unit 3

Pressure Ulcers and Skin Conditions

A pressure ulcer, also known as a pressure injury, is localized damage to the skin and underlying soft tissue, typically occurring over a bony prominence or in relation to medical devices. These injuries range from minor skin damage to large open ulcers and are often painful.

Pressure ulcers result from intense or prolonged pressure, leading to tissue anoxia as blood supply diminishes, compromising cell metabolism. Factors such as the environment, nutrition, perfusion, and comorbid conditions can affect the tissue's tolerance to pressure and shear.

Risk Factors

Certain patient groups are more at risk for developing pressure ulcers, including:

• Elderly patients – Skin is thinner, less elastic, and more prone to breakdown.

• Malnourished individuals – Lack of muscle and fat increases vulnerability.

• Patients with incontinence – Prolonged moisture softens skin, increasing breakdown risk.

• Immobile patients – Those who cannot reposition themselves regularly.

• Individuals with impaired circulation – Conditions like diabetes and peripheral vascular disease reduce blood flow, increasing risk.

Prevention and Management

Preventive measures are paramount for at-risk patients:

• Daily skin assessments to check for redness or early signs of damage.

• Proper skin hygiene – Keeping skin clean and dry, using lubricants for dry areas.

• Managing incontinence – Prompt cleaning and applying a moisture barrier.

• Frequent repositioning:

  • Weight shifts every 15 minutes for seated patients.

  • Turning every 2 hours for bedbound patients.

• Elevating heels to prevent pressure on bony prominences.

• Using pressure-reducing mattresses to redistribute weight.

• Optimizing nutrition – Protein intake is essential for healing wounds and maintaining skin integrity.

Risk Assessment – Braden Scale

The Braden Scale evaluates a patient’s risk for developing pressure ulcers. It assesses the following categories:

• Sensory perception – Ability to respond to pressure-related discomfort.

• Moisture – Exposure to moisture that may lead to skin breakdown.

• Mobility – Ability to change and control body positions.

• Nutrition – Adequate dietary intake to support healing.

• Friction and shear – The extent of movement and risk for tissue damage.

A lower score on the Braden Scale indicates higher risk, necessitating preventive interventions.

Stages of Pressure Ulcers                                                                                  

1. Stage 1 – Non-blanchable redness, skin intact.

2. Stage 2 – Partial-thickness skin loss, open wound or intact/ruptured blister.

3. Stage 3 – Full-thickness skin loss, visible fat layer.

4. Stage 4 – Full-thickness skin and tissue loss, exposed muscle, tendon, or bone.

5. Unstageable – Covered by slough or eschar, making it impossible to determine depth.

Treatment of Pressure Ulcers

• Regular wound assessments to monitor progression.

• Clean the wound with appropriate antiseptics.

• Debridement – Removal of necrotic tissue to promote healing

• Applying dressings according to wound type and severity.

• Negative pressure therapy – Encourages healing by removing excess fluid and promoting circulation.

Other Skin Conditions             

Dermatitis

• Inflammation of the skin due to allergies or irritants.

• Symptoms: Red, itchy lesions, oozing or dry patches.

• Treatment: Topical steroids, antihistamines, and avoiding triggers.

Psoriasis

• Chronic inflammatory disorder with rapid skin cell proliferation.

• Symptoms: Silvery, scaly plaques, primarily on elbows, knees, and scalp.

• Treatment: Daily baths, corticosteroids, and topical medications.

Herpes Simplex Virus (HSV)

• Recurring viral infection that remains dormant in the nerve ganglia.

• HSV-1: Causes cold sores.

• HSV-2: Causes genital herpes.

• Symptoms: Burning, tingling, painful vesicles that heal in about a week.

• Treatment: Antiviral medications (e.g., Acyclovir).

Shingles (Herpes Zoster)

• Reactivation of the varicella-zoster virus (chickenpox).

• Symptoms: Painful, blistering rash along a nerve pathway.

• Contagious until vesicles dry and scab.

• Treatment: Antiviral therapy (within 72 hours), corticosteroids, pain management.

Fungal Infections

• Candidiasis (oral thrush, skin folds) – Often occurs in warm, moist areas.

