STRUCTURE OF THE SKIN

1. EPIDERMIS is the outer portion of the skin.

It is made up of four or five layers, of which the most important are the inner and outer
layers.

STRATUM CORNEUM the outermost layer of the epidermis, is composed of numerous

thickness of dead cells. Functioning as a barrier, it restricts water loss and prevents fluids,
pathogens, and chemicals entering the body.

STRATUM GERMINATIVUM the innermost layer of the epidermis, continually

produces new cells, pushing the older cells toward the skin surface.

STRUCTURE OF THE SKIN

Keratinocytes, melanocytes and langerhan cells are located in the epidermal layer.

Keratinocytes are protein containing cells that give the skin strength and elasticity.

Melanocytes are found in the deeper epidermis which produces melanin, a pigment
that gives skin its color and provides protection from ultraviolet light.

Langerhan cells are mobile, their function is to phagocytize (engulf) foreign material
and trigger an immune response.

STRUCTURE OF THE SKIN

2. DERMIS lies below the epidermis and above the subcutaneous tissue.

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It is made of irregular fibrous connective tissue that provides strength and elasticity to the
skin and is generously supplied with blood vessels.

Within the dermis are sweat glands, sebaceous glands, ceruminous glands, hair and nail
follicles, sensory receptors, elastin, and collagen.

STRUCTURE OF THE SKIN

3. SUBCUTANEOUS LAYER is composed primarily of connective and adipose tissue. It
provides insulation, protection, and reserve of calories in the event of severe malnutrition. This
layer varies in thickness in different body sites.

For optimal function, all layers of the skin must be intact. Breaks in the skin increase the risk
of infection, for example, and may lead to significant harm.

Classifications of wounds
TYPES OF WOUNDS

SKIN INTEGRITY

CLOSED

if there are no breaks in the skin (Contusions (bruises) or tissue swelling from
fractures

OPEN

If there is a break in the skin or mucous membranes.

Includes abrasions, lacerations, puncture wounds, and surgical incisions.

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LENGTH OF TIME

ACUTE WOUNDS are expected to be of short duration

CHRONIC WOUNDS wounds that exceed the anticipated length of recovery. It
includes pressure, arterial, venous and diabetic ulcers.

These wounds are frequently colonized with bacteria, and healing is slow because of the
underlying disease process. A chronic wound may linger for months or years.

LEVEL OF CONTAMINATION

CLEAN WOUNDS - are uninfected wounds with minimal inflammation, may be open, or
closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts. There is
very little risk of infection for a clean wound.

CLEAN

CONTAMINATED WOUNDS are surgical incisions that enter the

gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection

for these wounds, but there is no obvious infection.

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LEVEL OF CONTAMINATION

CONTAMINATED WOUNDS include open, traumatic wounds or surgical incisions in

which a major break in asepsis occurred. The risk of infection is high for these wounds.

INFECTED WOUNDS are wounds with evidence of infection, such as purulent

drainage or necrotic tissue. Wounds are considered infected when the bacteria counts in the
wound tissues are above 100,000 organisms per gram of tissue.

Wound Types and Characteristics

CLOSED

CONTUSION ( Bruise) Tissue injury without breaking of skin.

Purple contusion 5x7 cm on left face

HEMATOMA Tissue injury that disrupts a blood vessels; pooling of blood

under the unbroken skin

2 in diameter hematoma on left face

SPRAIN Wrenching or twisting of a joint with partial rupture of its ligaments;

causes swelling

Swelling of right foot and round malleolus. No bruising noted

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OPEN

INCISION- Surgically made separation of tissues with clean, smooth edges

Approx. 3-in incision on R lower quadrant of abdomen; well

approximated; clean and dry with sutures intact

LACERATION Traumatic separation of tissues with clean, smooth edges

2 in jagged (pointy, uneven) laceration app 4 cm deep on L sole foot.

ABRASION- Traumatic scraping away of surface layers of skin

Raw appearing abraded area 2 1/2 in diameter on lateral aspect of lower

leg.

PUNCTURE Wound made by sharp, pointed object through sin or mucous

membranes and underlying tissue.

Small circular entry wound on R palm from sharp pointing nail

PENETRATING- Variable size open wound through skin and underlying

tissues made by a bullet or metal or wood fragment; may extend deeply into body

Jagged Deep wound 10 in posterior on L leg.

AVULSION Tearing away of a structure or a part, such as a fingertip,

accidentally or surgically.

Avulsion of L leg from VA. Attach only by skin.

ULCERATION Excavation of sin and/or underlying tissue from injury or

necrosis

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Ulceration on L sole foot 4 cm x 5 x 2 cm deep. Yellow drainage present.

Wound edges reddened.

TYPES OF WOUND DRAINAGE

EXUDATE fluid that oozes as a result of inflammation. Exudate may take several forms:
SEROUS EXUDATE consists of serum, the straw colored fluid that separates out of
blood when a clot is formed.

