Skin Integrity and Wound Healing Overview

Skin Integrity and Wound Healing

• Skin is composed of two main layers: epidermis and dermis.
• The epidermis is the outermost, thin layer.
• The dermis is the inner, thick layer that contains blood vessels, hair follicles, sweat glands, and nerve fibers.
• The hypodermis lies beneath the dermis, containing connective tissue and adipose tissue.
• The skin's functions include protection, thermoregulation, and sensation.

Functions of the Skin

• Protection: Protects against mechanical, thermal, physical injuries, harmful agents, excessive moisture/protein loss, and UV radiation.
• Thermoregulation: Protects the body from cold or heat, maintaining a constant core temperature.
• Sensation: The skin is the sense organ for touch and triggers a response to stimuli, including pain.

Conditions and Disorders Affecting the Skin

• Allergies (e.g., contact dermatitis)
• Blisters
• Bug bites (e.g., spider, mosquito)
• Skin cancer (e.g., melanoma)
• Skin infections (e.g., cellulitis)
• Skin rashes and dryness
• Skin disorders (e.g., acne, eczema, psoriasis, vitiligo)
• Wounds, burns (including sunburns), and scars

Definition of Skin Integrity

• Skin integrity is the maintenance of healthy, intact skin functioning as a protective barrier against external threats.
• Preserves skin's structure, function, and ability to repair itself after damage.

Risk Factors for Impaired Skin Integrity

• (Intrinsic Risk Factors - Internal)*

• Age-related changes:

  • Thinning of the skin (reduced collagen and elastin),
  • Decreased subcutaneous fat (increasing pressure injury risk),
  • Slower healing.

• Chronic medical conditions:

  • Diabetes (poor circulation and neuropathy increase skin breakdown risk, especially in feet)
  • Vascular diseases (e.g., PAD, reducing blood flow)
  • Immunosuppression (weakening the immune system, increasing infection risk)
  • Renal failure (can cause dry skin, increasing susceptibility to injury)

• (Extrinsic Risk Factors - External)*

• Pressure: Prolonged pressure on bony prominences (e.g., sacrum, heels, elbows) reduces blood flow, leading to tissue ischemia and pressure ulcers.

• Shear and Friction: Skin sliding over each other (e.g., sliding down in bed), damaging blood vessels and tissues.

• Moisture: Prolonged exposure to urine/feces (incontinence), excessive sweating creates a moist environment, weakening skin barrier.

• Poor hygiene: Inadequate cleaning, harsh cleansers.

• Medical devices: Tubes (e.g., nasogastric), catheters and oxygen masks.

• Environmental factors: Heat/humidity (excessive sweating), cold weather (drying).

• Medications: Corticosteroids (skin thinning, impaired healing), chemotherapy (skin sensitivity, increased infection risk), anticoagulants (bruising, skin tears).

• Nutritional deficiencies: Protein deficiency impairs tissue repair, and vitamin/mineral deficiencies affect healing.

• Impaired mobility: Prolonged pressure on bony areas increases pressure ulcer risk.

• Skin conditions: Eczema or psoriasis (inflammation weakens the skin barrier), dermatitis (irritation or allergic reactions damaging skin), fragile skin.

• Obesity or low body weight: Increased pressure, reduced blood flow or lack of subcutaneous fat.

Factors Affecting Wound Healing

• (Local factors)*

• Localized blood flow

• Tissue oxygenation

• Infection or foreign bodies

• Venous insufficiency

• (Systemic factors)*

• Age (alters inflammatory response, impairing healing)

• Obesity (infection, hematoma, pressure and venous injuries)

• Medications (corticosteroids impair granulation tissue formation)

• Nutrition (deficiencies can impact healing)

• Alcohol consumption (impair wound healing, increases infection)

• Smoking (impairs inflammatory phase, poor healing, increased infection)

• Stress (impaired immune response delays healing)

Phases of Wound Healing

• Hemostasis: Blood clotting to stop bleeding.
• Inflammation: White blood cells fight infection and remove debris.
• Proliferation: New tissue (connective tissue and blood vessels) grows, the wound tightens towards its center.
• Maturation: New tissue strengthens and gains flexibility.

Signs of Wound Infection

• Erythema (redness)
• Induration (hardened tissue)
• Pain
• Edema (swelling)
• Purulent exudate (yellow/green drainage)
• Wound odor

Nursing Care to Promote Wound Healing

• Minimize Pressure and Shear: Reposition patients frequently to relieve pressure on bony prominences, use support surfaces.
• Educate Patients: Teach patients about preventing injury, as appropriate (e.g., diabetics and neuropathy)
• Control Edema: Use compression dressings for venous ulcers.
• Promote Adequate Perfusion: Avoid elevating extremities for arterial ulcers.
• Manage Blood Sugar and Nutrition: Ensure proper nutrition and hydration
• Document and Communicate: Document assessments and interventions and communicate with the multidisciplinary health team.
• Referral: Refer to specialized wound care nurses, when appropriate.

Pressure Ulcers

• Pressure injuries are localized damages to the skin or underlying tissues, usually over bony prominences, caused by prolonged pressure combined with shear.
• Stages of pressure ulcers:
  • Stage 1: Intact skin with localized non-blanchable erythema
  • Stage 2: Partial-thickness skin loss with exposed dermis
  • Stage 3: Full-thickness skin loss with visible fat
  • Stage 4: Full-thickness skin and tissue loss with exposed bone/tendon.

Risk factors of pressure ulcers

• Immobility
• Incontinence
• Lack of sensory perception
• Poor nutrition and hydration
• Medical conditions affecting blood flow

Nursing Interventions to Protect Skin Integrity and Prevent Pressure Ulcers

• Conduct regular skin assessments (looking for redness, swelling, dryness, or breakdown).
• Use validated tools (e.g., Braden Scale, Norton Scale) to assess pressure ulcer risk.
• Identify high-risk patients (elderly, immobile, critically ill, diabetics, incontinence, or malnutrition).
• Reposition patients regularly; use pressure-relieving devices
• Use moisture management strategies and barrier creams to prevent skin damage.
• Educate patients and families about proper skin care and nutrition.
• Work with a multidisciplinary team (dieticians, physical therapists, and wound care specialists).