• anatomy & physiology of the skin
• identify patients at risk for altered skin integrity
• assessment of skin and wounds
• discuss interventions for prevention of pressure ulcers
• nursing interventions for patients experiencing issues with skin integrity
• compare and contrast wound care modalities

• protection
• thermoregulation
• identification
• metabolism/excretion
• fluid balance
• sensation
• (skin should be your first assessment)
• (skin excretion may cause rash - body's elimination of toxins)

• xerosis (red, itching, fissures)
• loss of subcutaneous fat
• loss of elasticity
• regeneration time
• chronic disease
• increased risk for breakdown
• increased healing time

• mobility
• nutrition
• hydration/fluid balance
• sensation
• circulation
• medications
• moisture (maceration, excoriation, incontinence)
• illness/fever/infection
• temperature
• lifestyle (smoking, diet, exercise, piercings-tattoos-tanning, hygeine)

of the following factors, which would put a client at greatest risk for impaired skin integrity?

a-the medication digoxin
b-moisture
c-decreased sensation
d-dehydration

• palpable, non-palpable, fluid filled
• above the skin, below the skin
• by size and shape
• macule: less than 1 cm, solely a change in color
• papule: solid elevated, circumscribed, less than 1 cm (eg. wart)
• nodule: larger than 1 cm
• pustule: filled with pus
• by configuration
• annular: circular - begins in center and spreads to periphery (eg. ringworm)
• confluent: lesions run together (eg. hives)
• linear: a scratch, streak or stripe

• Intentional vs. unintentional
• Based on skin integrity
• closed (intact) - contusion, hematoma, abscess
• open - abrasions, incisions, lacerations
• Level of Contamination
• clean - surgical incision
• clean contaminated - surgal incision that may become infected - respiratory, digestive
• contaminated - break in asepsis
• colonized  - chronic wounds have bacteria, but not doing any harm
• infected - bacteria overwhelm and do harm - releasing toxins, invading neighboring tissues, can go systemic

• Acute - short duration, expected to heal without complications
• Chronic
• Pressure ulcers - caused by pressure, often over bony prominences
• Arterial ulcers - inadequate circulation of oxygenation blood to tissue causing tissue ischemia and damage
• Venous stasis ulcer - incompetent venous valves (blood can't get back to heart and lungs) resulting in venous pooling and edema
• Diabetic ulcers

• superficial - only the epidermal layer of the skin
• partial thickness - extend through the epidermis but not through the dermis
• full thickness - extend into the subcutaneous tissue and beyond
• penetrating - full thickness wound that involves internal organs

• Inflammatory/Defensive Phase
• Hemostasis
• Inflammation and phagocytosis
• Reconstructive/Proliferative Phase
• Fibroblasts and collagen
• Granulation tissue
• Maturation Phase/Epithialization
• Remodeling
• Scarring

• regeneration
• in epidermal wounds
• no scar
• primary intention
• clean surgical incision/edges approximated
• minimal scarring
• Secondary Intention
• wound edges not approximated
• heals from inner layer to surface
• risk of infection
• Tertiary Intention
• initially heals by secondary intention
• granulating tissue sutured together

• Hemorrhage
• Internal (hematoma)
• External
• Infection
• Dehiscence
• Evisceration
• Fistulas

• Caused by unrelieved pressure that compromises blood flow to the area resulting in ischemia
• Most commonly occur over bony prominences
• Also caused by friction and shearing and moisture
• 15% of hospital patients, 10% of home-care patients and 20% of long-term care patients have pressure ulcers
• Risk assessment and prevention are key interventions

• Health Perception-Health Management
• Activity-Exercise
• Cognitive-Perceptual
• Nutrition-Metabolic

• typical activity level
• assistive devices
• areas of numbness or tingling
• pain
• recent changes in skin
• open sores, wounds, scars
• difficulty with healing
• medical history/medications/surgeries
• nutrition/hydration
• hygeine practices
• incontinence
• smoking
• exposure to sun

• color
• integrity (WNL: skin is warm, dry, and intact)
• texture
• lesions
• turgor/moisture
• hair distribution
• edema
• dressing

