SKIN INTEGRITY

AND
WOUND CARE
The skin
• The largest organ in the body and serves a variety of important functions in
maintaining health and protecting the individual from injury.
Important nursing functions are:
• maintaining skin integrity
• promoting wound healing.
Impaired skin integrity is a threat to:
• older adults;
• clients with restricted mobility,
• Clients with chronic illnesses, or trauma;
• and to those undergoing invasive health care procedures.
To protect the skin and manage wounds effectively, the nurse
must understand :
• the factors affecting skin integrity,
• the physiology of wound healing,
• and specific measures that promote optimal skin
conditions.
SKIN INTEGRITY

Intact skin refers to the presence of normal skin and skin layers uninterrupted
by wounds.
The appearance of the skin and skin integrity are influenced by:

1. internal factors such as genetics, age, and the underlying health of the
individual.
2. external factors such as activity.
FACTORS TO CONSIDER:
1. Genetics and heredity determine many aspects of a person’s skin, these
Includes:
• skin color,
• sensitivity to sunlight,
• and allergies.
2. Age influences skin integrity in that the skin of both the very young and the very
old is more fragile and susceptible to injury than that of most adults.
3. Wounds tend to heal more rapidly in infants and children.
4. Chronic illnesses and their treatments affect skin integrity.

• People with impaired peripheral arterial circulation may have skin on the legs
that damages easily.
• Some medications, corticosteroids for example, cause thinning of the skin
and allow it to be much more readily harmed.
• Many medications increase sensitivity to sunlight and can predispose one to
severe sunburns.
• Some of the most common medications that cause this damage are:
 certain antibiotics (e.g., tetracycline and doxycycline),
 chemotherapy drugs for cancer (e.g.,methotrexate),
 some psychotherapeutic drugs (e.g., tricyclic antidepressants).

5. Poor nutrition alone can interfere with the appearance and function of normal skin.
 TYPES OF WOUNDS
• Intentional wounds - trauma occurs during therapy.
• Example:
• Surgical wounds
• Venipunctures
• Removing a tumor
• Unintentional wounds - are accidental
• Example:
• a person may fracture an arm in an automobile collision.
• Closed wound – if tissues are traumatized without break in the skin
• Open wound – when the skin or mucous membrane is broken
Wounds can be classified according
1. To the nature of how they are acquired
2. To the degree of contamination
Types of wound according to how they are acquired
Types of wound according to how they are acquired

Incision wound Contusion wound Abrasion wound Puncture wounds

Types of wound according to how they are acquired

Laceration
2. Wounds can also be described according to the likelihood and degree of
wound contamination:

• Clean wounds - uninfected wounds in which there is minimal inflammation

and the respiratory, gastrointestinal, genital, and urinary
tracts are not entered.
Clean wounds are primarily closed wounds.

• Clean contaminated wounds - are surgical wounds in which the

respiratory, gastrointestinal, genital, or 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 - include wounds containing dead tissue and wounds
with evidence of a clinical infection, such as purulent drainage.
Wounds, excluding pressure ulcers and burns, are classified by
depth, that is, the tissue layers involved in the wound
PRESSURE
ULCERS
PRESSURE ULCERS
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.

OTHER TERM: decubitus ulcers, pressure sores, or bedsores.
Etiology of Pressure Ulcers
Pressure ulcers are due to localized ischemia, a deficiency in the blood supply to
the tissue.
• The tissue is compressed between two surfaces, usually the surface of
furniture such as the bed or chair and the bony skeleton.
• When blood cannot reach the tissue, the cells are deprived of oxygen and
nutrients, the waste products of metabolism accumulate in the cells, and the
tissue consequently dies. Prolonged, unrelieved pressure also damages the
small blood vessels.
Risk Factors
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,
and the presence of certain chronic conditions.
Stages of Pressure Ulcers
E. Unstageable/unclassified:
• full-thickness skin or tissue loss—depth unknown:
• Actual depth of the ulcer is completely obscured by
slough (yellow, tan, gray, green, or brown) and/or
eschar (tan, brown, or black) in the wound bed.

