Factors Affecting Skin Integrity: Friction, Shearing, and

Immobility
Many factors contribute to the development of pressure ulcers and promote
breaks in skin integrity. In this section, you will review the factors that contribute
to the development of skin breakdown. Being confined to bed or having limited
mobility places a client at risk for the development of pressure ulcers. Friction,
shearing, and immobility have significant effects on a client's skin integrity. They
are defined in this table:
Factor
Friction
Shearing

Immobility

2 hour rule! Skin breakdown can occur in as little as two hours. Be sure to teach
your clients to turn (off-load weight from areas of pressure) every two hours or to
assist them with turning as necessary.

Factors Affecting Skin Integrity: Decreased Mental Status and

Inadequate Nutrition
When caring for clients, it is important for you to assess their level of
consciousness and any signs of confusion. Decreased mental status will often
result in the client's inability to remember to off-load every two hours or to report
pain associated with prolonged pressure.
It is equally important to assess the client's nutritional status, due to the
following factors:

Inadequate nutrition increases the client's risk for skin breakdown related
to weight loss, muscle atrophy, and loss of subcutaneous tissue.

Inadequate intake of protein, carbohydrates, fluids, zinc, and vitamin C

contributes to pressure ulcer formation.

Hypoproteinemia results in the development of edema that decreases the

skin's elasticity, resilience, and vitality.

Factors Affecting Skin Integrity: Moisture and Foreign Substances

When a client is incontinent of feces and/or urine, the moisture on the skin
increases the client's risk of developing a pressure ulcer.

Digestive enzymes in the fecal material or from gastric tube drainage

contribute to the excoriation of the skin. Skin excoriation is the loss of
superficial skin layers, which is also noted as the denuding of the skin
area.

Moisture related to incontinence of feces or urine promotes maceration of

the skin. Maceration is the tissue softening by prolonged wetness. Urea
also contributes to maceration of the skin.

Moisture from secretions or excretions (urine, sweat, feces) contains

microorganisms that place the client at risk for skin breakdown and
infection.

Prevention: Barrier creams can be applied to the skin or skin to protect the periwound from various types of moisture

Factors Affecting Skin Integrity: Developmental Factors

Infants, children, and older adults are at special risk for alterations in skin
integrity due to the following factors:

Infants' skin and mucous membranes are easily injured and are prone to
the development of infection.

Children under the age of two have thinner skin, placing them at risk for
skin breakdown.

Older adults are prone to skin breakdown due to the loss of lean body
mass, thinning of the epidermis, decreased elasticity of the skin,
decreased oil production, decreased venous and arterial blood flow, and
decreased pain sensation.

Factors Affecting Skin Integrity: Chronic Medical Conditions

Chronic medical conditions increase a client's risk of developing skin breakdown
due to decreased circulation and decreased sensory perception. The most
common conditions that place a client at risk for skin breakdown are diabetes
and cardiovascular disease.
When caring for any client who is at risk for skin breakdown you must implement
proper lifting techniques, ensure proper positioning, and apply adequate pressure
relieving devices.

Nursing Process: Assessment

During the assessment of the client's skin integrity, you will interview the client
regarding diseases of the skin, previous bruising, general skin condition, skin
lesions, and usual healing of sores the client has experienced. Skin assessment
includes consideration of treated and untreated wounds.
Treated wounds: Treated wounds such as sutured incisions or sutured
lacerations are assessed to determine if the wound is healing, if the wound edges
are well approximated, and if any redness or drainage is present. The wound
dressing is inspected for drainage and odour. Assess the wound for:

Appearance

Size

Drainage

Swelling

Pain

Status of tubes or drains

Undermining or tunneling

Untreated wounds: Untreated wounds are seen after an injury. The bleeding
should be controlled with the application of pressure and, if wound is located on
an extremity, elevating the extremity. Cleanse the wound with normal saline and
cover it with a dressing until specific treatment orders are determined by the
health care provider. Apply ice to control swelling. If bleeding is excessive, assess
the client for shock.
Assess the wound for:

