Chapter 48
Skin Integrity and Wound Care
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Scientific Knowledge Base: Skin
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Dermal-epidermal junction
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Epidermis
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Separates dermis and epidermis
Top layer of skin
Dermis
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Inner layer of skin
Collagen
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Layers of the Skin
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Pressure Ulcers
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Pressure ulcer
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Pressure sore, decubitus ulcer, or bed sore
Pathogenesis
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Pressure intensity
• Tissue ischemia
• Blanching
Pressure duration
Tissue tolerance
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Pressure Ulcer with Necrosis
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Case Study

Mr. Omar Ahmed, a 76-year-old accountant,
has come to the hospital again, this time for
pneumonia. Before admission, he was unable
to eat and lost more than 20 lbs over the last
2 months. Three years ago, he had coronary
artery bypass surgery. As a precaution, he is
placed on telemetry monitoring. He also has
hypertension and type 2 diabetes mellitus.
His mobility is limited because of weakness.
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Case Study (cont’d)
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
Mr. Ahmed is retired. He lives in a one-family
home with his wife, Natalie. Their children
and grandchildren live nearby and visit often.
He complains that his “bottom hurts” from
lying in bed.
Lynda Abraham is the nursing student
assigned to the medical nursing unit. This is
her first hospital-based clinical practice.
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Risk Factors for Pressure Ulcer
Development
Impaired
sensory
perception
Alterations in
level of
consciousness
Impaired
mobility
Shear
Friction
Moisture
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Shear Force in Sacral Area
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Classification of Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
• Intact skin with nonblanchable redness
• Partial-thickness skin loss involving
epidermis, dermis, or both
• Full-thickness tissue loss with visible fat
• Full-thickness tissue loss with exposed bone,
muscle, or tendon
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Wounds
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Classification
Wound healing
Repair
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Partial-thickness wound repair
Full-thickness wound repair
• Hemostasis (fibrin)
• Inflammatory phase
• Proliferative phase (epithelialization)
• Remodeling
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Wound Colors
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Primary and Secondary Intention
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Complications of Wound Healing
Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration
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Nursing Knowledge Base
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Prediction and prevention of pressure ulcers
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Risk assessment
• Braden scale
Sensory perception, moisture, activity, mobility,
nutrition, and friction and shear
Prevention
• Economic consequences
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Factors Influencing Pressure Ulcer
Formation and Wound Healing
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Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds
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Assessment
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Skin
Pressure ulcers
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Predictive measures
Mobility
Nutritional status
Body fluids
Pain
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Pressure Ulcer on Heel
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Assessment
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Wounds
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Emergency setting
Stable setting
Wound appearance
Character of wound drainage
Drains
Wound closures
Palpation of wound
Wound cultures
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Penrose Drain
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Case Study (cont’d)

Lynda reviews the nursing assessment and finds that
Mr. Ahmed was admitted with a pressure ulcer. The
ulcer is a stage II, 1 × 2-inch and 1/8-inch deep
partial-thickness wound over his sacral area. No
necrotic tissue is present, and the wound bed has red
moist tissue. When Lynda prepares to conduct skin
assessment, she recalls information about the
pathogenesis of pressure ulcers and guidelines for
skin assessment for patients with darkly pigmented
skin.
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Case Study (cont’d)

Lynda observed care of a stage IV pressure
ulcer during an experience in an extended
care facility. From that experience, she
increased her knowledge about the
debilitating effects of pressure ulcers. In
addition, she was able to practice skin
assessment techniques during her clinical
experience in the extended care facility.
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Jackson-Pratt Drainage Device
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Wound Culturette Tube
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Case Study (cont’d)
Identify the
support surface
that would be
appropriate to
decrease
pressure on Mr.
Ahmed’s skin.
Inspect and
palpate the wound.
Conduct a calorie
count
• Mr. Ahmed cannot tolerate
positions that might relieve or
reduce pressure to his skin.
• The wound is a 1 × 2-inch, fullthickness ulcer over the sacral
area with a red moist base.
Reddened periwound skin.
• Mr. Ahmed is eating fewer than
1600 calories daily.
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Nursing Diagnosis and Planning
Risk for infection
Impaired tissue Acute or chronic
integrity
pain
Imbalanced nutrition: less than
Impaired skin
body requirements
integrity
Impaired
Ineffective
Risk for impaired
physical mobility peripheral tissue
skin integrity
perfusion
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Case Study (cont’d)
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
Goal: Pressure will be reduced to the sacral
area, and the wound will show movement
toward healing in 1 week.
Expected outcomes


