Tissue Integrity Outline

Tissue Integrity:
➢ The state of structurally intact and physiologically functioning epithelial tissues.

➢ Tissue integrity includes integumentary, mucus membrane, and subcutaneous tissues

uninterrupted by wounds. It is influenced by internal factors such as genetics, age, and
the underlying health of the individual as well as external factors such as activity and
injury.

Layers of the skin:

1. Epidermis: provides a waterproof

barrier and creates our skin tone
2. Dermis layer: contains connective
tissues, hair follicles, and sweat
glands
3. Subcutaneous layer (hypodermis):
consist of fat and connective tissues

Functions of the skin – skin

1. Protection
1. The skin consist of strong and elastic protein fibers, collagen, keratin, and elastin that
protects the body from UV radiation and mechanical, thermal, and physical injury
2. The skin also protects the underlying tissues from invasion of harmful microorganisms
2. Sensation
1. Contains somatic sensory receptors that aid in sensation
2. The nerves in the skin enable the perception of touch, pain, pressure, heat, and cold
3. Thermal regulation and insulation
1. Dilation of blood vessels and secretion of sweat by the eccrine sweat gland which
functions under the control of the CNS and enables body to release excess heat
4. Excretion and secretion
1. Excrete water to the skin surface via diffusion
2. Secrets waste products such as urea, salt, sodium, water via sweating
5. Immunity
1. Langerhan cells of the epidermis can interact with T cells to help protect the body
from bacterial agents
2. Phagocytic cells in the hypodermis can engulf bacterial cells — how the skin helps to
detect infections
6. Endocrine/Vitamin D production
1. Cells in epidermis produce vitamin D3 by using the energy stored in UV radiation
7. Growth/absorption
1. Can expand into the elastin fibers meaning as the organism grows so does the skin

Skin integrity and factors affecting integrity:

Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds

Internal Factors
➢ Genetics
➢ Skin color is a biologic variation (amount of melanin in skin)
➢ People with light skin tones produce less melanin than people with dark skin
tones
➢ Melanin helps protect skin from easy damage; other aspects of sensitivity to
light and any allergies a person may have
➢ Age
➢ Very young and very old skin are more fragile and susceptible to injury than
that of most adults
➢ Underlying health conditions
➢ Pts with peripheral artery disease — the skin on their legs may damage
easily
➢ Pt on steroids — can cause thinning of the skin
➢ Some meds can increase sensitivity to sunlight and predispose someone to
severe sunburns such as some antibiotics, chemotherapy drugs,
psychotherapeutic drugs
➢ Nutrition
➢ Appearance and function of skin are affected by poor diet; a well-balanced
diet is recommended

External Factors
➢ Activity
➢ Can affect integrity of the skin by pressure, friction, shearing (cutting), falls,
and surgical procedures
Pressure Injury risk factors

1.) Friction and shearing is a force acting parallel to the skin

a.) Example: when sheets are rubbing against the skin this can cause abrasion to the skin
removing superficial layers

2.) Immobility

a.) Extreme weakness, pain, or paralysis can hinder the ability to change positions and
relieve discomfort due to pressure bc they cannot move on their own

3.) Inadequate nutrition

a.) Can cause weight loss, muscle atrophy, and the loss of subcutaneous tissue

b.) Reduce the amount of padding between skin and bone — increasing the risk of
pressure ulcers development

4.) Fecal and urinary incontinence

a.) Moisture from incontinence promotes skin laceration which is tissue that is softened
by prolonged wetting or soaking and makes the epidermis more easily eroded and
susceptible to injury

b.) Digestive enzymes in feces, urea in urine, and gastric food draining contributes to skin
excoriation (area of the skin loses superficial layer)

c.) Long exposes to urine and stool can be hazardous to skin tissues

5.) Decreases mental status

a.) Pts who are unconscious, heavily sedated, or have dementia are more at risk for
pressure ulcers due to the diminished ability to recognize or respond to pain from
prolonged pressure

6.) Diminished sensations

a.) Pts who suffer from paralysis, stroke, or other neurologic diagnosis can cause loss of
sensation which reduces the ability to respond to trauma, severe heat and cold, and
healing that signals loss of circulation