• Tinea infections:

  • Tinea pedis (Athlete’s foot)

  • Tinea capitis (Ringworm of the scalp)

  • Tinea corporis (Body ringworm)

  • Tinea cruris (Jock itch)

• Treatment: Antifungal creams, oral antifungals, keeping skin dry.

Parasitic Infestations

Pediculosis (Lice)

• Transmitted through direct contact (hairbrushes, hats, close contact).

• Symptoms: Itching, visible eggs (nits) in hair.

• Treatment:

  • Lice treatment shampoos (permethrin, malathion).

  • Washing clothing/bedding in hot water.

  • Vacuuming surfaces to remove eggs.

Scabies

• Caused by mites burrowing into the skin.

• Symptoms:

  • Intense itching, especially at night.

  • Red burrow tracks between fingers, wrists, and elbows.

• Treatment:

  • Topical scabicides (permethrin, ivermectin).

  • Washing all clothing and bedding.

Warts (Viral Infection)

• Benign growths caused by the human papillomavirus (HPV).

• Types:

  • Common warts – Hands, fingers.

  • Plantar warts – Feet, can be painful.

• Treatment:

  • Cryotherapy (freezing).

  • Salicylic acid applications.

  • Laser or surgical removal for resistant cases.

QUESTIONS from Pressure Ulcers and Skin Conditions OUTCOMES

Pathophysiology of Skin Disorders

A nurse is caring for a client with a stage 3 pressure injury on the sacrum. Which of the following best describes the pathophysiology of pressure injuries?
a) An autoimmune response that attacks the skin layers
b) A bacterial infection that spreads from the epidermis to the dermis
c) Prolonged pressure causes ischemia, leading to tissue necrosis
d) An allergic reaction causing histamine release and vasodilation

2. Etiology of Diabetic Ulcers

A nurse is assessing a client with a diabetic foot ulcer. Which of the following factors contributes to the development of diabetic ulcers?
a) Increased collagen synthesis
b) Enhanced angiogenesis
c) Peripheral neuropathy and poor circulation
d) Overproduction of skin fibroblasts

3. Signs & Symptoms of Cellulitis

A nurse is assessing a client with cellulitis on their lower leg. Which of the following findings should the nurse expect?
a) Dry, scaly patches with silvery plaques
b) Red, swollen, warm skin with tenderness
c) Non-blanchable, purple discoloration of the skin
d) Fluid-filled vesicles along a dermatome

4. Nursing Interventions for Pressure Injuries

A nurse is planning care for a client with a stage 2 pressure injury. Which of the following interventions should the nurse include?
a) Apply a dry gauze dressing to the wound
b) Turn and reposition the client every 4 hours
c) Use a moisture-barrier cream to protect the skin
d) Massage the reddened area to promote circulation

5. Therapeutic Measures for Moisture-Associated Skin Damage (MASD)

A nurse is providing wound care for a client with incontinence-associated dermatitis (IAD). Which of the following actions should the nurse take?
a) Apply a hydrocolloid dressing over the affected area
b) Clean the skin with a pH-balanced cleanser and apply a barrier cream
c) Perform wound debridement daily
d) Use adhesive tape to secure dressings in place

6. Evaluating the Effectiveness of Diabetic Ulcer Treatment

A nurse is evaluating a client receiving treatment for a diabetic foot ulcer. Which of the following findings indicates that the treatment has been effective?
a) Increased wound exudate and pain
b) Granulation tissue formation and decreased wound size
c) Persistent foul-smelling drainage
d) Black eschar forming over the wound

7. Nursing Care for Skin Tears

A nurse is caring for an older adult client who has a skin tear on the forearm. Which of the following actions should the nurse take?
a) Remove any detached skin flaps
b) Apply a non-adherent dressing to the wound
c) Use tape to secure the dressing tightly
d) Clean the wound with an alcohol-based solution

8. Risk Factors for Pressure Injuries

Which of the following clients is at the highest risk for developing a pressure injury?
a) A 45-year-old client who walks independently but has a history of diabetes
b) A 72-year-old client who is immobile and incontinent
c) A 60-year-old client who has a healing stage 2 pressure injury
d) A 35-year-old client receiving IV antibiotics for cellulitis

