Are the steps of body’s natural processes of tissue repair, but it also varies depending on factors such as the type of healing, wound location and sizes.
Base structural support to wound (it provides wound strength); to feed new tissues; provides surface for epithelization; to decrease the size of defect; resurfacing of wound, wound closure
There is now the presence of purulent discharge, and the evidence of clinical infxn.
Hemorrhage can be caused by blood clots, slipped suture, or erosion of a blood vessel,INTERNAL HEMORRHAGE- can be detected by, swelling and distention at the area of the wound; EXTERNAL BLEEDING-appear under the area or escapes from the dressing and pools under the patient.
Infxn-bullet or knife wounds, intestinal surgeries, because the colonizing organisms complete with the new cell for O2 and nutrition and because their by products can interfere with a healthy surface condition, the presence of contamination can impair wound healing and may lead to infxn.
Skin integrity – wound
By the end of this presentation students should be able to:
Describe factors affecting skin integrity
Explain etiology of pressure ulcer
Identify clients at risk of pressure ulcers
Describe the four stages of pressure ulcer development
Differentiate primary and secondary wound healing
Describe the three phases of wound healing
Describe prevention and management of pressure ulcer
Skin: structure and
Skin is the largest organ in the body
Protects deeper tissues from:
Mechanical damage ( bumps & cuts)
Chemical damage (acids & bases)
Thermal damage (heat & cold)
Ultraviolet radiation (sunlight)
Intact skin refers to the presence of normal skin and skin layers uninterrupted
The appearance of skin and skin integrity are influenced by internal factors such
as age, genetics and underlying health of the individual as well as external
factors such as activity.
Many chronic illnesses and their treatments affect skin integrity
Eg.DM, cancer medicine may cause photo sensitivity (sensitive to sunrays)
People with impaired peripheral arterial circulation may have skin on the legs
that damages so easily
Poor nutrition also alter skin integrity
A wound can be defined as:
“A cut or break in the continuity of any tissue,
caused by injury or operation”
(Baillière’ s 23rd Ed)
Body wounds are
Intentional: operations, venipunctures
Unintentional : Accidental
Wounds may be classified
According to contamination
Clean: closed wounds
Clean contaminated: surgical wounds
Contaminated: Accidental wounds
Dirty or infected wounds: wounds with dead tissue,infection
Wound Types and
Contusion ( Bruise) – Tissue injury without
breaking of skin.
Hematoma – Tissue injury that disrupts a
blood vessels; pooling of blood under the
Sprain – Wrenching or twisting of
a joint with partial rupture of its
ligaments; causes swelling
Wounds are described
according to how they acquired
Incision- Surgically made separation
of tissues with clean, smooth edges
Laceration – Traumatic separation
of tissues with clean, smooth
Abrasion- Traumatic scraping away
of surface layers of skin
Puncture – Wound made by sharp,
pointed object through skin or mucous
membranes and underlying tissue.
Penetrating- Variable – size open
wound through skin and underlying
tissues made by a bullet or metal or
wood fragment; may extend deeply into
Avulsion – Tearing away of a
structure or a part, such as a
fingertip, accidentally or surgically
Ulceration – Excavation of skin
and/or underlying tissue from
injury or necrosis
Wounds can be classified according to their nature:
2. According to depth
Involves only the epidermis
Injury is usually the result of friction, shearing (cut) or
Involves the epidermis and the dermis
Wounds heal more quickly
Involves the epidermis, dermis, fat, fascia and exposes
In order to heal, all dead tissue must be removed so
that granulation tissue can gradually fill in the defect.
Pressure ulcer or Decubitus ulcer or bed sore is
any lesion caused by unrelieved pressure that
damage underlying tissue.
A Pressure ulcer is an area of skin that breaks
down when constant pressure is placed against
the skin or when pressure applied to the skin
over time is greater than normal capillary
closure pressure, which is about 32mmHg.
Critically ill patients have a lower capillary
closure pressure and a greater risk of pressure
Bed sores are accepted to be caused by 3 different tissue
- The compression of tissues. In most
cases, this compression is caused by
the force of bone against a surface,
as when a patient remains in a
single position for a lengthy
period. After an extended amount
of time with decreased tissue
perfusion, ischemia occurs and can
lead to tissue necrosis if left
force created when a skin of a
patient stays in one place as the
deep fascia and skeletal muscle slide
down with gravity. This can also
cause the pinching off of blood
vessels which may lead to ischemia
and tissue necrosis .
Eg: fowlers position
- Aforce resisting the shearing of
- This may cause excess shedding
through layers of epidermis.
Being unable to move certain parts of the body
without help such as after a brain or spine
Having chronic conditions such as DM, vascular
Altered skin moisture, excessively dry or
Urinary incontinence or bowel incontinence.
Malnourishment , anemia, vitamin deficiency
Use of casts, traction and restraints.
