CHAPTER 48: SKIN AND WOUND CARE

Pressure Ulcer: localized injury to the skin and underlying tissue over the bony prominences, as
result of pressure and/or friction. Factors contributing to pressure ulcers are: 
 decreased mobility
 decreased sensory perception
 fecal or urinary incontinence 
 poor nutrition 
1st is tissue ischemia: when the pressure on the capillary exceeds normal capillary pressure and
the tissue doesn't get enough O2. If the pressure is relieved then the vasodilation takes place =
redness (hyperemia). To check if the pressure ulcer is a real stage one ulcer; 
press over the affected area and if the area turns lighter and when you remove your finger and the
area turns red again then it is not an ulcer. But if it doesn’t turn lighter when you press the
affected area that means it is a stage 1 Ulcer.
Ulcer check: apply pressure to area , blanch = no ulcer / no blanch stays red = stage 1 

Stages of Ulcer: 
1. No-blanching and no skin break. pain, warm/cool, edema, discoloration of skin. 
2. Skin-break on the surface but is not deep (therefore, we don’t do wet-moist dressing).
Ointment/cream along with dry dressing is used. BLISTER: serosanguineous filled. 
3. Skin-break deep in the tissue (subcutaneous tissues exposed but no muscle/bone/tendons
exposed). We use wet to moist dressing. 
4. Wound goes down to muscle and even down to the bone in some cases. Can lead to
osteomyelitis or osteitis. 
Stages 3 and 4 can have necrotic tissue but only on the sides. If the slough or necrotic tissue
(eschar) is right in the middle of the wound bed, then we won't be able to see the depth of the
wound so it is considered UNSTAGEABLE. In such cases we do debridement (cut off) the
necrotic tissue or the slough so that we can see the depth of the wound and plan the treatment. 
Stage 1 can become 2 then 3 then 4, but stages NEVER downgrade regardless of healing.
Stage 4 will always be a stage 4
Wound classification: 

Onset and duration Causes Implications for

healing

Acute: Wound that proceeds through an Trauma, a surgical incision Wounds are usually
orderly and timely reparative process that easily cleaned and
results in sustained restoration of repaired. 
anatomical and functional integrity  wound edges are
clean and intact. 

Chronic: Wound that fails to proceed Vascular Compromise, Continued exposure

through an orderly and timely process to chronic inflammation, or to insult impedes
produce anatomical and functional repetitive insults to tissue  wound healing. 
integrity. 

Healing Process: 

Primary Intention: surgical incision, wound is Epithelialization. 

Closed wounds  sutured neatly  Heals fast and clean with
minimal scar formation.

Secondary Intention: wound from any other incident Wound heals by granulation
Wound edges not besides surgical incision such as tissue (new tissue with new
approximated  pressure ulcers, surgical wounds Blood vessels) formation,
with tissue loss. Incision is not wound contraction and
neat.  epithelialization. 

Tertiary Intention: wounds that were already healing Closure of wounds is delayed
Wound left open for and meshed but an accident due to risk of infection. 
several days, wound caused it to rip open. such
edges are approximated  wounds are contaminated and
require observation for signs of
inflammation
Drainage
o Serous – clear
o Sanguineous – red (bloody)
o Serosanguineous – pink
o Purulent – yellow/green  may indicate infection

Nutrients required in wound healing are: Proteins, Vitamin A,C, & E, fluid and Zinc. 
Complication of wound healing: 
 Hemorrhage: bleeding from the wound site or inside the wound tissues- hematoma. 
 Infection: presence of purulent drainage. 
 Dehiscence: When wound fails to heal properly, the layers of skin and tissue separate.
mostly occurs before collagen formation. Risk for wound healing=risk for dehiscence
 Evisceration: Total separation of wound layers with organs protruding out of the body.
Surgical repair. Nurses must use sterile methods, using normal saline, soak and cover the
organ in the sterile moist gauze. And observe for symptoms of shock. 

BONY PROMINENCES: 
 Pressure ulcer sites for: 
Supine position sitting position Lateral or side lying position

Occipital, scapula, spinous scapula, sacrum, ear, shoulder, anterior iliac spine, trochanter,
process, elbow, iliac crest, ischium, thigh, medial knee, lateral knee, lower leg,
sacrum, ischium, Achilles posterior knee, medial malleolus, lateral malleolus, lateral
tendon, heel, & sole.  sole,  edge of foot, posterior knee,