9. Signs of Wound Infection

A nurse is assessing a client’s wound and suspects infection. Which of the following findings support this conclusion?
a) Pale pink granulation tissue in the wound bed
b) Clear serous drainage from the wound
c) Increased warmth, swelling, and purulent drainage
d) A dry, intact scab over the wound

10. Patient Education on Pressure Injury Prevention

A nurse is providing discharge instructions to a client at risk for pressure injuries. Which of the following statements by the client indicates an understanding of the teaching?
a) "I should reposition myself every 4 to 6 hours while in bed."
b) "I will massage reddened areas to prevent skin breakdown."
c) "I will use a cushion when sitting for long periods."
d) "I should keep my skin dry by avoiding moisturizers."

Wound Care, Healing & Documentation

Key Wound Terminology

• Dehiscence: The reopening of a previously closed wound, which can occur due to improper suturing, excessive movement, or premature removal of stitches. This condition can delay healing and increase the risk of infection.

• Evisceration: A severe form of dehiscence where abdominal contents protrude through the wound opening. It is a medical emergency requiring immediate sterile covering and surgical intervention.

• Eschar: A dry, thick, and leathery layer of dead tissue that covers a wound. It is often black or brown and may require debridement to promote healing.

• Granulation Tissue: New, fragile tissue that forms as part of the wound healing process. It appears pink or red due to rich blood supply and is necessary for wound closure.

• Sinus Tract: A narrow channel that extends from a wound to underlying tissue or an internal organ. It often forms due to prolonged infection or abscess formation.

• Edema: The accumulation of fluid in tissues surrounding the wound, causing swelling. It can indicate inflammation, infection, or poor circulation.

• Erythema: Redness of the skin around a wound, often associated with inflammation or infection.

• Necrotic Tissue: Dead tissue that may appear black or yellow and inhibits healing. It often requires removal through debridement.

• Ischemia: Reduced blood supply to an area, leading to tissue damage and increased risk of ulceration or necrosis.

• Purulent Drainage: Thick, yellow, green, or foul-smelling pus, which indicates an infection in the wound.

• Slough is stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed.

• Keloids are hypertrophic scar tissue resulting from excessive collagen formation following a wound injury.

Wound Types & Classification

• Contusion: A bruise caused by blunt trauma, where blood vessels break under intact skin, leading to discoloration and swelling.

• Abrasion: A superficial wound caused by friction, such as a scrape or rug burn.

• Puncture Wound: A deep wound caused by a sharp object (e.g., needle, nail) that penetrates the skin and underlying tissue.

• Penetrating Wound: A wound where the causative object remains embedded in the tissue, requiring careful removal and monitoring for infection.

• Laceration: A deep cut or tear in the skin that often has jagged edges and may require sutures for closure.

Wound Cleanliness Categories:

• Clean: A wound with no infection, typically from minor injuries or surgical incisions.

• Clean-Contaminated: A surgically created wound that comes into contact with normal flora, such as the GI or respiratory tract.

• Contaminated: A wound exposed to bacteria or debris, such as those resulting from trauma.

• Infected: A wound showing signs of infection, including purulent drainage, fever, and inflammation.

• Colonized: A wound with bacteria present but no active infection.

Wound Healing Process

1. Inflammatory Phase (0-3 days):

   • Hemostasis occurs with clot formation and scab development.

   • White blood cells remove bacteria and debris through phagocytosis.

2. Proliferation Phase (4-21 days):

   • Fibroblasts generate collagen to strengthen new tissue.

   • Granulation tissue forms, and epithelialization begins.

3. Maturation Phase (up to years):

   • Scar tissue strengthens through collagen remodeling.

   • The wound contracts and becomes less noticeable over time.

Types of dressings

• Gauze Dressings:
  Absorbent cotton pads used for minor cuts, abrasions, and surgical sites.

• Transparent Film Dressings:
  Clear, adhesive films ideal for superficial wounds, IV sites, and minor burns.

• Hydrocolloid Dressings:
  Gel-forming pads that work best on shallow, non-infected wounds like pressure ulcers and blisters.