It is watery in consistency and contains very little cellular matter. You can expect this type
of drainage from a clean wound.

SANGUINEOUS EXUDATE is bloody drainage. It indicates damage to capillaries.

Fresh bleeding produces bright red drainage, whereas older, dried blood is dark, red
brown color. You will often see sanguineous exudate with deep wounds or wounds in
highly vascular areas.

SEROUSANGUINEOUS drainage, a combination of bloody and serous drainage, is most

commonly seen in new wounds.

PURULENT EXUDATE is thick, often malodorous, drainage that is seen in infected

wounds.

It contains pus, a protein rich fluid filled with WBCs bacteria, and cellular debris.
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It is commonly caused by infection from a pyogenic (pus forming) bacteria, such as

streptococci or staphylococci. Normally, pus is yellow in color, although it may take on
blue green color if the bacterium Pseudomonas aeruginosa is present.

PUROSANGUINEOUS EXUDATE is pus that is red tinged. It indicates that small

vessels in the wound area have ruptured.

TYPES OF DRESSINGS

HYDROGEL DRESSINGS

Hydrogels are indicated for management of pressure ulcers, skin tears, surgical
wounds, and burns, including radiation therapy burns. Because they contain up to
95% water, hydrogels cannot absorb much exudate and should be reserved for dry
wounds or wounds with minimal to moderate drainage.

Water and glycerin are the primary component of this nonadherent dressing; the
hydrogel maintains a moist wound surface and provides some absorption; these
products are permeable to oxygen and can fill dead spaces in a wound; a secondary
nonadhesive dressing may be required.

GAUZE DRESSING plain or impregnated with an anti microbial; this dressing packs
and fills the wounds; it absorbs drainage; gauze dressings are used for full and partial
thickness wounds with drainage.

TRANSPARENT DRESSING adhesive membrane that is occlusive to liquids and

bacteria; protects the wound and promotes autolytic debridement (removal of dead tissue
from wound);are impermeable to bacteria

Examples are Op site and Tegaderm

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HYDROCOLLOID DRESSINGS

Because they are occlusive, hydrocolloid dressings do not allow water, oxygen, or
bacteria into the wound. This may help facilitate angiogenesis and granulation.
Hydrocolloids also cause the pH of the wound surface to drop; the acidic
environment can inhibit bacteria growth.
Like hydrogels, hydrocolloids can help a clean wound to granulate or epithelialize
and encourage autolytic ( distruction of cells by own enzymes) debridement in
wounds with necrotic tissue. However, because of their occlusive nature,
hydrocolloids cannot be used if the wound or surrounding skin is infected.

ALGINATE DRESSINGS
Previous columns have addressed products that are appropriate for dry wound beds or
wounds with minimal exudate or drainage-namely, hydrogels and hydrocolloids.

Alginate dressings absorb moderate to high amounts of wound drainage. In wounds with

moderate to heavy drainage, the alginate forms a gel when it comes in contact with wound
fluid.

Capable of absorbing up to 20 times its weight in fluid, an alginate can be used in infected

and noninfected wounds. Because an alginate is highly absorbent, it should not be used
with dry wounds or wounds with minimal drainage; it could dehydrate the wound, delaying
healing.

COMPOSITE DRESSINGS

Contains as absorbent pad and an adhesive covering; purpose is to absorb

drainage; the advantage of this type of wound coverage is that it only has to be
changed three times a week.

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Made of three layers. The layers of the composite dressings combine to form an
antimicrobial barrier for moderate to heavy exuding wounds. Some composite
dressings also gradually release silver over time to promote healing. Our selection of
silver dressings include the popular Acticoat, Aquacel and Aquacel AG.

Composite dressings have multiple layers and can be used as primary or

secondary dressings. They are appropriate for wounds with minimal to heavy
exudate, healthy granulation tissue, necrotic tissue (slough or moist eschar), or a
mixture of granulation and necrotic tissue

Use composite dressings cautiously if the patient is dehydrated or has fragile skin.
Keep in mind that some insurers will not reimburse a facility or provider if a
composite dressing is used as a secondary dressing with a hydrogel or impregnated
gauze.

TRANSPARENT FILMS

Film dressings are flexible sheets of transparent polyurethane coated with an

acrylic adhesive. They can be used as a primary or secondary dressing.
These dressings are semipermeable, vary in size and thickness, and have an adhesive
that holds the dressing on the skin. They conform easily to the patient's body but do
not hold well in high-friction areas, such as the sacrum or buttocks.

Because films are transparent, the wound can be easily monitored.

Because films are semiocclusive and trap moisture, they allow autolytic debridement
of necrotic wounds and create a moist healing environment for granulating wounds.

PROCEDURE
Prevents contamination of previously cleaned.
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Prevents introduction of organism into wound.

Reduces excess moisture, which could eventually harbor microorganism.

Helps reduce growth of microorganism

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