Skin Integrity and

Wound Care

Dr. Abdul-Monim Batiha

Assistant Professor
Critical Care Nursing
Philadelphia University
 Factors Affecting Skin
Integrity
• Genetics and heredity
• Age
• Chronic illnesses and their
treatments
• Medications
• Poor nutrition
Copyright 2008 by Pearson Education, Inc.
 Risk Factors for Pressure
Ulcers
• Friction and shearing
• Immobility
• Inadequate nutrition
• Fecal and urinary incontinence
• Decreased mental status
• Diminished sensation
• Excessive body heat

Copyright 2008 by Pearson Education, Inc.

 Risk Factors for Pressure
Ulcers
• Advanced age
• Chronic mental conditions
• Poor lifting and transferring techniques
• Incorrect positioning
• Hard support surfaces
• Incorrect application of pressure-relieving
devices

Copyright 2008 by Pearson Education, Inc.

 Risk Assessment Tools
• Braden Scale for Predicting Pressure Sore
Risk
• Norton’s Pressure Area Risk Assessment
Form Scale

Copyright 2008 by Pearson Education, Inc.

• The Braden Scale for Predicting Pressure
Sore Risk consists of six subscales:
sensory perception, moisture, activity,
mobility, nutrition, and friction and shear. A
total score of 23 points is possible. An
adult who scores below 18 points is
considered at risk.
Figure 36-2 Braden Scale for Predicting Pressure Sore Risk. (From “Clinical Practice Guideline, Pressure Ulcers in
Adults: Prediction and Prevention,” by U.S. Department of Health and Human Services, PPPPUA Pub No. 92-0047, pp.
16–17, 1992, Rockville, MD: Public Health Service. Copyright © Barbara Braden and Nancy Bergstrom, 1988. Reprinted
with permission.)
Figure 36-2 (continued) Braden Scale for Predicting Pressure Sore Risk. (From “Clinical Practice Guideline,
Pressure Ulcers in Adults: Prediction and Prevention,” by U.S. Department of Health and Human Services, PPPPUA
Pub No. 92-0047, pp. 16–17, 1992, Rockville, MD: Public Health Service. Copyright © Barbara Braden and Nancy
Bergstrom, 1988. Reprinted with permission.)
 Four Stages of Pressure Ulcer
Formation

A B

C D
Copyright 2008 by Pearson Education, Inc.
 Four Stages of Pressure Ulcer
Formation
• Stage I: nonblanchable erythema signaling
potential ulceration
• Stage II: partial-thickness skin loss involving
epidermis and possibly dermis
• Stage III: full-thickness skin loss involving
damage or necrosis of subcutaneous tissue
• Stage IV: full-thickness skin loss with tissue
necrosis or damage to muscle, bone, or
supporting structures

Copyright 2008 by Pearson Education, Inc.

 Differentiate primary and
secondary wound healing.
 Primary Intention Healing
• Tissue surfaces closed
• Minimal or no tissue loss
• Formulation of minimal granulation and
scarring
• It is also called primary union or first
intention healing. An example is a closed
surgical incision.

Copyright 2008 by Pearson Education, Inc.

 Secondary Intention Healing
• Extensive tissue loss
• Edges cannot be closed
• Repair time longer
• Scarring greater
• Susceptibility to infection greater
• An example is a pressure ulcer.

Copyright 2008 by Pearson Education, Inc.

 Tertiary Intention Healing
(Delayed Primary Intention)
• Initially left open
• Edema, infection, or exudate resolves
• Then closed
• (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).

Copyright 2008 by Pearson Education, Inc.

Describe the three phases of
wound healing.
 Inflammatory Phase of Wound
Healing
• Immediately after injury; lasts 3 to 5 days
• Hemostasis (the cessation of bleeding)
• Phagocytosis (engulfing of
microorganisms and cellular debris by
macrophages).

Copyright 2008 by Pearson Education, Inc.

