SKIN INTEGRITY AND

WOUND HEALING
 Types of Wounds

 Intentional wounds – occur during therapy,

operations or venipuncture.

 Unintentional wounds – occur accidentally

Clean wounds
-are uninfected wounds in which minimal
inflammation is encountered and the respiratory,
alimentary, genital and urinary tracts are not
entered. Clean wounds are primarily closed
wounds.

Clean-contaminated wounds
-are surgical wounds in which the respiratory,
alimentary, genital and urinary tract has been
entered. Such wounds show no evidence of
infection.
Contaminated wounds
-include open, fresh, accidental wounds and surgical
wounds involving a major break in sterile technique
or a large amount of spillage from the
gastrointestinal tract. Contaminated wounds
show evidence of inflammation.

Dirty or infected wounds

-wounds containing dead tissue and wounds with
evidence of a clinical infection, such as purulent
drainage
PRESSURE ULCERS
Pressure Ulcers
 Pressure ulcers, decubitus ulcers, pressure sores or
bedsores = are any lesion caused by unrelieved
pressure ( a compressing downward force on a
body area) that results in damage to underlying
tissue (PPPPUA, 1992b).
 Etiology of Pressure Ulcers
 Pressure ulcers are due to localized ischemia, a
deficiency in the blood supply to the tissue.
(HOW IT EXISTS)
The tissue is caught between two hard surfaces
(the bed and the bony skeleton) and causes the blood
supply not to flow within the tissues leading to low
supply of oxygen and nutrients in cells and waste
products accumulate in the cells and leads to cell
death.
 Etiology of Pressure Ulcers

 Friction is a force acting parallel to the skin

surface. Examples are sheets rubbing against
the skin can create friction. Friction can abrade
the skin, that is, remove the superficial layers,
making it more prone to breakdown.
 Shearing force is a combination of friction
and pressure. Occurs commonly when a client
assumes a Fowler’s position in bed.
 Several factors contribute to the
formation of pressure ulcers

Friction and Shearing

Immobility
Inadequate Nutrition
Fecal and Urinary Incontinence
Decreased Mental Status
Diminished Sensation
Excessive Body Heat
Advanced Age
Chronic Medical Conditions
Other Factors (poor lifting
techniques, incorrect
positioning,
STAGES OF PRESSURE ULCER
FORMATION
 WOUND HEALING

Healing is a quality of living

tissue; it is also referred to as
regeneration (renewal) of tissues.
 Types of Wound Healing
Primary intention healing

Secondary intention healing

Tertiary intention(delayed primary

intention)
Primary intention healing

 occurs where the tissue surfaces have

been approximated (closed) and there
is minimal or no tissue loss; it is
characterized by the formation of
minimal granulation tissue and scarring.
It is also called primary union or first
intention healing.
A wound that is extensive and
involves considerable tissue loss,
and in which the edges cannot or
should not be approximated, heals
by secondary intention
healing.
 Wounds that are left open for 3 to 5
days to allow edema or infection to
resolve or exudate to drain and are then
closed with sutures, staples, or adhesive
skin closures heal by tertiary
intention. This is also called delayed
primary intention.
 Phases of Wound Healing
INFLAMMATORY PHASE

PROLIFERATIVE PHASE

MATURATION PHASE
INFLAMMMATORY PHASE

The inflammatory phase begins

immediately after injury and lasts 3 to
6 days. Two major processes occur
during this phase: hemostasis and
phagocytosis.
Hemostasis
(the cessation of bleeding) results from
vasoconstriction of the larger blood vessels in
the affected area, retraction (drawing back) of
injured blood vessels, the deposition of fibrin
(connective tissue), and the formation of
blood clots in the area
Phagocytosis
a process which stimulates the
formation of epithelial buds at
the end of injured blood vessels.
PROLIFERATIVE PHASE
The proliferative phase, the second phase
in healing, extends from day 3 or 4 to about
day 21 postinjury. Fibroblasts (connective
tissue cells), which migrate into the wound
starting about 24 hours after injury, begin to
synthesize collagen.
MATURATION PHASE