7.) Excessive body heat

a.) Elevated body temperature increases the metallic with the metabolic rate so the cells
need for oxygen is also increased — so when you have pressure areas where oxygen is
already insufficient and there is even less oxygen coming to that area this will inhibit the
ability to deal with severe infections
8.) Advanced age

a.) The loss of lean body mass, thinning of the epidermis layers, decrease elasticity, and
strength increase dryness, diminished pain perception, and demand venous and arterial
flow due to avian vascular walls — makes the older person more prone to impair skin
intelligence

9.) Chronic medical conditions

a.) Pts who have diabetes and cardiovascular disease are risk factors for pressure injuries
bc they compromise oxygen delivered to tissues and result in poor perfusion causing risk
for poor healing and pressure sores

10.) Other factors

a.) Poor lifting and transferring techniques

b.) Incorrect positions

c.) Hard support surfaces

d.) Incorrect application of pressure relieving devices

Assessment
WHO WHEN

The RN cannot delegate an assessment AM care

Repositioning

HOW WHAT to look for

Inspect — areas likely to have skin Color distribution

breakdowns such as skin folds (areas under Presence of edema
the breast and under the belly) Risk of breakdown — moist areas or red areas
Remove — anti-embolism stockings, braces, Skin turgor
or other medical devices Tattoos
Palpate — checking for temperatures, Piercings
moisture, and turgor; check pressure points Disruptions — lesions
like bony prominences (hip bones, tailbone, Odors
and heels of feet); check moist areas like
perineum areas (genitals
Repositioning —>

Abnormal Skin Assessments

PRIMARY LESIONS SECONDARY LESIONS
Develop during the evolutionary process of a
Basic reactions of the skin that hav definite skin disease; can develop from scratching or
appearance in size, shape, or structure from an infection
Macule - “patches” Scales
Tumor Crust
Vesicle Fissure
Papule Ulcer
Plaque Scar
Bulla Atrophy
Nodule Erosion
Wheal Lichenification - when the skin is thick and
leathery
Pustule - “cyst” Keloids

Braden Scale

a.) Used so that we can have a structured, consistent approach to assessing pts for risks

b.) Made up of 6 sub scales and a total of 23 points is possible and an adult who scores below 18
points is considered at risk

c.) The sub scales are sensory perception, moisture, activity, mobility, neutron, friction or shear

d.) Risk factors are rated on a scale of 1-4 with 1 being completely limited and 4 being no
impairment

e.) The scores from the 6 categories are added and the total score indicates a pts risk for
developing a pressure injury based on these ranges

***Mild risk: 15-18. Moderate risk: 13-14. High risk: 10-12. Severe risk: less than 9***

(know these risk scores for test)

3 Major Types of Exudates
Exudate — fluid and cells that have escaped from blood vessels during the inflammatory
process and is deposited in tissue or on the surface of tissue
1. Serous exudate — clear, watery plasma that consist mostly of serum which is the clear
portion of the blood; an example would be the clear fluid in a blister or burn
2. Purulent exudate — thicker than serous exudate because of the presence of puss which
consist of leukocytes, liquified dead tissue degree, and dead and living bacteria; can vary in
color such as hinges of blue, green, or yellow
3. Sanguineous exudate — large amounts of RBCs which indicates damage to capillaries that is
severe enough to allow RBCs to escape from plasma; often seen in open wounds and is bright
red and indicates active bleeding