F. Suspected deep tissue injury—depth unknown:

• purple or maroon localized area of discolored intact
skin or blood-filled blister due to damage of underlying
soft tissue from pressure and/or shear.
• Deep tissue injury may be difficult to detect in
individuals with dark skin tones.
• Evolution may include a thin blister over a dark wound
bed. The wound may further evolve and become
covered by thin eschar.
 IDENTIFYING PATIENTS AT RISK
Risk assessment tools provide nurses with systematic means of identifying
clients at high risk for preventable pressure ulcer development.

The tool chosen for use should include data collection in the areas of:
• immobility,
• incontinence,
• nutrition,
• and level of consciousness.
 RISK ASSESSMENT TOOLS
1. The Braden Scale for Predicting Pressure Sore Risk consists of
six subscales:
• sensory perception,
• moisture,
• activity,
• mobility,
• nutrition,
• and friction and shear
2. Norton’s Pressure Area Risk Assessment Scoring System. It includes the
categories of general physical condition, mental state, activity, mobility, and
incontinence.

The Braden and Norton tools should be used when the client first enters the health
care agency and whenever the client’s condition changes.
• In some long-term care facilities, a risk assessment using the Braden or Norton
scale is conducted on admission and then on a regular basis, usually weekly.
• This increases awareness of specific risk factors and serves as assessment
data from which to plan goals and interventions to either maintain or improve
skin integrity
TYPES OF WOUND EXUDATES
Exudate is a 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.

The three major types of exudate are serous, purulent, and

sanguineous.
1. 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. An example is the
fluid in a blister from a burn.
2. 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.
The process of pus formation is referred to as
suppuration.

Purulent exudates vary in color, some acquiring

tinges of blue, green, or yellow. The color may
depend on the causative organism.
3. 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.

Mixed types of exudates are often observed.
• A serosanguineous exudate consisting of both clear and blood-tinged drainage, is
commonly seen in surgical incisions.
• A purosanguineous discharge, consisting of pus and blood, is often seen in a new
wound that is infected.

Purulent discharge
COLORS OF WOUND BED
MANAGING EXUDATES
Hydrogels are
recommended
for wounds that range from
dry to mildly exudating and
can be used to degrade
slough on the wound
surface. 

Hydrogels have a marked
cooling and soothing effect
on the skin, which is
valuable in burns and
painful wounds.
Hydrocolloid dressings provide a
moist and insulating healing
environment which protects
uninfected wounds while allowing
the body's own enzymes to help
heal wounds.

These dressings are unique
because they don't have to be
changed as often as some other
wound dressings and are easy to
apply.
 Collagenase is an enzyme, works by
helping to break up and remove dead skin
and tissue. This effect may also help
antibiotics to work better and speed up the
body's natural healing process.
WOUND HEALING
 WOUND HEALING
Healing is a quality of living tissue; it is also referred to as regeneration (renewal) of tissues.
• Healing can be considered in terms of
• types of healing, - having to do with the primary care provider’s decision on
whether to allow the wound to seal itself or to purposefully
close the wound, and
• phases of healing, which refer to the steps in the body’s natural processes of
tissue repair.
• The phases are the same for all wounds, but the rate and extent of healing depends on
factors such as the type of healing, the location and size of the wound, and the health of
the client.
 THE PROCESS OF WOUND HEALING

Regardless of the type of wound, the body immediately attempts to repair

the injury and heal the wound.

The process of wound repair proceeds in three sequential phases:

1. inflammation,
2. proliferation,
3. remodeling.
THE PROCESS OF WOUND HEALING
Inflammation
Inflammation is the physiologic defense immediately after tissue injury, lasts
approximately 2 to 5 days.
Purposes:
1. to limit the local damage,
2. remove injured cells and debris,
3. prepare the wound for healing.
THE
INFLAMMATORY
PROCESS
Inflammation progresses through several stages:

