This document provides information about factors affecting skin integrity and wound classification. It describes the objectives of understanding wounds and preventing decubitus ulcers. Skin integrity relies on maintaining health and preventing injury. Wounds are classified by degree of contamination and depth. Pressure ulcers form from pressure and ischemia, and are staged from 1 to 4 based on tissue depth involvement. Risk factors include immobility and incontinence.

1. Saher Yousaf
10-02-2020

2. Objectives
At the completion of this unit, the student will be able to:
• Describe factors affecting skin integrity
• Define wounds and its classification
• Define decubetic ulcer (bed sore)
• List the causes of decubetic ulcer
• Differentiate four stages of pressure ulcers
• Identify clients at risk of pressure ulcers
• Identity risk factors of bedsores
• Apply nursing interventions to prevent decubetic ulcer.
• Define wound healing and types and process of wound healing

3. • The skin is the largest organ in the body and serves a variety of
important functions in maintaining health and protecting the individual
from injury. Important nursing functions are maintaining skin integrity
and promoting wound healing.
• Skin integrity refers to skin health. A skin integrity issue might mean
the skin is damaged, vulnerable to injury or unable to heal normally.

4. Factors Affecting Skin Integrity
• Genetics and heredity.
• Age.
• Chronic illnesses and their treatments.
• Medications.
• Poor nutrition

5. Wound
• An injury to living tissue caused by a cut, blow, or other impact,
typically one in which the skin is cut or broken.

6. TYPES OF WOUNDS
Degree of
wound
contamination
Acquired
Wound
Clean wounds
Clean-contaminated
wounds
Contaminated
wounds
Dirty or infected
wounds
Incision
Abrasion
Puncture
Laceration
Penetrating wound
Wounds by
depth
Partial
thickness
Full
thickness

7. Class Complete Course Done

8. TYPES OF WOUNDS
Degree of wound contamination
Body wounds are either intentional or unintentional.
• Clean wounds
• These are uninfected wounds in which there is minimal inflammation and the
respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean
wounds are primarily closed wounds.
• e.g:minor surgical procedures:cannulatiom

9. • Clean-contaminated wounds
• These are surgical wounds in which the respiratory, gastrointestinal,
genital, or urinary tract has been entered. Such wounds show no
evidence of infection.
•

10. • 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.

11. • Dirty or infected wounds
• Include wounds containing dead tissue and wounds with evidence of
a clinical infection, such as purulent drainage.

12. I CLAPP

13. Acquired wounds
Incisional Wound:
Sharp instrument (e.g., knife or scalpel)
Open wound; deep or shallow; once the edges have been sealed together as a part of
treatment or healing, the incision becomes a closed wound.

14. Contusion Wound:
Blow from a blunt instrument
Closed wound, skin appears ecchymotic (bruised) because of damaged
blood vessels.

15. Laceration Wound:
Tissues torn apart, often from accidents (e.g., with machinery)
Open wound; edges are often jagged

16. Abrasion Wound:
Surface scrape, either unintentional (e.g., scraped knee from a fall) or
intentional (e.g., dermal abrasion to remove pockmarks)
Open wound involving the skin

17. Penetrating wound:
Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal
fragments)
Open wound
Puncture Wound:
Penetration of the skin and often the underlying tissues by a sharp
instrument, either intentional or unintentional
Open wound

18. Classifying Wounds by Depth
• Partial thickness: confined to the skin, that is, the dermis and
epidermis; heal by regeneration
• Full thickness: involving the dermis, epidermis,
subcutaneous
tissue, and possibly muscle and bone; require connective tissue
repair.

19. Activity

20. 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. Pressure ulcers were previously called
decubitus ulcers, pressure sores, or bedsores

21. Images of pressure ulcers

22. Common sites of pressure ulcers

24. Etiology of Pressure Ulcers
• ischemia,
A deficiency in the blood supply to the tissue.

25. Risk Factors
Several factors contribute to the formation of pressure ulcers:
• Friction and shearing
• Immobility
• Inadequate nutrition
• Fecal and urinary incontinence
• Decreased mental status
• Diminished sensation
• Excessive body heat
• Advanced age

26. • The first stage is the mildest. It discolors the upper layer of skin.
commonly to a reddish color. In this stage, the wound has not yet
opened, but the extent of the condition is deeper than just the top of
the skin. The affected area may be sore to touch but has no surface
breaks or tears.

27. • In the second stage, patient experience some pain from the ulcer. The
sore area of skin has broken through the top layer and some of the
layer below. The break typically creates a shallow, open wound and
may or may not notice any drainage from the site.
• A stage 2 ulcer may appear as a serum-filled (clear to yellowish fluid)
blister that may or may not have burst. The surrounding areas of the
skin may be swollen, sore, or red. This indicates some tissue death or
damage.

29. • In the third stage Sores that have progressed to the third stage have
broken completely through the top two layers of the skin and into the
fatty tissue below. An ulcer in this stage may resemble a crater. It may
also smell bad.
• In this stage, it’s important to look for signs of infection including:
• foul odor
• pus
• redness
• discolored drainage

31. • Stage 4 ulcers are the most serious. These sores extend below the
subcutaneous fat into your deep tissues like muscle, tendons, and
ligaments. In more severe cases, they can extend as far down as the
cartilage or bone. There is a high risk of infection at this stage.
• These sores can be extremely painful. You can expect to see drainage,
dead skin tissue, muscles, and sometimes bone. Your skin may turn
black, exhibit common signs of infection, and you may notice a dark,
hard substance known as eschar (hardened dead wound tissue) in the
sore.