Chapter1
Skin integrity and wound care
LEARNING OUTCOMES
Mastery of content will enable you to:
Describe the anatomy and physiology of the skin.
Discuss normal phases of wound healing.
Describe the modes of wound healing.
Discuss abnormal wound healing.
Outline the factors affecting wound healing.
Conduct a head-to-toe skin assessment and
pressure injury risk assessment
Describe the differences between nursing care of
acute and chronic wounds.
Describe the principles of wound assessment and
management.
Discuss the assessment, management and
prevention strategies for common wound types.
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Ê
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The skin, or the integumentary system, is the body’s largest
/
ÊÎä£Ê FUNCTIONS OF THE SKIN
organ. It comprises 15% of the total body weight, has an
area of approximately 7600 square centimetres and receives FUNCTION OF
THE SKIN EXPLANATION
one third of circulating blood volume in the average adult
(Shores, 2007). Protection The skin provides a covering that is
Maintaining skin integrity is a complex process, one designed to protect us from damage
or injury
that is often taken for granted until damage occurs. As is
shown in Table 30-1, the skin has to perform many different Temperature control Sweat evaporates and cools the skin.
functions. Having a good understanding of the layers of the (thermoregulation) Blood vessels also dilate and constrict
skin and the functions of normal skin is important so that to prevent heat loss and maintain a
stable body temperature
you are able to recognise risk factors for poor skin integrity
and undertake actions to prevent skin breakdown or to Sensation and Nerve endings and receptors are
improve wound healing outcomes. communication found in the skin and these help
The following clinical example will be used throughout us to respond to touch, pain, heat or
cold
this chapter for you to ref lect on the key concepts and how
they apply to nursing practice. Metabolism The skin helps us to metabolise
vitamin D through exposure of the
skin to sunlight
UÊ ,/
Ê/
Elimination The skin helps us to eliminate waste
What factors in this clinical scenario might have contributed to through its function of excretion and
the development of this skin tear? secretion
CLINICAL EXAMPLE
Mr Bukowski, aged 78 years, is a widower who lives at Mr Bukowski has a past medical history of heart failure,
home; his daughter lives nearby. Mr Bukowski usually uses chronic obstructive pulmonary disease and hypertension
a wheelie walker to mobilise because he often becomes and he has had a deep vein thrombosis (DVT) of his left leg.
unsteady on his feet. Since he was only going out to collect His medications include aspirin, salbutamol inhaler, lisinopril,
the mail he decided to leave it inside, feeling confident that carvedilol, furosemide and a multivitamin. Mr Bukowski
he wouldn’t be walking very far. On his way to the letter currently smokes 15 cigarettes a day and has done so ever
box he tripped and fell, sustaining a large skin tear on his since leaving school at the age of 16.
left arm.
When he got back inside he applied some paper towel to
stop the bleeding, knowing that his daughter was coming
over for morning tea and would be able to fix it up then. A
few hours later, Mr Bukowski’s daughter arrived and decided
to take her father to his general practice clinic because she
wasn’t sure what to do.
On arrival at the clinic, Mr Bukowski is taken straight
through to the treatment room to be seen by the practice
nurse. This is not the first time that he has sustained skin
tears. On examination, the registered nurse notices that
Mr Bukowski has multiple skin tears on the left forearm
with extensive bruising (see Figure 30-1 below). She helps
Mr Bukowski to lie down on the examination couch and
FIGURE 30-1 Skin tear on Mr Bukowski’s arm.
goes to collect equipment and to take a look at his health ÕÀÌiÃÞÊ7Õ`Êi>}Ê ÕÌÞÊ"ÕÌÀi>V Ê-iÀÛVi]Ê+ÕiiÃ>`Ê1ÛiÀÃÌÞÊvÊ
records. Technology.