• Alginate Dressings:
  Seaweed-based, super absorbent dressings used for deep, heavily exuding wounds and burns.

• Foam Dressings:
  Cushioned and absorbent, perfect for wounds with moderate to heavy exudate, such as pressure ulcers.

• Hydrogel Dressings:
  Water-rich pads that hydrate dry or necrotic wounds, plus minor burns.

• Antimicrobial Dressings:
  Infused with silver/iodine, these help fight infection in wounds at risk, like surgical incisions.

• Silicone Dressings:
  Gentle, non-adherent dressings used on fragile skin, post-surgical sites, and to minimize scarring.

Types of Wound Healing Intentions:

• Primary Intention: Wounds with minimal tissue loss that are sutured closed, leading to rapid healing with minimal scarring.

• Secondary Intention: Wounds left open to heal by granulation, commonly seen in pressure ulcers and infected wounds.

• Tertiary Intention: Wounds initially left open to allow infection or drainage to resolve before surgical closure.

Signs of Wound Infection

• Redness, warmth, and swelling around the wound.

• Increased pain or tenderness.

• Presence of purulent drainage with foul odor.

• Fever and elevated white blood cell count.

• Delayed wound healing or tissue deterioration.

Wound Drainage Types

• Sanguineous: Bright red, fresh blood, commonly seen in new wounds.

• Serosanguineous: A pink mixture of blood and clear fluid, indicating normal healing.

• Serous: Clear, pale yellow drainage, often seen in healing wounds.

• Purulent: Thick, yellow or green pus, indicating infection.

• Seropurulent: A combination of clear and purulent drainage, signaling possible infection.

• Bile Drainage: Greenish fluid, often seen in post-gallbladder surgery wounds.

Wound Documentation

• Drainage Amount & Color: Document the type, volume, and consistency of drainage.

• Odor: Note any unusual or foul smells, which may indicate infection.

• Wound Size: Measure and record length, width, and depth.

• Sinus Tract Presence: Identify and measure any tunneling within the wound.

• Tissue Description: Document the presence of granulation, necrotic, or eschar tissue.

• Surrounding Skin Condition: Assess for erythema, ischemia, or edema.

• Dressing Type & Change Frequency: Specify the dressing type used and when changes are needed.

• Pain Management: Administer analgesia before dressing changes to minimize discomfort.

Diagnostic Tests for Wound & Skin Conditions

• Cultures: Identify bacterial, fungal, or viral infections.

• Skin Scraping: Detect fungal infections such as athlete’s foot or scabies.

• Biopsy: Evaluate suspicious lesions for malignancy.

• Wood’s Lamp: Uses ultraviolet light to detect fungal infections.

• Allergy Testing: Patch or scratch tests help determine allergic reactions to wound care products.

ATI & Nursing Questions

1.       What is the first action when a wound evisceration occurs?

2.       What phase of wound healing involves granulation tissue formation?

3.       What type of wound drainage indicates infection?

4.       How does dehiscence differ from evisceration?

5.       What signs indicate a wound is infected?

6.       Why is ischemia a concern in wound assessment?

7.       What is the purpose of a wound culture and sensitivity test?

8.       Which wound healing intention involves suturing a clean wound?

9.       How should wound documentation be structured?

10.   What is the expected color of granulation tissue in wound healing?

Skin assessment

• Purpose: Assess the patient’s skin as part of a tissue assessment, whether it’s a focused skin exam or part of a full-body inspection.

• Process:

  • Inspect: Look at color, texture, moisture, and lesions.

  • Palpate: Feel for texture, moisture, temperature, mobility, and turgor.

  • Engage: Ask questions, involve the patient, and provide education along the way.

Aging & the Integumentary System

• General Effects of Aging:

  • Slowed cell division and healing

  • Thinning of the skin and decreased subcutaneous fat

  • Reduced function of sebaceous and sweat glands

  • Deterioration of collagen and elastin (leading to wrinkles, dryness, and temperature regulation issues)

• Hair Changes:

  • Hair follicles become inactive

  • Melanocytes die → hair becomes thin and gray

• Quick Take: Aging might not give you that Snapchat filter glow, but it’s all part of life’s upgrade!

