chapter 48: skin Integrity and Wound Care

Chapter 48: Skin Integrity and Wound Care

Scientific Knowledge Base

Slide 2: Scientific Knowledge Base – Skin Structure

Key Points:

• Epidermis → The top/outer layer of skin.

• Dermis → The inner layer of skin, contains collagen (a protein that gives skin strength and flexibility).

• Dermal–Epidermal Junction → The area that separates the epidermis and dermis.

Think of it like this:

• Epidermis is like the paint on a house.

• Dermis is like the walls and framework inside.

• Dermal-Epidermal Junction is like the glue that holds both together.

Slide 3: Pressure Injuries (PI)

What is a Pressure Injury?

• Also called pressure ulcers, bed sores, or decubitus ulcers.

• Happens when there is too much pressure on the skin for a long time.

• This pressure cuts off blood flow, causing skin and tissue damage.

How Pressure Injuries Develop (Pathogenesis):

1. Pressure Intensity – If pressure is strong enough, blood flow stops → skin doesn’t get oxygen → tissue dies.

   • Tissue ischemia → Fancy word for "lack of blood flow = dying skin."

   • Blanching → When you press on healthy skin, it turns white and then returns to normal.

     • If it doesn’t turn white = early sign of a pressure injury.

2. Pressure Duration – The longer pressure stays on the skin, the more damage happens.

3. Tissue Tolerance – Some skin is more fragile than others.

   • Example: Elderly people, malnourished patients, or those with poor circulation are at higher risk because their skin is weaker.

Example to Help You Remember:

Think of a garden hose. If you step on it for a few seconds, water stops but starts flowing again when you move your foot (blanching = temporary pressure).
But if you stand on it for hours, the hose gets damaged and the water may never flow properly again (tissue ischemia = severe pressure injury).

Slide 4: Risk Factors for Pressure Injuries

Who is at Risk?

Some people are more likely to develop pressure injuries because their bodies can't protect their skin well.

Major Risk Factors:

1. Impaired Sensory Perception – If someone can’t feel pain or pressure, they don’t know when to move and relieve pressure.

   • Example: A patient with spinal cord injury or diabetes (nerve damage).

2. Impaired Mobility – If someone can’t move on their own, they stay in the same position too long.

   • Example: People who are paralyzed, in a coma, or very weak.

3. Altered Level of Consciousness (LOC) – If a person is too sick, sedated, or unconscious, they don’t realize they need to move.

   • Example: Someone under anesthesia, in a coma, or confused (dementia, stroke patients).

4. Shear – Skin moves one way, but the body moves another → This stretches skin layers and damages deep tissues.

   • Example: When a patient slides down in bed, their skin stays in place but the body moves, causing damage.

5. Friction – Repeated rubbing against surfaces can weaken the skin.

   • Example: Dragging a patient instead of lifting them properly when moving them in bed.

6. Moisture – Wet skin breaks down easily.

   • Example: Patients who are incontinent (can’t control urine or stool) or sweat a lot are at high risk.

Easy Way to Remember Risk Factors → "M.I.S.S.F.I.T"

• M → Moisture weakens skin

• I → Immobility (can’t move)

• S → Shear (skin pulled in different directions)

• S → Sensory loss (can’t feel pain)

• F → Friction (rubbing damages skin)

• I → Impaired consciousness (too sick, unconscious, or confused)

• T → Tissue tolerance (weaker skin = more risk)

Slide 5: Classification of Pressure Injuries

Pressure injuries are classified into 6 categories, depending on how deep the skin damage is.

Stages of Pressure Injuries:

1. Stage 1 → Red skin that does NOT turn white when pressed (non-blanchable).

   • Skin is intact but may feel warm, firm, or painful.

2. Stage 2 → Partial-thickness skin loss (outer layer of skin is missing).

   • Looks like an open blister or shallow wound with pink/red color.

3. Stage 3 → Full-thickness skin loss (deeper layers of skin are gone).

   • Fat (yellowish tissue) is visible, but not muscle, bone, or tendon.

4. Stage 4 → Severe skin loss, exposing muscle, bone, or tendons.

   • Very deep wound, high risk of infection.

5. Unstageable Pressure Injury → The wound is covered in dead tissue (slough or eschar), making it impossible to see the depth.

6. Deep-Tissue Pressure Injury (DTI) → Dark purple/maroon skin or blood-filled blister.

   • Skin may still be intact, but tissue underneath is severely damaged.