Assessment Labs
1. WBC — looking to see if it is decreased; if low this can cause a delay in healing and
increase possibility of infection
2. RBC — can tell if a pt has a decreased hemoglobin count which indicates poor oxygen
delivery to tissues; hemoglobin is a protein in RBCs that carry oxygen throughout the body
3. Platelet — counts amount of platelets in blood; platelets are cells that help your blood clot; a
low platelet count might be a sign of a certain cancer or infection; a high platelet count can put
you at risk for harmful blood clots or strokes; coagulation studies are important bc prolonged
coagulation time can result in excessive blood loss and prolonged clotting; hyper coagulation
can lead to intravascular clotting which is clotting in the blood vessels and results in a deficient
blood supply through the wound area
4. Serum Protein/Albumin — provides an indication of the body’s nutritional reserves for
rebuilding cells; albumin is a protein made by your liver and it is an important indicator of the
pts nutritional status; a value below 3.5 grams per deciliter indicates poor nutrition and can
result in poor healing and infection
5. Serum Albumin
6. Wound Culture and Sensitivity — a wound culture can confirm or rule out the presence of an
infection (wound care nurse does this); a sensitivity study is helpful in the selection of
appropriate antibiotic therapy
Nursing Process for Impaired Tissue Integrity- What happens during this Nursing Process?
1. Assessment — always includes the integumentary system; the nurse should always be alert
to skin abnormalities when providing routine care to pts
2. Observation and patient interview — conduct general observation of patients skin during
interview checking for color, erythema (superficial reddening of the skin as result of injury/
irritation), dryness, rashes, lesions, hyperpigmentation, and hypopigmentation. Want to inquire
about skin diseases, skin lesions, and healing of sores
3. Physical examination — include inspection and palpation of skin; looking at skin color
distribution, turgor, edema, and characteristics of lesions. Pay close attention to skin folds
around the breast, the groin, the perineum, and bony prominences (bones at high risk for
pressure ulcers). Remove anti-embolic stockings, braces, or other medical artificial devices to
assess the skin underneath
4. Diagnostic tests — skin biopsies to differentiate a benign lesion from skin cancer. Cultures
can be performed to identify infections on tissue samples or on drainage and exudate
5. Independent interventions — set goals to control the severity of the diagnosis, prevent
infection, and promote healing. Teach pt about good hygiene: rinse thoroughly after using soap
to prevent dryness, use moisturizing lotion after bathing, cleaning and dressing wounds, and
how to properly dispose of soil dressings. Teach pt how to recognize signs of an infection or
necrotic tissue. Encourage expertise and proper nutrition
6. Collaborative therapies — may include the nurse, UAP, a wound care nurse, nurse case
managers, HCP, a dermatologist, an oncologist, and maybe a surgeon
7. Pharmacologic/ Non-pharmacologic Therapy — directed by HCP; pts with skin integrity
issues can benefit from a variety of non-pharcologic therapies such as a wound bag, diet high
in protein, and diet high in vitamins that promotes healing (vitamins A & C)
Diagnosing Planning Implementing
Risk for pressure ulcer Maintain skin integrity Support wound healing

Risk for impaired skin
integrity
Impaired skin integrity -
applies to pressure ulcers into
wounds pending through the
epidermis but not through the
dermis
Avoid potential associated Prevent pressure ulcers
risk
Dressing and cleaning wounds
Supporting and immobilizing
wound

Impaired tissue integrity -

applies to pressure ulcers and
wounds leading into
subcutaneous tissue, muscle,
or bone

Risk for infection - Pts with

existing impaired skin or
tissue integrity may have
diagnosis such as risk for
infection if the skin
impairment is severe, if pt is
immunosuppressed, or if the
wound is caused by trauma

Acute pain - nerve

involvement within tissue
impairment or a consequence
of procedures used to treat the
wound

Pressure Ulcers are - Injury to skin or underlying tissue, usually over a bony prominence, as a
result of force alone or in combination with movement.

Preventable — hospitals are not reimbursed when these injuries occur in a hospital setting
Ischemia — a deficiency in blood supplies to tissue; when blood cannot reach the tissue the cells
are deprived of oxygen and nutrients.
Deprivation - The waste products of metabolism accumulate in the
cells and the tissue consequently dies. Prolonged unrelieved
pressure also damages the small blood vessels. After the skin has
been compressed it appears pale as if the blood has been squeezed
out of it.
Reactive Hyperemia - When pressure is relieved it takes on a
bright red flush color
Vasodilation - The flush is vasodilation; a process in which extra
blood flows to the area to compensate for the previous period of
impended or blocked blood flow. Some common areas are sacral
areas which are trochanter and heal (**remember to raise heals to
prevent pressure ulcers and turn pt every 2 hrs to prevent injury in
other areas**)

What is Ischemia?