 Proliferative Phase of Wound
Healing
• From post injury day 3 or 4 until day 21
• Fibroblasts (connective tissue cells) begin to
synthesize collagen, a protein that adds
tensile strength to the wound. Capillaries grow
across the wound, increasing the blood supply.
• Fibroblasts deposit fibrin, and granulation
tissue is formed. Granulation tissue is a
translucent red color. It is fragile and bleeds
easily.

Copyright 2008 by Pearson Education, Inc.

 Maturation Phase of Wound
Healing
• From day 21 until 1 or 2 years post injury
• Collagen organization
• Remodeling or contraction
• Scar stronger but is never as strong as
the original tissue.

Copyright 2008 by Pearson Education, Inc.

Identify three major types of
wound exudate.
 Exudate
• Material such as fluid and cells that have
escaped from blood vessels during
inflammatory process
• Deposited in tissue or on tissue surface
• 3 major types
– Serous
– Purulent
– Sanguineous (hemorrhagic)

Copyright 2008 by Pearson Education, Inc.

 Serous Exudate
• Mostly serum
• Watery, clear of cells
• E.g., fluid in a blister

Copyright 2008 by Pearson Education, Inc.

 Purulent Exudate
• Thicker
• Presence of pus
• Color varies with organisms

Copyright 2008 by Pearson Education, Inc.

 Sanguineous Exudate
• Hemorrhagic
• Large number of RBCs
• Indicates severe damage to capillaries

Copyright 2008 by Pearson Education, Inc.

 Mixed Exudate
• Serosanguineous (hemorrhagic) 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 the plasma.
• Mixed exudates include serosanguineous
(consisting of clear and blood-tinged
drainage) and purosanguineous discharge
(consisting of pus and blood).

Copyright 2008 by Pearson Education, Inc.

 Complications of Wound Healing
• Hemorrhage
• Infection
• Dehiscence
• Evisceration

Copyright 2008 by Pearson Education, Inc.

 Factors Affecting Wound
Healing
• Age
• Nutritional status
• Lifestyle
• Medications

Copyright 2008 by Pearson Education, Inc.

 Identify assessment data
pertinent to skin integrity,
pressure sites, and wounds.
 Nursing Process: Assessment

• Nursing history
– Review of systems
– Skin diseases
– Previous bruising
– General skin condition
– Skin lesions
– Usual healing of sores

Copyright 2008 by Pearson Education, Inc.

 Assessment Data
• Inspection and palpation
– Skin color distribution
– Skin turgor
– Presence of edema
– Characteristics of any skin lesions
– Particular attention paid to areas that are
most likely to break down

Copyright 2008 by Pearson Education, Inc.

 Assessment Data
• Untreated wounds
– Location
– Extent of tissue damage
– Wound length, width, and depth
– Bleeding
– Foreign bodies
– Associated injuries
– Last tetanus toxoid injection

Copyright 2008 by Pearson Education, Inc.

 Assessment Data
• Treated wounds
– Appearance
– Size
– Drainage
– Presence of swelling
– Pain
– Status of drains or tubes

Copyright 2008 by Pearson Education, Inc.

 Pressure Ulcers Video

Click here to view a video on pressure ulcers.

Back to Directory Copyright 2008 by Pearson Education, Inc.
 Assessment of Pressure Ulcers
• Location of the ulcer related to a bony prominence
• Size of ulcer in centimeters including length (head to
toe), width (side to side), and depth
• Presence of undermining or sinus tracts
• Stage of the ulcer
• Color of the wound bed
• Location of necrosis or eschar
• Condition of the wound margins
• Integrity of surrounding skin
• Clinical signs of infection

Copyright 2008 by Pearson Education, Inc.

 Assessment of Pressure Sites
• Inspect pressure areas for discoloration
and capillary refill or blanche response
• Inspect pressure areas for abrasions and
excoriations
• Palpate the surface temperature over the
pressure area sites
• Palpate bony prominences and dependent
body areas for the presence of edema
Copyright 2008 by Pearson Education, Inc.
Figure 36-3 Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.
Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s
position.
Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s
position.
Figure 36-3 (continued) Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s
position.
 Assessment of Laboratory Data

• Leukocyte count
• Hemoglobin level
• Blood coagulation studies
• Serum protein analysis
– Albumin level
• Results of wound culture and sensitivities

Copyright 2008 by Pearson Education, Inc.

