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📖Fundamentals Chapter 48 – Skin Integrity and Wound Care

🧬 Scientific Knowledge Base

🔹 Structure of the Skin

  • Epidermis → outer layer.
  • Dermis → inner supportive layer, collagen.
  • Dermal-epidermal junction → separates dermis & epidermis.

🔹 Pressure Injuries (Ulcers / Bedsores / Decubitus Ulcers)

  • Pathogenesis (Causes):
    • Pressure intensity → tissue ischemia, blanching.
    • Pressure duration.
    • Tissue tolerance.
  • Risk factors: impaired sensation, impaired mobility, altered Level of Consciousness (LOC), shear, friction, moisture.
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  • Classification:
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  • Stage 1 → Non-blanchable erythema of intact skin.
  • Stage 2 → Partial-thickness skin loss with exposed dermis.
  • Stage 3 → Full-thickness skin loss.
  • Stage 4 → Full-thickness skin/tissue loss (may expose bone/muscle).
  • Unstageable → depth obscured by slough/eschar.
  • DTPI (Deep Tissue Pressure Injury) → non-blanchable dark discoloration, blood-filled blister.
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🔎 Non-Blanchable
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🔎 Unstageable Pressure Injury
  • Other types:
    • Medical device-related PI.
    • Medical adhesive-related skin injury.

🩹 Wound Healing

🔹 Types of Repair

  • Partial-thickness repair.
  • Full-thickness repair.

🔹 Phases of Healing

  1. Hemostasis
  2. Inflammatory phase
  3. Proliferative phase (new tissue formation).
  4. Remodeling/Maturation.
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🔹 Complications

  • Hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
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🔎 Dehiscence

🧠 Nursing Knowledge Base

  • Prediction/Prevention → risk assessment tools.
  • Economic impact → pressure injuries = costly.
  • Factors influencing healing: nutrition, tissue perfusion, infection, age, psychosocial factors.

🧾 Nursing Process

Assessment

  • Through patient’s eyes.
  • Environment.
  • Skin.
  • Wounds: predictive measures, mobility, nutrition, fluids, pain.
  • Wound specifics: appearance, drainage, palpation, drains, closures, cultures.
  • Psychosocial aspects.

Nursing Diagnoses (Examples)

  • Risk for Infection.
  • Acute/Chronic Pain.
  • Impaired Mobility.
  • Impaired Peripheral Tissue Perfusion.

Planning

  • Set priorities.
  • Define outcomes.
  • Collaborate with team.

🛠 Implementation

Health Promotion

  • Nutrition.
  • Pressure injury prevention:
    • Skin care & incontinence management.
    • Positioning.
    • Support surfaces (special beds, mattresses).
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Acute Care

  • First Aid: hemostasis, cleaning.
    • ‣
    🔎 Hemostasis
  • Wound Management: debridement, protection, education, nutrition.
    • ‣
    🔎 Debridement
  • Dressings: purposes, types, changing, packing, NPWT, securing.
    • ‣
    🔎 NPWT (Negative Pressure Wound Therapy)
  • Comfort & Cleaning: wound irrigation, drain care, skin closures.
  • Drainage evacuation.
  • Bandages, binders, slings.
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  • Heat & Cold Therapy:
    • Assess tolerance.
    • Local effects: vasoconstriction/vasodilation.
    • Applications: compresses, soaks, sitz baths, heat/cold packs, ice bags/collars.

📊 Evaluation

  • Always evaluate through the patient’s eyes.
    • patient’s perspective, not only objective data
    • A wound might look improved to the nurse (less drainage, smaller size), but the patient may still: Experience severe pain, feel anxious about appearance and struggle with limited mobility or quality of life.
  • Assess patient outcomes.

⚠️ Safety Guidelines for Nursing Skills

  • Maintain aseptic technique.
  • Routinely assess for pressure injury risk.
  • Inspect skin daily.
  • Reduce friction and shear.
  • Remember: prior skin damage & chronic diseases (esp. vascular disease & diabetes) ↑ risk and delay healing.

🩹 Dressing in Wound Healing

  • A dressing is a sterile covering applied directly over a wound.
  • Its purpose is to protect, promote healing, and provide comfort.
  • It may be secured with bandages, tape, or specialized fixation systems.

🔹 Purposes of Dressings

  1. Protection → shields the wound from infection, contamination, or further trauma.
  2. Moisture balance → keeps the wound bed moist (which promotes faster healing) while absorbing excess drainage.
  3. Hemostasis → helps control bleeding.
  4. Absorption → manages exudate (wound drainage).
  5. Debridement support → some dressings help remove dead tissue.
  6. Comfort → reduces pain and protects sensitive tissue.
  7. Aesthetic → conceals the wound, reducing patient anxiety.

🔹 Types of Dressings (examples)

  • Gauze → absorbs drainage, often used as primary or secondary dressing.
  • Transparent film → protects from external contamination, allows visualization.
  • Hydrocolloid / Hydrogels → keep wound moist, help autolytic debridement.
  • Foam → absorbs large amounts of exudate.
  • Alginate → derived from seaweed, very absorbent, good for heavy drainage.
  • Negative-pressure wound therapy (NPWT) → special system that uses suction to promote healing.

📌 Key Point

👉 A dressing is more than just a cover — it creates the optimal environment for the wound to heal while preventing complications