s EPIDERMIS OUTERMOST LAYER OF THE SKIN
Scientific knowledge base s DERMIS MIDDLE LAYER
Normal integument s SUBCUTANEOUS LAYER BOTTOM LAYER OF THE SKIN
The epidermis and dermis are separated by a basement
The thickness of the skin varies depending on location, membrane, which is often referred to as the dermal–
with skin thickness ranging from 0.05 to 0.3 mm. The epidermal junction. The epidermis, or outer layer, is avascular
thickest skin is on the soles of the feet and the palms of the and approximately 0.04 mm thick, and has several layers
hands. The thicker the skin, the better it is able to withstand depending on the body location. The stratum corneum is the
injury. The skin consists of three layers (see Figure 30-2): thin, outermost layer of the epidermis. It consists of f lattened,
, * , / - Ê 1 , - \ Ê - / Ê --Ê"Ê 1,- Ê*, /
provides the tensile strength, mechanical support and
protection to the underlying muscles, bones and organs.
It differs from the epidermis in that it contains mostly
Epidermis
connective tissue and few skin cells. Collagen (a tough,
fibrous protein), blood vessels and nerves are composed of it.
Fibroblasts, which are responsible for collagen formation,
Dermis are the only distinctive cell type within the dermis.
The subcutaneous layer is the thickest layer of the skin;
it provides a supporting framework for the skin and is an
attachment and protective layer for underlying organs and
Adipose structures. It is made up of adipose and connective tissue
Tissue and blood vessels. The subcutaneous layer of the skin helps
to regulate the temperature of the skin and store lipids.
Muscle Understanding the integument’s layers is essential
in order to identify factors affecting the wound healing
Bone process. The epidermis functions to resurface wounds and
restore the barrier against invading organisms. The dermis
responds to restore the structural integrity (collagen) and
FIGURE 30-2
>ÞiÀÃÊvÊÌ iÊÃ°Ê the physical properties of the skin. Even though a wound
1Ãi`ÊÜÌ Ê«iÀÃÃÊvÊÌ iÊ >Ì>Ê*ÀiÃÃÕÀiÊ1ViÀÊ`ÛÃÀÞÊ*>iÊ7>à }Ê ]Ê£äÉäÇÉ£Ó° may close in the upper epidermal layer, the patient is at risk
of infection, circulatory impairment and tissue breakdown
dead, keratinised cells. The cells originate from the epidermal if the underlying dermis fails to heal.
layer called the stratum basale. Cells in the stratum basale
divide, proliferate and migrate towards the epidermal surface. Skin changes associated with ageing
After cells reach the stratum corneum, they f latten and die. Skin problems are common among older people, so it is
This constant movement ensures replacement of surface important to be able to recognise the characteristics of
cells sloughed off during normal desquamation. The thin ageing skin (Lawton, 2007). There are two types of skin
stratum corneum protects underlying cells and tissues from ageing: intrinsic ageing—alterations in the structure and
dehydration and prevents entrance of certain chemical agents. function of the skin due to normal maturity which occurs
However, the stratum corneum does allow evaporation of in all people; and extrinsic ageing—due to constant or
water from the skin and permits absorption of certain topically repeated exposure to environmental elements such as the
applied medications. sun. A summary of the normal intrinsic changes in ageing
The dermis is the middle layer of the skin, which skin can be found in Table 30-2.
/
ÊÎäÓÊ SKIN CHANGES ASSOCIATED WITH AGEING
TYPE OF PROBLEM EXPLANATION EXAMPLE
Decreased sensory This means when an older person injures their skin When an older person gets a skin tear they may not
perception they may not be aware they have done so realise that they have injured their skin until they
see the injured body part
Skin tear
Increased dryness The skin becomes drier and less supple because This is why many older people complain of dry,
sebaceous and sweat gland activity decreases as itchy skin
you age
, ÊUÊ-
Ê / ,/ 9Ê Ê7"1 Ê , 759
The skin becomes The skin decreases in turgor or thickness because Ageing skin has more risk of skin tears and bruises
thinner and less elastic of reduced collagen and elastic fibre production. and lesions as a result of thinner, less flexible skin
The collagen present becomes thinner and, when and a lifetime of exposure to the sun.
