Alterations in Physical Integrity
Ray: NR210
1.
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).
Overhead.
Classification of wounds asst. the nurse to assess for risk for infection. Note that many
of these overlap. Please trust me that these definitions are in your text – let’s just go
through these quickly.
A.
Intentional vs. Unintentional
Intentional:
Unintentional:
Usu. the result of therapy. Occur under
Occurs unexpectedly. Occurs under
aseptic conditions.
unsterile conditions.
Wound edges: usu. smooth/clean
Wound edges: sometimes jagged.
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B.
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.
A.
Acquisition
Incision:
 Wound made with a sharp instrument.
Contusion:
 Closed wound caused by a blow to the
body by blunt object.
 Bruise, characterized by swelling,
discoloration, pain.
Abrasion:
 Superficial wound.
 Scraping, rubbing of skin’s surface.
Closed
 Involves no break in skin integrity.

Wound edges are closed.
 If drainage system is in place, it is a
closed system.
Puncture/Perforating:
 Penetrating wound in which a foreign
object enters/exits an internal organ.
Laceration:
 Tearing apart of tissues.
 Wound has irregular edges.
Penetrating:
 Wound involving a break in epidermal
skin layer, as well as dermis and
deeper tissues or organs.
 Foreign object or instrument/object
entering deep into body tissues. Usu.
unintentional (gunshot wound).
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D.
Contamination
Clean wounds:
Closed surgical wound not entering GI,
respiratory, genital, uninfected urinary
tract, or oropharyngeal cavity.
Clean-contaminated wounds:
Surgical wound entering GI, respiratory,
genital, uninfected urinary tract, or
oropharyngeal cavity under controlled
conditions.
Contaminated wounds
 Open, traumatic, accidental wound.
 Surgical wound involving a break in
aseptic technique.
Dirty or infected wounds:
 Any wound that does not properly heal
and grows organisms.
 Old traumatic wound, surgical incision
into a area infected.
Let’s add a few more (overhead):
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.
2.
Wound Healing
Regeneration: The process of tissue renewal
A.
Stages of wound healing:
Defensive stage (Inflammatory Phase/Reaction)
(hemostasis, inflammation, cell migration &
epithelialization)
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.
Reconstructive stage (Proliferative Phase/Regeneration)
Filling in of the wound with new connective or granulation
tissue and the closing of the top of the wound by
epitheliazation.
B.
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 redge is present by
day 9.
Secondary Intention
 Wound edges do not
approximate.
 Wound is left open until it
becomes filled by scar tissue.
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

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.
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 cleancontaminated or
contaminated wound.
 Not closed until all evidence
of edema and wound debris
has been removed.
 Dressing is used to protect.
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
C.
Scarring is greater.
Wound drainage
Serous:
Clear, watery drainage
Purulent:
thick drainage (often yellow-green in color).
3.
Sanguineous:
Hemorrhagic drainage
Serosanguinous:
Drainage that is pink to light red in color.
Factors affecting wound healing.
Internal and external factors:
Vasculature
Smoking
Compromised host
Stress
Nutrition
Patient teaching
Obesity
Hospital "time"
Medications (immunosuppressants)
Blood sugar
4.
Factors inhibiting wound healing in the elderly.
Vascular changes
Atherosclerosis, arteriosclerosis
Hepatic function
reduced liver FX can impair the synthesis of blood clotting factors.
Immune response
can experience a reduction in the formation of antibodies and lymphocytes necessary to
prevent infection
Nutritional status
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Gerontological Consideration r/t Skin Integrity (p. 1546) (overhead)
Diminished epidermal cell activity
 After age of 50 cell renewal time is increase by one third.
 Epithelial cell renewal takes 30 or more days for the
elderly.
 This causes slower wound 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
The epidermis can slide – precipitates skin tears.
attachment.
Impaired immune function of skin cells
Increases the risk of infection
Hypodermics is decreased (insulator of
 Little subcutaneous padding over bony prominences.
the skin)
 More at risk for skin breakdown and heat stroke.
Loss in the amt. of collagen
 Decreased skin turgor
 Greater risk for shearing and tearing injuries.
5.
Complications of wound healing
Hemorrhage
s/s:
increased HR, increase, resp, lowered BP,
restlessness, thirst, cold, clammy skin
Risk of hypovolemic shock.
Hematoma: localized collection of blood
underneath the tissues.
Infection
s/s:
redness, swelling, pain, induration, fever,
increase in WBC's, purulent drainage
 Nosocomial Infection: A wound is infected if
purulent material drains from it. Even is a
culture is negative.
 A contaminated or traumatic wound may show
signs of infection in 2-3 days.
Dehiscence (with possible evisceration)
s/s:
unexplained fever, unexplained
tachycardia, unusual wound pain, prolonged
paralytic ileus
 Most commonly occurs before collagen tissue
has formed (3-11 days post op)
 Partial or total separation of wound edges.
 Obese clients, clients who smoke, client’s with
vascular disease are at higher risk.
Evisceration:
 Total separation of wound layers with
protrusion of visceral organs through a wound
opening.
 Medical emergency
 Requires surgical repair.
 Nurse places sterile towels soaked with sterile
saline over the wound, calls the MD.
 Watch for s/s shock, keep NPO, prepare for
surgery.
Let’s add:
Fistulas:
 An abnormal passage between two organs or
between an organ and the outside of the body.
 May be created for therapeutic purposes
(gastrostomy)
 Most often result of poor wound healing,
complication of disease, regional enteritis.
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
6.
Surgical wound infections usu. do not develop
until the 4th or 5th postop day.
Nursing Process in wound management.
Assessment
Untreated wounds
Control bleeding
Prevent infection
Control swelling and pain
Monitor vital signs as indicated
Assess for need for tetanus toxoid
Treated wounds: During wound care
appearance
Pain
drainage
wound drains(penrose, J-P, Hemovac)
Swelling
Induration
temperature
Sequential signs of primary wound healing:
absence of bleeding
inflammation
granulation tissue
scar formation
reduction in scar size
Significant Lab Data:
WBC, Hgb, Hct
BUN, Albumin
Wound cultures
Goals
Promote wound healing...
MD approximates wound edges (if appropriate)
prescribes wound care regime
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Nurse

