2. Objectives
Demonstrate use of four senses in observing
skin/wounds (listening, looking, touching,
smelling)
List ways to promote healing
Demonstrate routine care of wounds and
surgical drains
3. Objectives
Recognize signs/symptoms of inflammation
Demonstrate use of four senses in observing
dressing over wound site
Demonstrate correct technique of changing
clean and sterile dressings
Document and report care related to skin
integrity
4. Anatomy of Skin
The skin or integumentary system is the largest
system of the body. Hair, nails, and skin glands
are a part of this organ system.
The skin is a thin, relatively, flat organ that is
classified as a cutaneous membrane. It forms a
protective boundary between the internal
environment of the body and the external
environment.
7. Epidermis
The outer skin layer that is in direct contact
with the environment
The epidermis has five layers
Contains skin pigment (melanin) that gives
color to the skin
Contains a water repellant protein called
keratin
8. Epidermis
Cells in the epidermis constantly change and
regenerate (research suggests 35 days)
Injury to these cells may cause blisters &
calluses
9. Dermis
Contains no skin cells
Composed of collagen (a tough fibrous
protein
layer), blood vessels, and nerve cells
70% of the dermis layer is collagen which is
very important in wound healing
Dermis restores the physical properties of the
skin and its structural integrity
10. Dermis
Provides mechanical strength of the skin
Provides a reservoir storage area for water and
important electrolytes
Contains a specialized network of nerves and
nerve endings for sensation of pain, pressure,
touch, and temperature
11. Dermis
Hair follicles
Collagen makes the skin stretchable & elastic
Point of attachment for smooth and voluntary
muscles
12. Subcutaneous Layer
Is not part of the skin itself, but supplies the
major blood vessels and nerves to the skin
above
Loose spongy texture
Ideal site for rapid and relatively pain-free
absorption of injected medications
(subcutaneous injection)
13. Functions of the Skin
Functions of the skin are crucial for
maintenance of homeostasis.
1.Protection
Barrier against bacteria, foreign matter,
dehydration, ultraviolet (UV) light
2. Sensation
Sense organ
3. Movement without injury
4. Excretion
Regulating the volume and chemical content of
sweat
14. Functions of the Skin
5. Vitamin D production
Exposure of skin to UV light
6. Immunity
Specialized cells that attack and destroy
pathogenic microorganisms
7. Temperature regulation
Heat production and heat loss (shivering,
vasoconstriction, etc)
15. Wound - Definition
A break in the skin or mucous membrane;
An alteration in the integrity of the skin and
underlying tissues.
17. Risk Factors for Developing a
Wound
Broken skin
Age (young or old)
Nutritional Status
Stress
Hereditary
Disease process (acute or chronic)
Medical therapies - steroids, chemotherapy,
radiation, diuretics
18. Type of Wounds
1. Intentional - created for therapy
i.e., surgical
2. Unintentional - resulting from trauma
i.e., fall
3. Open wound - skin or mucous membrane is
broken
4. Closed wound - tissues are injured but the
skin is not broken
19. Type of Wounds
5. Clean wound - not infected, usually
intentional
6. Contaminated wound - high risk of
infection usually unintentional
7. Infected wound - (dirty wound) contains
bacteria; signs of infection
20. Type of Wounds
8. Chronic wound - wound that does not heal
easily; can be due to pressure or circulation
9.Partial-thickness wound - epidermis &
dermis of the skin is broken (superficial)
10. Full-thickness wound - epidermis, dermis,
subcutaneous tissue are involved and may
involve muscle and bone (penetrating)
21. Description of Wounds
Wounds can be described by cause:
1. Abrasion - scraping or rubbing away of the
skin
2. Contusion - closed wound caused by a blow
to the body
3. Incision - open wound with clean straight
edges
22. Description of Wounds
4. Laceration – open wound with torn tissues
and jagged edges
5. Penetrating wound – skin and underlying
tissue are pierced
6. Puncture wound - open wound from a
sharp object
23. Skin Tears
Occur most frequently in the elderly due to
skin changes in the elastic fibers in the
dermis, increased fragility of blood vessels,
changes in the membrane between the
epidermis & dermis, & thickening of collagen
These changes cause the skin to age and the
skin appears translucent, wrinkled, thin, dry,
fragile & lacking tensile strength