combined with less adipose or fatty tissue, the
skin support structure is compromised and skin
wrinkling occurs. Such skin is subject to friction
and shearing trauma
The skin on the back of the hands becomes thin
and transparent, while the skin on the back of the
neck has a furrowed appearance
Decreased tissue turgor
Decreased vitamin D This is often due to inadequate exposure to It may take longer for skin to repair and older
synthesis sunlight, decreased dietary intake or a medical people have an increased risk of fractures
condition
Reduction in immune Cells which trigger the immune system are slower Increased risk of infection for even minor injuries to
response to respond and less effective the skin
Decrease in Older people are less able to regulate their body This is why some older people complain of being
temperature control temperature due to changes in environmental cold even on a hot day
or thermoregulatory temperature
functioning
Vascularity or blood Blood vessels in the dermis become more fragile This is why older people bruise more easily and
supply of the skin is and there is decreased peripheral circulation may explain why fingernails lose their lustre and
diminished toenails thicken
Hormonal changes Facial hair in males decreases and yet increases in
females. Pubic and axillary hair thins, straightens,
greys and lessens because of reduced hormonal
functioning. Both males and females experience
overall hair loss from the trunk and extremities.
Hair loss on the lower limbs may also occur when
peripheral vascular disease is present
Hormonal changes also lead to drier skin
Changes in hair colour Scalp hair greys and balding occurs because of Hair colour and wrinkled skin
and balding a reduction in the number and functioning of
melanocytes, the cells which give hair and skin
their colour
The density and rate of scalp hair growth also
declines and the size of hair follicles change
leading to baldness
The amount of The amount of subcutaneous tissue decreases,
subcutaneous tissue particularly in the extremities, giving joints and
decreases bony prominences a sharp, angular appearance.
The hollows in the thoracic (chest), axillary (under
the arms) and supraclavicular (collar bone) regions
deepen
Loss of subcutaneous tissue
Skin integrity and wound care
LEARNING OUTCOMES
Mastery of content will enable you to:
Describe the anatomy and physiology of the skin.
Discuss normal phases of wound healing.
Describe the modes of wound healing.
Discuss abnormal wound healing.
Outline the factors affecting wound healing.
Conduct a head-to-toe skin assessment and
pressure injury risk assessment
Describe the differences between nursing care of
acute and chronic wounds.
Describe the principles of wound assessment and
management.
Discuss the assessment, management and
prevention strategies for common wound types.
, * / , Ê 2Ê U Ê -
Ê
757 / ,/ 9Ê Ê7"1 Ê ,
The skin, or the integumentary system, is the body’s largest
/
ÊÎä£Ê FUNCTIONS OF THE SKIN
organ. It comprises 15% of the total body weight, has an
area of approximately 7600 square centimetres and receives FUNCTION OF
THE SKIN EXPLANATION
one third of circulating blood volume in the average adult
(Shores, 2007). Protection The skin provides a covering that is
Maintaining skin integrity is a complex process, one designed to protect us from damage
or injury
that is often taken for granted until damage occurs. As is
shown in Table 30-1, the skin has to perform many different Temperature control Sweat evaporates and cools the skin.
functions. Having a good understanding of the layers of the (thermoregulation) Blood vessels also dilate and constrict
skin and the functions of normal skin is important so that to prevent heat loss and maintain a
stable body temperature
you are able to recognise risk factors for poor skin integrity
and undertake actions to prevent skin breakdown or to Sensation and Nerve endings and receptors are
improve wound healing outcomes. communication found in the skin and these help
The following clinical example will be used throughout us to respond to touch, pain, heat or
cold
this chapter for you to ref lect on the key concepts and how
they apply to nursing practice. Metabolism The skin helps us to metabolise
vitamin D through exposure of the
skin to sunlight
UÊ ,/
Ê/
Elimination The skin helps us to eliminate waste
What factors in this clinical scenario might have contributed to through its function of excretion and
the development of this skin tear? secretion
CLINICAL EXAMPLE
Mr Bukowski, aged 78 years, is a widower who lives at Mr Bukowski has a past medical history of heart failure,
home; his daughter lives nearby. Mr Bukowski usually uses chronic obstructive pulmonary disease and hypertension
a wheelie walker to mobilise because he often becomes and he has had a deep vein thrombosis (DVT) of his left leg.