Wound will decrease in diameter in 7 days.
No evidence of further wound formation will be
noted in 3 days.
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Quick Quiz!
1. The nursing assistant asks you the difference
between a wound that heals by primary or
secondary intention. You will reply that a
wound heals by primary intention when the
skin edges
A. Are approximated.
B. Migrate across the incision.
C. Appear slightly pink.
D. Slightly overlap each other.
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Implementation

Health promotion
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Topical skin care and incontinence management
• Protect bony prominences, skin barriers for incontinence.
 Positioning
• Turn every 1 to 2 hours as indicated.
 Support surfaces
• Decrease the amount of pressure exerted over bony
prominences.
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Avoiding Pressure Points
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Acute Care
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Management of pressure ulcers
Wound management
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Debridement (removal of nonviable, necrotic
tissue)
• Mechanical, autolytic, chemical, or sharp/surgical
Education
Nutritional status
Protein status
Hemoglobin
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Case Study (cont’d)
Post and implement a
turning schedule.
Obtain and place over
the patient’s mattress a
low-air-loss overlay.
• Repositioning redistributes
pressure.
• Redistributes the amount of
pressure on the bony prominences
Clean wound and
periwound skin; dry
periwound skin.
• Remove debris and old drainage
from wound site, preventing
further wound progression/skin
breakdown.
Apply a hydrocolloid
dressing to the wound.
• The use of hydrocolloid dressing
will support moist wound healing
and will protect the wound.
Determine in
collaboration with
dietitian an appropriate
diet.
• Adequate nutrition such as protein
intake, increased calorie count,
and vitamins aid in wound healing.
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Wound Irrigation
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First Aid for Wounds
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Hemostasis
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Cleaning
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Control bleeding.
• Allow puncture wounds to bleed.
• Do not remove a penetrating object.
Bandage
Gentle
Normal saline
Protection
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Purposes of Dressings
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Protect a wound from microorganism
contamination
Aid in hemostasis
Promote healing by absorbing drainage and
debriding a wound
Support or splint the wound site
Protect patients from seeing the wound (if
perceived as unpleasant)
Promote thermal insulation of the wound
surface
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Dressings
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Dry or moist
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Gauze
Film dressing
Hydrocolloid—protects the wound from
surface contamination
Hydrogel—maintains a moist surface to
support healing
Wound vacuum assisted closure (V.A.C.)—
uses negative pressure to support healing
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Transparent film dressing
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Dressings (cont’d)
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Changing
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Know type of dressing, placement of drains, and
equipment needed.
Prepare the patient for a dressing change
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Evaluate pain.
Describe procedure steps.
Gather supplies.
Recognize normal signs of healing.
Answer questions about the procedure or wound.
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During a Dressing Change

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Assess the skin beneath the tape.
Perform thorough hand hygiene before and
after wound care.
Wear sterile gloves before directly touching
an open or fresh wound.
Remove or change dressings over closed
wounds when they become wet or if the
patient has signs or symptoms of infection,
and as ordered.
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Dressings

Packing a wound
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Securing
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Assess size, depth, and shape
Tape, ties, or binders
Comfort measures