Anatomy of the Skin & Nails

Skin Layers

• Epidermis (Outermost): Contains keratin and melanocytes (for pigment production)

• Dermis (Middle):

  • Rich in collagen and connective tissue (provides stretch and support)

  • Houses blood vessels, nerves, hair follicles, and sensory receptors

• Subcutaneous Layer:

  • Made of adipose tissue and fat cells

  • Aids in temperature regulation and acts as a cushion

Nails

• Structure: Hard, clear plates of keratin with the nail bed underneath (where growth occurs)

• Function: Protects fingers and toes and provides clues about circulatory and systemic health

Skin & Nail Functions

• Protection: Shields against physical and microbial injuries

• Temperature Regulation: Through shivering and sweating

• Sensory Perception: Detects temperature, touch, and pain

• Vitamin D Production: Essential for calcium absorption (via sunlight, food, or supplements)

Data Collection: Subjective & Objective

Subjective Data (Health History)

• Ask about:

  • History of skin disorders (consider hereditary factors)

  • Risk factors such as diabetes, infections, or recent medication changes

  • Exposures (bathing habits, product use, environmental changes, travel, occupation)

  • Location, timing, severity, and factors affecting any skin issues

  • The patient’s own perception of their condition

Objective Data (Physical Examination)

• Inspection:

  • Evaluate overall skin color, consistency, and any lesions

  • Assess hair and nails

• Palpation:

  • Check for temperature, texture, moisture, mobility, and turgor

Skin Assessment: Inspection & Palpation

Inspection

• Skin Color:

  • Normal: Even and consistent with the patient’s genetic background

  • Pigments: Combination of melanin, keratin pigments, and vascular contributions

  • Note: In darker skin tones, palms and soles are typically lighter

• Color Variations & Abnormal Findings:

  • Hyperpigmentation: Localized increased melanin (birthmarks, sun damage, pregnancy)

  • Hypopigmentation: Decreased melanin (scars, stretch marks)

  •  

Abnormal Colors:

• Cyanosis: Bluish hue (check oral mucosa/nail beds in darker skin)

• Ecchymosis: Bruising with a color change from blue to yellow as it heals

• Petechiae: Small red or purple spots from tiny hemorrhages

• Erythema: Flushed, intense red or purplish skin indicating inflammation

• Jaundice: Yellowish discoloration (often seen in sclera, hard palate, palms/soles)

• Pallor: Paleness that may indicate anemia or circulatory issues

Texture & Integrity:

• Normal: Smooth and dry (variations can occur with oiliness or dryness)

• Aging Effects: Acne, wrinkles, and scarring from healed lesions

• Unexpected Findings:

  • Velvety Skin: Excessively smooth texture (may hint at thyroid issues)

  • Rough/Dry/Flaky: Could indicate dehydration or thyroid problems

  • Diaphoresis: Excessive sweating—could signal fever, anxiety, or even heart failure

Palpation

• Temperature:

  • Should feel similar to body temperature

  • Abnormal Findings:

    • Hyperthermia: Elevated temperature (fever/infection)

    • Hypothermia: Cooler areas (poor perfusion or shock)

• Mobility & Turgor:

  • Normal: Skin should rise quickly when pinched and return to flat

  • Delayed Return/Tenting: Suggests reduced elasticity (aging, dehydration, weight loss)

• Edema:

  • Definition: Excess fluid accumulation in tissues

  • Assessment:

    • Press for 3-4 seconds and observe for indentation

    • Graded as: +1 (2 mm), +2 (4 mm), +3 (6 mm), +4 (8 mm)

  • Note: Edema may mask true skin color changes

Nail Assessment

• Normal Characteristics:

  • Slight curvature or flatness with smooth, rounded cuticles

  • Uniform thickness, translucent appearance, and color similar to the skin

• Capillary Refill:

  • Apply pressure for 5 seconds; color should return in under 2 seconds

• Abnormal Findings:

  • Thickening, uneven ridges, brittleness, or yellowing

  • Color Changes:

