SKIN INTEGRITY

AND
WOUND CARE

Fundamentals of Nursing
Shawn Scott, RN, MSN

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 LEARNING OUTCOMES
1. Describe factors affecting skin integrity and breakdown.
2. Differentiate primary and secondary wound healing.
3. Describe the three phases of wound healing.
4. Identify the main complications of and factors that affect
wound healing.
5. Identify assessment data pertinent to skin integrity,
pressure sites, and wounds.
7. Identify nursing interventions to maintain skin integrity and
promote wound healing.
8. Describe nursing strategies to treat pressure ulcers,
promote wound healing, and prevent complications of
wound healing.

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 FACTORS AFFECTING SKIN INTEGRITY

• Age
• Chronic illnesses and their treatments
– Diabetes Mellitus
• Life style
– Smoking
– Street drugs
• Medications
– Steroid
• Altered nutrition
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 Types of Wounds
• Incision • Pressure ulcers
• Laceration • Arterial ulcers
• Penetrating • Venous ulcers
• Abrasion • Diabetic ulcers
• Puncture
– Intentional
– unintentional

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 PRESSURE ULCERS: A Costly Phenomena

• Human suffering
• Altered quality of life
• Epidemic among bed-bound
– Upwards of 2 million people
• Financial effects
• Healthcare services and resources
• Sentinel Event

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 COSTLY PHENOMENA (CONT)

• Average approx. $25,000 a wound (full thickness)

– Upwards of hundreds of thousands for a STAGE IV
wound (IHI)
• $1.3 - 3.0 billion dollars per year
• Increased length of stay
• Longer rehab/subacute long term stays
• Extended home care visits
• Loss of wages and increase disability costs
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 COSTLY PHENOMENA (CONT)

• Psychological/emotional/physical TRAUMA
– PRICELESS

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 RISK FACTORS FOR PRESSURE ULCERS
Need to knows!
• Immobility • Advanced age
• Friction and shearing force • Poor lifting and transferring
• Inadequate nutrition techniques
• Fecal and urinary • Incorrect positioning
incontinence • Hard support surfaces
• Decreased mental status • Incorrect application of
• Diminished sensation pressure-relieving devices
• Excessive body heat

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 RISK FACTORS FOR PRESSURE ULCERS

• Immobility • Friction and

Shearing Force

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 PRESSURE ULCER Staging
STAGING OF ULCERS “NORMAL” SKIN LAYERS
• Stage I: non-blanchable
erythema
• Stage II: partial-thickness
skin loss
• Stage III: full-thickness
skin
• Stage IV: full-thickness
skin loss
• Deep penetrating wound
• Cannot be staged

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ONLY THE TIP OF THE ICEBURG
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 PRESSURE ULCER Staging
Stage I
• Nonblanchable
erythema
• Signals potential
ulceration

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 PRESSURE ULCER Staging
Stage II:
Partial-thickness
skin loss involving
epidermis and
possibly dermis

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 PRESSURE ULCER Staging
Stage III:
Full-thickness
skin loss
Involves damage or
necrosis of
subcutaneous tissue

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 PRESSURE ULCER Staging
Stage IV
• Full-thickness
• Skin loss with
tissue necrosis or
damage to:
– muscle
– bone or
– supporting
structures

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 PRESSURE ULCERS
Stage II – Note the blisters Stage IV - Debrided

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PRESSURE ULCERS

Partial-Thickness
Skin loss involving the epidermis and dermis
Pressure Ulcer - Stage I Pressure Ulcer - Stage II

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 PRESSURE ULCERS
Full-Thickness
Skin loss involving all skin layers and subcutaneous tissue. May involve
underlying muscle, tendon or bone.

Pressure Ulcer - Stage III Pressure Ulcer - Stage IV

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HOW DO SURGICAL WOUNDS
HEAL?

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 PRIMARY INTENTION HEALING

• Tissue surfaces closed

• Minimal or no tissue loss
• Formulation of minimal
granulation and scarring

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 SECONDARY INTENTION HEALING
• Edges were closed & now
are open
• Repair time longer
• Scarring greater
• Susceptibility to infection
greater

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SECONDARY
INTENTION (cont.)
THREE KEY FEATURES:
•Margination
•Granulation of wound
bed
•Capillary budding
(Angiogenesis)

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 TERTIARY INTENTION HEALING
(Delayed Primary Intention)
• Initially left open
• Edema, infection, or
exudate resolves
• Then closed

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WOUND HEALING

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 WOUND HEALING: Inflammatory Phase

• Immediately after injury; lasts 3 to 6 days

• Hemostasis
• Phagocytosis

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WOUND HEALING: Proliferative Phase
1. From post injury day 3 or 4 until day 21
2. Collagen synthesis
– Support matrix of the wound (strength)

3. Granulation tissue formation

– Beefy red bumps
4. Angiogenesis – capillary budding
• Nutrition is critical for these elements to
occur

