Fundamentals of Nursing:
Standards & Practices, 2E
Chapter 35
Skin Integrity
and Wound
Healing
Wounds
The skin is the body’s largest organ
and is the primary defense against
infection.
A disruption in the integrity of body
tissue is called a wound.
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Physiology of Wound Healing
Defensive (inflammatory) phase
Reconstructive (proliferative) phase
Maturation phase
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Types of Healing
Primary intention healing
Secondary intention healing
Tertiary intention healing
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Kinds of Wound Drainage
Serous exudate
Purulent exudate
Hemorrhagic exudate
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Factors Affecting
Wound Healing
Age
Nutrition
Oxygenation
Smoking
Drug therapy
Diabetes mellitus
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Hemorrhage
Some bleeding from a wound is normal
during and immediately after initial
trauma and surgery. Hemostasis usually
occurs within a few minutes.
Hemorrhage (persistent bleeding) is
abnormal and may indicate a slipped
surgical suture, dislodged clot, or erosion
of a blood vessel.
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Swelling in the area around the wound
or affected body part and the presence
of sanguinous drainage from a surgical
drain may indicate internal bleeding.
Symptoms of hypovolemic shock
include decreased blood pressure,
rapid thready pulse, increased
respiratory rate, diaphoresis,
restlessness, and cool clammy skin.
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A hematoma is a localized
collection of blood underneath the
tissues;it may also be seen and
appear as a reddish blue swelling or
mass.
External hemorrhaging is detected
when the surgical dressing becomes
saturated with sanguinous drainage.
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Infection
Bacterial wound contamination is
one of the most common causes of
altered wound healing.
A wound can become contaminated
preoperatively, intraoperatively, or
postoperatively.
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If the amount of bacteria in a wound
is sufficient or the client’s immune
defenses are compromised, clinical
infection may result and become
apparent 2 to 11 days
postoperatively.
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Infection prolongs the inflammatory
phase of healing, competing for
nutrients, and producing chemicals
and enzymes that are damaging to
the tissues.
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Dehiscence and Evisceration
Dehiscence is the partial or complete
separation of the wound edges and the
layers below the skin.
Evisceration occurs when the client’s
viscera protrude through the disrupted
wound.
Wound dehiscence is most likely to occur
4 to 5 days postoperatively.
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Wound Classification
Wounds are usually described
based on their etiology. The
treatment for the wound varies
depending on the underlying disease
process.
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Classification systems describe the
cause of the wound, the status of
skin integrity, the extent of tissue
damage, cleanliness of the wound,
or descriptive qualities of the wound
(such as color).
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Examples of classifications systems
• RYB classification system
• Wagner ulcer grade classification
• Classification by thickness of skin loss
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Assessment of Wounds
Health history
• Conducted to elicit information
regarding medical conditions or
disease processes that are often
associated with delayed or disrupted
healing
• Should include aggravating and
alleviating factors - allergies to tape,
latex, medications, or other substances
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Physical examination
•
•
•
•
•
Location of wound
Size of wound
General appearance and drainage
Pain
Laboratory data
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Nursing Diagnoses
Impaired Tissue Integrity
Risk for Infection
Acute or ChronicPain
Disturbed Body Image
Deficient Knowledge
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Outcome Identification
and Planning
The goals for clients with wounds
generally focus on promoting wound
healing, preventing infection, and
educating the client.
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Implementation
Initiate emergency measures.
Cleanse the wound (review Procedure
35-2 on irrigating a wound).
Dress the wound (review Procedure 35-3
on applying a dry sterile dressing and
Procedure 35-4 on applying a wet to dry
dressing).
Monitor drainage of wounds.
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Provide suture care.
Check bandages, binders, and
slings.
Administer heat and cold therapy
(review Table 35-5 for overview of
heat and cold applications).
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Evaluation
If the goals are not achieved, the nurse
will need to examine the nursing
interventions and strategies that were
employed, and revise the nursing care
plan accordingly.
It is important to review techniques and
procedures, especially those performed
by the client or other caregivers.
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Pressure Ulcers
Pressure ulcers, also known as
bedsores or decubitus ulcers, are
localized areas of tissue necrosis that
tend to develop when soft tissue is
compressed between a bony prominence
and an external surface for a prolonged
period of time.
Pressure ulcers are due to ischemia.
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Physiology of pressure ulcers
• The reduction of blood flow causes
blanching of skin when pressure is
applied.
• Other forces acting in conjunction with
pressure contribute to pressure ulcer
formation - shearing and friction.
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Risk factors for pressure ulcers
•
•
•
•
•
•
•
Immobility
Inactivity
Incontinence
Malnutrition
Decreased mental status
Diminished sensation
Age-related changes
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Assessment
•
•
•
•
Stage I
Stage II
Stage III
Stage IV
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Nursing Diagnoses
• Nursing diagnoses for clients with
pressure ulcers will be similar to those
for clients with wounds.
• Using diagnoses such as Body Image
Disturbance and Anxiety will ensure
that the client’s symptoms are
addressed holistically.
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Outcome identification and planning
• Individualized outcomes based on the
client’s overall physical condition, the
stage of the wound, and the client’s
risk factors will help in identifying
priority interventions.
• Client teaching should be included as
an integral part of the planning
process.
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Implementation
•
•
•
•
Ensure proper hygiene and skin care.
Provide proper positioning.
Employ support surfaces.
Apply complementary therapies.
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Evaluation
• Evaluation of the plan of care for a
client with a pressure ulcer will
consider the physical signs of healing
and the status of the pressure ulcer, as
well as the client’s adaptation to the
altered skin integrity.
• Each intervention should be evaluated
for its effectiveness.
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