Easy Way to Remember the Stages

• Stage 1 → Red, intact skin (warning sign 🚨).

• Stage 2 → Shallow wound or blister.

• Stage 3 → Fat is visible.

• Stage 4 → Bone, muscle, or tendon exposed.

• Unstageable → Too much dead tissue to see depth.

• DTI → Deep bruise (purple/dark color, skin may look normal but damage is underneath).

Slide 6: Scientific Knowledge Base

Medical Device-Related Pressure Injuries (MDRPI)

• Caused by medical equipment putting pressure on the skin.

• Examples:

  • NC (nasal cannula)

  • NGT (nasogastric tube)

  • F/C (Foley catheter)

  • Casts

• These can create pressure injuries where the device touches the skin.

Medical Adhesive-Related Skin Injury

• Caused by sticky medical tape or adhesives.

• Can lead to:

  • Skin stripping (when tape pulls off top layers of skin).

  • Tape burns (skin reaction from the adhesive).

Wounds in General

• Wounds can be caused by trauma, injury, or surgery.

• Two types:

  1. Open wounds – Skin is broken; higher infection risk.

  2. Closed wounds – Skin is intact but tissue underneath is damaged (like bruises).

Examples:

• A cast rubbing on the heel can cause a pressure injury = MDRPI.

• Removing tape too quickly can peel skin = Adhesive-Related Injury.

• A surgical cut = open wound.

• A bruise from a fall = closed wound.

Slide 7: Wound Classifications – How Wounds Heal

Types of Wound Healing:

1. Primary Intention

   • Clean wound edges are brought together (usually with sutures, staples, or glue).

   • Heals quickly with minimal scarring.

   • Example: Surgical incision that’s stitched closed.

2. Secondary Intention

   • Wound is left open and heals naturally from the bottom up.

   • Takes longer and may leave a larger scar.

   • Example: Pressure ulcer or large open wound.

3. Tertiary Intention

   • A combination: wound is left open for a while, then closed later.

   • Used when there’s infection risk or swelling.

   • Example: Abdominal wound that needs monitoring before closing.

Wound Repair Types:

• Partial-Thickness Repair → Only top layers of skin are affected (like a scrape or shallow cut).

  • Heals faster with less scarring.

• Full-Thickness Repair → Affects all skin layers and possibly deeper tissue (like muscle).

  • Takes longer to heal and may need special care.

Quick Recap:

• Primary → Closed right away (surgical cut).

• Secondary → Left open to heal (pressure injury).

• Tertiary → Open first, then closed later (infection concerns).

Slide 10: 4 Phases of Full-Thickness Wound Healing

When a deep wound heals (involving all layers of skin), it goes through 4 steps or phases:

1. Hemostasis (Stop the bleeding)

• Happens right after injury.

• Blood vessels constrict, and a clot forms.

• Goal: Stop bleeding and start healing.

2. Inflammatory Phase (Body reacts)

• Begins within minutes to hours after injury.

• You’ll see: Redness, swelling (edema), warmth, and throbbing.

• White blood cells come to fight infection and clean the wound.

3. Proliferative Phase (Rebuilding starts)

• The wound starts filling in with granulation tissue (new pink/red tissue).

• The skin starts growing back.

• Blood vessels regrow to bring oxygen and nutrients.

4. Maturation/Remodeling Phase (Final repair)

• The wound closes, and granulation tissue becomes scar tissue.

• This phase can last weeks to months depending on how deep the wound is.

Quick Tip to Remember the Phases:

H.I.P.R.

• Hemostasis → Stop bleeding

• Inflammation → Body fights infection

• Proliferative → New tissue grows

• Remodeling → Scar forms

Slide 11: Complications of Wound Healing

Sometimes, wounds don’t heal the way they’re supposed to. These are common problems that can happen:

1. Hemorrhage

• Too much bleeding from the wound.

• Can happen internally or outside the body.

• Emergency if not controlled.

2. Infection

• Redness, swelling, pus, odor, or fever.

• Wound may look worse instead of better.

• Delays healing and can spread to other areas.

3. Dehiscence

• Wound reopens after being closed.

• Skin and tissue separate.

• Often caused by too much pressure (like coughing, vomiting, or lifting heavy stuff).

4. Evisceration

• Severe form of dehiscence → Organs come out of the wound.

• Life-threatening emergency → Cover with sterile, moist dressing and call for help immediately.