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 WOUND HEALING: Maturation Phase
• From day 21 until 1 or 2 years post injury
• Collagen organization
• Remodeling or contraction
• Tensile strength 70 – 80% or original
• Scar stronger

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 TENSILE STRENGTH
• “The amount of strength it takes to tear apart
a wound.” M. Ross 2010
– 2 weeks = approx. 10% of normal strength
– 4 weeks = approx. 40% of normal strength
– 7-12 months = approx 70 – 80% of normal strength
Margaret Terhune MD (2009)

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 EXUDATE
• Material such as fluid and cells that have
escaped from blood vessels during
inflammatory process
• Deposited in tissue or on tissue surface
• 4 major types
– Serous
– Sero-Sanguineous (SS)
– Sanguineous (hemorrhagic)
– Purulent

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 EXUDATE: Serous
• Mostly serum Clear to Amber Colored
• Watery, clear of cells Fluid in Blister
• E.g., fluid in a blister

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 EXUDATE: Sanguineous
• Hemorrhagic
• Thicker than water depending on # of RBCs
• Large number of RBCs
• Indicates severe damage to capillaries

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 EXUDATE: Purulent
• Thicker
• Presence of pus
• Color varies with organisms
– Yellow
– Gray
– Green

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 EXUDATE: Mixed
• Serosanguineous
– Clear, watery, blood-tinged drainage
– Pink watery
• Puro-sanguineous
– Pus and blood

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

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Dehiscence
• Primary wound has
separated
•Most likely to occur 4th or 5th
day post op before collagen
MATRIX has provided a
extensive network in wound
•Causes
•Straining
•Coughing/Sneezing
•Obesity
•Poor nutritional status
•Failure to support wound
•Suture failure

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Evisceration
• Wound is separated
and bowel is
protruding
MEDICAL EMERGENCY
•Stay with patient
•Notify MD
•Sterile
•NS (normal saline)
•HOB down
Why not sitting up?

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 NURSING PROCESS

Plan of Care for Skin Integrity Issues

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

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 SKIN ASSESSMENT TOOLS (EBP)
• Braden Scale for Predicting Pressure Sore Risk
• Norton’s Pressure Area Risk Assessment Form
Scale

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 SKIN ASSESSMENT: Braden Tool

Score range: 4-23. < 16 Potential for skin breakdown. < 12 Preventive measures.
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 Question 1

Your client has a Braden scale score of 15. The appropriate

nursing action is: Select all that apply.

1. Assess the client again in 24 hours; the score is within

normal limits.
2. Implement a turning schedule; the client is at increased risk
of skin breakdown.
3. Apply a transparent wound barrier to major pressure sites;
the client is at moderate risk of skin breakdown.
4. Request an order for a special low-air-loss bed; the client is
at very high risk of skin breakdown.

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 RYB COLOR GUIDE FOR WOUND CARE

• Red (protect)
– Granulation tissue
– Capillary budding
• Yellow (cleanse)
– purulent
• Black (debride)

This is a great basic key to help you with

determining what to do with wounds!

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 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

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 Assessment Data
• Surgical Wound • Wound length, width, and
– Appearance depth
– – Sterile Q-tips for measuring
Size
wound
– Drainage
– Presence of swelling
– Pain
– Status of drains or tubes
– Wound size

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 Assessment of Pressure Ulcers
1. Stage of the ulcer • Size of ulcer in cm
2. Color of the wound bed including length (head to toe),
width (side to side), and depth
3. Odor or lack of
4. Granulation tissue • Presence of undermining or
5. Capillary budding sinus tracts (tunneling)
6. Location of necrosis or
eschar
7. Condition of the wound
margins
8. Integrity of surrounding
skin (peri-wound skin)
9. Clinical signs of infection

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 Interventions: Assessments
• What else do you note about a wound:
– Color and type of wound tissue if open wound
– Visible necrotic tissue
– Presence of exudate
– Presence of odor
– Presence of granulation tissue, capillary budding,
and margination of the wound
– Peri-wound skin condition

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 Keloid Scar
•An overgrowth of
collagenous scar tissue
at a site of injury.

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 ASSESSMENT: Laboratory Data
• Leukocyte count
 5-11 ( 5,000-11,000mm3)
• Hemoglobin level
 12-16 g/dl
• Blood coagulation studies
– Prothrombin Time 11-13 sec
– INR 0.8 – 1.2
• Serum protein analysis
– Albumin level 3-5 g/dl
• Results of wound culture and sensitivities

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NURSING DIAGNOSES - Skin Integrity
– Impaired Skin Integrity (or risk for)
– Impaired Tissue Integrity (only used for
tissue other than skin)

– Nutrition Imbalance – less than body

requirements
– Pain (acute)
– Physical Immobility

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 Question 5

An appropriate nursing diagnosis for a patient

with large areas of skin excoriation resulting
from scratching an allergic rash is:
1. Risk for Impaired Skin Integrity.
2. Impaired Skin Integrity.
3. Impaired Tissue Integrity.
4. Risk for Infection.