provides ongoing wound assessment

provides aseptic wound care according to MD
specifications

documents wound status, keeps MD apprised of the wound
status as appropriate
Interventions: To promote healing/prevent complications...



adequate nutrition
prevent wound stress/trauma
 vomiting, coughing
 abdominal distention
prevent infection
aseptic wound care
Factors affecting wound care:
Type of wound
Location of the wound
Size
MD specifications re: wound care
Wound drainage or exudate
Presence of complicating factors
Wound status (open vs. closed)
Drain management:
open vs. closed
drainage systems
monitor drainage:
amt., consistency, etc.
Appro:
universal precautions & aseptic technique
Sutures/staples: used to approximate wound edges. Special kit for ea.
Heat and cold applications: How long apply? What do you do before you
apply the compress?
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Pressure Ulcers
Other terms: Pressure ulcer, pressure sore, decubitus
ulcer, bedsore.
Make an overhead of Skin layers
Normal Integument:
Two principal layers of the skin:
Epidermis. Outer layer.
 Stratum corneum is the thin, outermost layer.
Flattened,
dead, keratinized cells. Originate from the epidermal
layer (stratum basale). Protects underlying cells from
dehydration, prevents entrance of certain chemical
agents. Allows evaporation of water from the skin,
permits absorption of certain topically applied meds.
 stratum basale. Cells, proliferate, migrate toward the
epidermal surface. When cells reach the stratum corneum,
they flatten and die.
Dermis: Inner layer. Provides tensile strength,
mechanical support, protection to underlying muscles,
bones, organs. Contains connective tissue, few skin cells.
Collagen, blood vessels, nerves compose it.
I.
Overview.
A.
Tissue Ischemia: localized absence of blood or a major reduction
of blood flow resulting from mechanical obstruction.
B.
Blanching: Normal red tones of light-skinned client are absent.
Does not occur in clients with darkly pigmented skin.
C.
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.
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Overhead:
Characteristics of Intact Dark Skin that might alert nurses to the potential for
pressure ulcers (p. 1546)
Color
 Appears darker than surrounding skin
 May be purplish/bluish hue
 Natural or halogen light source best for assess skin
 Fluorescent light source, to be avoided, since it casts a bluish
hue, making accurate assessment difficult
Temperature  Initial warmth when compared with surrounding skin
 Later coldness as tissue is devitalized
Touch
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Appearance
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Indurated
Edema
Soft, boggy
Taut
Shiny
Itchy
D.
Normal reactive hyperemia: (overhead)
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.
E.
Abnormal reactive hyperemia: (overhead)
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.
F.
Induration: Area of localized edema under the skin. Feels harder
than the surrounding tissue.
Longer unrelieved pressure is applied, the greater the risk of skin breakdown.
Pressure causes decreased blood flow to tissues, Ischemia occurs. When
pressure is removed, there is a period of reactive hyperemia, or a sudden
increase in blood flow to the region. This is compensatory, and only effective if
pressure is moved before necrosis or damage occurs.
II.
Prediction & Prevention
A.
Risk Factors
1.
Impaired Sensory Input: Altered sensory perception for
pain and pressure are at greater risk. Normally one can tell
when a portion of their body senses too much pressure/pain
– and move accordingly
2.
Impaired motor function: clients who are unable to
change positions independently.
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3.
4.
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Alterations in LOC: These clients might be able to feel the
pain/pressure, but are unable to understand how to relieve it.
Comatose clients may not perceive the pressure.
Anesthetized clients are also at risk during surgical
procedures.
Casts, Traction, etc…Orthopedic Devices: Reduce
mobility. Extra mechanical force from the cast surface
rubbing on the skin. Also many times these devices
