Ch 33: Skin Integrity and Wound Care

Ch 33: Skin Integrity and Wound Care

Structures of the Skin

The skin is composed of three main layers, each with distinct functions and characteristics.

• Epidermis: The outermost layer, made of keratin, provides waterproof protection. It lacks blood vessels and regenerates quickly.

• Dermis: Located beneath the epidermis, this layer contains elastic tissue (mainly collagen), nerves, hair follicles, glands, immune cells, and blood vessels.

• Subcutaneous Layer: Anchors the skin to underlying tissues and provides insulation and cushioning.

Functions of the Skin

The skin performs several vital functions for overall health:

• Protection: Acts as a barrier against pathogens and physical injury.

• Body Temperature Regulation: Blood vessels dilate to dissipate heat and constrict to retain heat.

• Psychosocial: Contributes to self-image and social interactions.

• Sensation: Contains nerve endings for touch, pain, and temperature.

• Vitamin D Production: Synthesizes vitamin D when exposed to sunlight.

• Immunologic: Provides immune defense mechanisms.

• Absorption: Absorbs certain substances through the skin.

• Elimination: Excretes waste products via sweat.

Factors Affecting Skin Integrity

Several factors influence the health and resilience of the skin:

• Unbroken and Healthy Skin: Provides defense against harmful agents.

• Age, Tissue Amount, and Illness: Resistance to injury varies with these factors.

• Nourishment and Hydration: Well-nourished and hydrated cells resist injury.

• Adequate Circulation: Essential for maintaining cell life.

Developmental Considerations

Skin structure and function change throughout life:

• Children & Infants: Skin is thinner and more susceptible to injury and infection.

• Older Adults: Impaired circulation and collagen formation lead to decreased elasticity and increased risk for tissue damage.

Causes of Skin Alterations

• Body Composition: Very thin or obese individuals are more prone to skin injury.

• Dehydration: Fluid loss during illness increases risk of skin breakdown.

• Jaundice: Causes yellowish, itchy skin.

• Skin Diseases: Conditions like eczema and psoriasis may cause lesions requiring special care.

Types of Wounds

Wounds are classified based on cause, depth, and duration:

• Intentional: Surgical wounds.

• Unintentional: Traumatic wounds.

• Neuropathic/Vascular: Related to nerve or blood vessel issues.

• Pressure Related: Caused by prolonged pressure.

• Open/Closed: Skin broken or intact.

• Acute/Chronic: Duration of healing.

• Partial/Full Thickness/Complex: Depth of tissue involvement.

Wound Terminology

• Incision: Clean cut by a sharp instrument.

• Contusion: Injury by blunt force; skin intact, bruising present.

• Abrasion: Scraping of epidermal layers.

• Laceration: Tearing of skin and tissue.

• Puncture: Deep wound by a pointed object.

• Penetrating: Object remains embedded.

• Avulsion: Tearing away of tissue.

• Chemical/Thermal/Irradiation: Caused by chemicals, heat, or radiation.

• Pressure, Venous, Arterial, Diabetic Ulcers: Specific types of chronic wounds.

Principles of Wound Healing

Effective wound healing depends on several principles:

• Intact Skin: First line of defense against infection.

• Hand Hygiene: Essential in wound care.

• Systemic Response: The body responds to trauma throughout its systems.

• Adequate Blood Supply: Necessary for healing.

• Foreign Material: Healing is promoted when wounds are free of debris.

• Extent of Damage & Health: Both affect healing rate.

• Nutrition: Proper nutrition enhances healing.

Phases of Wound Healing

Wound healing occurs in four distinct phases:

• Hemostasis: Immediate response; blood vessels constrict, clotting begins, exudate forms.

• Inflammatory: Lasts 2-3 days; white blood cells (leukocytes, macrophages) migrate to wound, debris is removed, growth factors released.

• Proliferation: Lasts weeks; fibroblasts build new tissue, capillaries grow, epithelial layer forms, granulation tissue develops.

• Maturation: Begins ~3 weeks post-injury; collagen remodeled, scar forms (avascular, does not sweat or grow hair).

Local and Systemic Factors Affecting Wound Healing

• Local Factors: Pressure, dehydration (desiccation), overhydration (maceration), trauma, edema, infection, excessive bleeding, necrosis, biofilm presence.

• Systemic Factors: Age, circulation/oxygenation, nutrition, wound etiology, health status (e.g., corticosteroids, radiation), immunosuppression, medication, adherence to treatment.

Wound Complications

• Infection: Microbial invasion delays healing.

• Hemorrhage: Excessive bleeding.

• Dehiscence: Separation of wound edges.

• Evisceration: Protrusion of internal organs.

