Skin Integrity &
Wound Care
Functions of the Skin
The body’s first line of defense protecting it
from microbial and foreign substance invasion.
An intact skin surface provides a barrier to
harmful microorganisms.
A wound is a disruption in the normal integrity
of the skin.
Creates a potentially dangerous and possibly
life-threatening situation
Wound Complications
Infection
Hemorrhage
Dehiscence
Evisceration
Pressure Ulcers and Preventive Measures
Definition
A wound caused by unrelieved pressure
that results in damage to underlying tissue
Pressure-relieving measures:
Frequent turning
Pressure-relieving devices
Positioning
Pressure Ulcer Stages
Stage I
Observable pressure-related alteration of intact skin
Stage II
Partial-thickness skin loss involving epidermis/dermis
Stage III
Full-thickness skin loss involving damage of subcutaneous
tissue, extending to, but not through, underlying fascia
Stage IV
Full-thickness skin loss with extensive destruction or
damage to muscle, bone, or supporting structures
Cleaning a Wound and Applying a Dry,
Sterile Dressing
The goal of wound care is to promote tissue repair
and regeneration to restore skin integrity.
Wound care involves cleaning of the wound and the
use of a dressing as a protective covering over the
wound.
Wound cleansing is performed to remove debris,
contaminants, and excess exudate.
Sterile normal saline is the preferred cleansing
solution.
Assessments Made When Applying a
Saline Moistened Dressing
Assess the situation to determine the need for a dressing change;
confirm any physician orders relevant to wound care.
Assess the current dressing if there is one.
Assess the patient’s level of comfort and the need for analgesics
before wound care.
Assess the location, stage, drainage, and types of tissue present in
the wound; measure the wound.
Assess the surrounding skin for color, temperature, edema,
ecchymosis, or maceration.
Hydrocolloid Dressings
Definition
Wafer-shaped dressings with an adhesive backing to
provide adherence to the wound and skin
Functions
Absorb drainage, maintain a moist wound surface, cover
the wound surface, decrease risk for infection
Indication
Shallow to moderate-depth wounds with minimal
drainage; stay in place for 3 to 7 days
Expected Outcomes When Irrigating a
Wound
The wound is cleaned without
contamination or trauma and without
causing pain or discomfort.
The wound continues to show signs of
progression of healing.
The patient demonstrates understanding
about the need for wound irrigation.
Collecting a Wound Culture
Ordered if assessment of a patient and the patient’s
wound suggests infection
Identifies the causative organism to provide useful
information to select the most appropriate therapy.
Can be performed by a nurse or physician
Maintaining strict asepsis is crucial so that only the
pathogen present in the wound is isolated
Using the correct culturette kit for collection of an
aerobic or anaerobic organism is essential
Securing Montgomery Straps to a
Dressing
Definition
Prepared strips of nonallergenic tape with ties
inserted through holes at one end
A skin barrier is often applied before the straps
to protect the skin
Indications
Wounds that require frequent dressing changes,
such as wounds with increased drainage
The straps allow for wound care without
removing adhesive strips, decreasing skin
irritation and injury
Penrose Drain Use and Care
Hollow, open-ended rubber tube used after
surgical procedures or for drainage of an
abscess
Allows fluid to drain via capillary action into
absorbent dressings
Can be advanced or shortened to drain
different areas
The patency and placement of the drain are
included in the wound assessment
Biliary Drains or T Tubes
Uses
Placed in the common bile duct after removal of
the gallbladder (cholecystectomy) or a portion
of the bile duct (choledochostomy)
The tube drains bile while the surgical site is
healing
Care
The drainage amount is measured every shift,
recorded, and included in output totals
A Biliary Drain or T-Tube Drain
Caring for a Jackson-Pratt Drain
Uses
Collects wound drainage in a bulblike device
that is compressed to create gentle suction
Consists of perforated tubing connected to a
portable vacuum unit
Typically used with breast and abdominal
surgery
Care
Usually drains are emptied every 4 to 8 hours,
and when they are half full of drainage or air
Patency, placement, and the amount and
characteristics of the drainage are assessed
A Jackson-Pratt Drain
Use and Care of a Hemovac Drain
Perforated tubing connected to a portable vacuum
unit
Placed into a vascular cavity where blood drainage
is expected after surgery
Suction is maintained by compressing a springlike
device in the collection unit
Typically the drain is emptied every 4 or 8 hours
and when it is half full of drainage or air
Patency, placement of the drain, and the amount
and characteristics of the drainage are assessed
A Hemovac Drain
Applying Negative Pressure Wound
Therapy
Promotes wound healing and wound closure
through the application of uniform negative
pressure on the wound bed
Results in reduction in bacteria in the wound
and the removal of excess wound fluid, while
providing a moist wound healing environment.
The negative pressure results in mechanical
tension on the wound tissues, stimulating cell
proliferation, blood flow to wounds, and the
growth of new blood vessel
Assessments Made Prior to
Removing Sutures
Assess the appearance of the wound.
Approximation of wound edges, signs of
dehiscence
Color of the wound and surrounding area
Presence of wound drainage noting color,
volume, and odor
Assess stage of the healing process.
Assess the surrounding skin.
Color, temperature, edema, maceration, or
ecchymosis
Expected Outcomes When
Removing Surgical Staples
The staples are removed
without contaminating the incision area.
without causing trauma to the wound.
without causing the patient pain or discomfort.
The patient remains free from exposure to
infectious microorganism.
The patient remains free of complications that
would delay recovery.
The patient verbalizes positive aspects about self.
Therapeutic Effects of Sterile,
Warm, Moist Compresses
Promote circulation to the wound.
Encourage wound healing.
Decrease edema.
Promote consolidation of wound exudate.
Decrease pain and discomfort at the
wound site.
Assessments Made Prior to
Assisting Patient With a Sitz Bath
Review any orders related to the Sitz bath.
Determine patient’s ability to ambulate to the
bathroom and maintain sitting position for 15
to 20 minutes.
Inspect perineal/rectal area for swelling,
drainage, redness, warmth, and tenderness.
Assess bladder fullness and encourage patient
to void prior to sitz bath.
Using a Cooling
Blanket/Hypothermia Pad
Definition
A blanket-sized Aquathermia pad that conducts
a cooled solution, usually distilled water,
through coils in a rubber or plastic blanket or
pad
Uses
Helps to lower body temperature
May be preset to maintain a specific body
temperature