The skin is the largest organ of the body and serves a variety of important functions in

maintaining health and protecting the individual from injury. For healthy individuals,
maintaining skin integrity is not a problem but for those who have restricted mobility,
chronic illnesses, undergoing invasive health care procedures, this may be a problem.
One of the function of nurses is to maintain skin integrity. To do this, nurses must
understand the factors affecting skin integrity, the physiology of wound healing and
specific measures that promote optimal skin conditions.

INTERNAL FACTORS THAT INFLUENCED SKIN INTEGRITY

GENETICS AND HEREDITY - skin color, sensitivity to sunlight, and allergies.
AGE - very young and very old is more fragile and susceptible to injury than adults.
UNDERLYING HEALTH OF THE INDIVIDUAL - chronic illness and treatments
A. impaired peripheral arterial circulation - damage skin on legs
B. corticosteroids causes thinning of the skin
C. other medications that affect skin integrity - tetracycline, doxycycline, methotrexate
(for cancer), tricyclic antidepressants.

EXTERNAL FACTOR - ACTIVITY

SKIN INTEGRITY – refers to the presence of normal skin and skin layers uninterrupted
by wounds.

TYPES OF WOUNDS
INTENTIONAL - trauma occur during therapy like in surgeries and venipunctures
UNINTENTIONAL - wounds are accidental
CLOSED - without break in the skin
OPEN - when skin or mucous membrane is broken

According to degree of wound contamination:

Clean wounds - are uninfected wounds in which there is minimal inflammation and the
respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds
are primarily closed wounds.
Clean-contaminated wounds - are surgical wounds 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 wounds and surgical wounds
involving a major break in sterile technique or a large amount of spillage from the
gastrointestinal tract. Contaminated wounds show evidence of inflammation.
Dirty or infected wounds - include wounds containing dead tissue and wounds with
evidence of a clinical infection, such as purulent drainage.

CLASSIFYING WOUNDS BY DEPTH

Partial thickness: confined to the skin, that is, the dermis and epidermis; heal by
regeneration
Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly
muscle and bone; require connective tissue repair

Pressure ulcers consist of injury to the skin and/or underlying tissue, usually over a
bony prominence, as a result of force alone or in combination with movement.
Pressure ulcers were also called decubitus ulcers, pressure sores, or bedsores.

ETIOLOGY OF PRESSURE ULCERS

- Pressure ulcers are due to localized ischemia, a deficiency in the blood supply
to the tissue.
- The tissue is compressed by the furniture (such as the bed or chair) and the bony
skeleton.
- Blood cannot reach the tissue, the cells are deprived of oxygen and nutrients.
- Waste products of metabolism accumulate in the cells and the tissue dies.
- The skin appears pale
- When pressure is relieved, the skin takes on a bright red flush, called reactive
hyperemia (due to vasodilation).
- Reactive hyperemia usually lasts one half to three quarters as long as the
duration of impeded blood flow to the area, redness disappears, no tissue
damage is anticipated.
 - But if the redness does not disappear, then tissue damage has occurred.

FACTOR FOR FORMATION OF THE PRESSURE ULCERS

 FRICTION AND SHEARING
 IMMOBILITY
 INADEQUATE NUTRITION
- Causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.
 FECAL AND URINARY INCONTINENCE
- Moisture from incontinence promotes skin maceration (tissue softened by
prolonged wetting or soaking) and digestive enzymes in feces contribute to
skin excoriation (area of loss of the superficial layers of the skin)
 DECREASED MENTAL STATUS
- Less able to recognize and respond to pain due to prolonged pressure.
 DIMINISHED SENSATION
- Reduces ability to respond to trauma and recognize and provide healing
mechanisms for wound
 EXCESSIVE BODY HEAT
- Increases metabolic rate thus increasing need for oxygen
 CHRONIC MEDICAL CONDITIONS
- Compromise oxygen delivery to tissue by poor perfusion and thus cause poor
and delayed healing and increased risk of pressure sores
 ADVANCED AGE
- Due to changes in the skin brought about by aging process like:
a) Loss of lean body mass
b) Generalized thinning of the epidermis
c) Decreased strength and elasticity of the skin due to changes in the
collagen fibers of the dermis
d) Increased dryness due to a decrease in the amount of oil produced by
the sebaceous glands
e) Diminished pain perception due to a reduction in the number of
cutaneous end organs responsible for the sensation of pressure and
light touch
f) Diminished venous and arterial flow due to aging vascular walls.
OTHER FACTORS:
- poor lifting and transferring techniques
- incorrect positioning
- hard support surfaces
- incorrect application of pressure relieving devices
STAGES OF PRESSURE ULCERS

