Fundamentals of Nursing II

(NURS 202)

Lecture 6: Wound Care

& Skin Integrity
Spring 2023-2024

February 20, 2024 1

 Objectives
• Describe factors affecting skin integrity.
• Identify clients (assessment data) at risk for Skin breakdown (pressure
ulcers).
• Describe the four stages of pressure ulcer development.
• Differentiate between the three phases of wound healing.
• Identify three major types of wound exudate.
• Identify the main complications and factors that affect wound healing.
• Verbalize & demonstrate the steps of wound specimen, and wound
dressing using the nursing process approach.

February 20, 2024 2

Outlines
• Factors affecting skin integrity, and wound healing.

• Risk clients for Skin breakdown (pressure ulcers).

• Stages of pressure ulcers.

• Phases, factors affecting, and complications of wound healing.

• Types of wound exudate.

• The main competencies of the wound dressing (specimen, wound dressing) using the
nursing process approach.

February 20, 2024 3

 Brainstorming

What are these images?

What is the difference?

What do you need to deal with it?

What are the nursing, patient, and

family role?

What is a septic technique principles?

February 20, 2024 4
 Introduction
• Maintaining skin integrity and promoting wound healing are the main
nursing functions.

• Wound problems are not common among healthy people but are a threat to
older adults; patients with restricted mobility, chronic illnesses, or trauma;
and to those undergoing invasive health care procedures. So, the nurse must
understand the factors affecting skin integrity, the physiology of wound
healing, and specific measures that promote optimal skin conditions.

February 20, 202 5

4
 Factors Affecting Skin Integrity
Intact skin refers to the presence of normal skin and skin
layers uninterrupted by wounds. Factors affecting skin
integrity:
Genetics and heredity determine many aspects of a
person’s skin, including skin color, sensitivity to
sunlight, and allergies.
Age: The very young and the very old are more fragile
and susceptible to injury. Wounds tend to heal more
rapidly in infants and children.

Many chronic illnesses and their treatments affect skin

integrity.

Poor nutrition alone can interfere with the appearance

February 20, 2024
and function of normal skin. 6
 Question 1
Which of the following is considered the important nursing role
in maintaining skin integrity?
a) Promote wound healing
b) Take the correct wound specimen
c) Irrigating the contaminated wound
d) Apply heat or cold dressing

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 Types Of Wounds
Types Wound

Cause Condition

Intentional Unintentional Clean, Clean- Contaminated &

contaminated Dirty

e.g., Operations e.g., Accidental,

or venipunctures Fracture
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Types Of Wounds according to condition
• Clean wounds are uninfected wounds, with minimal inflammation,
and closed wounds.
• Clean-contaminated wounds are surgical wounds in which the
respiratory, gastrointestinal, genital, or urinary tract has been
entered, with 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 clinical infection, such as purulent
drainage.
February 20, 2024 9
 Types of Open Wound
Wound Cause Description
Incision Sharp instrument (e.g., knife or scalpel) Open wound; deep or shallow;

Contusion Blow from a blunt instrument Closed wound, skin appears ecchymosis
(bruised) because of damaged blood
vessels.
Abrasion Surface scrape, either unintentional Open wound involving the skin
(e.g., scraped knee from a fall) or
intentional
Puncture Penetration of the skin and often the Open wound involving the skin
underlying tissues by a sharp
instrument, either intentional or
unintentional
Laceration Tissues torn apart, often from accidents Open wound involving the skin

Penetrating Wound Penetration of the skin and the Open wound

underlying tissues, usually unintentional
February 20, 2024 10
 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. It is called: pressure sores or
bedsores.