Location and extent of tissue damage

Bleeding

Presence of foreign objects

Any other injuries such as fractures, internal bleeding, or head and spinal
cord injuries

Contamination; administer a tetanus shot as prescribed if the wound is

contaminated

Pertinent lab data relevant to assessing skin integrity includes the following:
LabResult

Decreasedleukocytelevel
Decreasedhemoglobinlevel
Prolongedcoagulation
Lowalbumin
Woundcultureandsensitivity

Nursing Process: Diagnosis

Clients who have impairments of the skin and underlying tissues often
experience pain and are at risk for the development of infection. Other
impairments to the skin may be related to issues with arterial or veneous flow,
damage to the mucous membranes or the subcutaneous tissues. Diagnosis
involves critical reflection re: the client's health history/status, presentation, and
data gathered in the assessment, to name a few.

Nursing Process: Planning

When caring for a client who is at risk for skin breakdown or has a wound, you
need to establish a plan of care to prevent the development of a wound and to
allow for treatment of the wound (respectively).
When preparing patients self-care of wounds in the home be sure to include the
following in your teaching:

The relationship between adequate nutrition and healthy skin, including

the need for adequate fluids, protein, vitamins B and C, iron, and calories

Positioning demonstrations to show how to prevent pressure on bony

prominences and body tissues

The importance of establishing a turning and repositioning schedule

Demonstrations of the application of appropriate skin protection agents

and devices

The importance of reporting persistent reddened areas

How to identify potential sources of skin trauma

Wound assessment including signs and symptoms of infection

Principles of asepsis, hand hygiene, and dressing change technique

Pain control strategies

Nursing Process: Implementation

While caring for clients, you will implement interventions to maintain skin
integrity and provide care to support wound healing. You will apply mechanical
devices to reduce the pressure on body parts of clients who are immobilized. The
following interventions support wound healing:

Maintain a moist wound bed (dry wound beds fail to heal).

Prevent microorganisms from entering the wound.

Provide 2,500 mL of fluids per day unless contraindicated.

Consult with the dietician and ensure the client has adequate protein;
vitamins C, A, B1, and B5; and zinc.

Keep pressure off the wound.

Ensure the client has a pressure relief mattress.

Help the client change position every 2 hr.

Provide passive and active range of motion exercises.

Utilize lifting devices to help change the client's position.

Elevate the head of the bed no higher than 30 degrees to prevent

shearing.

Prevent shearing and friction.

Maintain skin hygiene and prevent urine and feces contamination.

Maintain dry, clean bed linens that are free of wrinkles.

Apply dimethicone-based creams or alcohol-free barrier films as ordered

by health care provider or directed by institutional policy.

Do not massage over bony prominences or reddened areas on pressure

points.

Nursing Process: Evaluation

During the evaluation phase of the nursing process involved with skin integrity
and wound care, your role is to identify desired outcomes indicating the client
understands the teaching implemented and the client (or family member) is able
to perform dressing changes as recommended. You should also assess the client
and family's ability to assess the wound and provide proper positioning to
prevent the development of pressure ulcers. If desired outcomes such as lack of
healing, infection, or increased pressure on the wound or other body parts are
not achieved, you will want to assess the following factors:

Has the client's physical condition changed?

What risk factors does the client have related to skin breakdown and
infection?

Was the client able to be turned and repositioned according to the

schedule?

Is the client's nutritional and fluid intake adequate?

Did the client and family utilize the appropriate pressure relieving devices
properly to prevent skin breakdown?

Was the wound immobilized as ordered?

Were the client's dressing changes done as ordered, and were aseptic
techniques adhered to?

Was the appropriate dressing type utilized to enhance wound healing?

Was the client receiving antineoplastic, anti-inflammatory, or

corticosteroid agents (which interfere with wound healing)?

