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 skin to underlying tissues and provides insulation and cushioning.

Functions of the Skin

The skin serves multiple essential 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: Supports immune responses.

• Absorption: Absorbs certain substances.

• Elimination: Excretes waste products through sweat.

Factors Affecting Skin Integrity

Several factors influence the skin's ability to resist injury and heal.

• Healthy Skin and Mucous Membranes: Provide defense against harmful agents.

• Age, Tissue Amount, and Illness: Resistance to injury decreases with age, less tissue, or illness.

• Nourishment and Hydration: Well-nourished and hydrated cells are more resistant to injury.

• Circulation: Adequate blood flow is necessary for cell life and healing.

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 by 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: Depth of tissue involvement.

Wound Terminology

• Incision: Clean cut by 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 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: Body responds to trauma throughout.

• Blood Supply: Adequate perfusion is necessary.

• Foreign Material: Healing is promoted when wound is clean.

• Extent of Damage & Health: More damage and poor health slow healing.

• Nutrition: Proper nutrition enhances healing.

Phases of Wound Healing

Wound healing occurs in four overlapping 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, grow hair, or tan).

Local and Systemic Factors Affecting Wound Healing

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

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

Wound Complications

• Infection: Delays healing, may cause systemic illness.

• 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") are localized damage to skin and underlying tissue.

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

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

• Risks: Poor 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: Wounds can cause significant discomfort and emotional distress.

• Impact on Activities: May limit daily living activities.

• Body Image: Changes can affect self-esteem.

Assessment of Skin and Wounds

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

• Skin Assessment: Inspection and palpation, head-to-toe, focus on bony prominences, regular intervals depending on care setting.

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

Preventing Pressure Injuries

• Daily assessment of at-risk patients.

• Routine skin cleansing and moisturization.

• Protection from moisture (incontinence).

• Minimize friction/shearing.

• Proper positioning, turning, transferring.

• Use of support surfaces.

• Nutritional supplements.

• Promote mobility and activity.

Wound Dressings

Dressings serve multiple purposes in wound management.

• Provide comfort.

• Prevent/control infection.

• Absorb drainage.

• Maintain moisture balance.

• Protect wound and surrounding skin.

• Debride necrotic tissue.

• Stimulate healing.

• Ease of use and cost-effectiveness.

Types of Dressings

• Maintain moisture.

• Absorb moisture.

• Add moisture.

Changing Dressings and Cleaning Wounds

• Prepare patient and use aseptic technique.

• Hand hygiene before and after.

• Remove old dressing, cleanse wound, apply new dressing, secure.

• Clean with each dressing change; use new gauze for each wipe, clean from top to bottom or center outward.

• Use 0.9% normal saline for irrigation.

• Dry area with gauze; report drainage or necrotic tissue.

Types of 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

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, patient age/condition, body surface area.

Effects of Heat

• Dilates peripheral blood vessels

• Increases tissue metabolism

• Reduces blood viscosity, increases capillary permeability

• Reduces muscle tension

• Relieves pain

Effects of Cold

• Constriction of peripheral 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

Additional info: Academic context was added to clarify wound types, healing phases, and pressure injury stages. Definitions and examples were expanded for clarity and completeness.