Skin Integrity and wound care presentation

skin integrity and wound care

1. Topic: Skin Integrity and
Wound Care
Presented By:
•Muhammad Sufian
•Ayesha Khawar
•SamraShafi
•Sidra Nawaz
•Mukhtar Muneeb
JINNAH COLLEGE OF NURSING, FAISALABAD .

2. CONTENTS
Define decubeticulcer (bed sore)
List the causes of decubeticulcer
Identity rise bactarsof bedsores
Apply nursing interventions to prevent decubeticulcer.
Wounds, its types and stages

3. Skin Integrity
A skin integrity issue might mean the skin is
damage vulnerable to injury unable to heal
normally
An injury tissue cause by cut, blow the impact
typically one in which the skin is broken.

4. Pressure Ulcers
Pressure ulcers are also known as bed sores ordecubitus ulcers. It may be closed
or open. They form because of sitting or lying in one position for too long. This
leads to cutting off blood circulation over parts of your body and damaging
surrounding tissue. Pressure ulcers forms predominantly over skin that covers
bony areas of the body.
Common places:
Back of head
Shoulders
Back
Elbows
Hips
Ankles
Heels

5. Etiology of Pressure Ulcers
Pressure ulcers are due to localized ischemia, a
deficiency in the blood supply to the tissue.
The tissue is compressed between two surfaces,
usually the surface of furniture such as the bed or
chair and the bony skeleton.
When blood cannot reach the tissue, the cells are
the deprived of oxygen and nutrients, the waste
products of metabolism Its accumulate in the
cells, and the tissue consequently dies.

6. Etiology of Pressure Ulcers
After the skin has been compressed, it appears
pale, as if the blood had been squeezed out of it.
After the skin has been compressed, it appears
pale, as if the blood had been squeezed out of it.
When the pressure is relieved the skin takes on a
bright red flush called reactive hyperemia. The
flush is due to vasodilation.

7. Risk Factors of Pressure Ulcers
Several factors contribute
to the formation of
pressure ulcers:
1-Friction and shearing
2-Immobility
3-Inadequate nutrition
4-Decreased mental status
5-Diminished sensation
6-Excessive body heat
7-Advanced age

8. Risk Factors
FRICTION AND SHEARING
Frictionis a force acting parallel to the skin surface. For
example, sheets rubbing against skin create friction.
Friction can abrade the skin, that is, remove the
superficial layers, making it more prone to breakdown.
Shearingforce is a combination of friction and pressure.
It occurs commonly when a client assumes a sitting
position in bed. The force damages the blood vessels and
tissues in this area.

9. Risk Factors
INADEQUATE NUTRITION
Prolonged inadequate nutrition causes:-
1-Weight loss
2-Muscle atrophy
3-The loss of subcutaneous tissue.
More specifically inadequate intake of Protein,
Carbohydrates, Fluids, Zinc, Vitamin C.
Hypoproteinemia(abnormally low protein content in the
blood) can cause pressure sores.

10. Risk Factors
IMMOBILITY
Immobility refers to a reduction in the amount and control of
movement a person has. Normally people move when they
experience discomfort due to pressure on an area of the body. But
when have not been able to move due to weakness and pain,
then it causes the pressure ulcers.
EXCESSIVE BODY HEAT
Body heat is another factor in the development of pressure ulcers.
An elevated body temperature increases the metabolic rate, thus
increasing the cells' need for oxygen. This increased need is
particularly severe in the cells of an area under pressure, which are
already oxygen deficient.

11. Risk Factors
DECREASED MENTAL STATUS
Individuals with a reduced level of awareness, for example, those
who are unconscious, heavily sedated, or have dementia, are at
risk for pressure ulcers because they are less able to recognize and
respond to pain associated with prolonged pressure.
DIMINISHED SENSATION
Paralysis, stroke, or other neurologic disease may cause loss of
sensation in a body area. Loss of sensation reduces a person's
ability to respond to trauma, to injurious heat and cold, and to
the tingling ("pins and needles") that signals loss of circulation.

