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📖Fundamentals Chapter 48 – Skin Integrity and Wound Care
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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
  • Definition:

      • When you press on an area of redness in the skin with your finger, normal circulation causes the redness to temporarily fade (blanch) and then return once pressure is released.

    1. Blanchable = redness disappears with pressure → usually indicates temporary vasodilation, not permanent damage.
    2. Non-blanchable = redness does not fade when pressure is applied → suggests tissue ischemia and potential damage to capillaries/skin.
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🔎 Unstageable Pressure Injury

🔹 Definition

  • A full-thickness skin and tissue loss where the true depth of the wound cannot be determined because the wound bed is covered (obscured) by:
    • Slough → soft, yellow, tan, green, or gray tissue.
    • Eschar → thick, hard, dead tissue that is usually brown or black.

🔹 Why It’s “Unstageable”

  • To stage a pressure injury, you need to see the deepest tissue involved.
  • When slough or eschar is present, it’s blocking the view of the wound bed.
  • Until it’s removed (debrided), you cannot tell if the injury is Stage 3 (fat exposed) or Stage 4 (muscle/bone exposed).

🔹 Key Points

  • Unstageable ≠ less severe → it can actually be very deep, but the covering prevents assessment.
  • Stable, dry eschar on the heel or ischemic limb should not be removed, as it serves as the body’s natural protection.
  • Treatment goal: debridement (if appropriate), infection prevention, and protection of surrounding tissue.
  • 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.
    5. image

🔹 Complications

  • Hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
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🔎 Dehiscence
  • Dehiscence = the splitting or reopening of a previously closed wound.
  • Most commonly occurs at a surgical incision site when the wound fails to heal properly.

🧠 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.
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    🔎 Hemostasis

    Hemostasis is the body's physiological process for stopping bleeding from a damaged blood vessel by forming a clot

  • Wound Management: debridement, protection, education, nutrition.
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    🔎 Debridement

    Debridement is the removal of damaged tissue or foreign objects from a wound.

  • Dressings: purposes, types, changing, packing, NPWT, securing.
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    🔎 NPWT (Negative Pressure Wound Therapy)

    Negative pressure wound therapy (NPWT) is a treatment that uses continuous or intermittent subatmospheric pressure to promote wound healing

  • 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