    • Brown with streaks, bluish (poor oxygenation), or whitish (anemia)

  • Structural Variations:

    • Clubbed nails (spoon-like appearance, often linked to pulmonary disease)

    • Jagged edges (from biting or brittleness)

  • Delayed Refill: May indicate cardiovascular or respiratory issues

Hair Assessment

• Evaluation Factors:

  • Distribution, color, quantity, thickness, and texture

  • Check for hair loss or abnormal growth patterns

  • Areas to Assess: Scalp, face, chest (in men), eyebrows, and pubic hair

• Quick Note: Don’t let your hair go “viral” in shedding—it might be hinting at circulation issues!

Diagnostic Tests for Skin Conditions

Visual Diagnosis

• Some conditions can be diagnosed based solely on clinical appearance.

Additional Tests

• Cultures: To detect bacteria, fungi, or viruses

• Scraping: Especially useful for diagnosing fungal infections

• Fluid Expression: Analyzing fluid from lesions

• Biopsies:

  • Punch or incisional biopsies for suspicious or deeper lesions (often followed by suturing)

• Wood’s Lamp Examination: Uses fluorescence (e.g., to detect ringworm)

• Skin Testing: Patch or scratch tests for allergies (e.g., latex, nickel)

Lesion Assessment: The ABCDE Rule for Melanoma

• A – Asymmetry: One half doesn’t match the other

• B – Border Irregularity: Jagged or scalloped edges are suspicious

• C – Color Variation: Uneven distribution or a mix of colors

• D – Diameter: Lesions larger than a pencil eraser (>6 mm) are concerning

• E – Evolving: Changes in size, shape, or color over time

Lesion Descriptions

• Macule: Flat, <1 cm (e.g., mole, freckle)

• Patch: Flat, >1 cm (e.g., birthmark)

• Papule: Raised, <1 cm (e.g., wart, skin tag)

• Plaque: Raised, >1 cm (e.g., eczema, psoriasis)

• Nodule: Raised, solid, <2 cm (could be melanoma)

• Vesicle: Raised, fluid-filled, <1 cm (e.g., shingles, herpes)

• Bulla: Raised, fluid-filled, >1 cm

ATI Nursing Based Questions

1. What are the three layers of the skin, and what is the primary function of each layer?

2. How does the aging process affect the integumentary system, specifically in terms of collagen and elastin?

3. Which cell types in the epidermis are responsible for pigment production, and how might their decline affect skin appearance?

4. What are two subjective questions you would ask a patient when gathering their health history related to skin issues?

5. Describe the ABCDE rule for melanoma detection and explain what each letter stands for.

6. When assessing edema through palpation, what does a +2 grading indicate in terms of indentation depth?

7. What abnormal nail findings might suggest a circulatory or respiratory issue, and why is capillary refill important in this assessment?

8. How can Wood’s lamp examination be used in diagnosing skin conditions, and what condition is it especially useful for?

9. What are the key differences between hyperpigmentation and hypopigmentation, and what might each indicate about a patient’s health?

10. During a hair assessment, what findings would prompt you to consider a possible circulatory problem?

                                       ENGAGEMENT module SKIN INTEGRITY NOTES

Anatomy & Physiology of the Skin

Functions of the Skin

• Protection: Against infection, UV light, chemicals, and physical injury.

• Regulation: Controls temperature, fluid loss, and excretion (water, ammonia, urea).

• Sensation: Houses sensory neurons.

• Vitamin D Production: Aids calcium absorption.

Skin Layers

• Epidermis: Outer layer, waterproof, responsible for skin color, contains normal flora (e.g., Staphylococcus epidermidis, aureus, Cutibacterium acnes). Layers include:

  • Stratum Corneum

  • Lucidum (only in thick skin)

  • Granulosum

  • Spinosum

  • Basale

• Dermis: Contains sweat glands, hair follicles, blood vessels, muscle, and sensory neurons.

• Hypodermis (Subcutaneous Tissue): Deepest layer, contains adipose tissue, blood vessels, and connective tissue.

Temperature Regulation

• Heat Retention: Vascular constriction decreases blood flow to the skin.

• Heat Loss: Radiation and convection via increased blood flow.

