Chapter 36
Skin Integrity and
Wound Healing
Normal Structures and Function
of Healthy Skin
 The skin is the body’s largest organ and
the primary defense against pathogenic
invasion.
 The skin also contributes to temperature
regulation, prevents loss of internal fluids,
and provides sensory awareness.
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Normal Structures and Function
of Healthy Skin
 Epidermis
• Outermost layer of the skin
• Primary function is to maintain a barrier
against loss of internal fluids and pathogenic
invasion.
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Normal Structures and Function
of Healthy Skin
 Dermal-Epidermal Junction
• Anatomic point at which the epidermis
connects with the dermis
• Characterized by interdigitating connections
that provide resistance to superficial skin
injury.
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Normal Structures and Function
of Healthy Skin
 Dermis
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Innermost layer of the skin
Nourishes the basal layer of the epidermis.
Provides sensory awareness.
Contributes to temperature regulation.
Composed primarily of collagen and elastin
fibers.
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Normal Structures and Function
of Healthy Skin
 Hypodermis (Subcutaneous layer)
• Consists primarily of adipose tissue and
connective tissue.
• Critical role of providing “padding” and even
weight distribution over bony prominences.
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Normal Structures and Function
of Healthy Skin
 Fascia/Muscle Layer
• Fascia is a thin layer of connective tissue
covering the muscle.
• Muscle layer is composed of contractile
fibers that control position and movement.
• Muscle layer is the most metabolically active
layer of the skin and soft tissues.
• Muscle layer is most vulnerable to ischemic
damage.
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Normal Structures and Function
of Healthy Skin
 Changes Across the Lifespan
• Neonates and Infants
• Elderly Adults
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Strategies to Maintain Healthy
Skin
 Nutrition and Hydration
 Bathing and Lubrication
 Managing Pruritic Skin
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Strategies to Maintain Healthy
Skin
 Common Skin Lesions
• Bacterial Infections
• Fungal Infections
• Viral Infections
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Strategies to Maintain Healthy
Skin
 Inflammatory Conditions
 Cutaneous Malignancies
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Pressure Ulcer Formation
 A pressure ulcer is an area of skin and
tissue loss caused by prolonged or
excessive soft tissue pressure.
 Results in skin breakdown.
 Increasingly common problem among
clients in all health care settings.
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Pressure Ulcer Formation
 Pathology of Pressure Ulcers
• Tunneling
• Friction
• Maceration
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Pressure Ulcer Formation
 Assessment
• Use of a research-based risk assessment
tool to screen all non-ambulatory clients
- Braden scale
- Norton scale
• Nonblanching erythema
• Induration with palpation
• Extensive tissue damage
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Pressure Ulcer Formation
 Assessment
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Etiologic Risk Factors
Prolonged or High-Intensity Pressure
Shear Force
Compromised Tissue Tolerance
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Pressure Ulcer Formation
 Nursing Diagnosis
• Impaired Skin Integrity Related to
Pressure/Shear Injury
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Outcome Identification and
Planning
 Individualized outcomes are based on
the client’s overall physical condition, the
stage of the wound, and the client’s risk
factors.
 Client teaching is an integral part of the
planning process.
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Implementation
 Pressure ulcers can be prevented
through a variety of measures.
 Early identification of high-risk individuals
and contributing factors decrease the
possibility of pressure ulcer formation.
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Implementation
 Appropriate Use and Selection of
Support Surfaces
• A variety of support surfaces for bed and
chair are designed to reduce interface
pressures or to constantly change the
pressure points.
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Implementation
 Measures to Control Moisture and
Maceration
 Nutritional and Fluid Support
 Routine Skin Assessment
 Management for Shear Force
 Avoidance of Massage of Tissue at Risk
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Evaluation
 Physical signs of healing and the status
of the pressure ulcer
 Client’s adaptation to the altered skin
integrity
 Each intervention should be evaluated for
its effectiveness.
 Plan of care is revised to reflect most
beneficial actions.
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Wound Healing
 Definitions and Classifications of Wounds
• Acute
• Chronic
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Wound Healing
 Definitions and Classifications of Wounds
• Partial-thickness wounds involve partial loss
of the skin layers but do not involve the
deeper tissues.
• Full-thickness wounds involve total loss of
the epidermis and dermis with extension into
the subcutaneous tissue and possibly the
muscle.
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Wound Healing
 Partial-Thickness Wound Repair
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Brief inflammatory phase
Epithelial cell proliferation and migration
Vertical migration
Collagen synthesis (formation of new
connective tissue)
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Wound Healing
 Full-Thickness Wound Repair
• Inflammatory phase
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Control bleeding
Establish clean wound bed
Release of growth factors
Inflammatory response
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Wound Healing
 Full-Thickness Wound Repair
• Proliferative phase
- Granulation tissue
- Epithelialization
- Contraction
• Maturation phase (remodeling phase)
- 3 months to 2 years
- Hypertrophic scarring (keloid formation)
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Wound Management
 Identify and address etiologic factors.
