocytes, liquefied dead tissue debris, and dead and living bacteria. The process of pus
formation is referred to as suppuration.
3. Sanguineous exudate – consists of large amounts of red blood cells, indicating damage to
capillaries that is severe enough to allow the escape of red blood cells from plasma.
COMPLICATIONS OF WOUND HEALING
HEMORRHAGE
 Massive bleeding.
 A dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe bleeding.
 Internal haemorrhaging may be detected by swelling or distention in the area of the wound and,
possibly, by sanguineous drainage from a surgical drain.
 Hematoma - a localized collection of blood underneath the skin that may appear as a reddish
blue swelling (bruise)
INFECTION
 Contamination of a wound surface with microorganisms is an inevitable result because the
surface cannot be permanently protected from contact with unsterile objects.
 When the microorganisms colonizing the wound multiply excessively or invade tissues, infection
occurs.
 Infection suggested by a change in wound color, pain, odor or drainage is confirmed by
performing a culture of wound.
 A wound can be infected with microorganisms at the time of injury, during surgery, or
postoperatively. Surgical infection is most likely to become apparent 2 to 11 days
postoperatively.
DEHISCENCE WITH POSSIBLE EVISCERATION
 Dehiscence is the partial or total rupturing of a sutured wound. Dehiscence usually involves an
abdominal wound in which they layers of the skin also separate.
 Evisceration is the protrusion of the internal viscera through an incision.
 wound dehiscence is more likely to occur 4 to 5 days postoperatively before extensive collagen
is deposited in wound.
FACTORS AFFECTING WOUND HEALING
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developmental considerations
nutrition
lifestyle
medications
NURSING MANAGEMENT
ASSESSMENT OF WOUNDS
Untreated wounds - usually seen shortly after an injury
Treated wounds – usually assessed to determine the progress of healing. These wounds may be
inspected during changing of a dressing.
Sometimes the wound reaches under the skin surface. The edges of the wound around an open center
may be rae or appear healed, but the undermining can result in a sinus tract or tunnel that extends the
wound many centimeters beyond the main wound surface.
ASSESSING WOUNDS
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assess the location and extent of tissue damage. Measure the wound length, width, and depth.
Inspect the wound for bleeding. The amount of bleeding varies according to the type of wound
and location. Penetrating wounds may cause internal bleeding.
Control severe bleeding (a) applying direct pressure over the wound (b) elevating the involved
extremity.
Inspect the wound for foreign bodies
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Assess associated injuries such as fractures, internal bleeding, spinal cord injuries or head
trauma
If the wound is contaminated with foreign material, determine when the client last had a
tetanus toxoid injection. A tetanus immunization or booster may be necessary.
Prevent infection by (a) cleaning or flushing abrasions or lacerations with normal saline, and (b)
covering the wound with a clean dressing, if possible a sterile dressing is preferred. When
applying a dressing, wrap the wound tightly enough to apply pressure and approximate the
wound edges, if you are able. If the first layer of dressing becomes saturated with blood, apply a
second layer. Do so without removing the first layer of dressing, because blood clots might be
disturbed, resulting in more bleeding.
Control swelling and pain by applying ice over the wound and surrounding tissues.
If bleeding is severe or if internal bleeding is suspected, assess the client for signs of shock.
Pressure Ulcers
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Location of the ulcer, related to a bony prominence.
Size of ulcer in centimeters. Measure greatest length, width and depth.
Presence of undermining or sinus tracts, location described by position on the face of a clock, 12
o’clock as the client’s head.
Stage of the ulcer.
Color of the wound bed and location of necrosis or eschar.
Condition of the wound margins
Integrity of surrounding skin.
Clinical signs of infection
DIAGNOSING
 Risk for pressure ulcer: vulnerable to localized injury to the skin and/or underlying tissue usually
over a bony prominence as a result of pressure, or pressure in combination with shear.