What is Vasodilation?

Pressure Injury Risk Factors – Fundamentals book page 830

1. Friction and shearing — friction is sheets rubbing against the skin and can abrade the skin
and remove superficial layers making skin prone to break down; shearing is a combination of
friction and pressure often seen when a pt assumes a sitting position in bed (body tends to start
slipping towards food of the bed meaning this downward movement is transmitted to the sacral
bond and the deep tissue. The force damages the blood vessels and tissues in this area. **Both
friction and shearing are common for pts who are bed bound **
2. Immobility — a reduction in the amount and control of movement a person has. Paralysis,
extreme weakness, pain, or any cause of decreased activity can hinder a persons ability to
change positions independently when they feel pressure or discomfort
3. Inadequate nutrition — causes weight loss, muscle atrophy, and loss of subcutaneous tissue.
These three conditions reduce the amount of padding between the skin and bone which
increases the risk of pressure ulcer development
4. Fecal and urinary incontinence — creates moisture and moisture from incontinence
promotes skin maceration which is tissue that is softened by prolonged wetting or soaking.
Maceration makes epidermis more easily eroded and susceptible to injury. **Maceration is
common for pts who are bed bound**
5. Decreased mental status — pts who are unconscious, heavily sedated, or have dementia are
at risk for pressure ulcers because they are less able to recognize the kind of pain that is
associated with prolonged pressure
6. Diminished sensation
7. Excessive body heat — when body temp is evaluated the metabolic rate increases which
increases the cells need for oxygen
8. Advanced age — changes that happen with skin and supporting structures. The older pt is
more prone to impaired skin integrity
9. Chronic medical conditions — pts with diabetes and cardiovascular disease are risk factors
due to compromised oxygen deliverance to tissues by perfusion which causes poor and delayed
healing increasing the risk of pressure ulcers
10. Other factors — poor lifting and transferring techniques, incorrect positioning, hard support
surfaces, incorrect application of pressure relieving devices, and using a donut device which
is contraindicated because this can lead to skin breakdown by cutting off arterial flow
and venous drainage to and from bony prominences
***Nurses must do a pressure ulcer assessment upon admission and reassess pts daily while
in hospital***

Pressure Injury Prevention Goals

1. Providing nutrition and hydration — inadequate intake of calories, protein, vitamins, and
iron is a risk factor. Consider supplements for nutritionally compromised pts. Check their
protein by checking their albumen levels
2. Maintaining skin hygiene — minimize the force and friction applied to the skin when
bathing the pts and use mild cleansing agents. Avoid hot water. Moisturize dry skin. Keep skin
clean, dry, and free of irritation and maceration by urine, feces, and sweat
3. Avoiding skin trauma — provide a smooth, firm, and wrinkle free foundation for lying and
sitting. Position, turn, and transfer correctly to prevent friction and shearing. Elevate the head
of the bed no more than 30 degrees. Provide frequent shift in positions. Use lifting device such
as a trapeze if available or a lift team. Reposition every 2 hours. Do not massage over bony
prominences.
4. Providing supportive devices — an overlay mattress, a foam, and gel covering mattress or a
specialty bed can provide pressure relief

Psychological Effects of Wounds

1. Pain

2. Anxiety

3. Fear

4. Change in Body Image

Stages of Pressure Injury
***know stages of pressure injury, identify the stages of a wound, and what dressings to
use***
*infections are the most serious complication involved with pressure ulcers*
*when treating pressure ulcers the nurse must follow agency protocols and HCP orders*
*prompt treatment can prevent further tissue damage, pain, and facilitate healing of the wound*
*the epidermis, dermis, superficial tissue, musculoaponeurotic system which contains a figure
septum and next level consist of vessels and fascia then you have the muscle and then the motor
nerve
Stage 1 Stage 2 Stage 3 Stage 4 Unstageable
Pressure injury Partial thickness Full thickness Full thickness Base of ulcer
skin loss skin loss skin loss with covered by
Erythema involving the involving extensive slough (yellow,
(redness) that epidermis or damage or destruction and tan, gray, green,
does not go away dermis or both necrosis of the tissue necrosis or brown) and/or
and does not (Shallow crater, subcutaneous eschar (tan,
blanch (non- abrasion, or tissue which Damage to brown, or black)
blanchabe) blister) bound to but not muscle, bone, in wound bed
through the tendon, and joint
Dressing change: underlying fasciacapsules
transparent undermining may
Dressing change: be present
Hydrochloride