• Fistula Formation: Abnormal passage between organs or tissues.

Pressure Injuries

Pressure injuries (formerly "pressure ulcers") result from prolonged pressure, friction, or shearing forces.

• Risk Factors: Aging skin, chronic illness, immobility, malnutrition, incontinence, altered consciousness, spinal/brain injuries, neuromuscular disorders.

• Mechanisms: External pressure compresses blood vessels; friction/shearing tears vessels; microclimate (temperature/moisture) affects skin.

• Risks: Nutrition, hydration, immobility, mental status, age.

Stages of Pressure Injuries

• Stage 1: Nonblanchable erythema of intact skin.

• Stage 2: Partial-thickness skin loss with exposed dermis.

• Stage 3: Full-thickness skin loss; not involving underlying fascia.

• Stage 4: Full-thickness skin and tissue loss.

• Unstageable: Obscured full-thickness skin and tissue loss.

• Deep Tissue Pressure Injury: Persistent nonblanchable deep red, maroon, or purple discoloration.

Psychological Effects of Wounds

• Pain, Anxiety, Fear: Emotional responses to wounds.

• Impact on Activities: May limit daily living.

• Change in Body Image: Affects self-esteem and social interactions.

Assessment and Prevention

• Health History: Recent skin changes, activity, nutrition, pain, elimination.

• Skin Assessment: Inspection and palpation, including bony prominences; frequency varies by care setting.

• Wound Assessment: Appearance, size, depth, undermining/tunneling, drainage (serous, sanguineous, serosanguineous, purulent).

• Prevention: Daily risk assessment, routine cleansing, moisture management, minimizing friction/shearing, proper positioning, support surfaces, nutrition, mobility.

Wound Dressings and Management

• Purposes: Comfort, infection control, drainage absorption, moisture balance, protection, debridement, healing stimulation, ease of use, cost-effectiveness.

• Types: Dressings that maintain, absorb, or add moisture.

• Changing Dressings: Prepare patient, use aseptic technique, hand hygiene, remove old dressing, cleanse wound, apply new dressing, secure.

• Cleaning Wounds: Clean with each change, use new gauze for each wipe, clean from top to bottom/center to outside, irrigate with 0.9% normal saline, dry area, report drainage/necrosis.

Bandages and Binders

• Bandages: Roller bandages (circular, spiral, figure-of-eight turns).

• Binders: Slings, abdominal, chest, T-binders.

Drainage Systems

• Open Systems: Penrose drain.

• Closed Systems: Jackson-Pratt drain, Hemovac drain.

Color Classification of Open Wounds

Color	Action
Red	Protect
Yellow	Cleanse
Black	Débride
Mixed	Contains components of RY&B wounds

Home Health Care Teaching Topics

• Supplies

• Infection prevention

• Wound healing

• Appearance of skin/recent changes

• Activity/mobility

• Nutrition

• Pain

• Elimination

Hot and Cold Treatments

Thermal treatments are used to manage pain and promote healing.

• Factors Affecting Response: Method, duration, degree of heat/cold, patient age/condition, body surface area covered.

• Effects of Heat: Dilates blood vessels, increases metabolism, reduces blood viscosity, increases capillary permeability, reduces muscle tension, relieves pain.

• Effects of Cold: Constricts blood vessels, reduces muscle spasms, promotes comfort.

Devices for Heat Application

• Hot water bags

• Electric heating pads

• Aquathermia pads

• Hot packs

• Warm, moist compresses

• Sitz baths

• Warm soaks

Devices for Cold Application

• Ice bags

• Cold packs

• Hypothermia blankets

• Cold compresses

Key Definitions and Examples

• Contusion: Bruise caused by blunt force; skin remains intact but underlying tissue is injured.

• Maceration: Overhydration of skin, often due to incontinence, leading to breakdown.

• Débridement: Removal of dead or damaged tissue to promote healing; required for stage 3 pressure injuries.

• Granulation Tissue: New tissue formed during proliferation phase, foundation for scar development.

Wound Healing Phases: Summary Table

Phase	Main Events
Hemostasis	Vessel constriction, clotting, exudate formation
Inflammatory	WBC migration, debris removal, growth factor release
Proliferation	Fibroblast activity, new tissue, capillary growth, granulation
Maturation	Collagen remodeling, scar formation

Example: Pressure Injury Management

• Stage 3 pressure injuries require débridement via wet-to-dry dressings, surgical intervention, or proteolytic enzymes.

• Prevention includes regular assessment, skin care, nutrition, and mobility improvement.

Additional info: Academic context was added to clarify wound types, healing phases, and prevention strategies, as well as to provide definitions and examples for key terms.