12. Risk Factors
ADVANCED AGE
The aging process brings about several changes in the skin.
These changes include the following:
• Loss of lean body mass
• Generalized thinning of the epidermis
• Decreased strength and elasticity of the skin
• Increased dryness
• Diminished pain perception
• Diminished venous and arterial flow.

13. Stages of Pressure Ulcers

14. Stages of Pressure Ulcers

15. Stages of Pressure Ulcers

16. Stages of Pressure Ulcers

17. Nursing Interventions for Pressure
Ulcers
Intervention Dependent Independent
Assessment Collaborate with healthcare
team for wound evaluation
Regularly assess the patients skin
integrity
Wound DressingFollow physiciansorders for
specific dressings
Change dressings as needed based
onwound condition
Positioning Seek guidance from physical
therapy for optimal patient
positioning
Rotate patient every 2 hours to
relieve pressure.

18. Nursing Interventions for Pressure
Ulcers
Intervention Dependent Independent
NutritionalSupportConsultwith a dietitian for
personalized nutrition plans.
Ensureadequate protein and
calorie intake.
MobilityAssistanceInvolvephysical therapy for
mobility improvement.
Encourageregular changes in
position for immobile patients.
PainManagement Administerprescribed pain
medications.
Implementnon-pharmalogical
pain relief methods.

19. Nursing Interventions for Pressure
Ulcers
Intervention Dependent Independent
Hygiene Assistwith bathing as per
healthcare providers
instructions.
Maintaingood skin hygiene,
avoiding excessive moisture.
SupportSurfaces Usespecialized support
surfaces as recommended by
the healthcare provider.
Utilizepressure relieving
mattresses or cushions.
Monitoring Regularlymonitor vital signs
and laboratory values.
Keep a close watch on wound
healing progress

21. Wound
Awoundisaninjurytothebody'stissuescausedby
physical means,suchasacut,scrape,puncture,ortear.
Woundscan varyinseverityfromminortosevere,andthey
canoccuron thesurfaceoftheskinorinternallywithinthe
body.
Wounds typicallytriggerthebody'snaturalhealing
processes,which involveinflammation,clotting,tissuerepair,
andregeneration.
Properwoundcareisimportanttopreventinfectionand
promotehealing.

22. Degrees of Wounds
Clean wounds are uninfected wounds in which there is minimal
inflammation and the respiratory, gastrointestinal, genital and
urinary tracts are not enter. Clean wounds are primarily close
wound. Pain redness swelling heat etc.
Clean contaminated wounds are surgical wound in which the
respiratory gastrointestinal, genital or urinary tract has been
entered. Such wounds show no evidence of infection.
Contaminated wounds include open fresh, accidental wound
involved a major break in sterile technique or large amount of
spillage from the gastrointestinal tract. Contaminated wounds
show evidence of information.

23. Degrees of wounds
Dirty and infected wounds include wound containing
dead tissue and wound with evidence of a clinical
infection, such as purulent drainage.
Classifying wound by depth
Partial Thickness:
Confined to the skin that is, the dermis and epidermis
heal by regeneration.
Full Thickness:
Involving the dermis subconscious, tissue and possibly
muscle and bone required connective tissue repair.

24. Types of Wounds
Incision wound
Contusion wound
Abrasion wound
Puncture wound
Laceration wound
Penetratingwound

25. Types of Wounds
Incision
Anincisionisasurgicalcutmadethroughtheskinand sometimes
othertissuelayers,typicallyperformedduring medicalproceduresto
accessunderlyingstructures,remove diseasedtissue,orfacilitateother
interventions.
Contusion
Acontusion isessentiallyafancytermforabruise.Itoccurs when
bloodvesselsundertheskinaredamaged,usuallydue tosomesortof
bluntforcetrauma.Whenyougetacontusion, theareamightswell
upandbecomediscoloredbecauseblood leaksfromthedamaged
vesselsintothesurroundingtissue.