1. First stage
• local changes occur.
• Immediately following an injury, blood vessels constrict to control blood loss and confine
the damage.
• Shortly thereafter, the blood vessels dilate to deliver platelets that form a loose clot.
• The membranes of the damaged cells become more permeable, causing release of
plasma and chemical substances that transmit a sensation of discomfort.
• The local response produces the characteristic signs and symptoms of inflammation:
swelling, redness, warmth, pain, and decreased function.
• A second wave of defense follows the local changes when leukocytes and
macrophages (types of white blood cells) migrate to the site of injury, and the
body produces more and more white blood cells to take their place.
• Leukocytosis (increased production of white blood cells) is confirmed and
monitored by counting the number and type of white blood cells in a sample of
the client’s blood. Laboratory blood test that reflect this result is the CBC &
Differential count.
• Increased white blood cells, particularly neutrophils and monocytes, suggest
an inflammatory and, in some cases, infectious process.
Proliferation stage
Proliferation is the (period during which new cells fill and seal a wound) occurs from 2 days to 3
weeks after the inflammatory phase.
• Characterized by the appearance of granulation tissue (combination of new blood
vessels, fibroblasts, and epithelial cells), which is bright pink to red because of the
extensive projections of capillaries in the area.
• Granulation tissue grows from the wound margin toward the center. It is fragile and easily
disrupted by physical or chemical means. As more and more fibroblasts produce collagen
(a tough and inelastic protein substance), the adhesive strength of the wound increases.
• Toward the end of the proliferative phase, the new blood vessels degenerate, causing the
previously pink color to regress.
 Remodeling or 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.
• The collagen fibers themselves, which were initially laid in a haphazard
fashion, reorganize into a more orderly structure.
• During maturation, the wound is remodeled and contracted.
• The scar becomes stronger but the repaired area is never as strong as
the original tissue.
• In some individuals, particularly dark-skinned individuals, an abnormal amount
of collagen is laid down. This can result in a hypertrophic scar, or keloid.
The integrity of skin and damaged tissue is restored by
1. resolution (process by which damaged cells recover and re-establish their
normal function),
2. Regeneration (cell duplication),
3. scar formation (replacement of damaged cells with fibrous scar tissue).
Fibrous scar tissue acts as a nonfunctioning patch. The extent of scar tissue
that forms depends on the magnitude of tissue damage and the manner of wound
healing.
TYPES OF WOUND HEALING

• Healing by First or Primary intention

• Second intention
• Third intention
 The speed of wound repair

The speed of wound repair and the extent of scar tissue that forms depend on
whether the wound heals by first, second, or third intention:

First-intention healing,
Also called healing by primary intention, is a reparative process in which the
wound edges are directly next to each other. Because the space between the
wound is so narrow, only a small amount of scar tissue forms. Most surgical
wounds that are closely approximated heal by first intention
Healing by first intention
 Second-intention healing
The wound edges are widely separated, leading to a more time-consuming
and complex reparative process.

Because the margins of the wound are not in direct contact, the granulation
tissue needs additional time to extend across the expanse of the wound.

Healing by second intention is prolonged when the wound contains body

fluid or other wound debris.
Wound care must be performed cautiously to avoid disrupting the
granulation tissue and retarding the healing process.
Healing by second intention
Third-intention healing
The wound edges are widely separated and are later brought together with
some type of closure material. This reparative process results in a
broad, deep scar.
Generally, wounds that heal by third intention are deep and likely to contain
extensive drainage and tissue debris. To speed healing, they may contain
drainage devices or be packed with absorbent gauze.
COMPLICATIONS TO WOUND HEALING

The key to wound healing is adequate blood flow to the injured tissue.

Factors that may interfere include

• compromised circulation;
• infection; and purulent, bloody, or serous fluid accumulation that prevent skin and
tissue approximation.
• excessive tension or pulling on wound edges contributes to wound disruption and
delays healing.
• poor nutrition,
• impaired inflammatory or immune responses secondary to drugs like corticosteroids,
• obesity
The nurse assesses the wound to determine whether it is intact or shows evidence of unusual
swelling, redness, warmth, drainage, and increasing discomfort.
Two potential surgical wound complications:
1. Dehiscence (separation of wound edges)
Dehiscence is the partial or total rupturing of a sutured wound. Dehiscence usually
involves an abdominal wound ich the layers below skin also separate. Wound
dehiscence is more likely to occur 4 to 5 days postoperatively before extensive
collagen is deposited in the wound.
2. Evisceration (wound separation with protrusion of organs)
Evisceration is the protrusion of the internal viscera through an incision.

