Skin Integrity and Wound Care

SKIN INTEGRITY
AND WOUND CARE

Skin Intact Skin
 It is the largest organ in the body and  It refers to the presence of normal skin
serves a variety of important functions in and skin layers uninterrupted by wounds.
maintaining health and protecting the
individual from injury.
THE APPEARANCE OF THE SKIN INTEGRITY ARE
INFLUENCED BY INTERNAL FACTORS SUCH AS:
 Genetics (and heredity) – determine many aspects of a person’s skin, including skin color,
sensitivity to sunlight, and allergies.
 Age – influences skin integrity in that the skin of both the very young and the very old is
more fragile and susceptible to injury than that of most adults. Wounds tend to heal more
rapidly in infants and children.
THE APPEARANCE OF THE SKIN INTEGRITY ARE
INFLUENCED BY INTERNAL FACTORS SUCH AS:
 Underlying Health of the individual – people with impaired peripheral arterial circulation
may have skin on the legs that damages easily. Some medications cause thinning of the
skin and allow it to be much more readily harmed. Many medications increase sensitivity
to sunlight and can predispose one to severe sunburns such as antibiotics (e.g.,
tetracycline and doxycycline), chemotherapy drugs for cancer (e.g., methotrexate), and
some psychotherapeutic drugs (e.g., tricyclic antidepressants.
 Poor nutrition
TYPES OF WOUNDS
INTENTIONAL UNINTENTIONAL
 The trauma occurs during therapy and  They are accidental (e.g., a person may
operations or venipunctures are example. fracture an arm in an automobile collision).
 Although removing a tumor is  Closed wound – tissues that are

therapeutic, the surgeon must cut into traumatized without a break in the skin.
body tissues, thus traumatizing them  Open wound – when the skin or mucous
membrane surface is broken.
TYPES OF WOUNDS ACCORDING TO HOW THEY
ARE ACQUIRED
TYPE CAUSE DESCRIPTION AND
CHARACTERISTICS
Incision Sharp instrument (e.g., knife or Open wound; deep or shallow;
scalpel) once the edges have sealed
together as a part of treatment or
healing, the incision becomes a
closed wound.
ARE ACQUIRED
CHARACTERISTICS
Contusion Blow from a blunt instrument Closed wound, skin appears

ecchymotic (bruised) because of
damaged blood vessels
Abrasion Surface scrape, either Open wound involving the skin
unintentional ( e.g., scraped
knee from fall) or intentional
(e.g., dermal abrasion to remove
pockmarks)
Puncture Penetration of the skin and often Open wound
the underlying tissues by a sharp
instrument, either intentional or
unintentional
ARE ACQUIRED
CHARACTERISTICS
Laceration Tissues torn apart, often from Open wound; edges are often
accidents (e.g., with machinery) jagged
Penetrating wound Penetration of the skin and the Open wound
underlying tissues, usually
unintentional (e.g., from a bullet
or mental fragments)
ARE ACQUIRED
Incision
ARE ACQUIRED
Contusion
ARE ACQUIRED
Abrasion
ARE ACQUIRED
Puncture
ARE ACQUIRED
Laceration
ARE ACQUIRED
Penetrating wound
TYPES OF WOUND ACCORDING TO THE
LIKELIHOOD AND DEGREE OF CONTAMINATION
CLEAN WOUNDS
 They are uninfected wounds in which
there is minimal inflammation and the
respiratory, gastrointestinal, genital, and
urinary tracts are not entered.
 They are primarily closed wounds.
CLEAN-CONTAMINATED WOUNDS
 They are surgical wounds in which the
respiratory, gastrointestinal, genital, or
urinary tract has been entered.
 Such wounds shows no evidence of
infection.
CONTAMINATED WOUNDS
 It includes open, fresh, accidental
wounds and surgical wounds involving a
major break in sterile technique or a
large amount of spillage from the
gastrointestinal tract.
 It shows evidence of inflammation.
DIRTY OR INFECTED WOUNDS
 It include wounds containing dead tissue
and wounds with evidence of a clinical
infection, such as purulent drainage.
WOUND HEALING
HEALING
 It is a quality of living tissue

 It is also referred to as regeneration (renewal) of tissues
 It can be considered in terms of:
 Types of healing – having to do with the primary care provider’s decision on whether to allow
the wound to seal itself or to purposefully close the wound
 Phases of healing – which refer to the steps in the body’s natural processes of tissue repair.
TYPES OF WOUND HEALING
PRIMARY INTENTION HEALING

 It occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue
loss.
 It is characterized by the formation of minimal granulation tissue and scarring.
 It is also called primary union or first intention healing.
 An example is a closed surgical incision
 Another example would be the use of tissue adhesive, a liquid glue that can be used to seal clean
lacerations or incisions and may result in less noticeable scars.
SECONDARY INTENTION HEALING

 A type of healing in which a wound that is extensive and involves considerable tissue
loss, and in which the edges cannot or should not be approximated
 An example is a pressure ulcer.
 It differs from primary intention healing in three ways: (1) the repair time is longer, (2)
the scarring is greater, and (3) the susceptibility to infection is greater.
TERTIARY INTENTION
 It heals wounds that are left open for 3 to 5 days to allow edema or infection to resolve
exudate to drain and are then closed with sutures, staples, or adhesive skin closures.
 This is also called delayed primary intention.
PHASES OF WOUND HEALING
INFLAMMATORY PHASE
 It begins immediately after injury and lasts to 6 days.
 It also involves vascular and cellular responses intended to remove any foreign
substances and dead and dying tissues – the blood supply to the wound increases,
bringing it oxygen and nutrients needed in the healing process – the area appears
reddened and edematous as a result – exudate of fluid and cell debris is a normal
accumulation and helps cleans the wound.
 Two major processes occur during this phase: hemostasis and phagocytosis.
HEMOSTASIS
 (cessation of bleeding) results from vasoconstriction of the larger blood vessels in the
affected area, retraction (drawing back) of injured black vessels, the deposition of fibrin
(connective tissue), and the formation of blood clots in the area – the blood clots provide
a matrix of fibrin that becomes the framework for cell repair – a scab (consists of blood
clots and dead dying tissue) may form on the surface of the wound that serves to aid
hemostasis and inhibit contamination of the wound by microorganisms – below the scab,
epithelial cells migrate into the wound from the edges.
 Epithelial cells – serve as a barrier between the body and the environment, preventing the
entry of microorganisms.
PHAGOCYTOSIS
Leukocytes (specifically neutrophils) move into the interstitial space
These are replaced about 24 hours after injury by macrophages
These macrophages engulf microorganisms and cellular debris by a process known as

phagocytosis
PROLIFERATIVE PHASE
 It is the second phase in healing, extends from day 3 or 4 to about day 21 post injury
MATURATION PHASE
> It begins on about day 21 and can extend 1 or 2 years after the injury.

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SKIN INTEGRITY

AND WOUND CARE

 Although removing a tumor is  Closed wound – tissues that are

Contusion Blow from a blunt instrument Closed wound, skin appears

 It is a quality of living tissue

PRIMARY INTENTION HEALING

SECONDARY INTENTION HEALING

Leukocytes (specifically neutrophils) move into the interstitial space

These are replaced about 24 hours after injury by macrophages

These macrophages engulf microorganisms and cellular debris by a process known as

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