Easy Way to Remember the 4:

"HIDE" = Hemorrhage, Infection, Dehiscence, Evisceration

Slide 12: Predicting & Preventing Pressure Injuries

As nurses, one of your most important roles is to prevent pressure injuries before they happen.

Key Points:

1. Risk Assessment

• Use tools like the Braden Scale to predict a patient's risk for developing pressure injuries.

• You assess things like:

  • Mobility

  • Moisture

  • Nutrition

  • Sensation

  • Activity level

  • Friction/shear

The lower the score, the higher the risk!

2. Economic Consequences

• Pressure injuries are expensive to treat.

• Hospitals may not get reimbursed if a pressure injury develops while the patient is in their care.

• Prevention is more cost-effective than treatment!

In Simple Terms:

• If we catch the risk early and take the right steps, we can protect the patient and save money.

Slide 13: What Influences Wound Healing and Pressure Injuries?

Several things can slow down or speed up how a wound heals.

1. Nutrition

• The body needs protein, vitamins (like A and C), and calories to build new skin.

• Poor nutrition = slower healing and weaker skin.

2. Tissue Perfusion

• Wounds need oxygen-rich blood to heal.

• If blood doesn’t flow well (like in people with diabetes, heart issues, or smoking history), healing is delayed.

3. Infection

• Germs can invade the wound and slow healing or make it worse.

• Signs: redness, swelling, pain, pus, or fever.

4. Age

• Older adults heal slower than younger people.

• Their skin is thinner and blood flow is reduced.

5. Psychosocial Impact

• Wounds can affect a person’s self-esteem and mental health.

• Some people may feel embarrassed, anxious, or depressed, especially if the wound affects how they look or live.

Example:

Imagine a patient with diabetes, who is 80 years old, doesn’t eat much, and has a leg wound. All these factors will make healing much slower.

Slide 14: Critical Thinking in Wound Care

This slide reminds you that understanding the science behind skin and wounds helps you give better care.

Key Takeaways:

1. Know What’s Normal

   • You need to understand what healthy skin looks like and how wounds normally heal.

   • This helps you spot problems early.

2. Know the Causes

   • Learn how pressure injuries develop (from pressure, shear, friction, etc.).

   • Also understand how diseases (like diabetes or poor circulation) affect healing.

3. Observe & Learn

   • Look at the wound regularly.

   • Watch how it changes. Is it getting better or worse?

   • This helps you recognize signs of infection, healing, or complications.

In Simple Words:

The more you know and observe, the better you can care for your patient’s skin and wounds.

Slide 15: Assessment – Start with the Patient

This part is about how to begin your wound care assessment as a nurse. It’s not just about the wound—you start with the patient as a whole.

Key Points:

1. Through the Patient’s Eyes

   • Ask the patient:

     • How do you feel about your wound?

     • Do you have any pain, discomfort, or concerns?

   • Understand their emotions, fears, and goals.

2. Include the Family

   • Family members can help with:

     • Sharing information about the patient’s health or routines.

     • Supporting the patient emotionally.

     • Helping with home care if needed.

3. Assess the Environment

   • Is their home or hospital bed helping or hurting skin healing?

   • Look at things like:

     • Cleanliness

     • Bed surfaces

     • Access to mobility aids

4. Inspect the Skin

   • Look head to toe, including bony areas (like heels, elbows, and tailbone).

   • Check for:

     • Redness

     • Swelling

     • Open areas

     • Discoloration

Bottom Line:

You’re not just looking at the wound, you’re looking at the whole person and their surroundings.

Slide 17: Assessing Wounds & Pressure Injuries

Now that you've looked at the patient as a whole, here’s how you assess the actual wound and related risk factors.

Wounds and pressure injuries

What to Check

1. Predictive Measures

   • Use tools like the Braden Scale to see if the patient is at risk for a pressure injury.

2. Mobility

   • Can the patient move on their own?

   • Do they need help turning in bed or shifting in a chair?

3. Nutritional Status

   • Are they eating enough protein, vitamins, and fluids?

   • Poor nutrition means slower healing.

4. Body Fluids

   • Are there fluids (like urine, sweat, or wound drainage) irritating the skin?

   • Too much moisture = skin breakdown.

5. Pain/Sensation

   • Ask the patient:

     • Is the wound painful?

     • Can they feel pressure in that area?

   • People who can’t feel pressure (like diabetics) are at higher risk for unnoticed injuries.

In Simple Terms:

You’re checking if the patient has risk factors that might make a wound worse or slow it down from healing.

