Skin Integrity and Wound Care

• Intact Skin - refers to the presence of normal skin and skin layes uninterrupted with wounds
• Wounds - disruption of skin Integrity
• Type of wounds

  • Incised wound - sharp instrument (open wound
• Contusion - blow from a blunt instrument
• Abrasion - surface scrape
• Puncture - penetration of the skin
• Laceration - tissues torn apart, often from accidents
• Penetrating wounds - penetration of the skin
• Clean wound - are uninfected wound in which minimal inflammation is encountered and the respiratory, genital, and urinary tract are not entered. 


  are primarily closed wound
• Clean-contaminated wounds - are surgical wounds in which respiratory, alimentary, genital, or urinary tract has been entered, such wounds show no evidence of infection (high risk of infection)
• Contaminated Wounds - include open, fresh, accidental wounds, and surgical wounds involving a major break in sterile technique there is an evidence of inflammation
• Dirty or Infected wounds - wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage (pus)
• Wound thickness:

  1. Superficial - loss of epidermis only
  2. Partial Thickness - loss of epidermis + dermis
  3. Full Thickness - loss of dermis, subcutaneous fat and sometimes bone
• Braden Scale - predicting pressure sore risk that consist of six subscales :

  • Sensory perception
  • Moisture
  • activity
  • mobility
  • nutrition
  • friction and shear
• The higher score, the lower risk

  The lower score, the higher risk
• Age - slower healing process and phases of wound healing are affected
• Nutrition - optimal wound healing requires adequate nutrition. Deficiencies of nutrients impede the normal process that allow progression of stages of wound healing
• Oxygen - plays a very crucial role in wound healing, is needed for cellular function, and can kill bacteria and cause resistance to infection. The O2 stimulates the creation of new blood vessels and also aids growth factors to form new skin
• Smoking - Nicotine is a vasoconstrictor that reduces blood flow, resulting in ischemia and impaired healing of injured tissue
• Drug Therapy - impair wound healing
• Diabetes Mellitus - major contributors to chronic wounds healing problems
• Hemorrhage (persistent bleeding) - abnormal and may indicate a lipped surgical sture, dislodged clot, or erosion of a blood vessel
• Dehiscence - partial or complete separation of the wound edges and the layers below skin
• Evisceration - occurs when the client's viscera protrude thru disrupted wound
• Nursing process in for Altered Skin Integrity

  • Assessment of wounds: Health history (allergies...), physical examination, laboratory data
  • Nursing Diagnosis - impaired tissue integrity, risk for infection, disturbed body image, acute or chronic, and deficient knowledge
• When using a swab or gauze to cleanse a wound, work from the clean area outward toward the dirtier area
• When irrigating a wound, warm the solution to room temperature, to prevent lowering of the tissue temp.
• Maceration - softening and breaking down of skin due to prolonged moisture
• Tunneling or sinus tract - narrow opening or passageway extending from a wound underneath the skin in any direction through soft tissue and results in dead space with potential for abscess formation.
• Types of Wound Healing:

  • Primary Intention Healing: 


  Clean, narrow incision, inflammation and proliferation, minimal scarring, remodeling
• Types of Wound Healing:

  • Secondary Closure 


  Broader-based wound, granulates over and heals from the base, wide more visible scar
• Types of Exudate:

  • Serous
  • Fibrinous
  • Serosanguinous
  • Sanguinous
  • Seropurulent
  • Purulent
  • Haemopurulent
  • Haemorrhagic
• Serous - clear straw-colored, normal
• Fibrinous - cloudy, may indicate fibrin stands present, normal
• Serosanguinos - opaque/ pink, may indicate the presence of red blood cells and capillary damage
• Sanguinos - red, may indicate trauma to blood vessels, low protein content due to malnutrition, indicate venous or congestive cardiac failure, presence of fistula
• Purulent - yellow/ grey/ green, may indicate infection, contains pyogenic(pus-generating)organisms and inflammatory cells
• Haemopurulent - dark, blood-stained, viscous/sticky, will indicate an infection and will contain neutrophils, dead/dying bacteria, and inflammatory cells. Consequent damage to dermal capillaries leads to blood leakage
• Haemorraghic - dark red, thick/ sticky, indicates infection/trauma, capillaries are so friable they readily break down and spontaneous bleeding occurs, not to be confused with bloody exudate produced by over-enthusiastic debridement
• Stage of Healing:

  • Inflammatory
  • Proliferative
  • Maturation