24. Skin Tears
Upper and lower extremities most common
site
80% of skin tears occur on the arms and
hands
Tears are caused by friction and shearing
Tears are painful and can lead to wound
complications
25. Principles of Tissue Healing
The body’s ability to handle tissue trauma
is influenced by:
Extent of damage, i.e. skin intact or broken
Person’s state of health, i.e. nutritional status
Body’s response to trauma
Healing is promoted when wound is free of
foreign bodies and bacteria
26. Phases of Wound Healing
Inflammatory or Defensive Stage
Starts when skin integrity is impaired and
continues from 4 - 6 days
Homeostasis - blood vessels constrict,
platelets stop bleeding forming clots to
scabs
Inflammatory response - increased blood flow
and vascular permeability causing redness
& edema
27. Phases of Wound Healing
Inflammatory or Defensive Stage
White blood cells - arrive & clean cell of
debris
Epithelial cells - move to base of wound
margins for 48 hours
28. Phases of Wound Healing
Proliferative or Reconstruction Stage
Closure begins on day 3 or 4 & continues for
2 - 3 weeks
Fibroblasts with vitamin C & B for repair
Collagen - provides strength and structure
Epithelial cells - duplicate damaged cells
29. Phases of Wound Healing
Maturation Stage
Final stage of healing & may last for 1
year as the scar strengthens
31. Types of Wound Healing
Primary intention - Incision edges of a clean
surgical incision remain close, tissue loss is
minimal & skin quickly regenerates
Secondary intention - Open wound with
tissue loss and jagged edges, there is a gap
between the edges, granulation tissue
gradually fills in the area of defect with
scar tissue
32. Types of Wound Healing
Tertiary intention
Sometimes called delayed intention or closure
Surgical wounds are left open 3 - 5 days & then
stapled or sutured closed
34. Signs & Symptoms of Infection
1. Erythema and edema
2. Painful and tender
3. Drainage & odor - tan, cream, green,
yellow
4. Fever
5. Fatigue
35. Signs & Symptoms of Infection
6. Rash
7. Change in WBC
8. Loss of appetite
9. Mucous membrane sores
10. Elderly: confused, agitated, incontinent
36. Wound Drainage
The exudate deposited in or on tissue
surfaces during inflammatory & destructive
phases of healing.
Drainage must leave the wound for healing to
occur
Trapped drainage can lead to infection and
other complications
38. Types of Wound Drainage
3. Serosanguineous drainage
Thin watery drainage that is blood tinged
4. Purulent drainage
Thick green, yellow, or brown drainage
39. Drains
When large amounts of drainage are
expected, the physician inserts a drain to aid
in healing. drainage systems can be opened or
closed.
Penrose drain
An open drain that drains exudate onto the
dressing; no suture; safety pin prevents
slippage into the wound; drains by gravity
40. Drains
Hemovac
Closed suction drainage, sutured in place
Jackson-Pratt
Closed suction drainage, sutured
T-tube
Closed drainage, sutured; drains by gravity
41. Drains
Keep drainage tubes free of kinks
Drainage collection reservoir is emptied every
eight hours and when 1/2 to 1/3 full
Drainage volume decreases 2 - 3 days after
insertion
Report any purulence, foul odor, redness
around insertion site, bleeding
45. Measuring Drainage
Note the number and size of dressings with
drainage (describe amount)
Weighing dressing before and after removal
Measuring the amount of drainage in the
collection receptacle
Record on I&O form
46. Wound Complications
Hemorrhage
May be internal or external
Shock
Low or falling blood pressure; rapid, weak pulse;
rapid respirations; skin - cold, moist, and pale;
restless; confusion; loss of consciousness
Infection
Dehiscence
Separation of wound layers, usually abdominal, caused by
wound stress (coughing, vomiting, abdominal distention);
surgical emergency
47. Wound Complications
Evisceration
Separation of wound with protrusion
of abdominal organs, surgical emergency,
cover with normal saline sterile dressings,
notify RN immediately
Fistula
An abnormal tube-like passage from a normal
cavity or tube to a free surface or to another
cavity
48. Wound Observations
Wound location
May have multiple wounds from surgery or trauma
Wound size and depth
Measure in centimeters
Size - measure from top to bottom, side to side
Depth - use a sterile swab into the depth of the
open wound, RN supervision
Wound appearance
Red, swollen, area around wound warm to touch,
sutures, staples - intact or broken