Non-blanchable
erythema signals (presents as a
potential Dressing change: deep crater, with Assess for
ulcerations hydrochloride or without osteomyelitis
undermining or
adjacent tissues) Fever, pain,
and fatigue are
Can stick a Q-tip Symptoms
under the surface
of the skin at the Dressing change:
edge of the Hydrochloride
wound
Nursing Nursing Nursing Nursing
Interventions Interventions Interventions Interventions

Cleanse area Cleanse area Infected wound Most serious bc

that has exudate dermis and
Use barrier Protective and necrotic underlying layers
cream/ointments dressing: tissue have died (goes
moisture through sub-q
Protective retaining Nurse would tissue, muscle,
dressings: transparent film need to debris and bone)
transparent film the wound and
Hydrocolloid to keep moist Consider special
Redistribute noninflected beds (air-
pressure wounds only Need an fluidized beds)
antimicrobial
Frequent Frequent agent for wound Note sharp
positioning positioning debridement may
be required
Elevate heals off Comfort
bed measures

Initiate frequent Assess for

quality schedule necrosis and
infection

Hydrogels —
liquefy necrotic Assess for
tissue and fill in complications
dead space such as
(glycerin or Osteomyelitis
water-based non- (bone infection)
adhesive) and Sepsis

Alginates —
Absorb exudates Assess for
and eliminate undermining
dead space (used which is region
for pressure directly under
ulcers, skin tears, wound and under
venoustais edge of wound
ulcers, surgical
wounds,
chemical debris
Why do we use Wound Dressings?

1. Protect from mechanical injury

2. Protect from microbial contamination

3. Provide or maintain moist wound healing

4. Thermal insulation

5. Absorb drainage or deride a wound or both

6. Prevent hemorrhage (apply as pressure dressing)

7. Splint or immobilize (facilitating healing and preventing injury)

Factors Considered for the Types of Wound Dressings to use:

1. Location, size, type of wound

2. Amount of exudate

3. Requires debridement of infection present

4. Frequency of dressing change, ease, or difficulty of dressing application and cost

Two popular dressing changes are transparent film and hydrocolloid dressing

Transparent film — often applied to wounds that are ulcerated or burned; act as temporary skin
and are nonporous, nonabsorbent, self-adhesive dressings that do not require changing. Usually
the nurse will leave them alone until the wound has healed

Hydrocolloid dressing — frequently used over pressure ulcers; advantages include lasting 3 to 7
days, not needing a cover dressing, and being water resistant so the pt can shower with this
dressing on. Act as temporary skin and provide an effective bacterial barrier. Decreases pain
which then reduces the need for analgesics (painkillers). Hydrocolloids can NOT be used for
infected wounds or those with deep tracks or fistulas bc they can facilitate anaerobic bacterial
growth
Dressings Review:

1. Avoid transparent film on fragile skin

2. You can use hydrocolloid dressings on fragile skin but not on infected wounds

3. Hydrogels liquify necrotic tissue or slough

4. Alginates absorb and eliminate dead space

Types of Wounds

Untreated Wounds Treated Wounds

Usually seen shortly after an injury (ex. scene
of an accident, in the ER)
Control severe bleeding by applying direct
pressure over the wound and elevating the
extremity
Prevent infection by cleaning or flushing
abrasions or lacerations with normal saline
then cover wound with clean dressing or
sterile dressing if possible. Wrap the wound
tight so you are applying pressure and
approximate wound edges meaning you’ll size
the wound. If first layer of dressing becomes
saturated with blood then apply a second layer
but do NOT remove the first layer because
you do not want to disturb the clotting blood
and cause more bleeding
Usually sutured wounds needing to be
observed to determine how healing is
progressing
Assess appearance of wound/surrounding
tissue. Healthy granulation tissue will be pink
in color as opposed to dark red. Granulation
tissue is an important component in the wound
healing process (granulation = happy to see bc
healing is taking place)
Determine progress of healing when changing
the dressing of the wound. If you cannot
assess the wound directly then you will
inspect the dressing and ask pt about their pain
level