 Establish appropriate goals.
 Provide systemic support and topical
therapy.
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Wound Management
 Assessment
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Location, dimensions and depth
Stage of the wound
Status of wound bed (eschar, slough)
Exudate
Status of wound edges (flat, red, moist,
closed)
• Status of surrounding skin
• Pain
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Assessment
 Factors Affecting Wound Healing
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Perfusion and Oxygenation
Nutritional Status
Diabetes Mellitus
Corticosteroids
Aging
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Assessment
 Laboratory Data
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Cultures of wound drainage
Elevated WBC count
Decreased leukocyte
Albumin
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Nursing Diagnoses
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Impaired Tissue Integrity
Risk for Infection
Pain
Disturbed Body Image
Deficient Knowledge (wound care)
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Outcome Identification and
Planning
 Targeted outcomes are based on client’s
identified needs and individualized on
basis of client’s condition.
 Focus is on promoting wound healing,
preventing infection, and educating the
client.
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Implementation
 Systemic Support Measures
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Tissue perfusion and oxygenation
Nutritional support
Glucose levels within normal limits
Compensation for chronic steroid intake
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Implementation
 Topical Therapy
• Wound cleansing
• Dressing selection
• Debridement of necrotic tissue
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Implementation
 Topical Therapy
• Monitor drainage of wounds
- Penrose drains
- Jackson-Pratt drains
- Hemovac drains
• Maintenance of open proliferative wound
edges
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Drainage Systems: Closed
System
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Drainage Systems: Tube and
Reservoir System
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Evaluation
 Achievement or Maintenance of Skin
Integrity
• Wound healing
• Prevention of infection
• Client education
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Management Guidelines for
Specific Wounds
 Abrasions and Lacerations
 Surgical Incisions
 Skin Tears
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Types of Wounds
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Management Guidelines for
Specific Wounds
 Lower Extremity Ulcers
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Venous ulcers
Arterial ulcers
Neuropathic ulcers
Atypical ulcers
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Management Guidelines for
Specific Wounds
 Burns
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Thermal, chemical, or electrical causes
Epidermal burns
Superficial partial-thickness burns
Deep partial-thickness burns
Full-thickness burns
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Contusions, Strains, and
Sprains: Management
Guidelines
 Contusions are bruises of the soft tissues
with no break in the skin surface.
 Contusions resolve spontaneously and
require no active management.
 Application of ice for 24 hours following
injury can reduce the amount of edema
and bruising.
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Contusions, Strains, and
Sprains: Management
Guidelines
 Strains represent “stretch” injuries of
muscles, tendons, or ligaments.
 Application of ice for 24 hours to reduce
swelling and bleeding, elevation to
reduce swelling, use of an elastic wrap or
sling, and aspirin or acetaminophen as
needed.
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Contusions, Strains, and
Sprains: Management
Guidelines
 First- and second-degree sprains involve
trauma to ligaments, tendons, or bones
around a joint.
 Caused by twisting or pulling forces.
 Nonsteroidal anti-inflammatory drugs,
ice, elastic wrap or sling, and restricted
activity until symptoms resolve
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Contusions, Strains, and
Sprains: Management
Guidelines
 Third-degree sprains represent a more
serious injury.
 Characterized by separation of tendons
and ligaments from their bony
attachments.
 Produce severe bleeding, swelling, pain,
and loss of function.
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Contusions, Strains, and
Sprains: Management
Guidelines
 Management of Third-Degree Strains
• Rest
• Crutch to prevent weight bearing during
ambulation
• Ice for 24 to 72 hours
• Compression with an elastic wrap
• Soft cast or sling
• Elevation
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Contusions, Strains, and
Sprains: Management
Guidelines
 Management of Third-Degree Sprains
• Narcotic analgesics for severe pain
• Restricted mobility for up to 3 weeks
• Surgery may be required for reattachment or
removal of torn tendons and ligaments.
• Potential for developing post-traumatic
arthritis
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Administer Heat and Cold
Therapy
 Heat and cold therapies require nursing
care that assesses both the
vasoconstriction and vasodilation of an
individual.
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Administer Heat and Cold
Therapy
 Conditions that necessitate precautions
in the use of heat and cold applications:
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Neurosensory impairment
Impaired mental status
Impaired circulation
Open wounds, broken skin, scar formation,
edema
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Administer Heat and Cold
Therapy
 Heat Therapy
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Promotes vasodilation
Decreases blood viscosity
Increases tissue metabolism
Increases capillary permeability
Reduces muscle tension
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Administer Heat and Cold
Therapy
 Cold Therapy
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Promotes vasoconstriction
Increases blood viscosity
Decreases tissue metabolism
Local anesthetic effect
Decreases muscle tension
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