BRADEN SCALE FOR PRESSURE ULCER SORE RISK

- A tool used to assess high risk patient for pressure ulcer development
- A total score of 23 points is impossible and a score of 18 is considered at risk

NORTON'S PRESSURE AREA RISK ASSESSMENT

COMMON PRESSURE SITES
- Back of head and ears
- Shoulder
- Elbow
- Hip
- Lower back
- Buttocks
- Inner knees
- Heel

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. It is also called primary union or first intention
healing. An example, a closed surgical incision, use of tissue adhesive (a liquid
glue that can be used to seal clean lacerations or incisions and may result in less
noticeable scars)
Secondary intention healing
- An example is a pressure ulcer, differs in primary intention in three: (1) The repair
time is longer (2) the scarring is greater (3) the susceptibility to infection is
greater.
Tertiary intention
- Wounds that are left open for 3 to 5 days to allow edema or infection to resolve
or exudate to drain, then closed with sutures, staplers or adhesive skin closures.
Also called delayed primary intention.

Phases of wound healing

1. Inflammatory phase
2. Proliferative phase
3. Maturation phase

Exudate - refers to the material such as fluid and cells that has escaped from blood
vessels during the inflammatory process and is deposited in tissue or on tissue
surfaces.
The nature and amount of exudate vary according to the tissue involved, the intensity
and duration of the inflammation and the presence of organisms.

TYPES OF WOUNDS EXUDATE

A serous exudate consists chiefly of serum (the clear portion of the blood) derived from
blood and the serous membrane of the body, such as the peritoneum. It looks watery
and has few cells. An example is the fluid in a blister from a burn.
A purulent exudate is thicker than serous exudate because of the presence of pus,
which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria.
The process of pus formation is referred to as suppuration. Purulent exudates vary in
color, some acquiring tinges of blue, green, or yellow. The color may depend on the
causative organism.
A sanguineous exudate consists of large amounts of red blood cells, indicating
damage to capillaries that is severe enough to allow the escape of red blood cells from
plasma. This type of exudate is frequently seen in open wounds.

Complications of Wound Healing

1. Hemorrhage
CAUSES: a dislodged clot, a slipped stitch or erosion of a blood vessel
SIGNS: swelling or distention in the area of the wound, hematoma (appears
reddish blue swelling)
NURSING INTERVENTION: apple pressure dressing to the wound and monitor
vital signs
MEDICAL INTERVENTION: return to OR for surgical intervention

2. Infection
CAUSE: microorganisms colonize and multiply excessively or invade the tissue
SIGNS AND SYMPTOMS: change in wound color, pain, oder, fever, elevated,
WBC
 3. Dehiscence - is the partial or total rupturing of a sutured wound.
4. Evisceration - is the protrusion of the internal viscera through an incision.
FACTOR FOR OCCURENCE: obesity, poor nutrition, multiple trauma, failure of
suturing, excessive coughing, vomiting, and dehydration.
- Usually involves abdominal wound in which the layers below the skin also
separate.
- Occurs 4-5 days post-op before extensive collagen is deposited in the wound.
SIGN: patient may feel something has given way
NURSING INTERVENTION: wound should be quickly supported by large sterile
dressing soaked in sterile normal saline, place patient in supine with knees bent
to decrease pull on the incision.
MEDICAL INTERVENTION: surgical repair of the area.

Factors affecting wound healing

1. Developmental consideration - healthy children and adult heal more quickly than
elderly and had chronic illnesses
2. Nutrition - rich in protein, carbohydrates, lipids, vitamin A and C and minerals
3. Lifestyle - persons who exercise regularly heals faster than those who smokes and
alcohol drinker
4. Medication - anti-inflammatory drugs (steroids and aspirin) and antineoplastic agents
interfere with healing. Prolonged use of antibiotic makes a person susceptible to wound
infection

Purposes of Wound dressing

1. To protect the wound from mechanical injury
2. To protect the wound from microbial contamination
3. To provide or maintain moist wound healing
4. To provide thermal insulation
5. To absorb drainage or debride a wound or both
6. To prevent hemorrhage
7. To splint or immobilize the wound site and thereby facilitate healing and prevent
injury.
Types of dressing
1. Woven gauze sponges - these are absorbent and wick away the wound exudate.
They can be used to pack wound as well. They come in various texture and
sizes.