Nursing Strategies to Promote Wound Healing: Purpose of Wound

Dressings
You will apply dressings to wounds for the following reasons:

Protect from further injury

Prevent microbial contamination

Maintain moisture

Provide thermal insulation

Absorb wound drainage

Provide dbridement

Prevent hemorrhage

Splint or immobilize the wound site and thereby facilitate healing and
prevent injury

Nursing Strategies to Promote Wound Healing: Types of Dressings

You will apply various types of dressings to promote wound healing. The type of
dressing will depend on the location, size, and type of wound, the amount of
exudate, whether the wound is infected, requires debridement, and the
frequency of the dressing change. The selection of dressing will change as the
wound changes. For example, as the exudate increases or decreases you will
need to chose an appropriate dressing. The following table describes two types of
dressings, transparent and hydrocolloid:
Type of
Dressing
Transparent
dressings

Description

Hydrocolloid
dressings

Act as temporary skin

Are applied to ulcerated or burned areas
Are nonporous, nonabsorbent, self-adhesive
dressings
Are left in place until healing has occurred or
as long as they remain intact
Transparent; you are able to assess the
wound through the dressing
Semi-occlusive; allow the exudate to promote
epithelial growth, which will hasten wound healing
and reduce infection
Are most commonly used over decubitus
ulcers
Last 37 days
Can be molded to uneven body surfaces and
provide a bacterial barrier
Decrease pain associated with the pressure
ulcer
Absorb moderate drainage and can be
applied to slowly draining wounds
Should not be applied to infected wounds or
wounds with deep tracts or fistulas

Nursing Strategies to Promote Wound Healing: Cleaning Wounds

You will clean the wound to provide debridement and remove microorganisms.
When cleaning a wound:1

Follow standard precautions for personal protection.

Heat liquids as ordered or to normal body temperature if recommended to

prevent lowering the temperature of the wound, which slows the healing
process.

Cleanse the wound every time the dressing is changed for any wounds
that are grossly contaminated with bacteria, slough, or necrotic tissue.
This will enhance wound healing.

There is no need to clean wounds that appear clean with little exudate at
every dressing change. Unnecessary cleaning can delay wound healing by
traumatizing newly produced delicate tissue.

Cleanse and pack wounds with gauze, not cotton, to prevent the fibers
from adhering to the wound. The fibers can adhere to granulation tissue
and promote infection.

Clean superficial noninfected wounds by irrigating with normal saline. The

hydraulic pressure of an irrigating stream of fluid dislodges contaminating
debris and reduces bacterial growth.

Avoid drying the wound after cleansing it. The fluid left behind will assist in
retaining wound moisture.

Hold cleaning sponges with forceps or with a sterile gloved hand.

Clean from the wound in an outward direction to avoid transferring

organisms from the surrounding skin into the wound.

Nursing Strategies to Promote Wound Healing: Supporting and

Immobilizing Wounds
Bandages and binders are applied to:2

Support a wound

Immobilize a wound

Apply pressure

Secure a dressing

Retain warmth

Bandages: Strips of cloth are applied as a wrap around a body part. They are
usually supplied in rolls and are 1.5 to 7.5 cm wide. In addition:

Bandages should support normal positioning if possible to avoid strain on

ligaments and muscles.

The skin should be padded over bony prominences to prevent friction from
the bandage and abrasion of the skin.

Always bandage the body part from the distal to proximal end to promote
venous blood flow return.

Bandage with even pressure to prevent interference with blood circulation.

If possible, leave the fingers or toes exposed to enable assessment of the

adequacy of blood circulation to the extremity.

Cover dressings with bandages at least 5 cm beyond the edges of the

dressing to prevent the dressing and wound from becoming contaminated.

Binders: Binders are a type of bandage designed for specific body parts.

A triangular bandage fits the arm to support the forearm, prevent swelling
of the hand, and relieve pressure on the shoulder joint.

Straight abdominal binders are placed smoothly around the body with the
upper border of the binder at the waist and lower border at the gluteal
fold. Be certain that the binder is not placed over the waist (which might
interfere with breathing) or too low (which might interfere with elimination
or walking).

