Chapter 38 Skin Integrity and Wound Care
Pressure Injuries: localized damage to the skin and underlying soft tissue usually over a bony
prominence.
Pressure Injury Classification:
Stage 1 Pressure Injury: intact skin with a localized area of no blanchable erythema, which
may appear differently in darkly pigmented skin.
Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis. The wound bed is
viable, pink or red, and moist, or injury may manifest as an intact or ruptured serum-filled blister.
(fat/tissue is not visible)
Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the
ulcer, and granulation tissue and epibole (rolled wound edges) are often present.
Fascia, muscle, tendon, ligament, cartilage, or bone is not exposed.
Slough is usually light yellow/cream colored and moist and soft. Eschar is black/brown, dry,
thick, and leathery.
Stage 4 Pressure Injury: Full thickness skin and tissue loss with exposed or directly palpable
fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
Epibole (rolled edges), undermining, and tunneling often occur.
Deep tissue pressure injury: Intact or nonintact skin with localized area of persistent non
blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark
wound bed or blood-filled blister.
Unstageable Pressure Injury: Full-thickness skin and tissue loss in which extent of tissue
damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
Tissue ischemia: decreased blood flow to tissues
Reactive hyperemia: redness of the skin resulting from dilation of the superficial capillaries
Blanchable hyperemia: able to change the color by pressing on the spot
Non-blanchable Hyperemia: redness that persists after palpation and indicates tissue damage
Factors Contributing to Pressure Injury Formation
Shear: The force exerted against the skin while the skin remains stationary, and the bony
structures move is called shear.
Example: patient slides down in the bed
, Friction: surface damage caused by the skin rubbing against another surface that often results in
an abrasion. An abrasion is the loss of the epidermis. Body areas most at risk for friction is the
elbows and the hells.
Moisture: Moisture softens the skin and reduces its resistance to other physical factors such as
pressure or shear.
Nutrition: Poor nutrition, specifically severe protein deficiency, increase the risk of the
breakdown of soft tissue and alters fluid and electrolyte balance.
Age: The dermis is thin in neonates and become thin in older adults. An older adult’s skin is
more vulnerable to pressure, shear, and friction.
Origins of Pressure Injuries: The longer pressure is applied, the more likely it is that tissue loss
will occur.
Wound assessment (regardless of cause) includes the following parameters: anatomical location,
extent of tissue involvement (full-thickness or partial thickness loss), size (dimensions and depth
of wound), tissue type (viable or nonviable) and percentage of wound tissue, volume and color of
wound exudate, and condition of surrounding skin.
Wound Healing Process: A wound with little or no tissue loss such as a clean surgical incision
heals by primary intention. The skin edges approximate, or close together, and the risk for
infection is minimal.
A wound involving loss of tissue such as a severe laceration or a chronic wound such as a
pressure injury heal by secondary intention. The skin edges cannot come together because of the
extensive tissue loss, and healing occurs gradually.
Granulation tissue: red, moist tissue consisting of blood vessels and connective tissue
There are also instances in which a surgical wound is initially closed in the deep tissue layers;
however, the subcutaneous fat and skin layers are left open. This method of wound closure is
called tertiary intention or delayed primary closure. An example of wound closure by delayed
primary closure occurs when a patient has a ruptured appendix.
Wounds heal by one of two mechanisms: partial-thickness wound repair or full-thickness wound
repair. Partial-thickness repair is necessary when loss of only the epidermis and/or part of the
dermis. Full-thickness wound repair is necessary with loss of the epidermis; loss of the dermis;
and possible extension into subcutaneous layer, bone, and muscle.
Partial Thickness Wound Repair
Inflammatory response: Erythema and edema are the first response, bringing white blood cells
to the site. Appears red and swollen. Subsides in less than 24 hours.
Epidermal repair: Epidermal cells begin migration across the wound. Peak epithelial
proliferation occurs 24 to 72 hours after injury. Wounds kept in a moist environment heal in
Pressure Injuries: localized damage to the skin and underlying soft tissue usually over a bony
prominence.