 Risk for impaired skin integrity: vulnerable to alteration in epidermis and/or dermis which may
compromise health.
 Impaired skin integrity: altered epidermis and/or dermis
 Impaired tissue integrity: damage to mucous membrane, cornea, integumentary system,
muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.
 Risk for infection: if the skin impairment is severe, the client is immunosuppressed, or the
wound is caused by trauma.
 Acute pain: related to nerve involvement within the tissue impairment or as a consequence pf
procedures used to treat the wound.
PLANNING
The major goals for clients at risk for impaired skin integrity are to maintain skin integrity and to avoid
potential associated risks. Client with Impaired skin integrity need goals to demonstrate progressive
wound healing and regain intact skin within a specified time frame.
Client Teaching
Skin Integrity
Maintaining Intact Skin
 Discuss relationship between adequate nutrition healthy skin.
 Demonstrate appropriate positions for pressure relief.
 Establish a turning or repositioning schedule.
 Demonstrate application of appropriate skin protection agents and devices.
 Instruct to report persistent reddened areas.
 Identify potential sources of skin trauma and means of avoidance.
Promoting wound healing
 Discuss importance of adequate nutrition.
 Instruct in wound assessment and provide mechanism for documenting.
 Emphasize principles of asepsis, especially hand hygiene and proper methods of handling used
dressings.
 Provide information about signs of wound infection and other complications to report.
 Reinforce appropriate aspects of pressure ulcer prevention.
 Demonstrate wound care techniques such as wound cleansing and dressing changing.
 Discuss pain control measures, if needed.
IMPLEMENTING
The four major areas in which nurses can help clients develop optimal conditions for wound healing are
maintaining moist wound healing, providing sufficient nutrition and hydration, preventing wound
infections, and proper positioning.
I.
II.
III.
IV.
Moist Wound Healing
The dressing and frequency of change should support moist wound bed conditions. Wound beds
that are too dry or disturbed too often fail to heal.
Nutrition and Fluids
Clients should be assisted to take in at least 2,500mL of fluids a day unless conditions
contraindicate this amount. The nurse should ensure that clients receive sufficient protein,
vitamins C, A, B1, B5, and zinc.
Preventing Infection
2 main aspects to controlling wound infection: preventing microorganisms from entering the
wound, and preventing the transmission of bloodborne pathogens to or from the client to
others.
Positioning
To promote wound healing, clients must be positioned to keep pressure off the wound. Changes
of position and transfers can be accomplished without shear or friction damage.
PREVENTING PRESSURE ULCERS
 Providing Nutrition
 Maintaining skin hygiene
 Avoiding skin trauma
 Providing supportive device
TREATING PRESSURE ULCERS
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The RYB Color Code
This concept is based on the color of an open wound – red, yellow, black – rather than
the depth or size of a wound.
Wounds that are red are usually in the late regeneration phase of tissue repair. The
nurse protects red wounds by:
A. Gentle cleansing
B. Protecting periwound skin with alcohol-free barrier film
C. Filling dead space with hydrogel or alginate
D. Covering with an appropriate dressing
E. Changing dressing as infrequently as possible.
Yellow wounds are characterized primarily by liquid or semiliquid “slough” that is often
accompanied by purulent drainage or previous infection. The nurses cleanses yellow
wounds to remove nonviable tissues. Methods used may include applying damp-todamp normal saline dressings, irrigating the wound, using absorbent dressing materials.
Black wounds are covered with thick necrotic tissue, or eschar. Black wounds require
debridement. Debridement may be achieved in four different ways: sharp, mechanical,
chemical and autolytic.
DRESSING WOUNDS
Dressings are applied for the following purposes:
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To protect the wound from mechanical injury
To protect the wound from microbial contamination
To provide or maintain moist wound healing
To provide thermal insulation
To absorb drainage or debride a wound or both
To prevent haemorrhage
To splint or immobilize the wound site and thereby facilitate healing and prevent injury.