• temperature
• tenderness
• crepitus
• edema

laboratory and diagnostic tests:

• Complete Blood Count (CBCs)
• Erthrocyte Sedimentation Rate (ESR)
• C-Reactive Protein (CRP)
• Comprehensive Metabolic Panel (albumin, total protein, kidney function, glucose)
• Wound and Blood Cultures, Biopsy
• Coagulation Studies (PTT, PT/INR)

Braden scale:

• sensory perception
• moisture (too much or too little)
• activity
• mobility
• nutrition
• friction and shear

• arterial ulcers
• venous stasis ulcers
• diabetic ulcers
• pressure ulcers
• hyperemia
• redness that does not blanch is the first sign of skin breakdown
• with dark skin may present as discoloration or firmness

• acute wounds
• local infection: purulent or foul smelling drainage, erythema, edema, warmth, increasing pain
• systemic: fever, chills, general malaise, ^WBCs, ^HR and RR
• Chronic Wounds: foul odor, change in the color of the wound bed, new tunneling, absence of granulation tissue, or it becomes friable (bleeds easily)

• Risk for Infection
• Pain
• Disturbed Body Image

Maintenance of Intact Skin or Healing of Wounds

• Patient will maintain intact skin until day of discharge as evidenced by good skin turgor, no erythema, edema, or breaks in skin
• Wound will show progressive decrease in size, a decrease in drainage, improvement of the surrounding skin, and no evidence of infection a.e.b. absence of erythema, drainage or odor

■ Monitor any reddened areas closely.
■ Turn every 1– 2 hours, as appropriate.
■ Turn with care (e.g., avoid shearing) to prevent injury to fragile skin.
■ Post a turning schedule at the bedside, as appropriate.
■ Avoid massaging over bony prominences.
■ Utilize specialty beds and mattresses, as appropriate.
■ Avoid use of “donut” type devices in the sacral area.

Other Interventions
■ Nutrition Management 
■ Positioning
■ Pressure Management
■ Skin Surveillance

■ Monitor characteristics of the wound, including drainage, color, size, and odor.
■ Cleanse with normal saline or a nontoxic cleanser, as appropriate.
■ Apply an appropriate ointment to the skin/lesion, as appropriate.

Other Interventions
■ Pruritus
■ Management
■ Skin Surveillance
■ Wound Irrigation

■ Débride the ulcer, as needed.
■ Cleanse the ulcer with the appropriate nontoxic solution, working in a circular motion from the center.
■ Cleanse the skin around the ulcer with mild soap and water.
■ Monitor for infection in the wound.
■ Position every 1– 2 hours to avoid prolonged pressure.

Other Interventions
■ Wound Care
■ Pressure Management
■ Infection Protection
■ Medication
■ Administration

• Assessment
• Bony prominences
• Skin folds
• Braden Scale
• Meticulous Skin Care
• Do not massage over bony prominences
• Manage Moisture
• Keep linens dry and wrinkle free

• Frequent position changes
• #1 way to prevent pressure ulcers
• Avoid friction and shearing
• Use Draw Sheet
• Use of therapeutic mattresses, cushions, and pillows
• Adquate Nutrition
• Vitamin C, Zinc, Protein, and Fluids
• Patient and Family Teaching

• Relieve Pressure!!!
• Promote Granulation
• Remove debris and necrosis
• Absorb excess exudate
• Keep moist
• Debride if necessary
• Keep surrounding skin dry
• Prevent or Treat Infection
• Manage Edema
• Promote Circulation

• Sharp: use of a sharp instrument, such as scalpel or scissors, to remove devitalized tissue
• Mechanical: may be performed via the use of wet-to-dry dressings, hydrotherapy (whirlpool), or lavage
• Enzymatic: the application of a topical enzymatic agent to the wound
• Autolysis: use of an occlusive moisture-retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue

• Protect from contamination and heat loss
• Aid hemostasis
• Absorb drainage
• Debride the wound
• Splint the wound site
• Prevent drying of the wound bed
• Keep the surrounding tissue dry and intact
• Provide comfort to the patient