When dehiscence or evisceration occurs, the wound should be quickly supported by

large sterile dressings soaked in sterile normal saline. Place the client in bed with
knees bent to decrease pull on the incision. The surgeon must be notified
immediately because surgical repair of the area may be necessary.
Factors Affecting Wound Healing
DEVELOPMENTAL CONSIDERATIONS
Healthy children and adults often heal more quickly than older adults, who are more likely to
have chronic diseases that hinder healing.

1. 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.
• Malnourished clients may require time to improve their nutritional status before
surgery, if this is possible.
• Obese clients are at increased risk of wound infection and slower healing because
adipose tissue usually has a minimal blood supply.
2. 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.
• Smoking reduces the amount of functional hemoglobin in the blood,
thus limiting the oxygen-carrying capacity of the blood, and constricts
arterioles.
3. MEDICATIONS
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.
WOUND MANAGEMENT
Wound management involves changing dressings, caring
for drains, removing sutures or staples when directed
by the surgeon, applying bandages and binders, and
administering irrigations.
Dressings
A dressing (cover over a wound) serves one or more purposes:
• Keeping the wound clean
• Absorbing drainage
• Controlling bleeding Types and sizes of dressings
• Protecting the wound from further injury differ depending on their

• Holding medication in place purpose. The most common

• Maintaining a moist environment wound coverings are gauze,

transparent, and hydrocolloid
dressings
Gauze Dressings
Gauze dressings are made of woven cloth fibers. Their highly
absorbent nature makes them ideal for covering fresh wounds
that are likely to bleed or wounds that exude drainage.

Unfortunately, gauze dressings obscure the wound and interfere

with wound assessment. Unless ointment is used on the wound
or the gauze is lubricated with an ointment such as petroleum,
granulation tissue may adhere to the gauze fibers and disrupt the
wound when
removed.

Gauze dressings usually are secured with tape. If gauze

dressings need frequent changing, Montgomery straps (strips
of tape with eyelets) may be used
Transparent Dressings
Transparent dressings are clear wound coverings. One of
their chief advantages is that they allow the nurse to
assess a wound without removing the dressing.

• they are less bulky than gauze dressings

• They do not require tape because they consist of a
single sheet of adhesive material.
• They commonly are used to cover peripheral and
central intravenous insertion sites.

Transparent dressings are not absorbent, so if wound

drainage accumulates, they tend to loosen. Once a
dressing is no longer intact, many of its original purposes
are defeated.
Hydrocolloid Dressings
Hydrocolloid dressings are self-adhesive, opaque, air-
and water-occlusive wound coverings.
• They keep wounds moist.
• Moist wounds heal more quickly because new cells
grow more rapidly in a wet environment.
• If the hydrocolloid dressing remains intact, it can be
left in place for up to 1 week.
• Its occlusive nature also repels other body substances
such as urine or stool.
For proper use, a hydrocolloid dressing must be sized
generously, allowing at least a 1-inch margin of healthy
skin around the wound.
 Hydrocolloid dressing
Transparent dressing

Gauze dressing
Drains
Drains

Drains are tubes that provide a means for removing blood

and drainage from a wound.
• They promote wound healing by removing fluid and
cellular debris.
• Some drains are placed directly within a wound, the
current trend is to insert them so that they exit from a
separate location beside the wound.

• This approach keeps the wound margins

approximated and avoids a direct entry site for
pathogens.

The physician may choose to use an open or closed drain.

Open Drains
Open drains are flat, flexible tubes that provide a pathway
for drainage toward the dressing.e.g.Penrose drain

• Draining occurs passively by gravity and capillary action

(movement of a liquid at the point of contact with a solid,
which in this case is the gauze dressing).
• Sometimes a safety pin or long clip is attached to the drain
as it extends from the wound.
• This prevents the drain from slipping within the
tissue.

• As the drainage decreases, the physician may instruct the

nurse to shorten the drain, enabling healing to take place
from inside toward the outside of the
Closed Drains
Closed drains are tubes that terminate in a
receptacle.
• Some examples of closed drainage systems are a
Hemovac and Jackson-Pratt (JP)
• Closed drains are more efficient than open drains
because they pull fluid by creating a vacuum or
negative pressure.
• This is done by opening the vent on the
receptacle, squeezing the drainage collection
chamber, then capping the vent.
Jackson Pratt drainage system

Hemovac drain
 Sutures and Staples
Sutures, are knotted ties that hold an incision together, generally are constructed from
silk or synthetic materials such as nylon. Staples (wide metal clips) perform a
similar function.

