Skin

Integrity

FUNDAMENTALS OF NURSING PRACTICE

 01 Introduction

Content
02 Factors affecting skin integrity

FUNDAMENTALS OF NURSING PRACTICE

03 Types of wounds

Outline 05 Degree of contamination of the

wound

Topics for discussion

06 How are they acquired?

07 Types of Wound by depth

 What is Skin?
Skin is the body's outer covering that protects against heat

and light, injury, and foreign substances such as bacteria,

viruses, and infections. It regulates body temperature and

stores water, fat, and vitamin D.

The skin weighs about 6 pounds and is the body's largest

FUNDAMENTALS OF NURSING PRACTICE

organ. It is made up of 3 main layers: the epidermis and the

dermis, and the subcutaneous.

Factors affecting the Skin Integrity

Internal Factors
- Genetics, age, the underlying health of the
individual, mobility, and body weight.

External Factors
- Skin color, sensitivity to light, pressure, moisture, and
allergies
Wound and its
-
an injury to the body (as from violence, accident, or

surgery) that typically involves laceration or breaking of a

types membrane (such as the skin) and usually damage to

underlying tissues.

Incision Abrasion
Contusion

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- Open wound; deep or shallow; once
- Open wound involving the skin
- Closed wound, skin appears
the edges have been sealed together

as a part of treatment or healing, the

ecchymotic (bruised) because

Cause by
incision becomes a closed wound. of damaged blood vessels. -Surface scrape, either

unintentional (e.g., scraped knee

Cause by Cause by from a fall) or intentional (e.g.,

- Sharp instrument (e.g., knife or

-Blow from a blunt instrument dermal abrasion to remove

scalpel)
pockmarks)

Puncture Laceration Penetrating wound

- Open wound Open wound; edges are

- Open wound
often jagged
Cause by Cause by
- Penetration of the skin and
Cause by Penetration of the skin and the

often the underlying tissues

Tissues torn apart, often from
underlying tissues, usually

by a sharp instrument, either

accidents (e.g., with
unintentional (e.g., from a bullet or

intentional or unintentional machinery) metal fragments)

Clean wounds / Class 1
Types of wounds

Types of Wounds
are uninfected wounds in which there is minimal in- inflammation and the

respiratory, gastrointestinal, genital, and urinary tracts are not entered.

Clean wounds are primarily closed wounds. Example: abdominal incision

from primary closure of exploratory surgery for repair of splenic

on the degree of

laceration following blunt trauma

Clean-contaminated wounds / Class 2

contamination and

are surgical wounds in which the respiratory, gastrointestinal,

obtained.

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genital, or urinary tract has been en- tered. Such wounds show no

evidence of infection. Example: tonsillectomy.

Contaminated wounds / Class 3

Includes 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. Open traumatic wounds that are more than 12–24 hours

old also fall into this category. Example: hemorrhoidectomy.

Dirty or Infected wounds / Class 4

Types of Wounds
Include wounds containing dead tissue and wounds with

evidence of clinical infection, such as purulent drainage.

Example: chronic wound debridement.

 TYPES OF WOUND BY DEPTH
Pressure Ulcers
consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination

with movement. Pressure

ulcers were previously called decubitus ulcers, pressure sores, or bedsores.

Stage 1 Stage 2

sores are not open wounds. The skin may be

the skin breaks open, wears away, or forms an ulcer,

painful, but it has no breaks or tears. The skin

which is usually tender and painful. The sore expands

appears reddened and does not blanch. Skin

into deeper layers of the skin. It can look like a scrape

temperature is often warmer. And the stage 1 sore

(abrasion), blister, or a shallow crater in the skin. Looks

can feel either firmer or softer than the area

like a blister filled with clear fluid. At this stage, some

around it. skin may be damaged beyond repair or may die.

Stage 3 Stage 4

the sore gets worse and extends into the tissue

very deep, reaching into muscle and bone and

beneath the skin, forming a small crater. Fat may

causing extensive damage. Damage to deeper

show in the sore, but not muscle, tendon, or bone. tissues, tendons, and joints may occur.

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References: William C. Shiel Jr. (2021, March 29). Definition of skin. MedicineNet.

https://www.medicinenet.com/skin/definition.html

Kozier, B., Erb, G. L., & Berman, A. (2016). Fundamentals of nursing: Concepts, process, and

practice (10th ed.). Prentice Hall.

Healthwise staff. (2021, July 6). MyHealth.Alberta.ca. Stages of Pressure Injuries.

https://myhealth.alberta.ca/Health/pages/conditions.aspx?

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hwid=zm2442#:~:text=Pressure%20injuries%20are%20described%20in,and%20then%20remove

%20your%20finger).

Definition of wound. (n.d.). Dictionary by Merriam-Webster: America's most-trusted online

dictionary. https://www.merriam-webster.com/dictionary/wound