Why pressure ulcer is the best indicator for nursing

intervention?
February 20, 2024 11
 Pressure Ulcer

Relieve
Persist pressure pressure

Redness
Reactive Disappear
Vasodilation of
hyperemia(Bright red
Blood Vessels
flush )

Tissue damage No tissue

damage

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 The Mechanism of Pressure Ulcer
Etiology of Pressure Ulcers

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 Loss of fat, muscle & tissue, Vitamin D deficiency
Malnutrition Altered mental&
Muscle atrophy, edema sensory Status
hypoproteinemia) Sedative, Chronic illness CVD,
Incontinence
(Maceration, CVS (Skin breakdown
and impaired wound
healing)

Immobility
Elderly (Advance
Paralysis, Age)
decrease activity

Risk
Friction & Factors Excessive heat
(increased requirement
Shearing for O2, and metabolic
Pressure rate)

Ulcer
 Question 2

Which of the following are primary risk factors for pressure

ulcers
a) Low-protein diet
b) Insomnia
c) Constipation
d) Sleeping on a waterbed

February 20, 2024 15

 Stages of Pressure Ulcers

February 20, 2024 16

 Stages of Pressure Ulcers
Stage Description
Stage I Nonblanchable erythema signaling potential ulceration.

Stage II Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the
epidermis and possibly the dermis

Stage III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that
may extend down to,

Stage IV Full-thickness skin loss with tissue necrosis or damage to muscle, bone, or
supporting structures
February 20, 2024 17
 Stages of Pressure Ulcers
Stage Description

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.

Suspected deep tissue Depth unknown: purple or maroon localized area of discolored
injury intact skin or blood-filled blister due to damage of underlying soft
tissue from pressure and/or shear.

February 20, 2024 18

 Matching (Homework)
Answer A B
Stage I a) Subcutaneous tissue necrosis or damage and involves
muscle, bone, or supporting structures
Stage II b) No skin breakdown but includes redness and pain.

Stage III c) Abrasion, blister, in the epidermis and may reach to the
dermis.

Stage IV d) Full-thickness skin loss involving damage or necrosis of

subcutaneous tissue.

February 20, 2024 19

 Nursing Role: Risk Assessment Tools For Pressure Ulcers
1. Braden Scale For Predicting
Pressure Sore Risk:
It consists of six subscales:
sensory perception, moisture,
activity, mobility, nutrition, and
friction and shear. A total of 23
points is possible and an adult
who scores below 18 points is
considered at risk.

February 20, 2024 20

Nursing Role: Risk Assessment Tools For
Pressure Ulcers
2. Norton’s Pressure Area Risk
Assessment Scoring System:
It includes the categories of
general physical condition,
mental state, activity, mobility,
and incontinence. A category of
medications is added by some
users, resulting in a possible
score of 24. Scores of 15 or 16
should be viewed as indicators,
not predictors, of risk.
February 20, 2024 21
 Question
Your client has a Braden scale score of 17. Which is the appropriate
nursing action?
a) Assess the client again in 24 hours; the score is within normal limits.
b) Implement a turning schedule; the client is at increased risk of skin
breakdown.
c) Apply a transparent wound barrier to major pressure sites; the client
is at moderate risk of skin breakdown.
d) Request an order for a special low-air-loss bed; the client is at very
high risk of skin breakdown

February 20, 2024 22

The common sites of Pressure Ulcer
 Question
Your client is only comfortable lying on the right or left side (not
on the back or prone). Which of the following site will be common
for pressure ulcers?
a) Breasts
b) Toe
c) Cheek
d) Shoulder

February 20, 2024 24

 Nursing Intervention (Pressure Ulcer)
The management of pressure ulcers is interdisciplinary, including primary
care physicians, dermatologists, infectious disease consultants, social
workers, psychologists, dietitians, podiatrists, home and wound-care
nurses, rehabilitation professionals, and surgeons.