Pressure ulcer classification
erythema .skin intact
involving epidermis and
Full thickness involves
to subcutaneous tissue
Full thickness involves
muscle and bone
All wounds heal following a specific
sequence of phases which may overlap
The process of wound healing depends on
the type of tissue which has been damaged
and the nature of tissue disruption
The phases are:
Remodeling or maturation phase
PHASES OF WOUND HEALING
1. INFLAMMATORY PHASE
-starts immediately after injury and lasts 3-6
2 major processes occur during this phase …
HEMOSTASIS AND PHAGOCYTOSIS
- Tissue and capillaries are destroyed, plasma and
blood leaks. Area blood vessels constrict, platelets
aggregates and bleeding stops, scabs ( rough
protective crust) forms, preventing entry of
The macrophages engulf microorganisms
and cellular debris by a process known as
Characterized by edema, erythema, pain,
increase blood flow, to wound resulting
localized redness and edema, attracts
WBC and wound growth factors.
WBC arrive-clear debris from wound.
Exposure of plasma to
Release of Histamine
Activation of Hageman Factor
Inc bld Flow
-extends from day 3 to about day 21
Macrophages continue to clear the
wound debris, Stimulates Fibroblast
to synthesize collagen .( For tissue
New capillary networks are formed.
REMODELLING OR MATURATION
-final healing stage begins about 21 day
may continue for I year or more.
Re modelling of scar tissue to provide
TYPES OF WOUND HEALING
FIRST INTENTION HEALING-partial
- a clean incision is made with primary
closure, minimal scarring.
-expected when the edges of clean surgical
incisions are sutured together, tissue loss
is minimal or absent if the wound is not
contaminated with microorganism.
-e.g.-abrasion or skin tear.
SECOND INTENTION HEALING
-accompanies traumatic open wounds with tissues loss or
wounds with a high microorganisms count.
-go though a process involving scar tissue formation a heal
slowly because of the volume of tissue needed to fill the
-e.g.-contaminated surgical wound, pressure ulcer.
Delayed primary healing
If there is high infection risk – patient is given antibiotics
and closure is delayed for a few days e.g. bites
Factors affecting healing
Blood glucose levels (impaired white cell function)
• Hydration (slows metabolism)
Age: children and adults quick healing than elderly
Lifestyle- enhances blood circulation
Nutrition: Protein, carbohydrate, lipids, vit A, C, zinc, iron,
copper require for healing. Malnourishment delay healing
Blood albumin levels (‘building blocks’ for repair, colloid
osmotic pressure - oedema)
Life style: Activity increase Oxygen and vascular supply
Medication- Corticosteroids, Aspirin(depress immune
TYPES OF WOUND DRAINAGE
Exudate :is fluid and cell material
Escaped from blood vessels
Serous -clean, watery
Purulent - thick, yellow, green, tan or brown.
(Pus)process of pus formation called
Sanguineous - bright red, indicative of active
Sero sanguineous -pale, red, watery mixture
of serous and sanguineous.
Wound fluid (purulent exudates)
Basic principle of specimen collection: Only wounds
with clinical signs of infection, deteriorating, or fail to
heal should be sampled for Gram’s stain and culture
History and physical examination
Skin disease,Skin condition, lesions, skin
turgor,edema, pressure areas.
Assess wounds :
Untreated wounds(immediate after an injury)
Treated wounds(sutured wounds)
Assessing untreated wounds
Location, tissue damage, measure length width and
Inspect for bleeding, foreign bodies( soil, broken glass
Injuries like fractures, internal bleeding, spinal cord
injury , head injury
Determine Tetanus toxoid injection
Assessment of Pressure ulcer
Assess total skin condition of the patient once in
Inspect each pressure site for erythema.
Palpate the skin for increased warmth.
Inspect for dry skin, moist skin, and breaks in
Note the drainage and color.
Evaluate level of motility.
Evaluate circulatory status.
Assess neurovascular status.
Determine presence of incontinence.
Norton’s pressure area assessment form
Very bad 1
Ambulatory 4 Full
Risk for impaired Skin integrity
Impaired skin integrity
Impaired tissue integrity
Risk for infection
Prevention of pressure sores
Look for reddened areas ,blisters,sores,or
Change position at least every 2 hours to
Use items that can help to reduce pressure like
pillows, foam padding, etc.
Eat well balanced meals that contain enough
Drink plenty of water(8-10 glasses of water per
Exercise daily including range of motion
Keep the skin clean and dry.
