Chapter 31

Skin Integrity and Wound Care

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Functions of the Skin

Protection
Body temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunologic
Absorption
Elimination

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Cross-Section of Normal Skin

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Factors Affecting the Skin

Unbroken and healthy skin and mucous membranes

defend against harmful agents.
Resistance to injury is affected by age, amount of
underlying tissues, and illness.
Adequately nourished and hydrated body cells are
resistant to injury.
Adequate circulation is necessary to maintain cell life.

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Developmental Considerations
In children younger than 2 years, the skin is thinner and
weaker than it is in adults.
An infants skin and mucous membranes are easily
injured and subject to infection; a childs skin becomes
increasingly resistant to injury and infection.
The structure of the skin changes as a person ages; the
maturation of epidermal cells is prolonged, leading to
thin, easily damaged skin.
Circulation and collagen formation are impaired, leading
to decreased elasticity and increased risk for tissue
damage from pressure.

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Causes of Skin Alterations

Very thin and very obese people are more susceptible to

skin injury.
Fluid loss during illness causes dehydration.
Skin appears loose and flabby.
Excessive perspiration during illness predisposes skin to
breakdown.
Jaundice causes yellowish, itchy skin.
Diseases of the skin, such as eczema and psoriasis, may
cause lesions that require special care.

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Types of Wounds

Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex

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Principles of Wound Healing

Intact skin is the first line of defense against
microorganisms.
Careful hand hygiene is used in caring for a wound.
The body responds systematically to trauma of any of its
parts.
An adequate blood supply is essential for normal body
response to injury.
Normal healing is promoted when the wound is free of
foreign material.
The extent of damage and the persons state of health
affect wound healing.
Response to wound is more effective if proper nutrition is
maintained.
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Phases of Wound Healing >

Hemostasis
Clotting and blood vessel constriction
Inflammatory
Fluid release, WBCs move to wound
Proliferation
Regeneration of tissue
Maturation
New tissue, scar tissue formation

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Local Factors Affecting Wound Healing

Desiccation (dehydration)
Maceration (overhydration)
Trauma
Edema
Infection
Excessive bleeding
Necrosis (death of tissue)
Presence of biofilm (thick grouping of microorganisms)

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Systemic Factors Affecting Wound Healing

Age: children and healthy adults heal more rapidly
Circulation and oxygenation: adequate blood flow is
essential
Nutritional status: healing requires adequate nutrition
Wound condition: specific condition of the wound affects
healing
Health status: corticosteroid drugs and postoperative
radiation therapy delay healing
Immunosuppression
Medication use

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Wound Complications
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation

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Factors Affecting Pressure

Ulcer Development
Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders

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Mechanisms in Pressure
Ulcer Development
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood
vessels

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Pressure Ulcer Assessment

Risk assessment
Mobility
Nutritional status
Moisture and incontinence
Appearance of existing pressure ulcer
Pain assessment

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Stages of Pressure Ulcers

Stage I: nonblanchable erythema of intact skin

Stage II: partial-thickness skin loss
Stage III: full-thickness skin loss; not involving
underlying fascia
Stage IV: full-thickness skin loss with extensive
destruction
Unstageable: base of ulcer covered by slough and/or
eschar in wound bed

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Measurement of a Pressure Ulcer

Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract

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Cleaning a Pressure Ulcer

Clean with each dressing change.

Use careful, gentle motions to minimize trauma.
Use 0.9% normal saline solution to irrigate and clean the
ulcer.
Report any drainage or necrotic tissue.

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Psychological Effects of Wounds

Pain
Anxiety
Fear
Impact on activities of daily living
Change in body image

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Wound Assessment

Inspection for sight and smell

Palpation for appearance, drainage, and pain
Serous drainage- clear serum
Serosanguineous drainage- serum and blood
Sanguineous drainage- bloody drainage
Purulent drainage- Infected
Sutures, drains or tubes, and manifestation of
complications

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Purposes of Wound Dressings

Provide physical, psychological, and aesthetic comfort

Remove necrotic tissue
Prevent, eliminate, or control infection
Absorb drainage
Maintain a moist wound environment
Protect wound from further injury
Protect skin surrounding wound

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Presence of Infection

Wound is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated, with dehiscence
present.

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Types of Wound Dressings

Dry or moist gauze
Iodoform gauze, vaseline gauze
Telfa
Gauze dressings
Transparent dressings
Hydrocolloidals- autolytic debridement (duoderm)
Enzymatic- Accuzyme
Alginates- Aquacel
Mechanical debridement
Surgical debridement
Hyperbaric treatment
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Application of Bandages

Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn
Recurrent-stump bandage

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Types of Binders
Straight: used for chest and abdomen
T-binder: used for rectum, perineum, and groin area
Sling: used to support an arm

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Type of Drainage Systems

Open systems
Penrose drain
Closed systems
Jackson-Pratt drain
Hemovac drain

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Color Classification of Open Wounds

R = redprotect
Y = yellowcleanse
B = blackdbride
Mixed woundcontains components of RY&B wounds

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Topics for Home Health Care Teaching

Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination

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Factors Affecting the Response

to Hot and Cold Treatments
Method and duration of application
Degree of heat and cold applied
Patients age and physical condition
Amount of body surface covered by the application

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Effects of Applying Heat

Dilates peripheral blood
vessels
Increases tissue
metabolism
Reduces blood viscosity
and increases capillary
permeability
Reduces muscle tension
Helps relieve pain

Methods of heat
application:
Hot water bags or
bottles
Electric heating pads
Aquathermia pads
Hot packs
Warm, moist
compresses
Sitz baths
Warm soaks

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Effects of Applying Cold

Constructs peripheral blood vessels

Reduces muscle spasms
Promotes comfort
Methods of cold application:
Ice bags
Cold packs
Hypothermia blankets
Cold compresses to apply moist cold

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