Pathophysiology of Wounds

Types of Wounds

• Acute Wounds: Skin incisions, tears, abrasions, moisture-associated damage.

• Chronic Wounds: Open >1 month, associated with diabetes, vascular issues, or immobility.

Wound Healing Stages

1. Hemostasis & Inflammation (0–3 days): Clotting cascade, vasoconstriction, fibrin mesh formation, neutrophil recruitment.

2. Proliferation (3–10 days): Granulation tissue forms, fibroblasts proliferate, new vascular structures develop.

3. Tissue Remodeling (21 days–1 year): Collagen strengthens, wound contracts, angiogenesis response stops.

Factors Affecting Wound Healing

• Systemic Factors: Advanced age, chronic diseases (diabetes, PAD, venous hypertension), poor circulation, malnutrition, stress.

• Local Factors: Moisture, pressure, friction, shearing, infection.

• Lifestyle Factors: Smoking, alcohol use, obesity.

Epidemiological & Etiological Risk Factors

• Common Risk Factors: Age >65, poor mobility, incontinence, poor nutrition, altered cognition, multiple medications.

• Skin Damage Causes:

  • Moisture-Associated Skin Damage (MASD): Due to incontinence or sweat retention.

  • Shearing & Friction: Common in immobile clients.

  • Trauma & Skin Tears: Risk increased in elderly, chronic illness, steroid use.

Chronic Wounds & Their Presentation

• Diagnostic Tests: ABI <0.8 suggests arterial perfusion issues, Doppler ultrasound for venous problems.

• Lab Tests: CBC, albumin, pre-albumin, bacterial protease activity (BPA), excessive inflammatory protease activity (EPA).

Nutritional Needs for Wound Healing

Pressure Injuries (PIs)

• Pathophysiology: Breakdown due to unrelieved pressure over bony prominences (sacrum, heels, hips).

• Risk Factors: Immobility, incontinence, poor nutrition, moisture, friction, shearing.

• Incidence: ICU (10–20%), Long-term care (20–30%).

Pressure Injury Staging

• Lab Tests: WBC count, wound cultures, albumin/prealbumin for nutritional assessment.

Wound & Pressure Injury Management

Nursing Process

1. Recognize Cues: Assess wound size, depth, color, drainage (COCA: Color, Odor, Consistency, Amount).

2. Analyze Cues: Identify risk factors (diabetes, immobility, PAD).

3. Prioritize Hypotheses: Treat infections first, optimize perfusion and nutrition.

4. Generate Solutions: Establish wound healing goals.

5. Take Action: Implement wound care strategies.

Wound Dressing Principles

• Wet wounds: Absorb excess moisture.

• Dry wounds: Apply moisture-retaining dressings.

Advanced Therapies

• Negative Pressure Wound Therapy (NPWT): Removes exudate, reduces healing time.

• Hyperbaric Oxygen Therapy (HBOT): Increases oxygenation, reduces edema.

• Electrical Stimulation Therapy: Reduces infection, enhances perfusion.

Infections & Inflammation

Wound Infection Continuum

1. Contaminated: Micro-organisms present, no infection.

2. Colonized: Microbes multiplying, no immune response.

3. Local Infection: Redness, swelling, pain, drainage.

4. Spreading Infection: Extends beyond wound (e.g., cellulitis).

5. Systemic Infection: Bloodstream invasion (sepsis).

• Common Pathogens: Staphylococcus aureus, MRSA, Group A Streptococcus.

• Risk Factors: Immunocompromised state, diabetes, steroid use.

Anaphylaxis

• Signs: Hives, throat tightness, difficulty breathing, dizziness.

• Management: Administer epinephrine IM, call 911, provide oxygen.

Pharmacology

Medications for Wound & Skin Conditions

Client Education & Nursing Considerations

• Prevention Strategies: Moisture control, pressure relief (reposition q2h), proper nutrition.

• Teaching Techniques: Use the teach-back method, written/verbal/multimedia education.

• Psychosocial Impact: Address stigma, depression, and social isolation.

• Special Populations: Older adults have thinner skin, slower healing, and higher infection risk.