unsteady on his feet. Since he was only going out to collect His medications include aspirin, salbutamol inhaler, lisinopril,
the mail he decided to leave it inside, feeling confident that carvedilol, furosemide and a multivitamin. Mr Bukowski
he wouldn’t be walking very far. On his way to the letter currently smokes 15 cigarettes a day and has done so ever
box he tripped and fell, sustaining a large skin tear on his since leaving school at the age of 16.
left arm.
When he got back inside he applied some paper towel to
stop the bleeding, knowing that his daughter was coming
over for morning tea and would be able to fix it up then. A
few hours later, Mr Bukowski’s daughter arrived and decided
to take her father to his general practice clinic because she
wasn’t sure what to do.
On arrival at the clinic, Mr Bukowski is taken straight
through to the treatment room to be seen by the practice
nurse. This is not the first time that he has sustained skin
tears. On examination, the registered nurse notices that
Mr Bukowski has multiple skin tears on the left forearm
with extensive bruising (see Figure 30-1 below). She helps
Mr Bukowski to lie down on the examination couch and
FIGURE 30-1 Skin tear on Mr Bukowski’s arm.
goes to collect equipment and to take a look at his health ÕÀÌiÃÞÊ7Õ`Êi>}Ê ÕÌÞÊ"ÕÌÀi>V Ê-iÀÛVi]Ê+ÕiiÃ>`Ê1ÛiÀÃÌÞÊvÊ
records. Technology.
s EPIDERMIS OUTERMOST LAYER OF THE SKIN
Scientific knowledge base s DERMIS MIDDLE LAYER
Normal integument s SUBCUTANEOUS LAYER BOTTOM LAYER OF THE SKIN
The epidermis and dermis are separated by a basement
The thickness of the skin varies depending on location, membrane, which is often referred to as the dermal–
with skin thickness ranging from 0.05 to 0.3 mm. The epidermal junction. The epidermis, or outer layer, is avascular
thickest skin is on the soles of the feet and the palms of the and approximately 0.04 mm thick, and has several layers
hands. The thicker the skin, the better it is able to withstand depending on the body location. The stratum corneum is the
injury. The skin consists of three layers (see Figure 30-2): thin, outermost layer of the epidermis. It consists of f lattened,
, * , / - Ê 1 , - \ Ê - / Ê --Ê"Ê 1,- Ê*, /
provides the tensile strength, mechanical support and
protection to the underlying muscles, bones and organs.
It differs from the epidermis in that it contains mostly
Epidermis
connective tissue and few skin cells. Collagen (a tough,
fibrous protein), blood vessels and nerves are composed of it.
Fibroblasts, which are responsible for collagen formation,
Dermis are the only distinctive cell type within the dermis.
The subcutaneous layer is the thickest layer of the skin;
it provides a supporting framework for the skin and is an
attachment and protective layer for underlying organs and
Adipose structures. It is made up of adipose and connective tissue
Tissue and blood vessels. The subcutaneous layer of the skin helps
to regulate the temperature of the skin and store lipids.
