03/05/2022
SKIN INTEGRITY AND WOUND CARE
TYPES OF WOUNDS
➢Incision:
Cause: sharp instrument (e.g., knife or scalpel)
Open wound; deep or shallow; once the edges
have been sealed together as a part of treatment
or healing, the incision becomes a closed wound.
➢Contusion
Cause: blow from a blunt instrument
Closed wound, skin appears ecchymotic
(bruised) because of damaged blood vessels.
➢Abrasion
Cause: surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks)
Open wound involving the skin.
➢Puncture
Cause: pe*******on of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional.
➢Laceration
Cause: tissues torn apart, often from accidents (e.g., with machinery) Open wound; edges are often jagged.
➢Penetrating wound
Cause: pe*******on of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments).
TYPES OF WOUND HEALING
➢Primary intention 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.
Example: closed surgical incision.
➢Secondary intention healing: A wound that is extensive and involves considerable tissue loss,
and in which the edges cannot or should not be approximated, heal
Secondary intention healing compared to Primary intention healing.
(1) The repair time is longer, (2) the scarring is greater, and (3) the susceptibility to
infection is greater.
📚Terms:
Friction: force acting parallel to the skin surface.
Shearing: combination of friction and pressure.
Pressure ulcers: injury to the skin and/or underlying tissue, usually over a bony prominence (due to localized Ischemia).
Exudate: a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation.
Dehiscence: the splitting or bursting open of a wound.
Evisceration: protrusion of the internal viscera through an incision.
(SELECTED) TYPES OF WOUND DRESSINGS
➢Transparent film
Purpose: provide protection against contamination and friction; to maintain a clean moist surface that facilitates cellular migration; to provide insulation by preventing fluid evaporation; and to facilitate wound assessment.
➢Hydrocolloids
Purpose: absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; to protect the wound from bacterial contamination, foreign debris, and urine or f***s; and to prevent shearing.
➢Hydrogel
Purpose: liquefy necrotic tissue or slough, rehydrate the wound bed, and fill in dead space.
➢Polyurethane foams
Purpose: absorb up to heavy amounts of exudate; to provide and maintain moist wound healing; to provide thermal insulation.
Credits:
Kozier & Erb's Fundamentals of Nursing Concepts, Practice, and Process. (10th Edition)