2. Non- adherent dressing (Telfa) - these are used over clean wounds. They have a
shiny face that does not stick to wounds, but does not allow drainage to pass thru
to the gauze in the upper layer

3. Wet to dry dressing - these are used for mechanical debridement of necrotic
tissue. Gauze moistened with the prescribed solution is placed over or into the
wound and allowed to dry. When the dressing is pulled off, the debris adhering to
it is also removed.

4. Self- adhesive Transparent Film (Acuterm, Tegaderm, Op-site) - - these act as

temporary second skin and are ideal for small, superficial wounds. they adhere
wellm serve as a barier to bacteria, allow the wound to breathe, keep the wound
moist permit viewing the wound, do not require a secondary dressing, and can be
removed without damaging underlying tissues
5. Hydrocolloid Dressing or HCD ( duoderm, dermiflex, biofilm) - these are
occlusive dressings. DO not need a cover and are water resistant. They can be
molded to uneven body surface. They can be used to heal granulating wound
and to debride necrotic wounds autolytically

6. Hydrogel dressing ( Aquasorb, Intrasite gel, Transorb) - these are water or

glycerin-based amorphous-gel impregnated gauze or sheet dressings. They are
used on partial to full thickness wounds, deep wounds with exudate, necrotic
wounds and burns. They have a high water content, are soothing to the wound,
can debride the wound, are easily removed without sticking, and can be used in
infected wounds.

7. Other types:
a. Foam dressing
b. Alginate dressing
DRESSING
- Is a strip of cloth used to wrap some part of the body.

PURPOSES:
1. It supports dressings and at the same time permits air to circulate.
2. It can be impregnated with petroleum jelly or other medications for application to
wounds.
3. To provide pressure to an area.

BASIC TURNS FOR BANDAGING:

1. Circular turns - are used to anchor bandages and to terminate them.
2. Spiral turns - are used to bandage parts of the body that are fairly uniform in
circumference.
3. Spiral reverse - are used to bandage cylindrical parts of the body that are not
uniform in circumference.
4. Recurrent turns - are used to cover distal parts of the body.
5. Figure of eight - are used to bandage an elbow, ankle, or knee because they
permit some movement after application.

REST AND SLEEP

REST
- Diminish state of activity, calmness, relaxation without emotional stress.
- Freedom from anxiety
SLEEP
- A state of consciousness in which the individual’s perception and reaction to the
environment is decreased
PHYSIOLOGY OF SLEEP
- RETICULAR ACTIVATING SYSTEM (RAS)
- SEROTONIN

Theories of Sleep
1. Active Theory of Sleep – proposes that there are centers that cause sleep by
inhibiting other brain centers.
2. Passive Theory of Sleep – states that the RAS of the brain simply fatigues and
therefore becomes inactive thus, sleep occur.

STAGES OF SLEEP
- RAPID EYE MOVEMENT (REM)
- NON-RAPID EYE MOVEMENT (NREM)
PRN – AS NEEDED OR AS NECESSARY

Nursing Interventions to Promote Sleep

• Helping nurse – patient relationship
• Promote comfort and relaxation.
• Create restful environment.
• Attend to bedtime rituals.
• Adequate exercise. Exercise at least 2 hours before sleep to enhance NREM, not
immediately before sleep.
• High protein food. Protein contains tryptophan which is a CNS depressant.
• Use the bed mainly for sleep.
• Use sedative-hypnotics judiciously.
• Observe habits of sleep periodicity and wake up time.
• Avoid caffeine and alcohol in the evening.
• Go to bed when sleepy.

Common Sleep Disorders

1. Insomnia – difficulty in falling asleep, intermittent sleep, premature awakening.
2. Hypersomnia – excessive sleep (day and night), related to psychologic problems,
CNS damage, metabolic disorders.
3. Narcolepsy (“Sleep Attack “) – overwhelming sleepiness, REM uncontrolled
4. Sleep Apnea – periodic cessation of breathing during asleep. It is characterized by
snoring.

Parasomnias:
1. Nocturnal Enuresia – bedwetting
2. Somniloquy – sleep talking.
3. Nocturnal Erections – “Wet Dreams” usually experienced by adolescent males
4. Bruxism – clenching and grinding of teeth during sleep. May erode and diminish the
height of dental crowns and may cause the teeth to become loose.
5. Somnambolism – sleep walking
6. Night Terrors – after having slept for few hours, the child bolts upright in bed, shakes
and screams appears pale and terrified.