 Nursing Diagnoses
– Risk for Impaired Skin Integrity
– Impaired Skin Integrity:
– Impaired Tissue Integrity
– Risk for Infection
– Pain

Copyright 2008 by Pearson Education, Inc.

 Goals in Planning Client Care
• Risk for Impaired Skin Integrity
– Maintain skin integrity
– Avoid or reduce risk factors
• Impaired Skin Integrity
– Progressive wound healing
– Regain intact skin
• Client and family education
– Assess and treat existing wound
– Prevention of pressure ulcers
Copyright 2008 by Pearson Education, Inc.
 Measures to Prevent
Pressure Ulcers
• Providing nutrition
• Maintaining skin hygiene
• Avoiding skin trauma
• Providing supportive devices

Copyright 2008 by Pearson Education, Inc.

 Providing Nutrition
• Maintain fluid intake of at least 2500 mL per
day unless contraindicated, sufficient protein,
vitamins C, A, B1, B5, and zinc.
• Dietary consultation and nutritional
supplements should be considered for
nutritionally compromised clients.
• Weight should be monitored as should lab data
monitoring e.g. lymphocyte count, protein
(especially albumin), and hemoglobin levels.

Copyright 2008 by Pearson Education, Inc.

 Maintaining Skin Hygiene
• Use mild cleansing agents that do not disrupt the skin’s
“natural barriers,”_
• avoid using hot water, exposure to cold and low
humidity;
• apply moisturizing lotions while the skin is moist after
bathing;
• keep skin clean, dry and free of irritation and
maceration by urine, feces, sweat, and dry skin
completely after a bath. Apply skin protection
(dimethicone-based creams or alcohol-free barrier films)
if indicated._Avoid massaging over bony prominences
since massage may lead to deep tissue trauma.

Copyright 2008 by Pearson Education, Inc.

 Avoiding Skin Trauma
• Smooth, firm surfaces
• Semi-Fowler’s position
• Frequent weight shifts
• Exercise and ambulation
• Lifting devices
• Reposition q 2 hours
• Turning schedule
• Avoid the use of baby powder and cornstarch
which create harmful abrasive grit and are a
respiratory hazard

Copyright 2008 by Pearson Education, Inc.

 Providing Supportive Devices
• Mattresses
• Beds
• Wedges, pillows
• Miscellaneous devices

Copyright 2008 by Pearson Education, Inc.

Figure 36-6 Heel protector. (Courtesy of Gaymar Industries, Inc.)
Figure 36-7 Alternating pressure mattress (Ease).
Figure 36-8 Low-air-loss bed.
Figure 36-9 Low-air-loss and air-fluidized combo bed (Clinitron/Rite Hite). (Courtesy of Hill-Rom Services, Inc.
Reprinted with permission. All rights reserved.)
 Treating Pressure Ulcers
• Minimize direct pressure
• Schedule and record position changes
• Provide devices to reduce pressure areas
• Clean and dress the ulcer using surgical asepsis
• Never use alcohol or hydrogen peroxide
• Obtain C&S, if infected
• Teach the client
• Provide ROM exercise

Copyright 2008 by Pearson Education, Inc.

 RYB Color Guide for
Wound Care
• Red (protect)
• Yellow (cleanse)
• Black (debride)

Copyright 2008 by Pearson Education, Inc.

