Skin Integrity and Wound Care Essentials

Skin

Largest organ, weighs ~12 lbs, ~15% TBW.

Acid Mantle

Skin's protective barrier, pH 4.5 - 5.5.

Vitamin D Synthesis

Requires sunlight for production in skin.

Thermoregulation

Body temperature control via sweating and goosebumps.

Epidermis

Top layer of skin, provides barrier protection.

Dermis

Inner layer of skin, contains collagen and blood vessels.

Collagen

Protein providing structure and strength to skin.

Hypodermis

Layer beneath skin, stores fat and insulates.

Pressure Injury

Damage to skin and underlying tissue from pressure.

Stage 1 Pressure Injury

Intact skin with non-blanchable redness present.

Stage 2 Pressure Injury

Partial-thickness skin loss involving epidermis and dermis.

Stage 3 Pressure Injury

Full-thickness tissue loss, visible fat may be present.

Stage 4 Pressure Injury

Full-thickness loss with exposed muscle, tendon, or bone.

Unstageable Pressure Injury

Base obscured by slough, cannot determine stage.

Deep Tissue Pressure Injury (DTPI)

Maroon, non-blanchable intact skin or blood blister.

Risk Factors for Pressure Injuries

Includes impaired mobility, moisture, poor nutrition, age.

Wound Healing Complications

Includes hemorrhage, infection, dehiscence, and evisceration.

Delayed Wound Healing

Caused by anemia, malnutrition, smoking, and infection.

Medical Adhesive Injury

Skin damage from medical adhesive use.

Medical Device Injury

Pressure injury caused by medical devices.

Wound Care Best Practices

Frequent repositioning and meticulous skin care essential.

Partial-thickness wound repair

Involves inflammatory response and epithelial migration.

Full-thickness wound repair

Includes hemostasis, inflammation, proliferation, and remodeling.

Wound healing assessment

Conducted on admission and with condition changes.

POA documentation

Must be recorded within 24 hours of admission.

Wound bed description

Includes sutures, granulation, and maceration assessment.

Wound culture procedure

Clean with NS; avoid pus or dead tissue.

Levine Quantitative Swab Technique

Method for accurate wound culture sampling.

Braden Scale

Tool for assessing pressure injury risk.

Braden scoring mild

Score of 15-18 indicates mild risk.

Braden scoring moderate

Score of 13-14 indicates moderate risk.

Braden scoring high

Score of 10-12 indicates high risk.

Braden scoring severe

Score of 9 or less indicates severe risk.

Nursing diagnoses for wounds

Includes impaired healing and skin integrity issues.

Nursing process planning

Interventions based on risk assessment and patient goals.

Q2H turn schedule

Reposition patients every two hours to prevent pressure.

Dressing change preparation

Evaluate pain and administer analgesics beforehand.

Dressing change procedure

Carefully clean and manipulate dressings to minimize pain.

Wound packing materials

Includes packing strips, gauze, and alginates.

Negative-pressure wound therapy

Technique to promote healing in complex wounds.

Dressing securement methods

Use tape, bandnet, or roll gauze for dressing.

Patient education

Involves teaching about wound care and prevention.

Nursing process evaluation

Assess if wound healing is progressing positively.

Wound response evaluation

Assess measurements, drainage, inflammation, and pain.

Moisture management

Aim for moist wounds, avoid extremes of wet/dry.

Signs of infection

Indicators include fever, drainage, and redness.

Healing potential factors

Malnutrition, perfusion, care adherence, and motivation.

Primary intention healing

Edges approximated with sutures, glue, or staples.

Wound infection indication

Purulent drainage from the incision site.

Surgical drains

Devices placed to remove fluid post-surgery.

Drain site care

Clean from insertion site outward to prevent infection.

Cleansing intervals

Clean drain sites at ordered intervals and as needed.

Skin protection

Keep dressings clean, dry, and intact.

Ostomy definition

Surgical opening in abdomen for waste exit.

Stoma

Opening formed for stool or urine exit.

Bowel diversions

Includes jejunostomy, ileostomy, colostomy types.

Bladder diversions

Includes vesicostomy and ileal conduit types.

Compassion in ostomy care

Show empathy and maintain professionalism with patients.

Ostomy odor management

Deodorants available to manage odor issues.

Nursing interventions

Actions taken to address patient care needs.

NPWT

Negative Pressure Wound Therapy for wound management.

Leak assessment

Determine leak location in NPWT dressing.

Drain output monitoring

Note location, type, and amount of drain output.

Heat and cold implementation

Requires MD order; assess tolerance factors.

Overexposure assessment

Evaluate effects of prolonged heat or cold exposure.

Leak Assessment

Identify incision leak location due to moisture.

Stoma Paste

Used to seal skin creases around stomas.

Transparent Film

Drape applied to check for skin seal.

MARSI

Medical Adhesive Related Skin Injury risk.

Specialty Bed Decision Tree

Guides selection of appropriate mattress surfaces.

Q 2 Hours Repositioning

Turn patients every two hours post-op.

Float Heels

Technique to prevent pressure injuries on heels.

Nutritional Support

Encourage hydration and good nutrition for skin health.

Barrier Cream

Protects skin from incontinence-related damage.

Skin Assessment in Dark Skin

Assess color, temperature, and tenderness changes.

Chronic Tissue Damage

Consider in skin folds for wheelchair-bound patients.

Pale Pink Skin

Indicates potential skin loss in darker skin.

Gray/Lavender Skin

May indicate moisture or fungal rash.

Repositioning Frequency

Wheelchair-bound patients need repositioning every hour.

Incontinence Care

Essential to prevent skin breakdown in vulnerable patients.

Wheelchair Cushion

Recommended to redistribute pressure and prevent injuries.

ROM Exercises

Prevent contractures and improve patient mobility.

Device-Related Injuries

Caused by improper fitting of wheelchair frames.

Skin Integrity Maintenance

Essential for preventing pressure injuries.

Skin Care Bundle

Includes surface, movement, incontinence, and nutrition.