Slide 18: Assessing Surgical & Traumatic Wounds

These are wounds caused by surgery or accidents (not pressure injuries), and they need a thorough check.

What to Look For:

1. Emergency Setting

   • If the wound just happened (like in the ER), check:

     • Bleeding

     • Contamination (is it dirty?)

     • Severity

2. Stable Setting

   • If the patient is already being cared for (like in the hospital), focus on:

     • Healing progress

     • Signs of infection

     • Is the wound getting better or worse?

3. Wound Appearance

   • Look at:

     • Color

     • Size

     • Edges (are they open or coming together?)

     • Tissue type (healthy red? yellow slough? black eschar?)

4. Character of Wound Drainage (pg. 1327)

   • What’s coming out of the wound? Could be:

     • Serous → clear/yellow fluid

     • Sanguineous → bloody

     • Serosanguineous → mix of clear and blood

     • Purulent → thick, smelly pus (sign of infection)

5. Palpation of Wound

   • Gently touch around the wound to feel for:

     • Warmth (infection?)

     • Tenderness

     • Hard areas (swelling underneath)

6. Drains

   • Is there a drain in place?

   • Check:

     • Type of drain

     • How much fluid is coming out

     • Color of the fluid

7. Wound Closures

   • Are there staples, sutures, or glue?

   • Are they intact or coming loose?

8. Wound Cultures

   • If there’s a sign of infection, a culture may be taken to find out which bacteria are present.

9. Psychosocial

   • How does the patient feel about the wound?

   • Are they embarrassed, anxious, or scared?

   • This affects healing and cooperation.

Summary:

You’re checking not just the wound, but also what’s coming out of it, how it feels, how it’s being treated, and how the patient feels about it.

Slide 19 Nursing Diagnoses – What’s the Problem?

Once you’ve done your assessment, you need to figure out what the patient’s main issues are related to their wound or skin condition. These are your nursing diagnoses.

Common Nursing Diagnoses for Wound & Skin Care:

1. Risk for Infection

   • The wound is open or at risk of becoming infected.

   • Example: A surgical site or pressure injury in a high-risk patient.

2. Impaired Skin Integrity

   • The skin is broken or damaged.

   • Example: A patient with a pressure injury or tape-related skin damage.

3. Acute or Chronic Pain

   • The patient is in pain now (acute) or has long-term pain (chronic) related to their wound.

4. Impaired Mobility

   • The patient can’t move freely, which increases the risk of more pressure injuries or delays healing.

5. Impaired Peripheral Tissue Perfusion

   • Blood isn’t flowing properly to the skin/tissues, which slows down healing or causes damage.

   • Common in diabetics or patients with circulation issues.

Think of These Diagnoses as the "Why" Behind Your Care Plan:

Each one helps guide what nursing actions you'll take to support healing and prevent complications.

Slide 20: Planning – What’s the Goal?

Once you know the patient’s problems (nursing diagnoses), the next step is to make a plan to help them heal and stay safe.

Key Steps in the Planning Phase:

1. Outcomes

   • What do you want to achieve?

   • Make goals that are:

     • Specific

     • Measurable

     • Realistic

     • Time-bound

   • Example: “The wound will decrease in size by 1 cm in 1 week.”

2. Setting Priorities

   • Focus on the most serious problems first.

     • Example: Treating infection comes before changing dressings.

   • Ask yourself:

     • What can harm the patient the most if not fixed right away?

3. Teamwork and Collaboration

   • You’re not doing this alone!

   • Work with:

     • Wound care nurses

     • Dietitians (for nutrition)

     • Physical therapists (for mobility)

     • Doctors and case managers

Summary:

You make a clear plan with goals, choose what’s most important, and work with a team to make it happen.

Slide 21: Implementation – Promoting Health & Preventing Pressure Injuries

This step is all about taking action. You’ve made the plan—now you carry it out to keep the patient’s skin healthy and promote healing.

Key Nursing Interventions:

1. Nutrition

• Make sure the patient is getting:

  • High-protein meals

  • Hydration

  • Vitamins (A & C) and zinc

• Nutrition is fuel for healing!

2. Preventing Pressure Injuries

Topical Skin Care & Incontinence Management

• Keep the skin clean and dry.

• Use barrier creams to protect against moisture.

• Clean urine/stool as soon as possible to prevent breakdown.

Positioning

• Turn patients at least every 2 hours to relieve pressure.

