Chapter 47
Skin Integrity and
Wound Care
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Skin
• Structure: epidermis and dermis
• Function
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Pressure Ulcers: Pathogenesis
• Pressure intensity
• Pressure duration
• Tissue tolerance
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Risk for Pressure Ulcer
Development
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Impaired sensory perception
Impaired mobility
Alteration in level of consciousness
Shear
Friction
Moisture
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Classification of Pressure Ulcers
• Stage I: persistent red, blue, or purple
tones; no open skin areas
• Stage II: partial-thickness skin loss;
presents as an abrasion or blister
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Classification of Pressure Ulcers
(cont'd)
• Stage III: full-thickness skin loss with
damage or necrosis of subcutaneous
tissue; presents as a deep crater
• Stage IV: full-thickness skin loss with
extensive destruction, necrosis, or
damage to muscle, bone, other
structures
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Wound Classification
• Skin integrity: open, closed,
acute,chronic
• Cause: intentional, unintentional
• Severity of injury: superficial,
penetrating, perforating
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Wound Classification (cont'd)
• Cleanliness: clean, cleancontaminated, contaminated,
infected, colonized
• Descriptive qualities: laceration,
abrasion, contusion
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Process of Wound Healing
• Primary intention
• Secondary intention
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Wound Repair
• Partial thickness: inflammatory
response, epithelial proliferation and
migration, reestablishment of
epidermal layers
• Full thickness: inflammatory phase,
proliferative phase, and remodeling
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Complications of Wound Healing
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Hemorrhage—shock
Infection
Dehiscence
Evisceration
Fistula formation
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Factors Influencing Wounds
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Nutrition
Tissue perfusion
Infection
Age
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Psychosocial Impact of Wounds
• Body image
• Social resources
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Assessment
• Skin: color, temperature, turgor,
integrity
• Risk for pressure ulcers: Norton and
Braden scales
• Nutritional status
• Exposure of skin to body fluids
• Pain
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Assessment of Traumatic
Wounds
• Wounds: emergency setting
– Abrasions
– Lacerations
– Punctures
• Appearance
– Amount of bleeding
– Size
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Assessment of Wounds in a
Stable Setting
• Appearance: size, healing
• Character of drainage: serous,
sanguineous, serosanguineous,
purulent
• Drains
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Wounds: Stable Setting (cont'd)
• Closures: staples, sutures
• Palpation of wound
• Wound cultures: aerobic, anaerobic
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Nursing Diagnoses
• Risk for infection
• Imbalanced nutrition: less than body
requirements
• Pain
• Impaired skin integrity
• Impaired tissue integrity
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Planning
• Goals and outcomes
– Wound improvement within 2 weeks
– No further skin breakdown
– Increase in caloric intake by 10%
• Setting priorities
• Continuity of care
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Implementation:
Health Promotion
• Prevention of pressure ulcers
– Skin care
– Positioning
– Use of support surfaces
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Implementation: Acute Care
• Management of pressure ulcers and
wounds
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Wound Management
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Prevent and manage infection
Cleanse the wound
Remove nonviable tissue
Manage exudate
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Wound Management (cont'd)
• Protect the wound
• Client education
• Nutritional support
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First Aid for Wounds
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Control of bleeding
Cleansing
Application of topical growth factors
Protection
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Dressings
• Purpose
• Types: gauze, wet-to-dry, Telfa,
transparent, hydrocolloid, hydrogel,
foam, alginate
• Changing or reinforcing dressings
• Packing a wound: wound VAC
• Securing the dressing
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Dressing Changes
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Administer required analgesic
Explain steps of procedure to client
Gather all necessary supplies
Prepare sterile field, as indicated
Remove old dressing, assess area, and
provide necessary care using appropriate
aseptic technique
• Answer client’s questions and document
care provided
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Wound Care
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Cleansing skin and drain sites
Wound irrigations
Suture/staple care and removal
Drainage evacuation
Comfort measures
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Application of Bandages
and Binders
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Inspect underlying skin
Cover exposed wounds
Assess condition of dressings
Assess skin of areas distal to
bandage
• Use appropriate technique to apply
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Hot and Cold Therapy
• Assessment for temperature
tolerance
• Bodily responses to heat and cold
• Local effects of heat and cold
• Factors influencing tolerance
• Choice of moist or dry
• Compresses, packs, soaks, sitz
baths, aquathermia pad
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Evaluation
• Client care
• Client expectations
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