2. By the end of this presentation students
should be able to:
Describe factors affecting skin integrity
Identify clients at risk of pressure ulcers
Describe the four stages of pressure ulcer
development
Differentiate primary and secondary wound
healing
4. The skin is the largest organ in the body and
it serves a number of functions including:
protection, thermoregulation
To protect the skin and manage wounds
effectively, the nurse must understand factors
affecting skin integrity, the physiology of
wound healing and specific measures that
promote optimal skin conditions
5. Intact skin refers to the presence of normal skin
and skin layers uninterrupted by wounds
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
People with impaired peripheral arterial
circulation may have skin on the legs that
damages so easily
6.
7. A wound is a break in the skin integrity
TYPES OF WOUNDS
Accidental wounds: occur when the skin is
exposed to extremes in temperature,
exposure to chemicals, excessive pressure,
trauma and radiation
Common accidental wounds are abrasions,
lacerations and puncture wounds
8. An abrasion is caused when the skin rubs against
a hard surface . Friction scrapes away the
epithelial layer of the skin, exposing the
epidermal or dermal layer
LACERATION: Is an open wound or cut. Most
lacerations affect only the upper layers of the
skin and subcutaneous tissues, but permanent
damage may occur if there is injury to internal
structures such as muscles, tendons, blood
vessels or nerves.
Accidents involving auto mobiles , machinery or
knives may result in lacerations
CONTUSION: Is a wound caused by blunt trauma
9. It is created when tissue is penetrated by a
sharp pointed instrument like nails, pins
SURGICAL WOUNDS: They are intentional
wounds that vary from simple to superficial
to deep.
10. Classification of Wounds
• 1) Clean Wound:
– Operative incisional wounds that follow
nonpenetrating (blunt) trauma.
• 2) Clean/Contaminated Wound:
uninfected wounds in which no or minimal
inflammation is encountered but the
respiratory, gastrointestinal, genital, and/or
urinary tract have been entered.
11. • 3) Contaminated Wound:
open, traumatic wounds or surgical wounds
involving a
major break in sterile technique that show
evidence of
inflammation.
4) Infected Wound:
old, traumatic wounds containing dead tissue and
wounds with evidence of a clinical infection (e.g.,
purulent drainage
12. The severity of the wound determines the
time for healing, the degree of pain and the
probability of wound complication.
OSTOMIES: Are surgical openings in the
abdominal wall that allow part of the intestine
to open onto the skin.
STASIS DERMATITIS: Is caused by impairment
of venous return secondary to varicose veins.
Pooling of blood leads to oedema,
vasodilatation and plasma extravasation all of
which may result in dermatitis
13. Pressure sores are also called decubitus
ulcers or bed sores. They occur when
capillary blood flow to the skin is impaired.
These ulcers occur primarily as a result of
unequal distribution of pressure over certain
parts of the body. Because of decreased
blood flow , the supply of nutrients and
oxygen to the skin and underlying tissues is
impaired. This causes cells to die and
decompose and form an ulcer
14. If the pressure is not relieved and no
treatment instituted, damage may spread and
involve the fascia, muscle and bone. Infection
commonly occur.
15.
16. Stage 1: involves inflammation and reddening
of the skin. Any breakdown present during
this stage involves only the epidermis. Usually
stage 1 ulcers are reversible if pressure is
relieved
STAGE II. Ulcer appears as a shallow crater or
a blister. It involves the dermis and can
penetrate to the subcutaneous layer.
17. Ulcer involves destruction of subcutaneous layer
and capillary beds. The ulcer is not painful but
may have foul smelling yellow or green drainage.
Stage III ulcer may require months to heal.
STAGE IV: Involves extensive damage to
underlying structures and may extend to the
bone. On the skin surface , the wound may
appear small but beneath the skin, the tunnels
extend away from the opening. They are usually
necrotic and have foul smelling drainage
18. At the edges the ulcer may develop a leathery
black crust(eschar) which may eventually
cover the ulcer. Infectious complications such
as osteomylitis are common.
19. Factors causing ulcer formation include:
increased pressure and decreased tissue
tolerance.
Pressure can be increased by decreased
mobility, decreased activity and decreased
sensory/ perceptual ability.
Extrinsic factors that decrease tissue
tolerance and increase the likelihood of
pressure sore development are: moisture,
friction, shearing force. Other contributing
factors are: age, malnutrition.
20. This increases the risk of pressure sore
development because inadequately nourished
cells are easily damaged. Severely
malnourished patients experience weight
loss, decreased subcutaneous tissue, and
decreased muscle mass. This limit the
amount of padding between skin and
underlying bone, aggravating the effects of
pressure over bony prominences.
21. Can occur when patients are confused, comatose
or if one is taking medications that alter normal
cognitive process. When this occurs, patients are
less aware of pressure build up and not
reposition themselves as needed to prevent
ulceration.
MOISTURE
Moisture can predispose the skin to breakdown.
Skin which is continuously exposed to moisture
becomes macerated. Incontinence often causes
the patient to lie in urine or faeces.
22. Occurs when two surfaces rub together. When
the skin rubs against a hard surface such as
beddings, small abrasions may occur.
SHEARING FORCE: Occurs when tissue layers
move on each other causing stretching of
blood vessels
23. Pressure sores usually develop over bony
prominences where body weight is
distributed over a small area with inadequate
padding. When in supine, the greatest points
of pressure are back of the skull, the elbows,
the sacrum, the coccyx and heels. When
sitting, the greatest points of pressure are the
ischial tuberosities and the sacrum