Muscle Understanding the integument’s layers is essential
in order to identify factors affecting the wound healing
Bone process. The epidermis functions to resurface wounds and
restore the barrier against invading organisms. The dermis
responds to restore the structural integrity (collagen) and
FIGURE 30-2
>ÞiÀÃÊvÊÌ iÊÃ°Ê the physical properties of the skin. Even though a wound
1Ãi`ÊÜÌ Ê«iÀÃÃÊvÊÌ iÊ >Ì>Ê*ÀiÃÃÕÀiÊ1ViÀÊ`ÛÃÀÞÊ*>iÊ7>à }Ê ]Ê£äÉäÇÉ£Ó° may close in the upper epidermal layer, the patient is at risk
of infection, circulatory impairment and tissue breakdown
dead, keratinised cells. The cells originate from the epidermal if the underlying dermis fails to heal.
layer called the stratum basale. Cells in the stratum basale
divide, proliferate and migrate towards the epidermal surface. Skin changes associated with ageing
After cells reach the stratum corneum, they f latten and die. Skin problems are common among older people, so it is
This constant movement ensures replacement of surface important to be able to recognise the characteristics of
cells sloughed off during normal desquamation. The thin ageing skin (Lawton, 2007). There are two types of skin
stratum corneum protects underlying cells and tissues from ageing: intrinsic ageing—alterations in the structure and
dehydration and prevents entrance of certain chemical agents. function of the skin due to normal maturity which occurs
However, the stratum corneum does allow evaporation of in all people; and extrinsic ageing—due to constant or
water from the skin and permits absorption of certain topically repeated exposure to environmental elements such as the
applied medications. sun. A summary of the normal intrinsic changes in ageing
The dermis is the middle layer of the skin, which skin can be found in Table 30-2.
/
ÊÎäÓÊ SKIN CHANGES ASSOCIATED WITH AGEING
TYPE OF PROBLEM EXPLANATION EXAMPLE
Decreased sensory This means when an older person injures their skin When an older person gets a skin tear they may not
perception they may not be aware they have done so realise that they have injured their skin until they
see the injured body part
Skin tear
Increased dryness The skin becomes drier and less supple because This is why many older people complain of dry,
sebaceous and sweat gland activity decreases as itchy skin
you age
, ÊUÊ-
Ê / ,/ 9Ê Ê7"1 Ê , 759
The skin becomes The skin decreases in turgor or thickness because Ageing skin has more risk of skin tears and bruises
thinner and less elastic of reduced collagen and elastic fibre production. and lesions as a result of thinner, less flexible skin
The collagen present becomes thinner and, when and a lifetime of exposure to the sun.
combined with less adipose or fatty tissue, the
skin support structure is compromised and skin
wrinkling occurs. Such skin is subject to friction
and shearing trauma
The skin on the back of the hands becomes thin
and transparent, while the skin on the back of the
neck has a furrowed appearance
Decreased tissue turgor
Decreased vitamin D This is often due to inadequate exposure to It may take longer for skin to repair and older
synthesis sunlight, decreased dietary intake or a medical people have an increased risk of fractures
condition
Reduction in immune Cells which trigger the immune system are slower Increased risk of infection for even minor injuries to
response to respond and less effective the skin
Decrease in Older people are less able to regulate their body This is why some older people complain of being
temperature control temperature due to changes in environmental cold even on a hot day
or thermoregulatory temperature
functioning
Vascularity or blood Blood vessels in the dermis become more fragile This is why older people bruise more easily and
supply of the skin is and there is decreased peripheral circulation may explain why fingernails lose their lustre and
diminished toenails thicken
Hormonal changes Facial hair in males decreases and yet increases in
females. Pubic and axillary hair thins, straightens,
greys and lessens because of reduced hormonal
functioning. Both males and females experience
overall hair loss from the trunk and extremities.
Hair loss on the lower limbs may also occur when
peripheral vascular disease is present
Hormonal changes also lead to drier skin
Changes in hair colour Scalp hair greys and balding occurs because of Hair colour and wrinkled skin
and balding a reduction in the number and functioning of
melanocytes, the cells which give hair and skin
their colour
The density and rate of scalp hair growth also
declines and the size of hair follicles change
leading to baldness
The amount of The amount of subcutaneous tissue decreases,
subcutaneous tissue particularly in the extremities, giving joints and
decreases bony prominences a sharp, angular appearance.
The hollows in the thoracic (chest), axillary (under
the arms) and supraclavicular (collar bone) regions
deepen
Loss of subcutaneous tissue