Shared Decision Family Engagement Communication

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 Nursing Intervention (Pressure Ulcer)
• Basic components of pressure ulcer management are reducing or relieving
pressure on the skin, debriding necrotic tissue, cleansing the wound, managing
bacterial load and colonization, and selecting a wound dressing.
Management

Improving Nutrition Status

Assessment, Prevention

Stage I Stage II Stage III Stage IV

Apply moist dressing, Apply dressings include transparent films,

Treating the transparent, and cleanse hydrogels, alginates, foams, and
cause the wound hydrocolloids. Surgical Procedure &
antibiotics
February 20, 2024 26
 Assessment
Pressure Ulcers assessment:
• Location, Size of ulcer in centimeters.
• Measure the length, width, and depth (to measure depth, insert a sterile
applicator swab at the deepest part of the wound, and then measure it
against a measuring guide)
• Stage of the ulcer
• Color of the wound bed and location of necrosis (dead tissue) or eschar.
• Condition of the wound margins.
• Integrity of surrounding skin.
• Clinical signs of infection, such as redness, warmth, swelling, pain,
odor, and exudate (note the color of exudate).
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 Wound Healing

February 20, 2024 28

 Wound Healing
• Healing is a quality of living tissue; it
is also referred to as the regeneration
(renewal) of tissues. It is the wound to
seal itself or purposefully closes the
wound.
• Phases of healing are the steps in the
body’s natural processes of tissue
repair.

February 20, 2024 29

 Wound Healing
• Types of wound healing:
1- Primary intention healing occurs where the tissue surfaces
have been approximated (closed) and there is minimal or no
tissue loss; minimal granulation tissue and scarring. It is also
called primary union or first intention healing.

February 20, 2024 30

 Wound Healing
• Types of wound healing:
2- Secondary intention healing
(e.g., pressure ulcer healing).
(1) The repair time is longer,
(2) The scarring is greater,
(3) The susceptibility to infection is
greater.
3- Tertiary intention healing: Wounds are
left open for 3 to 5 days to allow edema or
infection to resolve.
February 20, 2024 31
 Phases Wound Healing

1- Inflammatory 2- Proliferative: lasts for 21 days Maturation or Remodeling

Last for 3-6 days post-injury. Fibroblasts migrate into It lasts for 1 to 2 years
the wound after 24hrs

Hemostasis Phagocytosis: Contracted the wound

Vasoconstriction, clots Granulation tissue: and continue
Macrophages engulf Collagen remains the Hypertrophic scare
formation from dead forming new fibroblasts and
microorganisms and wound closed and (Keloid)
tissue capillaries and becomes more
cellular debris strength translucent red tissue stronger

February 20, 2024 32

 Types of Wound 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.
Type Description
Serous It is a 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. (fluid blister from burn)
Purulent Thicker than serous (presence of pus), consists of leukocytes, liquefied
dead tissue debris, and dead and living bacteria. Suppuration the
formation of pus. It has different colors blue, green, yellow
Sanguineous It 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.

February 20, 2024 33

 Question
Which of the following changes occurs during the maturation phase of
wound healing?
a) Hemostasis
b) Phagocytosis
c) Collagen formation
d) Keloid formation

February 20, 2024 34

 Lifestyle
Age
Exercise improves
Wound for a healthy
circulation and
child heals faster
smoking reduces HB
than an older adult
function.
Medication (steroids &
aspirin interfere with Nutrition (Protein,
healing, long using of CHO, Lipids vitamins,
antibiotics causing and iron, zinc &
infection. Treated by copper
insulin Factors
Affecting
Wound
Healing

February 20, 2024 35

 Complications of Wound Healing

Escape of blood
from a wound
Hemorrhage

Internal Hge.
Complication

Changing wound
Infection color, pain, odor,
or drainage
February 20, 2024 36
 Complications of Wound Healing
Hemorrhage:
• Escape of blood from a wound is normal but if it becomes massive bleeding and
abnormal will cause hemorrhage.
• A dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe
bleeding.
• Internal hemorrhage caused a hematoma which is a localized collection of blood
underneath the skin that may appear as a reddish-blue swelling (bruise).
• It can happen during the first 48 hours after surgery.
• During an emergency of hemorrhage:
A. A nurse should apply pressure dressings to the wound
B. Monitor the client’s vital signs.
C. If bleeding continues the client must be taken to the operating room for surgical
intervention.
February 20, 2024 37
 Complications of Wound Healing
Infection :
• It Contamination of a wound surface with microorganisms (colonization)
is an inevitable result because the surface cannot be permanently
protected from contact with unsterile objects.
• Infection suggested by a change in wound color, pain, odor, or drainage
is confirmed by performing a culture of the wound.
• Severe infection causes fever and an elevated white blood cell count.
• Surgical infection is most likely to become apparent 2 to 11 days
postoperatively.