The maturation phase begins on

about day 21 and can extend 1 or
2 years after the injury. Fibroblasts
continue to synthesize collagen.
Kinds of wound drainage
Exudate
Exudate is material, such as fluid and cells, that
has escaped from blood vessels during the
inflammatory process and is deposited in tissue
or on tissue surfaces. The nature and amount of
exudate vary according to the tissue involved,
the intensity and duration of the inflammation,
and the presence of microorganisms
Three major types of exudate
serous exudate

purulent exudate

sanguineous exudate
Serous Exudate
A serous exudate consists chiefly of
serum (the clear portion of the blood)
derived from blood and the serous
membranes of the body, such as the
peritoneum. It looks watery and has few
cells
Purulent Exudate
A purulent exudate is thicker than serous
exudate because of the presence of pus, which
consists of leukocytes, liquefied dead tissue
debris, and dead and living bacteria. Purulent
exudates vary in color, some acquiring tinges of
blue, green, or yellow. The color may depend on
the causative organism.
Sanguineous Exudate
A sanguineous exudate consists of
large amounts of red blood cells,
indicating damage to capillaries that is
severe enough to allow the escape of
red blood cells from plasma. This type
of exudate is frequently seen in open
wounds.
Complications of Wound
Healing
 HEMORRHAGE

 INFECTION

 DEHISCENCE WITH POSSIBLE

EVISCERATION
HEMORRHAGE
Some escape of blood from a wound
is normal. Hemorrhage (massive
bleeding), however, is abnormal. A
dislodged clot, a slipped stitch, or
erosion of a blood vessel may cause
severe bleeding.
INFECTION
Contamination of a wound surface with
microorganisms (colonization) is an inevitable
result because the surface cannot be permanently
protected from contact with unsterile objects.
Because the colonizing organisms compete with
new cells for oxygen and nutrition, and because
their by-products can interfere with a healthy
surface condition, the presence of contamination
can impair wound healing and lead to infection.
DEHISCENCE WITH POSSIBLE
EVISCERATION
Dehiscence is the partial or total
rupturing of a sutured wound. Dehiscence
usually involves an abdominal wound in which
the layers below the skin also separate.

Evisceration is the protrusion of the

internal viscera through an incision
Factors Affecting Wound Healing

DEVELOPMENTAL
CONSIDERATIONS
NUTRITION
LIFESTYLE
MEDICATIONS
DEVELOPMENTAL CONSIDERATIONS

Healthy children and adults often

heal more quickly than older adults,
who are more likely to have chronic
diseases that hinder healing.
NUTRITION

Wound healing places additional

demands on the body. Clients require a
diet rich in protein, carbohydrates,
lipids, vitamins A and C, and minerals,
such as iron, zinc, and copper
LIFESTYLE
People who exercise regularly
tend to have good circulation and
because blood brings oxygen and
nourishment to the wound, they are
more likely to heal quickly.
MEDICATION

Anti-inflammatory drugs (e.g.,

steroids and aspirin) and antineoplastic
agents interfere with healing.
Prolonged use of antibiotics may make
a person susceptible to wound
infection by resistant organisms.
Figure 36–4 • Parallel swabs
used to measure wound
depth.
A,This guide Provides the diameter of the
wound irrespective of camera distance.
 Preventing Pressure Ulcers
 Preventing Infection – preventing
microorganisms from entering the wound and
preventing the transmission of blood borne
pathogens
 Positioning – positioned to keep pressure off
the wound
 Preventing Pressure Ulcers – to maintain
skin integrity
 Providing Nutrition - diet supports wound
healing, monitor weight to help assess
nutritional status

 Maintaining Skin Hygiene - use mild

cleansing agents and avoid using hot water

 Avoiding Skin Trauma – providing the

client with a smooth, firm, and wrinkle-free
foundation on which to sit or lie helps prevent
skin trauma
 Providing Supportive Devices –
pressure on the bony prominences should
remain below capillary pressure for us much
time as possible through a combination of
turning, positioning, and use of pressure-
relieving surfaces

 Treating Pressure Ulcers – follow the

agency protocols and physician orders that
prevent tissue damage and pain and facilitate
wound healing
Debridement (removal of the necrotic material)

Achieved in different ways:

1. Sharp debridement – scalpel or scissors is
used to separate and remove dead tissue.
2. Mechanical debridement – through
scrubbing force or wet-to-damp dressing
3. Chemical debridement – is more selective
than sharp or mechanical techniques
4. Autolytic debridement – dressings that
contain wound moisture
 DRESSING WOUNDS
Dressings are applied for the following
purposes:
• To protect the wound from mechanical
injury
• To protect the wound from microbial
contamination
• To provide or maintain moist wound
healing
• To provide thermal insulation
• To absorb drainage or debride a
wound or both
• To prevent hemorrhage (when
applied as a pressure dressing or with
elastic bandages)
• To splint or immobilize the wound
site and thereby facilitate healing and
prevent injury
TYPES OF DRESSING
Transparent Wound Barriers/
Adhesive films
Impregnated non-adherent
dressings
Hydro-gels
Hydrocolloids
Polyurethane foams
Exudate absorbers (alginates)
HEAT AND COLD APPLICATION
Local Effects of Heat
- Heat causes vasodilation and
increase blood flow to the affected area,
bringing oxygen, nutrients, antibodies,
and leukocytes
Local Effects of Cold
- Cold lowers the temperature of the
skin and underlying tissues and causes
vasoconstriction
 Systemic Effects of Heat
and Cold

Heat = a drop in blood pressure/ decrease in

blood pressure (causes fainting)

Cold = increase blood pressure (causes

shivering)
Variables Affecting Physiologic
Tolerance to Heat and Cold

Body part – the back of the hand and foot

are not very temperature sensitive while the
inner aspect of wrist, forearm, neck and
perineal area are temperature sensitive.
Size of the exposed body part – the
larger the area exposed to heat and cold, the
lower the tolerance
Individual tolerance – persons who have
neurosensory impairments may have a high
tolerance, but greater risk of injury
Length of exposure – people feel hot or cold
applictions most while the temperature is
changing. After a period of time, tolerance
increases
Intactness of skin – injured skin areas are
more sensitive to temperature variations
 Specific conditions necessitate
precautions in the use of hot or cold
applications

 Neurosensory impairment
 Impaired mental status
 Impared circulation
 Immediately after injury or surgery
 Open wounds
 Adaptation of Thermal Receptors
 When subjected to an abrupt change in
temperature, the receptors are strongly
stimulated initially. The strong stimulation
declines rapidly during the first few
seconds and then more slowly during the
next half hour or more as the receptors
adapt to the new temperature.
Rebound Phenomenon
 The rebound phenomenon occurs at the
time the maximum therapeutic effect of the
hot or cold application is achieved and the
opposite effect begins.
 An understanding of the rebound
phenomenon is essential for the nurse and
client. Thermal applications must be halted
before the rebound phenomenon begins.
Applying Heat and Cold
 Heat and Cold can be applied to the body in both
dry and moist forms.
 Dry Heat = hot water bottle, aquathermia pad,
disposable heat pack, or electric pad
 Moist Heat = compress, hot pack, soak, or sitz
bath
 Dry Cold = cold pack, ice bag, ice glove, or ice
collar
 Moist Cold = compress or a cooling sponge
bath
For all local applications of heat or cold,
the nurse needs to follow these
guidelines:
• Determine the client’s ability to tolerate the
therapy.
• Identify conditions that might contraindicate
treatment (e.g., bleeding, circulatory
impairment).
• Explain the application to the client.
• Assess the skin area to which the heat or cold
will be applied.
• Ask the client to report any discomfort.
• Return to the client 15 minutes after
starting the heat or cold therapy, and
observe the local skin area for any untoward
signs (e.g., redness). Stop the application if
any problems occur.
• Remove the equipment at the designated
time, and dispose of it appropriately.
• Examine the area to which the heat or cold
was applied, and record the client’s
response.
Aquathermia Pad Hot and Cold Packs

Electric Heating Pads Soaks

Sitz Baths Ice Gloves, Ice Collar

Compresses Cooling Sponge Bath

Supporting and immobilizing wounds

Bandages and binders purposes:

•Supporting a wound
•Immobilizing a wound
•Applying pressure
•Securing a dressing
•Retaining warmth