Maintaining skin integrity and promoting wound healing is an integral part of competent nursing care. The skin is the body’s largest organ. The purposes of the skin are to provide a mechanical barrier against pathogens, regulate temperature, prevent loss of fluids, provide sensory awareness, and provide an acidic environment hostile to bacterial growth. The layers of the skin are the epidermis and the dermis. The epidermis, the outer layer, provides a barrier against water loss and pathogen invasion. The basal (lowest) layer is the only layer that produces new cells. As new epidermal cells are formed, old ones migrate to the surface. The epidermis also contains melanocytes, pigment-producing cells, and Langerhans’ cells, which are part of the immune system.

The dermis is the innermost layer of the skin. The functions of the dermis are to nourish the basal layer of the epidermis, provide sensation, and regulate the body temperature. The dermis is made up of collagen and elastin, blood vessels, cutaneous nerves, sweat glands, sebaceous glands, and hair follicles. It contains fibroblasts, which synthesize collagen, and macrophages, which phagocytize invading pathogens. The dermal-epidermal junction is the connection between the epidermis and the dermis. The hypodermis, or subcutaneous tissue, contains adipose and connective tissue and is the layer under the dermis.

The internal factors affecting the skin and soft tissue are nutrition, hydration, and chronic use of steroids. The external factors affecting the skin and soft tissue are bathing, lubrication, injuries that make the skin more vulnerable to pathogens, and ultraviolet light. Strategies that contribute to skin health and tissue integrity across the lifespan include good nutrition, keeping the skin clean, using moisturizers, avoiding exposure to the sun, using sunscreen, and monitoring the skin for lesions.

Common skin infections are bacterial, usually staphylococcal or streptococcal; fungal, both candida and dermatophyte pathogens; and viral, including herpes simplex and herpes zoster. Examples of bacterial infections are folliculits, an infection and inflammation of the hair follicle, and impetigo, a staphylococcal aureus infection seen in children. Candida infections are common in people whose skin is exposed to moisture and in clients on antibiotics. Fungal infections include tinea pedis (athlete’s foot), tinea cruris (jock itch), or tinea corporis (ringworm). Inflammatory skin conditions are usually in the form of contact dermatitis, an inflammation of the skin in response to an environmental irritant or allergen, such as poison ivy or poison oak. Skin malignancies, such as basal cell carcinoma, squamous cell carcinoma, and malignant melanoma, are related to exposure to the sun.

Clients in health care settings are at risk for pressure ulcers; this is particularly true of clients who are elderly, debilitated, and/or immobile. Pressure ulcers are areas of skin and tissue loss caused by prolonged or excessive soft tissue pressure. Three types of external forces affect the skin: pressure, shear, and friction. Pressure, particularly over a bony prominence, causes compression on a blood vessel and loss of blood flow to the area. Shear force occurs when tissue layers slide against one another. Friction is a rubbing across the skin that has a sanding effect. Skin that is macerated (over-hydrated) is more vulnerable to other pressure, shear, and friction, thus the importance of keeping an immobile client clean and dry.

Risk assessment tools for skin breakdown include the Braden scale and the Norton scale. Clients who are “at risk” should immediately be placed on a pressure sore prevention protocol. Pressure sores are classified by their extent of damage. The first sign is an area of nonblanching erythema, which is an area of redness that cannot be dissipated with direct pressure. The next type of pressure ulcer presents itself as an area of induration (inflammation and hardness). The most extensive type of ulcer is an open area that extends to bone and muscle layers. Occasionally, an ulcer exhibits “tunneling,” which is an area of soft tissue destruction under intact skin that extends from the primary area of ulceration.

The risk factors for developing pressure ulcers are altered sensory function or level of consciousness, altered activity and mobility, excessive moisture, malnutrition, exposure to shear and friction, and general debilitation. Pressure ulcers are prevented through identification of people at risk, skin hygiene, turning and positioning, and using support surfaces, such as heel protectors. Pressure ulcer care requires constant reassessment and evaluation of treatment measures.

Treatment of wounds is important due to the skin’s protective functions. Wounds are classified by onset and duration, tissue layer involved, and mechanisms of healing. By onset and duration, an acute wound is one that has occurred suddenly and heals in an orderly manner. A chronic wound is one that is caused by a chronic condition or one that fails to heal in an orderly manner. By tissue layer involved, a partial-thickness wound involves partial loss of the skin layers but not deeper tissues. A full-thickness wound involves the epidermis, dermis, subcutaneous tissue, and possibly the muscle. By mechanisms of healing, healing can be by primary intention (through surgery); by secondary intention, requiring the wound to be left open and heal through granulation, contraction, and epithelialization; or by tertiary intention, requiring the wound to be left open initially and then closed surgically. The ideal way to heal is through regeneration of lost tissue. Any wound that extends into the deep dermis and beyond heals by scar formation.

Wound care involves the steps of the nursing process. Parameters of the assessment of the wound are (1) location; (2) dimension; (3) depth; (4) stage; (5) status (for example: is this an eschar wound, a dry, brown-black tissue; or is it sloughing, a soft gray or yellow-white tissue); (6) volume, color, and odor of any exudate, or fluid released as a result of inflammation; (7) status of wound edges; (8) status of surrounding skin; and (9) pain associated with the wound or wound care. Additionally, cultures of wound drainage confirm infection and identify the organism involved, and sensitivity tests indicate the most useful antibiotic for the infection.

Parameters of the assessment of the healing of a wound include assessment of tissue perfusion and oxygenation, nutritional status, diabetes mellitus, corticosteroids, and aging. Perfusion is necessary for the delivery of oxygen and nutrients to the wound. Oxygen is essential for the proliferation of fibroblasts, the synthesis of collagen, activity of leukocytes, and reepithelization. Nutrients provide the amino acids, vitamins, and minerals for healing. Diabetes mellitus causes elevated glucose levels, interfering with leukocytosis, and predisposes the client to infection. Corticosterioids have an anti-inflammatory affect and inhibit the repair process.

Nursing diagnoses appropriate for clients with wounds include Impaired Tissue Integrity, Risk for Infection, and Pain. The goals for caring for a client with a wound are usually to promote healing, prevent infection, and educate the client. Treatment consists of topical therapy, the care of the wound by cleansing, often with irrigation; wound dressing; debridement of necrotic tissue; monitoring drainage; and monitoring the wound itself. Dressing selection depends upon whether the wound has exudate (drainage) or tunneling. Normal saline solution is usually used for irrigation and cleaning. The client may have drains, such as the Penrose drain that works by gravity and has an open end that drains onto dressings, or a closed-suction drainage system, which has a reservoir that creates negative pressure and collects exudate.

Wound care often depends upon the type of wound the client has. Abrasions (scratches), lacerations (cuts), and skin tears are cleaned carefully and may be dressed with a topical antibiotic or anesthetic as well as a bandage. Surgical incisions evidence a healing ridge by the fifth to ninth day postoperatively. Two complications of surgical wounds are wound dehiscence (partial or complete separation of the wound edges and the layers below the skin) or evisceration (protrusion of the internal viscera through a disrupted wound). Several types of lower extremity ulcers (venous, arterial, neuropathic, and atypical) are challenges for health professionals. Contusions (bruises), strains (stretching of muscles, tendons, or ligaments), and sprains (trauma to ligaments, tendons, or bones around a joint) are usually treated with ice packs and other supportive care.