Control swelling and pain by applying ice

over the wound and surrounding tissue. If
bleeding is severe or internal, assess the pt for
signs of shock or rapid arthritic pulse, cold
clammy skin, pallor, and low BP
Classifying Types of Wounds
*body wounds are either intentional or unintentional
*intentional trauma occurs during therapy (ex. an operation or venous pump)
*unintentional wounds are accidental such as a fractured arm that appears in a skating accident
*wound excluding pressure injuries and burns are classified by depth which is the tissue layers
involved in the wound

Intentional or Unintentional Depth

1. Open — when the skin on mucous 1. Superficial — only the epidermis layer
membrane surface is broken the wound
is considered open
Ex. laceration or incision

2. Closed — when the tissues are
traumatized without a break in the skin the
wound is considered closed
Ex. crushing injury or a bruise
2. Partial thickness — involve dermis and
epidermis
Healed by regeneration
3. Full thickness/penetrating — involve
dermis, epidermis, subcutaneous tissue,
and possibly muscle and bone

May require connective tissue repair

Ex. knife wound

Measurements of wounds

Size of wound (length and width)

Depth of wound
Presence of undermining tunneling or sinus tract — sinus tract is a narrow opening or
passageway extending from a wound underneath the skin in any direction through soft
tissue and it results in dead space and has the potential for abscess formation

RYB Color Code – based on color of an open wound

Red wounds are protected by gently cleansing the wound protecting the peri-wound skin
which is the skin that extends about 4 centimeters beyond the wound edge. Use alcohol
free barrier form. Fill in dead space with hydrogel or alginate covering the appropriate
dressing such as transparent film, hydrochloride dresses, or a clear absorbent acrylic
dressing and changing the dressing as frequently as possible

Yellow wounds are characterized primarily by liquid to semi-liquid sought that is often
accompanied by purulent drainage or a previous infection. The nurse will cleanse yellow
wounds to remove nonviable tissues by applying a damp to damp normal saline dressing,
irrigating the wound, using absorbent dressing materials such as impregnated hydrogel or
alginate dressing and consult with primary care provider about the need for a topical
antimicrobial to minimize bacterial growth
Black wounds are covered with thick necrotic tissue or eschar and require debridement
which is when you remove the necrotic tissue before you can save the wound and the
wound can heal. Once the scar is removed the wound is treated as yellow and then red.
When more than one color is present the nurse treats the most serious color first so that is
black then yellow then red

Example of wound with various types of

tissues — yellow, red, and black

Types of Debridement - only for black wounds

1. Sharp — scalpel or scissors; used to separate and remove dead tissue. Specialty trained
wound care nurses can perform this procedure

2. Mechanical — accomplished through

scrubbing forth or damp to damp
dressing

3. Chemical — more selective than sharp

or mechanical technique. Collagenase
enzymes are used. Currently a debris
ointment called pain urea is most
recommended for chemical degrees
breaking down dead skin or tissue in
wounds

4. Autolytic — dressings such as

hydrocolloid and clear absorbent acrylic
dressing trap the wound drainage against the eschar. The body’s own enzymes in the
drainage breaks down the necrotic tissue. This method takes longer than other 3 but it
is most selective and causes the least damage to healthy surrounding tissues
Cleaning Wounds –

Wound cleaning involves

the removal of debris
such as excess loss,
necrotic tissue, bacteria,
and other
microorganisms. The
choice of the cleaning
agent and the method
used depends largely on
the agency’s protocol and
HCP preference

Wound Irrigation and Packing –

Nurse can irrigate wound to remove bacteria and

debris without injury to to tissue. Irrigation/lavage is
the washing or flushing out of an area. A sterile
technique is required for wound irrigation bc there is
a break in skin integrity. Irrigation pressure should
range from 4 to 15 psi which is pounds per square
inch. Want to use piston syringes instead of bulb
syringes to irrigate a wound. For a deep wound with
small opening a sterile straight catheter may also be
necessary. Some providers advocate the use of a
commercial oral water jet for wound cleansing