immobilize the client.
Any equipment that exerts pressure on a pt’s skin can cause
pressure ulcers. Oxygen tubing, NG tubing.
B.
Contributing Factors of Pressure Ulcer Formation
Shearing Force
Obesity
Pressure exerted against the skin in a direction
 Adipose tissue in small quantities protects the
parallel to the body’s surface.
skin.
Client’s bone slides down into the skin and exerts  Moderate to severe obesity, adipose tissue is
a force. Subqu. Fat is the most susceptible.
poorly vascularized, more susceptible to
Ischemia.
Friction
Infection
Mechanical force exerted when the skin is
Infection with fever increases body’s metabolic
dragged across a surface.
demands. Makes already hypoxic tissue even mo
Affect the epidermis.
so.
Edema
Impaired Peripheral Circulation
shift of fluid from extracellular fluid volume to the
 Decreased circulation impedes the body’s abil
tissues
to compensate (normal reactive hyperemia).
Poor nutrition can be a factor in the development
 Pt’s in shock and who are taking vasopressorof.
type medications also have impaired periphera
circulation.
Anemia
Older adults
decre. Levels of hemoglobin reduce the oxygenMore freq. occurrence of pressure ulcers.
carrying capacity of the blood
Poor nutrition can cause.
Cachexia
Generalized ill health and malnutrition. Usu. asso
with severe diseases (CA, end-stage cardiac
disease, etc).
Poor nutrition can precipitate – and worsens.
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Let’s add Nutrition:
Well nourished client requires at least 1500 cal/day for nutritional
maintenance. Enteral feedings, parenteral nutrition are available to
maintain optimal caloric intake.
Ready availability of protein, vitamins (A & C), and trace minerals
zinc and copper are essential.
Albumin is frequ used to assess the client’s nutrition status. Below
3g/100 ml is at risk.
C.
Evaluation Tools:
Norton Scale
Total score: 5-20
Lower score indicates a higher risk for pressure ulcer development.
Cosnell Scale
Total score: 5-20
A higher score indicates a higher risk for pressure ulcer
development.
Braden Scale
Total score: 6-23
Lower score indicates a higher risk for pressure ulcer development.
Be sure to review – esp. the Braden scale. You should be familiar with the
categories, and with how the score relates to the risk for pressure ulcer
development.
C.
Pathogenesis of Pressure Ulcers
Intensity of pressure & capillary
Duration & sustenance of
closing pressure
pressure
Tissue
Tolerance
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D.
I.
II.
III.
IV.
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Classification of Pressure Ulcers – staging or color
Staging of Pressure Ulcers
Nonblanchable erythema of the intact skin. Observable pressurerelated alteration of intact skin.
Indicators may include:
 changes in skin temperature,
 tissue consistency (firmer than surrounding tissue), and
 sensation (pain, itching).
Partial-thickness skin loss involving epidermis and /or dermis. Ulcer is
superficial. Presents as an abrasion, blister, shallow crater.
Full-thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to but not through underlying fascia.
Ulcer presents as a deep crater. Might/might not undermine
adjacent tissue.
Full-thickness skin loss with extensive destruction; tissue necrosis; or
damage to muscle, bone, or supporting structures.
The major problem with sequential numbering of pressure ulcers is that these
wounds do not heal in reverse order. The nurse must use some other
classification system to describe a healing wound.
(overhead)
“black wounds”
“yellow wounds”
“red wounds”
Classification of Wounds by Color
Necrotic
Wounds with exudate, yellow fibrous debris
Wounds in active healing phase and are clean with pink to red
granulation and epithelial tissue
F. Nsg process and pressure ulcers (p. 961-970) (p. 1567-1625)
1. Assessment:
2. Nsg DX
3. Planning
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4. Implementation
a.
Prevention
Hygiene
Positioning
Support Surfaces
b.
Treatment
Debridement, Cleansing, Dressing Application
Eschar
Sloughing
Moist Wound-healing
Nutritional status
(Protein status, hemoglobin)
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