26. Types of Wounds
Abrasion
Anabrasionisasuperficialruborwearingofftheskin,usually
causedbyscrapeorabrushburn. Abrasionsareusuallyminor
injuriesthatcanbetreatedathome. Theskinmaybleedsmall
amountatthetimeoftheInjury orattimesoverthenextfew days
ifrubbedorscratched.
Puncture Wound
A"puncturewound"isatypeofcutthatismadewhena sharp
object,likeanail,goesthroughtheskinandintothe tissue
underneath.Thistypeofwoundcanalsobecausedby animalor
humanbites.Puncturewoundsaremorelikelythan otherminor
woundstogetinfected.

27. Types of Wounds
Laceration
Alacerationorcutreferstoaskinwound.Unlikeanabrasion,
noneoftheskinismissing.
Acutistypically thoughtofasa woundcausedbyasharp
object,likeashardofglass.
Lacerationstendtobecausedbyblunttrauma.
Penetratingwounds
Penetratingwoundsarecausedbyobjectsthatpenetratethe
body,thatis,theypiercetheskinandlacerate,disrupt, destroy,or
contuseadjacenttissue,thuscreatinganopen wound.
Penetratinginjuriescanhavemultipleetiologies;the most
commonaregunshotwoundsandsharpinstruments.

28. WOUND HEALING
Wound healing refers to the natural
physiological process by which the body
repairs and restores damaged tissue
integrity following injury or trauma.

29. Types of Wound Healing
The types of healing are influenced by the amount of tissue loss.
Two types:
1-Primary intention healing
2-Secondar intension healing.
Primary Intension Healing 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.
(i.e) Closed surgical incision.

30. Types of Wound Healing
Secondary Intension Healing
It occurs where the tissue surfaces have not been
approximated.
(i.e) Pressure ulcer.
Secondary intention healing differs from primary
intention healing in three ways:
(1) The repair time is longer
(2) the scarring is greater
(3) the susceptibility to infection is greater.

31. Phases of Wound Healing
Wound healing can be broken down into three
phases:-
Inflammatory
Proliferative
Maturation or
Remodeling

32. Phases of Wound Healing
INFLAMMATORY PHASE
Two major processes occur during this phase: hemostasisandphagocytosis.
Hemostasis:-It results from:
Vasoconstriction of the larger blood vessels Retraction (drawing back) of
injured blood vessels. The deposition of fiber in the formation of blood clots.
During cell migration, 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.

33. Phases of Wound Healing
PROLIFERATIVE PHASE
The proliferative phase, the second phase in healing, extends from day
3 or 4 to about day 21 post injury.
Fibroblasts (connective tissue cells), which migrate into the wound
starting about 24 hours after injury, begin to synthesize collagen.
Collagen is a whitish protein substance that adds tensile strength to the
wound.
Two processes occur:-
1) Granulation Tissue Formation
2) Scar Formation

34. Phases of Wound Healing
MATURATION PHASE
The maturation phase begins on about day 21 and can extend 1 or
2 years after the injury. Fibroblasts continue to synthesize collagen.
The collagen fibers themselves, which were initially laid in a hap
hazard fashion, reorganize into a more orderly structure.
Duringmaturation, the wound is remodeled and contracted. In
some individuals, particularly dark-skinned individuals, an
abnormal amount of collagen is laid down. This can result in a
hypertrophic scar, or keloid.

35. References
Kozier, B. (1983). Fundamentals of Nursing: Concepts, process, and
practice
Carper, B. A. (1978). Fundamental patterns of knowing in Nursing.
Advances in Nursing Science
Reddy, M., Gill, S. S., & Rochon, P. A. (2006). Preventing Pressure
Ulcers: A Systematic Review
Murphree, R. W. (2017). Impairments in skin integrity. Nursing
Clinics of North America
Martin, P. (1997). Wound Healing--Aiming for perfect skin
regeneration. Science