Pressure Injury Classification:
Stage 1 Pressure Injury: intact skin with a localized area of no blanchable erythema, which
may appear differently in darkly pigmented skin.
Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis. The wound bed is
viable, pink or red, and moist, or injury may manifest as an intact or ruptured serum-filled blister.
(fat/tissue is not visible)
Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the
ulcer, and granulation tissue and epibole (rolled wound edges) are often present.
Fascia, muscle, tendon, ligament, cartilage, or bone is not exposed.
Slough is usually light yellow/cream colored and moist and soft. Eschar is black/brown, dry,
thick, and leathery.
Stage 4 Pressure Injury: Full thickness skin and tissue loss with exposed or directly palpable
fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
Epibole (rolled edges), undermining, and tunneling often occur.
Deep tissue pressure injury: Intact or nonintact skin with localized area of persistent non
blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark
wound bed or blood-filled blister.
Unstageable Pressure Injury: Full-thickness skin and tissue loss in which extent of tissue
damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
Tissue ischemia: decreased blood flow to tissues
Reactive hyperemia: redness of the skin resulting from dilation of the superficial capillaries
Blanchable hyperemia: able to change the color by pressing on the spot
Non-blanchable Hyperemia: redness that persists after palpation and indicates tissue damage
Factors Contributing to Pressure Injury Formation
Shear: The force exerted against the skin while the skin remains stationary, and the bony
structures move is called shear.
Example: patient slides down in the bed
, Friction: surface damage caused by the skin rubbing against another surface that often results in
an abrasion. An abrasion is the loss of the epidermis. Body areas most at risk for friction is the
elbows and the hells.
Moisture: Moisture softens the skin and reduces its resistance to other physical factors such as
pressure or shear.
Nutrition: Poor nutrition, specifically severe protein deficiency, increase the risk of the
breakdown of soft tissue and alters fluid and electrolyte balance.
Age: The dermis is thin in neonates and become thin in older adults. An older adult’s skin is
more vulnerable to pressure, shear, and friction.
Origins of Pressure Injuries: The longer pressure is applied, the more likely it is that tissue loss
will occur.
Wound assessment (regardless of cause) includes the following parameters: anatomical location,
extent of tissue involvement (full-thickness or partial thickness loss), size (dimensions and depth
of wound), tissue type (viable or nonviable) and percentage of wound tissue, volume and color of
wound exudate, and condition of surrounding skin.
Wound Healing Process: A wound with little or no tissue loss such as a clean surgical incision
heals by primary intention. The skin edges approximate, or close together, and the risk for
infection is minimal.
A wound involving loss of tissue such as a severe laceration or a chronic wound such as a
pressure injury heal by secondary intention. The skin edges cannot come together because of the
extensive tissue loss, and healing occurs gradually.
Granulation tissue: red, moist tissue consisting of blood vessels and connective tissue
There are also instances in which a surgical wound is initially closed in the deep tissue layers;
however, the subcutaneous fat and skin layers are left open. This method of wound closure is
called tertiary intention or delayed primary closure. An example of wound closure by delayed
primary closure occurs when a patient has a ruptured appendix.
Wounds heal by one of two mechanisms: partial-thickness wound repair or full-thickness wound
repair. Partial-thickness repair is necessary when loss of only the epidermis and/or part of the
dermis. Full-thickness wound repair is necessary with loss of the epidermis; loss of the dermis;
and possible extension into subcutaneous layer, bone, and muscle.
Partial Thickness Wound Repair
Inflammatory response: Erythema and edema are the first response, bringing white blood cells
to the site. Appears red and swollen. Subsides in less than 24 hours.
Epidermal repair: Epidermal cells begin migration across the wound. Peak epithelial
proliferation occurs 24 to 72 hours after injury. Wounds kept in a moist environment heal in