Carefully remove tape.
Gently clean the wound.
Administer analgesics before dressing change.
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V.A.C. (Vacuum-Assisted Closure)
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V.A.C. (cont’d)
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Before and After V.A.C. Therapy
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Montgomery Ties
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Cleaning Skin
1. Clean in a direction from the least
contaminated area such as from the wound
or incision to the surrounding skin or from an
isolated drain site to the surrounding skin.
2. Use gentle friction when applying solutions
locally to the skin.
3. When irrigating, allow the solution to flow
from the least to the most contaminated area.
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Cleaning Skin and Drain Sites
Cleaning
Irrigation
Apply noncytotoxic
solution.
To remove exudates, use sterile
technique with 35-mL syringe and
19-gauge needle.
Suture Care
Drainage Evacuators
Consult health care facility
policy.
Portable units exert a safe,
constant, low-pressure vacuum to
remove and collect drainage.
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Methods for Cleaning a Wound Site
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Cleaning a Drain Site
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Staples and Remover
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Types of Sutures
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Removal of Intermittent Suture
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Drainage Evacuators
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Quick Quiz!
2. A postoperative patient arrives at an
ambulatory care center and states, “I am not
feeling good.” Upon assessment, you note an
elevated temperature. An indication that the
wound is infected would be
A. It has no odor.
B. A culture is negative.
C. The edges reveal the presence of fluid.
D. It shows purulent drainage coming from the
incision site.
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Bandages and Binders
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Functions: create pressure, immobilize and/or
support a wound, reduce or prevent edema,
secure a splint, secure dressings
Bandages


Rolled gauze, elasticized knit, elastic webbing,
flannel, and muslin
Binder application

Breast, abdominal, sling
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Securing Binders
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Case Study (cont’d)


In preparation for her husband’s discharge,
Mrs. Ahmed is interested in learning how to
change Mr. Ahmed’s pressure ulcer dressing.
Lynda develops a teaching plan to include
Mrs. Ahmed, with the outcome goal that “At
the end of the teaching session, Mrs. Ahmed
will perform an acceptable return
demonstration of dressing application.”
What teaching and evaluation strategies
would be appropriate?
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Heat and Cold Therapy

Assessment for temperature tolerance

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Assess the skin and skin integrity.
Assess the patient’s response to stimuli.
Assess the equipment being used.
Identify any contraindications.
Bodily responses to heat and cold
Local effects of heat and cold
Factors influencing heat and cold tolerance
Application of heat and cold therapies
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Contraindications to Cold and Heat
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Cold is contraindicated:





If the site of injury is edematous
In the presence of neuropathy
If the patient is shivering
If the patient has impaired circulation
Heat is contraindicated:



For areas of active bleeding
For an acute localized inflammation
Over a large area if a patient has cardiovascular
problems
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Case Study (cont’d)

Lynda observes Mr. Ahmed’s wound and measures it
to be 1 × 1 inch with serous drainage and red color.


Lynda palpates underlying skin around wound; the
skin remains intact.


Achievement of outcome by improved tissue type and
reduced wound size
Achievement of outcome by no evidence of advancing ulcer
or tissue damage
She asks Mr. Ahmed about discomfort; he denies any
new sensations at the wound site.

Achievement of outcome by no evidence of new tissue
damage
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Quick Quiz!
3. A surgical wound requires a Hydrogel
dressing. The primary advantage of this
type of dressing is that it provides
A. An absorbent surface to collect wound
drainage.
B. Decreased incidence of skin maceration.
C. Protection from the external environment.
D. Moisture needed for wound healing.
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Evaluation



Was the etiology of the skin impairment addressed?
Were the pressure, friction, shear, and moisture
components identified; and did the plan of care
decrease the contribution of each of these
components?
Was wound healing supported by providing the
wound base with a moist protected environment?
Were issues such as nutrition assessed and a plan of
care developed that provided the patient with the
calories to support healing?
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Case Study (cont’d)

Lynda Abraham has completed her clinical
experience with Mr. Ahmed. His pressure ulcer is still
present, but it is reduced in size and demonstrates
progress toward healing. No other sites of
nonblanchable erythema were noted, and the rest of
his skin remains intact. Lynda taught Mrs. Ahmed
how to assess her husband’s skin for signs of
increased risk for or further breakdown. Lynda, with
the help of her instructor, devised a plan of care for
the home, and they are meeting with the home care
nurse today when she visits Mr. Ahmed at the
hospital.
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