February 20, 2024 38

 Nursing Management
Assessing
• Assessment of Skin Integrity: the nurse removed any devices that
interfere with the assessment including Nursing History and Physical
Assessment
• Assessment of Wounds (Untreated Wounds are seen shortly after an
injury, the Treated wound are indicated by suture, scare, and dressing).
Assessing wounds for location, bleeding, type, cause, and associated
injuries.
• Assessing Laboratory Data: decrease WBCs delay wound healing, and
decrease HB affects the supply of O2

February 20, 2024 39

 Diagnosing
The NANDA formulates diagnoses relate to clients who have skin wounds
or who are at risk for skin breakdown as follows:
• Risk for Pressure Ulcer over a bony prominence-related pressure, or
pressure in combination with shear.
• Risk for Impaired Skin Integrity: vulnerable to alteration in the
epidermis and/or dermis which may compromise health.
• Impaired Skin Integrity: (altered epidermis and/or dermis)
• Risk for infection related to altered skin integrity (Presence of surgical
wound)
• Acute Pain related to nerve involvement within the tissue impairment.

February 20, 2024 40

 Planning & Implementation

The major goals for caring for Impaired
Skin Integrity
• Maintain skin integrity
• Avoid potential associated risks.
• Improve wound healing & regain intact
skin within a specified time frame
Promote wound healing:
•Providing sufficient nutrition
and hydration.
•Preventing wound infections&
proper positioning.

February 20, 2024 41

 Dressing Wounds
Dressings are applied for the following purposes:
• To protect the wound from mechanical injury, and
infection
• To provide or maintain moist wound healing and prevent
hemorrhage.
• To provide thermal insulation.
• To absorb drainage or debride a wound or both
• To splint or immobilize the wound site and thereby
facilitate healing and prevent injury.

February 20, 2024 42

 Dressing Wounds
Types of Dressings Various dressing materials are available to cover wounds. It
depends on
(a) Location, size, and type of the wound;
(b) Amount of exudate;
(c) Whether the wound requires debridement or is infected; and
(d) Consider frequency of dressing change, ease or difficulty of dressing application, and
cost

February 20, 2024 43

 Types of wound dressing
Item Gauze Foam Transparent film Hydrocolloid Hydrogel
Description Gauze, or Soft and gentle wound The adhesive is on Dressings are Treating wounds
cloth, dressings made of one side of the film absorbent pads that are too dry or
dressings are polyurethane foam. dressing. that are incredibly need some extra
made of Do not stick to the Monitor a wound flexible. help healing.
woven cotton wound. without being Intentionally add
fabric in Keeping the wound exposed to the moisture to an
various sizes area moist, foam elements. injury
and shapes dressings can promote
faster healing of the
wound area.
When On an infected Pressure ulcers On IV sites Burn wounds On excessive dry
wound Minor burns Lacerations Necrotic wounds wound areas
frequent Skin grafts Abrasions Pressure ulcers Wounds with
dressing Diabetic ulcers Second-degree burns Venous ulcers dead tissue
changes On a surgical incision Painful or necrotic
site wounds

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 Wound Dressing
• Taking Wound specimen
• Cleaning the wound
• Irrigating the wound
• Caring of the Drainage system

February 20, 2024 45

 Question
Which of the following technique indicate that the nurse performs a wound
culture specimen correctly?
a) Cleansing of the wound prior to obtaining the specimen
b) Swabbing for the specimen in the area with the largest collection of
drainage
c) Removing crusts or scabs with sterile forceps and then culturing the site
beneath
d) Waiting 8 hours following a dose of antibiotics to obtain the specimen