• Use pillows or foam wedges to reduce pressure on bony areas.

Support Surfaces

• Use special beds, cushions, and mattresses for high-risk patients.

• These help redistribute pressure and protect skin.

Summary:

Keep the skin clean and dry, move the patient often, feed them well, and use the right tools and surfaces to protect their skin.

Slide 22: Acute Care – Implementation: acute care

Now we focus on how to handle actual wounds and pressure injuries during care.

1. First Aid for Wounds

Hemostasis (stop the bleeding)

• Apply gentle pressure.

• Use clean or sterile materials.

• Elevate the area if needed.

Cleaning

• Use normal saline or another safe solution.

• Always clean from least contaminated to most contaminated area.

  • Example: Clean from the wound center out.

2. Management of Pressure Injuries

Wound Care

• Apply appropriate dressings.

• Keep the wound moist but not wet—this helps it heal.

Supportive Measures

• Ensure good nutrition, mobility, and hydration.

• Reduce moisture, pressure, friction, and shear.

Continued Reassessment

• Check wounds regularly for signs of healing or problems (like infection).

• Adjust care plan as needed.

In Simple Words:

When treating wounds, your goal is to:

• Stop the bleeding

• Keep it clean

• Apply the right dressings

• Help the body heal with good care and monitoring

Slide 23: Wound Management – How to Help the Wound Heal

Now we're getting into more detailed wound care strategies you’ll use during acute care.

Goal: Optimize Wound Healing

That means doing everything possible to help the wound heal properly and quickly.

Main Strategies:

1. Debridement

   • Removing dead tissue (slough or eschar) to promote healthy healing.

   • Can be done with:

     • Special dressings

     • Irrigation

     • Scissors or surgical tools (by trained professionals)

2. Protection

   • Keep the wound covered and clean.

   • Use appropriate dressings to protect from germs and friction.

3. Education

   • Teach patients:

     • How to care for their wounds at home.

     • Signs of infection to watch out for.

     • Why turning, eating well, and hygiene matter.

4. Nutritional Status

   • Make sure the patient is getting the nutrients needed for healing.

   • May involve a dietitian for support.

Bottom Line:

Take away what doesn’t belong (debridement), protect the wound, teach the patient, and keep their body strong with good food.

Slide 24: Dressings – Tools for Healing and Protection

Dressings are not just bandages—they play a huge role in wound healing.

What Dressings Do:

• Protect the wound from germs.

• Absorb drainage (so it doesn’t sit on the skin).

• Help maintain a moist healing environment.

• Support tissue regeneration.

• Reduce pain and risk of infection.

Types of Dressings:

Different wounds need different dressings. Your job is to choose the right one based on:

• Wound depth

• Amount of drainage

• Presence of infection or dead tissue

Examples (from textbook):

• Gauze – For cleaning and covering simple wounds.

• Hydrocolloid – Keeps wounds moist (good for healing).

• Foam – Absorbs lots of drainage.

• Transparent film – Lets you see the wound while protecting it.

Other Key Techniques:

• Changing Dressings

  • Do it when saturated, according to schedule, or when ordered.

  • Always use clean/sterile technique.

• Packing a Wound

  • Fill deep wounds gently with dressing material (not too tight!).

  • Helps promote healing from the bottom up.

• Negative-Pressure Wound Therapy (NPWT)

  • A special dressing with a vacuum device that:

    • Removes drainage

    • Pulls wound edges together

    • Speeds healing

• Securing Dressings

  • Use tape, ties, or bandages to keep dressing in place.

Summary:

Dressings aren’t one-size-fits-all. Choose the right type, use clean technique, and know how and when to change them.

Slide 25: More Wound Care – Keeping Patients Comfortable and Clean

This slide is about making sure your patient feels better while their wound is healing, and using the right tools to support that process.

1. Comfort Measures

• Manage pain before dressing changes.

• Offer position changes, gentle techniques, and emotional support.

• Make the experience as comfortable as possible.

2. Cleaning Skin and Drain Sites

• Use gentle, sterile technique.

• Basic skin cleaning:

  • Wipe from clean to dirty (center of wound out).

• Irrigation:

  • Flushes out bacteria and debris using saline and sometimes a syringe.

  • Use gentle pressure (don’t damage tissue).

3. Skin Closures

• Check if wound is closed with:

  • Sutures

  • Staples

  • Steri-strips

  • Surgical glue

• Make sure closures are clean, dry, and intact.