Supporting and Immobilizing Wounds -

1. Supporting a wound — when pt has a fractured bone

2. Immobilizing a wound — when pt has a strained shoulder

3. Applying pressure to improve venous blood flow — use elastic bandages

4. Securing a dressing — used for a pt with a surgical abdominal wound

5. Retaining warmth — use flannel bandages for a pt with rheumatoid arthritis to retain
warmth

Types of Drains – important for nurse to frequently assess the color and amount of
drainage coming from the wound

Surgical drains and suction are

inserted to permit the drainage of
excess sanguineous fluid and
promote healing the underlying
tissue. Drains are important to
use in some wounds bc without a
drain the pt would heal on the
surface and trap discharge
internally potentially causing an
abscess to form. Use a close wound drainage system
which consist of a drain connected to either an
electronic suction or a portable drainage suction such
as a Hemovac or Jackson Pratt (JP). The closed
system reduces the possible entry of microorganisms
into the wounds through the drain. The drainage
tubes are sutured in place and connected to a
reservoir

Principles of Wound Healing –

1. Regeneration — refers to the quality of the living tissue; also known as renewal of
tissue

2. Types of healing — primary care physician can decide on different types of healing;
allowing wound to heal itself or to purposely close the wound

3. Phases of healing — refers to the steps in the body’s natural processes of tissue repair.
The phases are the same for all wounds but the rate and extent of healing depends on
factors such as the location, size, and the health of the pt
Types of Wound Healing – depends on the amount of tissue that is lost

1. Primary/first intention healing happens where the

tissue surfaces have been approximated or closed
and there is minimal or no tissue loss.
Characterized by the formation of minimal
granulation tissue and scaring. An example is a
closed surgical incision and when tissue adhesives
are used such as dermabond which is a liquid group
that can be used to seal lacerations or incisions.
This can result in less scarring.

2. When you have a wound that is extensive and

involves considerable tissue loss where the edges
cannot or should not be approximated that would
will heal by secondary intention healing. An
example is a pressure ulcer. The repair time is
longer, the scaring is greater, and the susceptibility
to infection is greater

3. Tertiary intention healing is when you leave a

wound open for 3 to 5 days allowing edema or infection to resolve or exudate to drain
and is then closed with either sutures, staples, or adhesive skin closures. Also called
delayed primary intentions
Phases of Wound Healing - ***know palpable healing ridge in healing process***
Inflammatory Phase -
begins immediately after
injury and last 3 to 6 days
Hemostasis — cessation of
bleeding results from
vasoconstriction of larger
blood vessels in the affected
areas. Retraction which is
the drawing back of injured
blood vessels. The
deposition of fiber which is
connective tissue and the
formation of blood clots in
areas. The blood clots will
provide a matrix of fibrin
that becomes a framework
for cell repair. Then a scab
should form on the wound
and consist of clots or dead
and dying tissue. The scab
will aid in hemostasis and
inhibits contamination of
the womb by
microorganisms
Proliferative Phase -
second phase of healing and
extends from day 3 or 4 to
around day 21 after the
injury. Fibroblasts which is
connective tissue cells
migrate into the wound
starting about 24 hrs post
injury and begin to
synthesize collagen
Collagen — whitish protein
substance that adds central
strength to the wound. As
the amount of collagen
increases the strength of the
wound increases so the
chances of the wound
remaining closed also
increases. If the wound is
sutured or raised, a
palpable healing ridge
appears under the impact of
suture line. In a wound that
is not sutured, the new
collagen is often visible
Maturation Phase - also
called remodeling phase
begins around day 21 and
it can extend 1 to 2 days
after the injuries
Fibroblasts — contains its
synthesized collagen. The
collagen fibers reorganized
from their haphazard
structure into a more
orderly structure so during
maturation the wound is
remodeled and contracted.
The scar becomes stronger
but the repaired area is
never as strong as the
original tissue
Phagocytosis — when
macrophages engulf
microorganisms and
cellular debris. This
happens during cell
migration where leukocytes
move into the interstitial
space and then leukocytes
are replaces about 24 hrs
after the injury by
macrophages. This
inflammatory process is
essential to healing
Granulation tissue —
capillaries will grow across
the wound increasing the
blood supply. Fibroblasts
will move from the
bloodstream into the wound
depositing fibrin. The tissue
will start to become a
translucent red color called
granulation tissue
(remember granulation =
happy healing). Fragile and
bleeds easily when the skin
edges of the wound are not
sutured the area must be
filled in with granulation
tissue
Eschar — when the
granulation tissue matures
bordering epithelial cells
migrate to it multiplying
over the connective tissue
base to fill the wound. If
the wound does not close
by epithelial civilization the
area becomes covered with
dry plasma proteins and
dead cells called eschar. If
the wound is not covered
by epithelial cells it
becomes covered with thick
grey fibrous tissue that is
eventually converted into
thin scar tissue

