Skin Integrity and Wound Care

Factors Affecting Skin Integrity Genetics and heredity
Age
Chronic illnesses and their treatments
Medications
Poor nutrition
Clean Wound
Uninfected wound
Minimal inflammation
The respiratory, alimentary, genital, urinary tracts are not entered
Clean wounds primarily closed wounds
clean-Contaminated Wound
Surgical wounds in which respiratory, alimentary, genital or urinary tracts has been entered.
No evidence of infection
Open, fresh, accidental wounds and surgical wounds.
Major break in sterile technique or large amount of spillages from gastrointestinal tract.
Evidence of inflammation
Wounds containing dead tissue.
Wound with evidence of clinical infection
Purulent discharge
Complications of Wound Healing
Hemorrhage – internal or external
Infection
Dehiscence – separation of healing wound
Evisceration – organs protrude through wound
Fistula – unnatural opening between organs
Delayed Wound Closure
Wound dressing
Use isotonic saline
Antimicrobial preparation
Use warm solution
If wound is clean avoid repeated cleansing
Avoid use cotton
Wound irrigation (Lavage)
Wound packing
Assessment of Pressure Ulcers
Location of the ulcer related to a bony prominence
Size of ulcer in centimeters including length (head to toe), width (side to side), and depth
Presence of undermining or sinus tracts
Stage of the ulcer
Color of the wound bed
Location of necrosis or eschar
Condition of the wound edges
Integrity of surrounding skin
Clinical signs of infection
Inspect pressure areas for discoloration and capillary refill or blanche response
Inspect pressure areas for abrasions and excoriations
Palpate the surface temperature over the pressure area sites
Palpate bony prominences and dependent body areas for the presence of edema