Describes the type of material present
In the base of the wound:
Granulating tissue (red)
Necrotic tissue (black)
RED YELLOW BLACK (RYB CODE)
Infected tissue (green)
• Aims: support
granulation, protect new
tissue, keep moist
Assess depth and
Moist wound surface –
• Aim: to liquefy slough and
aid its removal
• Dead cells accumulated in
• Prepare wound bed for
• Assess wound depth and
• Hydrogels, hydrocolloids,
alginates and hydrofibre
• Aims: to debride and
Provide the right
• Assess wound
• Aims: reduce exudate,
odour and promote
Clinical signs of
Swab wound – systemic
exudate and odour
Change dressings daily
• Aims: to provide suitable conditions for
, films, hydrocolloids
Disturb as little as possible
COMPLICATIONS OF WOUND HEALING
-risk of hemorrhage is greatest during the 1st
48 hours after surgery.
-emergency -- should apply pressure
dressing to the wound and monitor vital
-surgical infection is apparently 2-11 days
- watched for presence of changed in wound
color, pain or drainage-culturing of the
3. DEHISCENCE WITH POSSIBLE
-may occur 4-5 days postoperatively.
-involves an abdominal wound in which the
layers below the skin separates.
- an increase in flow of serosanguinous
drainage into the dressing can indicate
- If occurs should be quickly supported by
sterile dressing soaked in sterile normal
Client in bed with knees bent…
why? To decrease pull on the incision.
and? Notify physician……
1. DRESSINGS - material applied to wound
with or without medication, to give
protection and assist in healing.
-what are the purposes?
To protect the wound from mechanical injury
Splint or immobilized the wound.
Prevent contamination from bloody
Promote homeostasis, (pressure
Debride the wound
to kill or inhibit microorganism
provide a physiologic environment
conducive to healing
provide mental and physical comfort for
What are the types of dressings?
a. DRY TO DRY DRESSINGS
-used primarily for wounds closing by
-offers good protection, absorption &
-they adhere to the wound surface when
- when remove can cause pain and
disruption of granulation tissue.
b. WET TO DRY DRESSINGS
-used for untidy or infected wounds that must
be debrided and closed by secondary
>how can it be done?
-gauze saturated with sterile saline or
antimicrobial sol’n. is packed into the wound,
the wet dressing are then covered by dry
>when to changed?
-when it becomes dry
c. WET TO WET DRESSINGS
-used on clean open wounds or on
-provide a more physiologic environment
(warmth moisture) which can enhance the
local healing processes and assure greater
-surrounding tissues can become ulcerated.
high risk for infection.
2. DRAINS- device or a tube used
to draw fluids from an internal
body cavity to the surface.
-what are the purposes?
a) placed in the wounds only when
abdominal fluid collections are
b) placed near the incision site
> wound drainage-drains placed
within the wounds are attached
to a portable suction with a
e.g. hemovac, jackson-pratt,
3. BINDERS AND BANDAGES
-what are the purposes?
Creates pressure over the body parts
Immobilize body parts
Reduce or prevent edema
Secure a splints
A process of cleansing the wound using
∆ To aid debridement The ideal dressing
• A dressing that
∆ To remove excess
creates the optimum
∆ To control bleeding
∆ To protect a wound • Wound debridement
∆ To support healing • Wound cleansing
• Alternative therapies
TYPES OF DRESSINGS
Hydrogels are indicated for
management of pressure ulcers,
skin tears, surgical wounds, and burns,
including radiation therapy burns.
Because they contain up to 95% water,
hydrogels cannot absorb much
exudate and should be reserved for
dry wounds or wounds with minimal to
Because they are occlusive, hydrocolloid
dressings do not allow water, oxygen, or bacteria
into the wound. This may help facilitate
angiogenesis and granulation. Hydrocolloids
also cause the pH of the wound surface to drop;
the acidic environment can inhibit bacteria
Because of their occlusive nature, hydrocolloids
cannot be used if the wound or surrounding skin
Alginate dressings absorb moderate to high
amounts of wound drainage.
An alginate can be used in infected and
noninfected wounds. Because an alginate is
highly absorbent, it should not be used with
dry wounds or wounds with minimal
drainage; it could dehydrate the wound,
Made of three layers. The layers of the composite dressings combine to
form an antimicrobial barrier for moderate to heavy exuding wounds. Some
composite dressings also gradually release silver over time to promote
Composite dressings have multiple layers and can be used as primary or
secondary dressings. They are appropriate for wounds with minimal to
heavy exudate, healthy granulation tissue, necrotic tissue (slough or moist
eschar), or a mixture of granulation and necrotic tissue
composite dressings cautiously used if the patient is dehydrated or has
Film dressings are flexible sheets of transparent
polyurethane coated with an acrylic adhesive. They
can be used as a primary or secondary dressing.
These dressings are semipermeable, vary in size and
thickness, and have an adhesive that holds the
dressing on the skin. They conform easily to the
patient's body but do not hold well in high-friction
areas, such as the sacrum or buttocks.
Because films are transparent, the wound can be
Because films are semiocclusive and trap moisture,
they allow autolytic debridement of necrotic wounds
and create a moist healing environment for