Complications of Wound Healing – include hemorrhage, infections, dehiscence, and

dehiscence with evisceration

1. Hemorrhage — severe bleeding that can be caused by dislodged clots, slip stitch, or
erosion of a blood vessel. Internal hemorrhaging may be detected by swelling or
dissension in the area of the wound and possibly by sanguineous drainage from a
 surgical drain. Some pts have a hematoma which is a localized collection of blood
underneath the skin that may appear as a reddish blue swelling color or bruise. The risk
of hemorrhage is greatest during the first 48 hours after surgery.

2. Infection — the
contamination of
microorganism is
inevitable for wound
surfaces but the
presence of
contamination can
also impair wound
healing and lead to an
infection. When a
microorganism is
colonizing the wound
multiplying,
excessively, simply,
or vain tissue
infection occurs.
There will be a
change in color, an
odor, more pain, and
drainage in the wound. An infection can be confirmed by performing a wound culture

3. Dehiscence is the partial or total rupture of a wound (usually abdominal). The layers
below the skin also separate

4. Dehiscence with evisceration — evisceration is the profusion of the internal viscera

through and incision. This can happen due to obesity, poor nutrition, multiple trauma,
failure of suturing, excessive coughing, vomiting, or dehydration

Factors Effecting Wound Healing –

1. Developmental considerations — age: healthy children and adults often heal more
quickly than older adults bc older adults are more than likely to have chronic diseases
that hinder healing such as reduced liver function which can impair the synthesis of
blood clotting factors.

2. Nutrition — Wound healing places additional demands on the body so nutrition plays
an important factor in healing. Pts will require a diet high in protein, carbohydrates,
 lipids, vitamins A & C, minerals such as iron and copper. If a pt is malnourished the
HCP may have to improve their nutritional status before surgery. Obese pts are at risk
for wound infection and slower healing bc adipose tissue has a minimal blood supply

3. Lifestyle — excreting regularly helps bc leads to good circulation. Since blood brings
oxygen and nourishment to the wound people who expertise are more likely to heal
quickly. People who smoke heal slower bc smoking reduces the amount of functional
hemoglobin in the blood which limits the oxygen carrying capacity of the blood and
contract arterial

Practice questions —

Answer: D

Rationale: The nurse should frequently assess

the color and amount of drainage coming
from the wound. If the drain output is
deceptive and the drainage is bloody this may
indicate a hemorrhage. Suction from the
hemovac to drainage is responsible for
keeping the catheter in place. Clapping the
catheter to the drain the hemovac is not
necessary

Answer: B

Rationale: The pt is at risk for impaired

wound healing due to skin breakdown,
immobility, and poor nutrition

Answer: C

Rationale: Granulation tissue is the primary

type of tissue that will fill in a wound that is
healing by secondary intention
Answer: B

Rationale: Serious drainage is normal and is

an expected finding. Other options indicate
signs and symptoms of a wound infection

Answer: B

Rationale: This was described as stage III

pressure ulcer

Answer: B

Rationale: albumin is a protein made by your

liver and is important indicator of pts
nutritional status. A value below 3.5 indicated
poor nutrition and can result in poor healing
and infections