This document discusses skin integrity and wound care. It describes factors that affect skin health like age, illness, and activity level. Wounds are breaks in skin integrity and can be accidental or surgical. The stages of pressure ulcer development and types of wound healing are explained. Finally, it outlines the three phases of wound healing - defensive, reconstructive, and maturation - and factors that can influence the healing process like nutrition, circulation, and immune function.

1. SKIN INTEGRITY AND WOUND
CARE
BY: Nelson Munthali Dip/RN

2. objectives
 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

3.  Describe the three phases of 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. SKIN INTEGRITY
 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

7. WOUND
 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. abrasions
 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

9. Puncture wounds
 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
 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. Pressure sore

15. ULCER STAGING
 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.

16. Stage III
 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

17.  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.

18. RISK FACTORS
 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.

19. ALTERED NUTRITIONAL
STATUS
 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.

20. ALTERED MENTAL STATUS
 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.

21. FRICTION
 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

22. COMMON LOCATIONS
 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

23. Wound healing
 When the skin is wounded, a type of healing
by replacement occurs.
PHASES OF WOUND HEALING
Defensive phase
It is also known as inflammatory or exudative
phase. The body responds to the wound by
setting up defenses against further invasion
It involve combined forces of hemostasis,
inflammation and cell migration to control
bleeding, seal the wound , and protect the
wound from bacterial contamination.

24. hemostasis
 Is the process to stop bleeding, and is the first
step in defensive phase. It occurs as a result of
vasoconstriction of injured vessels, platelet
aggregation and clot formation, deposition of
fibrin which forms a matrix for cellular repair.
 The inflammatory response is the next step in
defensive phase. The venules dilate, capillaries
open and there is increased vascular
permeability to plasma. Symptoms may
include : pain, redness, swelling and warmth.

25. Reconstructive phase
 The reconstructive or proliferative phase begins on
the third or fourth day after injury. In this phase,
which lasts about two weeks, the fibroblasts
multiply and form a network for migrating cells.
Collagen synthesis is the major event at this phase.
MATURATION PHASE
The maturation or modeling phase which completes
healing process begins about three weeks after the
injury and may last up to two years. The number of
fibroblasts decreases and collagen synthesis
stabilises .

26. TYPES OF WOUND HEALING
 Wounds heal differently depending on
whether or not tissue loss has occurred.
HEALING BY FIRST INTETION
 Wounds with minimal tissue loss such as
clean surgical incision, shallow structured
wounds heal by first intention (approach
each other ) rapidly . Granulation tissue is
not visible and scarring is generally
minimal. Infection risk is lower when
wounds heal by first intention.

27. Healing by second intention
Wounds with tissue loss such as deep
lacerations, burns and decubitus ulcers have
that do not rapidly approximate
HEALING BY THIRD INTENTION
Healing by third intention occurs when a
wound is closed at a later stage after wound
surfaces have already started granulating.
This may happen when a deep wound is not
sutured.

28. FACTORS AFFECTING WOUND
HEALING
There are many factors that can affect wound healing:
Nutrition: nutritional defincies retard wound healing
by pronging the exudative phase and inhibiting
collagen synthesis. Patients with protein deficient
are more likely to develop infections
Circulation of oxygen: blood circulation to the
involved wound and oxygenation of the tissues
greatly influence wound healing. Wound healing is
slowed when there is reduced cellular blood flow
and that is the reason for prolonged healing in bed
sores.

29. Immune cellular function
 Immunosupression delays wound healing. Any
underlying condition that lowers immune
function will lead to delayed wound healing.
There are also drugs that affect the immune
system like corticosteroids which would lead
to delay in wound healing. Chemotherapy and
radiation retard wound healing.
DRUGS: A number of drugs in addition to those
that affect the immune response alters wound
healing
Oral anticoagulants given to decrease the chance
of thrombus formation increase chances of
bleeding

30. stress
 Physical and emotional stress triggers the
release of catecholamines. They cause
blood vessels to constrict, decreasing blood
flow to the wound.
Local factors
 Usually, a surgical incision made using
strict aseptic technique heals faster

31. COMPLICATIONS OF WOUND
HEALING
 Delayed wound healing can cause a number of
complications which includes: hemorrhage,
hematoma formation, infection, dehiscence,
evisceration and fistula
 Hemorrhage: after initial trauma, bleeding is
expected, but within several minutes
hemostasis occurs. However, when large blood
vessels are cut or patient has poor clotting
ability, bleeding may continue. Bleeding may
occur internally or externally.

32. hematoma
 Hematoma is a localised collection of blood appears as a
swelling or mass underneath the skin surface and often
has a bluish color.
Infection: a break in the skin creates a port of entry for
microorganisms.
Dehiscence and evisceration
Dehiscence is total or partial disruption of the wound
edges. As wound edges separate an increase in drainage
occurs.
Evisceration is protrusion of viscera through a wound
opening. It can follow dehiscence if the wound is not
closed.

33. fistula
 A fistula is an abnormal tube like
passageway that forms between two organs
or from one organ to the outside of the
body. Normal wound healing promotes
tissue closure, thus preventing abnormal
communication between organs of the body.