Wound Skin Integrity

• 1. epidermis- top layer, no blood vessels
• 2. dermis- middle layer, nerves and hair
• 3. sub q- bottom layer, ct, adipose, fat, blood and lymph

• 1. protection
• 2. temp regulation
• 3. self esteem
• 4. sensation
• 5. vit. D production
• 6. immunological
• 7. absorption
• 8. elmination

• -younger then 2- skin thiner and weaker
• -infant skin can be easily injured
• -structure of the skin changes as they age

• -very thin and obese people suffer skin injury
• -dehydration
• -excessive sweating
• -jaundice
• -disease of the skin- eczema

a break/disruption in the normal integrity of the skin/tissue

 mechanical force/physical force

compromised circulation secondary to pressure or pressure combined with friction

injury and poor venous return, resulting from underlying conditions-

injury and underlying ischemia

injury and underlying diabetic neuropathy

• planned invasive therapy or treatment (surgery)
• -less chance of infection
• -wound edges are aproximated

• accidental/trauma
• -edges are jagged
• -higher risk of infection
• -may have multiple wounds
• -longer healing time

• -skin broken-portal entry
• -increase infection
• -delayed healing

• results of blow,force, or strain
• skin surface not open
• ecchymosis -bruising
• hematoma-clot

• heals within a few days/weeks
• -wound edges approximated
• lower risk of infection

• does not progress through normal healing
• wound edges are not approximated
• increase infection
• healing time delayed

• well approximated
• surgical incisions usually heal
• if delayed healed in secondary intention

• not well approximated
• large open wounds
• longer to heal and more scar tissue

• delayed primary
• wound left open for days
• edema /infection to resolve/drain and close

• hemostasis-
• immediately after injury
• vessels constrict and clotting starts
• platelet activated
• pus formed

• inflammatory phase
• 4-6 weeks
• wbc -move in
• leukocytes-kill bacteria
• macro phages- begins growth

• proliferation phase
• -last several weeks 
• -new tissue built
• -granualtion tissue- scar tissue
• -firbroblast activated

• maturation phase
• - about 3 weeks after injury
• - new collagen ---scar

• 1. pressure-disrupts blood supply
• 2. Desiccation- cell death
• 3. Maceration- too moist bc of fecal and urine
• 4.trauma
• 5. edema- not enough oxygen--swelling
• 6. infection
• 7. necrosis

• 1.age
• 2.circulation
• 3.nutritional status
• 4. wound condition
• 5.meds and health stat
• 6. immunosuppression