4. Drainage Evacuation

• If there’s a drain, monitor:

  • Amount, color, and consistency of the fluid.

  • Types of drains:

    • Penrose (open)

    • Jackson-Pratt (JP) or Hemovac (closed suction)

• Empty and record output as ordered.

5. Bandages, Binders, and Slings

• Binders:

  • Wide bandages that support the abdomen or chest.

  • Help with swelling or keeping dressings in place.

• Slings:

  • Support an arm or shoulder after injury/surgery.

• Roll Bandages:

  • Used for wrapping arms, legs, or other body parts to secure dressings or provide support.

Summary:

Keep the patient comfortable, the skin clean, wounds protected, and dressings/drains secured and monitored.

Slide 26: Heat & Cold Therapy – How the Body Responds

This slide is about using temperature therapy to help with pain, inflammation, or healing—but safely!

What Heat Does:

• Increases blood flow

• Relaxes muscles

• Helps reduce stiffness or chronic pain

• Can promote healing

What Cold Does:

• Reduces blood flow

• Numbs pain

• Decreases swelling and inflammation

• Good for acute injuries (sprains, bruises, etc.)

Check Temperature Tolerance

Before applying heat or cold, always assess if the patient:

• Can feel the temperature (some may have nerve damage)

• Has any skin conditions or wounds

• Can tolerate the therapy safely

Local Effects (on the spot being treated):

• Too much heat → can burn or cause swelling

• Too much cold → can freeze tissue or decrease circulation

Factors That Affect Tolerance:

1. Location – Skin on bony areas is more sensitive

2. Age – Babies and older adults have thinner skin

3. Body Fat – More fat = more insulation (less sensitivity to temperature)

Simple Tip:

Always check the skin before and after, limit the time (usually 15-20 minutes), and never apply directly to bare skin.

Slide 27: How to Apply Heat and Cold Therapies

This slide lists ways nurses apply heat or cold to help patients feel better or reduce swelling/pain.

HEAT THERAPIES:

1. Warm, Moist Compresses

   • A towel soaked in warm water

   • Helps with muscle tension or wound healing

2. Warm Soaks

   • The body part is soaked in warm water (like a hand or foot)

   • Great for loosening stiff joints or cleaning wounds

3. Sitz Baths

   • A warm water bath for the perineal area (after childbirth or rectal surgery)

   • Soothes and promotes healing

4. Commercial Heat Packs

   • Pre-packaged, microwaveable or chemical-activated heat pads

COLD THERAPIES:

1. Cold, Moist or Dry Compresses

   • Used to reduce swelling or bruising

2. Cold Soaks

   • Like a warm soak, but in cold water to calm inflammation

3. Ice Bags or Collars

   • Used for headaches, surgical sites, or injuries

   • Be sure to wrap in cloth—never put ice directly on skin!

Safety Reminder:

Always monitor the skin during treatment, limit time to 15-20 minutes, and check patient comfort regularly.

Slide 28: Evaluation – Did the Plan Work?

This final step in the nursing process is all about checking your results.

Key Points:

1. Through the Patient’s Eyes

   • Ask the patient:

     • Do they feel better?

     • Has their pain decreased?

     • Are they satisfied with how the wound is healing?

   • It’s important to include their feedback.

2. Patient Outcomes

   • Did the wound:

     • Get smaller?

     • Have less drainage?

     • Show signs of healing (new tissue, less redness)?

   • If yes → continue the plan!

   • If no → adjust the care plan or try something new.

In Simple Terms:

You look at what you did and decide: “Is it working?” If it’s not, you re-evaluate and change the approach.

Slide 29: Safety Guidelines – Protect Your Patient

This slide highlights key safety rules every nurse should follow when caring for skin and wounds.

1. Aseptic Technique

• Use clean or sterile techniques when changing dressings.

• This helps prevent infections from getting into the wound.

2. Routine Skin Assessments

• Check the patient’s skin daily:

  • Head to toe

  • Front and back

  • Pay special attention to bony areas

3. Minimize Friction and Shear

• Use tools like:

  • Lift sheets

  • Transfer devices

• Helps avoid rubbing or sliding damage to fragile skin.

4. Know the Patient’s History

• Patients with:

  • Chronic skin damage

  • Diabetes

  • Vascular disease

• Are at higher risk for pressure injuries and slower wound healing.

• Take extra precautions with these patients.

Summary:

Follow infection control, assess skin regularly, move patients gently, and be aware of medical history that affects skin health.