Staples do not encircle a wound like sutures; instead, they form a bridge that holds the
two wound margins together. Staples are advantageous because they do not compress
the tissue should the wound swell.
Steri-Strips are thin adhesive bandages often used by surgeons as a backup
to dissolvable stitches or after regular stitches are removed.
CLEANING WOUNDS
Guidelines

• Follow standard precautions for personal protection.

• Wear gloves, gown, goggles, and mask as indicated.

• Use solutions such as isotonic saline or wound cleansers to clean or

irrigate wounds.

• If antimicrobial solutions are used, make sure they are well diluted.
• When possible, warm the solution to body temperature before use.

Rationale: This prevents lowering the wound temperature, which slows the healing

process. Do not microwave solutions. Microwave heating could cause the solution to

become too hot.

• If a wound is grossly contaminated by foreign material, bacteria, slough, or necrotic tissue, clean

the wound at every dressing change.

Rationale: Foreign bodies and devitalized tissue act as a focus for infection and can delay

healing.
• If a wound is clean, has little exudate, and reveals healthy granulation tissue,
avoid repeated cleaning.
Rationale: Unnecessary cleaning can delay wound healing by traumatizing newly
produced, delicate tissues, reducing the surface temperature of the wound, and
removing exudate, which itselfmay have bactericidal properties.

• Use gauze squares or nonwoven swabs that do not shed fibers. Avoid using cotton balls
and other products that shed fibers onto the wound surface.
Rationale: The fibers become embedded in granulation tissue and can act as foci for
infection. They may also stimulate “foreign body” reactions, prolonging the inflammatory
phase of healing and delaying the healing process.
• Clean superficial noninfected wounds by irrigating them with normal saline.
Rationale: The hydraulic pressure of an irrigating stream of fluid dislodges
contaminating debris and reduces bacterial colonization.

• Avoid drying a wound after cleaning it.

Rationale: This helps retain wound moisture.

• Hold cleaning sponges with forceps or with a sterile gloved hand.

• Clean from the wound in an outward direction to avoid transferring organisms from the

surrounding skin into the wound.

• Consider not cleaning the wound at all if it appears to be clean.

• Clean the wound from the cleanest area toward the least clean.
• If the wound is circular, this would be from the center of the wound
outward.
• For a linear wound, cleanse from top to bottom, beginning in the middle
and moving progressively laterally
• Use a single swab or small gauze square for each stroke, and discard
each swab after use.
Rationale: Prevent transferring of microorganisms back to a cleaned area
• Allow the antimicrobial agent to dry to ensure adhesion of tape when applied.
• Cover the wound with the gauze dressing.
• Secure the dressing with tape in the opposite direction of the incision or across
a joint.
• Place a strip of tape at each end of the dressing and in the middle if
needed
IRRIGATING THE WOUND
• An irrigation (lavage) is the washing or flushing out of an area.
• Sterile technique is required for a wound irrigation because there is a break in the skin
integrity. (Unless if the wound is infected).
• Irrigation pressures should range from 4 to 15 pounds per square inch (psi).
(PSI) is a common unit of pressure used in many different pressure measuring
applications).
• Below 4 psi, such as when using a bulb syringe, the irrigation may not be effective,
and above 15 psi it may damage tissues.
• A 30- to 60-mL piston syringe with a 19-gauge needle or catheter provides
approximately 8 psi.
• Using piston syringes instead of bulb syringes to irrigate a wound also reduces
the risk of aspirating drainage.
• For deep wounds with small openings, a sterile straight catheter may also be
necessary.
• Some providers advocate the use of a commercial oral water jet for wound
cleansing.
• This can be effective if kept at the lowest setting since middle settings
often exceed 40 psi and can drive microorganisms further into the wound.
• Frequently used irrigation solutions are sterile normal saline, lactated Ringer’s
solution, and antibiotic solutions.
• Fill the syringe with solution and instill it into the wound without touching the wound
directly.
• Repeat the process until the draining solution seems clear.
• Dry the skin and apply the sterile dry dressing, fasten with an adhesive tape.
END OF TOPIC