Assessments Prior to Applying a Bandage or Binder

Inspect and palpate for swelling.

Inspect the wound and wound drainage.

Inspect the adequacy of circulation.

Assess the client's pain on a scale of 1 to 10.

Assess the client's ability to change and reapply the dressing to promote
self-care and independence.

Assess the impact of the bandages and dressing on the client's capabilities
regarding activities of daily living.

Nursing Strategies to Promote Wound Healing: Hot and Cold

Applications
The application of heat and cold provides the body with local and systemic
effects, as shown in the following table:
Applicatio

Benefits

How Applied

Recommended

n Of
Heat

to Treat

Promotes
vasodilation
Increases
capillary
permeability
Increases
cellular
metabolism
Increases
inflammation
Provides a
sedative effect

Cold

Promotes
vasoconstriction
Decreases
capillary
permeability
Decreases
cellular
metabolism
Slows
bacterial growth
Decreases
inflammation
Provides a
local anesthetic
effect

Dry heat:

Hot
water bottle
Aquath
ermia pad

Disposa
ble heat
pack

Electric
pad
Moist heat:
Compre
ss
Hot
pack
Soak
Sitz
bath

Muscle
spasm
Inflammat
ion
Pain
Contractu
re
Joint
stiffness

Dry cold:

Cold
pack

Ice bag
Ice
glove

Ice
collar
Cooling
blanket
Moist cold:
Compre
ss
Cooling
sponge bath

Muscle
spasm
Pain
Traumatic
injury
High body
temperature

Stages of Pressure Ulcer Development and Wound Healing: Stage I

The most common alteration in skin integrity you will observe is the pressure or
decubitus ulcer. Pressure ulcers are characterized by the extent of tissue
damage. There are four stages of pressure ulcers.
Stage I: The skin remains intact and possesses redness that does not blanch. It
is most commonly localized over a bony prominence such as the sacrum. It is
difficult to observe the blanching of skin in clients whose skin is darkly
pigmented. Upon palpation, the client may have pain. The skin will be firm and

the skin temperature will be either warmer or cooler than the remainder of the
skin surfaces.

Stages of Pressure Ulcer Development and Wound Healing: Stage II

Stage II: The stage II pressure ulcer has partial thickness loss of dermis. The
ulcer may be small and shallow with pink tissue in the wound bed. There is no
sloughing of skin noted. The ulcer, which appears shiny and dry, may possess
greater deep tissue damage. Some ulcers will have a fluid-filled blister.

Stages of Pressure Ulcer Development and Wound Healing: Stage III

Stage III: The stage III pressure ulcer has full-thickness tissue loss.
The subcutaneous fat may be visible, but the bone, tendon, and muscle are not
visible. Sloughing may be present but does not obscure the depth of the tissue
loss. Undermining and tunneling may occur. It is important to use a sterile,
cotton-tipped applicator to determine the extent of the tunneling. The
development of wound depth will depend on the site of the wound. Areas with
greater amounts of adipose tissue are more likely to develop deep Stage III
ulcers.

Stages of Pressure Ulcer Development and Wound Healing: Stage IV

Stage IV: The stage IV pressure ulcer has full thickness tissue loss. The client's
bone, tendon, and/or muscle may be exposed. The exposed bone or tendon is
visible and can be palpated. Sloughing of tissue or eschar may be present on all
or parts of the wound bed. Undermining and tunneling may be noted, and the
depth of the ulcer will vary based on the anatomical location. Wounds extending
into the muscle, fascia, tendon, or joint increase the client's risk of
developing osteomyelitis.

Stages of Pressure Ulcer Development and Wound Healing: Types of

Wound Healing

When caring for clients with any alteration in skin integrity, it is important to
assess and document the extent of wound healing. Wound healing is the
regeneration of tissues. The phases of wound healing are the same for every
client, but the rate of healing depends on factors such as the type of healing, the
location and size of the wound, and the client's health status. Types of healing
are described in the following table:
Type of Healing
Primary intention healing
Secondary intention healing
Tertiary intention healing