 Red wounds
• Need to be protected to avoid disturbance
to regenerating tissue. The nurse protects
the wound by gentle cleansing, covering
periwound skin with alcohol-free barrier
film, filling dead space with hydrogel or
alginate, covering the wound with an
appropriate dressing such as transparent
film, hydrocolloid dressing, or a clear
absorbent acrylic dressing, and changing
the dressing as infrequently as possible.
 Yellow wounds
• are characterized primarily by liquid to
semiliquid “slough” that is often
accompanied by purulent drainage or
previous infection.
• The nurse cleanses yellow wounds to
remove nonviable tissue. Methods used
may include applying moist-to- moist
normal saline dressings, irrigating the
wound, using absorbent dressing
materials such as impregnated hydrogel or
alginate dressings, and consulting with the
primary care provider about the need for a
topical antimicrobial to minimize bacterial
growth.
 Black wounds
• are covered by thick necrotic tissue or
eschar. They require debridement
(removal of dead tissue). Debridement
may be achieved in four different ways:
sharp, mechanical, chemical, autolytic,
and use of fly larvae (maggots). Once
eschar is removed, the wound is treated
as yellow, then red.
 Promoting Wound Healing
• Fluid intake
• Protein, vitamin, and zinc intake
• Dietary consult
• Nutritional supplements
• Monitor weight/lab values

Copyright 2008 by Pearson Education, Inc.

 Controlling wound infection
• Prevent entry of microorganisms
• Prevent transmission of pathogens

Copyright 2008 by Pearson Education, Inc.

 Types of Wound Dressings

• Transparent film
• Impregnated nonadherent
• Hydrocolloids
• Clear absorbent acrylic
• Hydrogel
• Polyurethane foam
• Alginate

Copyright 2008 by Pearson Education, Inc.

 Transparent film
• is used to provide protection against
contamination and friction, to maintain a
clean moist surface that facilitates cellular
migration, to provide insulation by
preventing fluid evaporation, and to
facilitate wound assessment.
 Impregnated nonadherent
dressings
• are used to cover, soothe, and protect
partial- and full-thickness wounds without
exudate.
 Hydrocolloid dressings
• are used to absorb exudate; to produce a
moist environment that facilitates healing
but does not cause maceration of
surrounding skin; to protect the wound
from bacterial contamination, foreign
debris, and urine or feces; and to prevent
shearing.
 Clear absorbent acrylic dressings

• maintain a transparent membrane for easy

wound bed assessment, provide bacterial
and shearing protection, maintain moist
wound healing, and can be used with
alginates to provide packing to deeper
wound beds.
 Hydrogels
• are used to liquefy necrotic tissue or
slough, rehydrate the wound bed, and fill
in dead space.
 Polyurethane foams
• absorb up to heavy amounts of exudate,
providing and maintaining moist wound
healing.
 Alginates (exudate absorbers)
• are used to provide a moist wound surface
by interacting with exudate to form a
gelatinous mass, to absorb exudate, to
eliminate dead space or pack wounds, and
to support debridement.
 Types of Bandages
• Gauze
– Retain dressings on wounds
– Bandage hands and feet
• Elasticized
– Provide pressure to an area
– Improve venous circulation in legs
• Binders
– Support large areas of body
• Triangular arm sling; straight abdominal binder

Copyright 2008 by Pearson Education, Inc.

Figure 36-10 The strips of tape should be placed at the ends of the dressing and must be sufficiently long and wide
to secure the dressing. The tape should adhere to intact skin.
Figure 36-11 Dressings over moving parts must remain secure in spite of the client’s movement. Place the tape over
a joint at a right angle to the direction the joint moves.
Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client’s movement. Place
the tape over a joint at a right angle to the direction the joint moves.
Figure 36-11 (continued) Dressings over moving parts must remain secure in spite of the client’s movement. Place
the tape over a joint at a right angle to the direction the joint moves.
Figure 36-12 Montgomery straps, or tie tapes, are used to secure large dressings that require frequent changing.
Figure 36-13 Vacuum-assisted closure (VAC) system for wounds.
Figure 36-14 Starting a bandage with two circular turns.
Figure 36-15 Applying spiral turns.
Figure 36-16 Applying spiral reverse turns.
Figure 36-17 Starting a recurrent bandage.
Figure 36-18 Completing a recurrent bandage.
Figure 36-19 Applying a figure-eight bandage.
Figure 36-20 Large arm sling.
Figure 36-20 (continued) Large arm sling.
Figure 36-21 A straight abdominal binder.
Obtaining a Wound Specimen

Copyright 2008 by Pearson Education, Inc.

Irrigating a Wound
Skill 36-2

Copyright 2008 by Pearson Education, Inc.