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 Rationales 5

1. This client has an actual impairment of the integrity of the

skin due to the rash and the scratching so is no longer “at
risk.”
2. This client has an actual impairment of the integrity of the
skin due to the rash and the scratching.
3. Because the damage is at the skin level, it is not impaired
tissue integrity since that would involve deeper tissues.
4. Surface excoriation is also not prone to becoming infected.

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 PATIENT OUTCOMES:
• Risk for Impaired Skin Integrity
– Maintain skin integrity
– Through to D/C patient will have no signs of skin
breakdown.
• Impaired Skin Integrity
– Progressive wound healing
– Regain intact skin
– By D/C patient will have improved skin integrity as
evidenced by:
• Wound showing signs of margination, granulation
tissue and capillary budding.

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 INTERVENTIONS -
Wounds and Pressure Ulcers
• Avoiding skin trauma
• Mobilization & reducing time in one position
• Providing nutrition
• Maintaining skin hygiene
• Providing supportive devices
• Consult WOCN (Wound Ostomy Continence
Nurse)

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 Interventions - Assessment
• Measuring a wound – Critical *
– Size in cm (not inches)
– Depth of wound (use a cotton tipped swab)
measure against a disposable ruler.
– Wound tunneling (use cotton tipped swab)
determine if there are areas of the wound that
tunnel deeper into the tissue than the surface
wound you can see. Measure how deep these are
and document all of the above.

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 Interventions – Care of Sutures
• Keep clean and dry
• Wound initially prone to surface
contamination for 24 – 48 hours
• Ointment for 24 – 48 hours only (MD order)

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 INTERVENTIONS: Avoiding Skin Trauma
• Smooth, firm surfaces
• 30 degrees or less in bed
• Frequent weight shifts
• Exercise and ambulation
• Lifting devices
• Reposition q 1-2 hours
• Turning schedule

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INTERVENTIONS: PROVIDING NUTRITION
• Fluid intake
• Protein, vitamins, zinc
• Dietary consult
• Lab trends
– Protein
– Albumin
• Weight

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 INTERVENTIONS: Maintaining Skin Hygiene
• Mild cleansing agents
• Avoid “hot” water
• No scrubbing
• No rubbing boney prominences
• Moisturizing lotions/skin protection lotions
• Reduce irritants
– Incontinence Scented lotions/soaps
– Wound drainage

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 Pressure Ulcer Prevention - IHI
• Conduct pressure ulcer • Manage moisture
assessment on
• Optimize
admission
nutrition/hydration
• Braden score of less
• Minimize pressure
than 18 – At risk patient
– Turning
• Reassess all patient – Mobilizing
every day – Mattress (pressure
• Inspect skin of at risk reducing surface)
patients every day.

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

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INTERVENTIONS: 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 patient
• Provide ROM exercise
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INTERVENTIONS: Promoting Wound Healing
• Fluid intake
• Protein, vitamin, and zinc intake
• Dietary consult
• Nutritional supplements
• Monitor weight/lab values

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 INTERVENTIONS: Preventing Complications
• Prevent entry of microorganisms
• Prevent transmission of pathogens

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Obtaining Wound
Culture
1. Flush wound with NS
2. Swab with culturette
3. Use “Z” tract method
over wound

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 Question 2

Proper technique for performing a wound

culture includes which of the following?

1. Cleansing the wound prior to obtaining the

specimen.
2. Swabbing for the specimen in the area with
the largest collection of drainage.
3. Removing crusts or scabs with sterile forceps
and then culturing the site beneath.
4. Waiting 8 hours following a dose of
antibiotic to obtain the specimen.
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 Types of Wound Dressings
• Hydrocolloids -
• Dry gauze –
Duoderm
4x4 or ABD
• Enzymatic Debridement
• Transparent film -
– Debride necrotic tissue
Tegaderm
• Elastic - ACE
• Impregnated – Provide pressure to area and
nonadherent - decrease edema
Adaptic, Aquaphor • Binder
– Support large area of body

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 Question 3

A patient has a pressure ulcer with a shallow, partial skin

thickness, eroded area but no necrotic areas. You note
there is a small amount of SS and tan drainage on the
wound. Which of the following interventions would you do
to treat the wound?
1. Dry gauze
2. Hydrocolloid
3. Tegaderm
4. No dressing is indicated
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 THERAPEUTIC EFFECTS OF HEAT
Physiologic Effects Indications for Heat
• Vasdilation • Muscle spasms
• Increases capillary • Inflammation
permeability • Pain
• Increases cellular • Contracture
metabolism • Joint stiffness
• Increases inflammation
• Produces sedative effect

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 THERAPEUTIC EFFECTS OF COLD
Physiologic Effects Indications for Cold Therapy
• Vasoconstriction • Muscle spasms
• Decreases capillary • Inflammation
permeability
• Pain
• Decreases cellular
metabolism • Traumatic injury
• Slows bacterial growth
• Decreases inflammation
• Local anesthetic effect

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 APPLYING HEAT
•Aqua-K pad
•Moist Compress: Adding
a moist warm towel with
Aqua-K pad

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