• Removes exudate, slough, foreign material and microorganisms
• Promotes tissue healing
• Be careful not to damage granulating tissue
• Normal Saline is best (irrigation or cleansing)
• Keep periwound area clean
• Use principles of clean technique or sterility

• Document appearance of wound with accurate descriptors (i.e. location, stage, appearance, inflammation, size, drainage, odor, etc.)
• What dressings or products were used (or as ordered)
• Patient response to procedure

• Determine whether there are any contraindications to treatment (impaired circulation, bleeding, wound complications, impaired sensation, inability to tolerate treatment)
• Moist Heat - irrigations, compress, hot soaks, sitz bath - reapply and change water frequently to maintain constant temperature
• Dry Heat - electric heating pads, disposable hot packs, hot water bags
• Never place heat source directly on skin
• Apply heat intermittently, leave on for no more than 15-20 minutes at a time (helps prevent tissue injury, helps prevents rebound)

• Determine whether there are any contraindications to treatment (impaired circulation, bleeding, wound complications, impaired sensation, inability to tolerate treatment)
• cooling baths, cold compress, ice collars, ice bags, commercially prepared ice packs, aquapads
• avoid direct contact with skin
• apply cold intermittently, no more than 15-20 minutes at a time to help prevent tissue injury and prevent rebound

• Stage I - Non-blanchable erythema of intact skin, in individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators
• Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater
• Stage III - Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining
• Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with Stage IV ulcers
• Non-stageable - a pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible: this means that wounds covered with eschar and/or slough cannout be staged, and should be documented as non-observable or non-stageable
• Deep tissue injury - pressure-related deep tissue injury under intact skin or deep tissue injury under intact skin

• Measure in centimeters - always document length x width x depth
• Length - head to toe direction
• Width - hip to hip direction
• Depth - measure deepest part of visible wound bed

• document using the "clock system" with head=12:00 (example: 2 cm undermining at 3 o'clock)
• tunneling - course or pathway that can extend in any direction from the wound, results in dead space
• undermining - tissue destruction underlying intact skin along wound margins
• sinus tract - a drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface

• type:
• sanguineous - thin, bright red
• serosanguineous - thin, watery, pale red to pink
• serous - thin, watery, clear
• purulent - thick or thin, opaque tan to yellow
• foul purulent - thick opaque yellow to green with offensive odor
• amount
• none - wound tissues dry
• scant - wound tissues moist, no measurable drainage
• small - wound tissues very moist, drainage <25% dressing
• moderate - wound tissues wet, drainage involves 25 - 75% dressing
• large - wound tissues filled with fluid - involves >75% dressing
• odor
• describe presence or absence of odor - strong, foul, pungent, fecal, musty, sweet

• adherence of the tissue
• nonadherent - easily separated froum wound base
• loosely adherent - pulls away from wound, but attached to wound base
• firmly adherent - does not pull away from wound
• amount - describe in % (example: 50% wound bed covered with soft yellow slough, 50% beefy red granulation tissue), may also use "clock system" in describing location of necrotic tissue in wound bed
• tissue types
• slough - usually lighter in color, thinner and stringy in consistency, color - can be yellow, gray, white, green, brown
• eschar - usually darker in color, thicker and hard consistency black or brown in color
• granulation tissue - it is usually beefy-red, granular, bubbly in appearance; should be differentiated from a smooth red wound bed; color of tissue - red, pink, pale pink or full dusky red
• epithelialization - can appear as deep pink, then progress to peraly pink/light purple from edges in full thickness wound or may form islands in the wound base with superficial wounds
• foreign bodies

• definition - defined or undefined edges
• attachment - attached or unattached edges
• rolled under (epibole) - macerated - fibrotic - callused
• border shape

• occiput
• acromion process
• scapula
• olecranon
• sacrum
• ischial tuberosity
• lateral knee
• metatarsals
• calcaneus
• lateral malleolus
• medial malleolus 
• trochanter
• coccyx
• lumbar vertebrae
• thoracic vertebrae