NLE Integumentary & Skin Integrity — Skin Integrity and Wound CareConcept Map

Concept

Skin Anatomy and Physiology

Sub Concepts

• Epidermis (avascular outer layer)
• Dermis (blood vessels, nerves, hair follicles, glands)
• Subcutaneous tissue/Hypodermis (fat and connective tissue)
• Functions: Protection, temperature regulation, fluid balance, sensation

Relationship To Central

Foundation for understanding skin integrity compromise

Concept

Pressure Injury Pathophysiology

Sub Concepts

• Sustained pressure exceeds capillary closing pressure (~32 mmHg)
• Tissue ischemia and cellular death
• Contributing factors: Pressure intensity/duration, shear, friction, moisture, impaired mobility, sensory deficits, poor nutrition, advanced age, reduced tissue perfusion
• High-risk sites: Sacrum, coccyx, heels, ischial tuberosities, greater trochanters, elbows, occiput

Relationship To Central

Leading cause of skin integrity loss in immobile patients

Concept

Pressure Injury Staging (NPUAP/NPIAP System)

Sub Concepts

• Stage 1: Intact skin with non-blanchable erythema
• Stage 2: Partial-thickness loss, exposed dermis (shallow ulcer or blister)
• Stage 3: Full-thickness loss, subcutaneous fat visible, no bone/tendon exposed
• Stage 4: Full-thickness loss with exposed bone, tendon, muscle, or cartilage
• Unstageable: Base obscured by slough/eschar
• Deep Tissue Pressure Injury (DTI): Persistent non-blanchable deep purple/maroon or blood-filled blister
• Never reverse-stage; document as 'healing Stage X'

Relationship To Central

Critical classification for assessment, documentation, and intervention planning

Concept

Wound Assessment

Sub Concepts

• Location and size (length, width, depth in cm)
• Undermining and tunneling assessment
• Wound bed tissue: Granulation, slough, eschar
• Exudate assessment: Amount and type (serous, sanguineous, serosanguineous, purulent)
• Wound edges and periwound skin status
• Signs of infection: Erythema, warmth, edema, purulent drainage, foul odor, increased pain, fever

Relationship To Central

Systematic evaluation guides treatment decisions

Concept

Wound Healing Types and Phases

Sub Concepts

• Primary intention: Clean, well-approximated edges (minimal scarring)
• Secondary intention: Significant tissue loss, open healing by granulation (more scarring)
• Tertiary intention: Delayed closure after initial open management
• Phase 1 - Hemostasis: Immediate vasoconstriction and clot formation
• Phase 2 - Inflammatory (days 1-4): Vasodilation, phagocytosis, leukocyte migration
• Phase 3 - Proliferative (days 4-21): Collagen deposition, granulation tissue, epithelialization
• Phase 4 - Maturation/Remodeling (day 21 to 1-2 years): Collagen remodeling, 70-80% tensile strength

Relationship To Central

Understanding healing trajectory informs care planning

Concept

Factors Impairing Wound Healing

Sub Concepts

• Advanced age
• Poor nutrition (protein, vitamin C, zinc deficiency)
• Diabetes and poor glycemic control
• Impaired perfusion and peripheral vascular disease
• Smoking
• Corticosteroids and immunosuppression
• Infection and high bacterial load
• Moisture imbalance

Relationship To Central

Risk factors requiring nursing intervention

Concept

Pressure Injury Prevention

Sub Concepts

• Reposition bedbound patients every 2 hours, chairbound every 1 hour
• Use pressure-redistribution surfaces (foam, alternating-pressure, low-air-loss mattresses)
• Float heels with pillows under calves
• Keep head of bed at or below 30 degrees to reduce shear
• Use 30-degree lateral tilt positioning
• Keep skin clean and dry; manage incontinence promptly
• Use pH-balanced cleansers and moisture-barrier creams
• Do NOT massage over bony prominences
• Optimize nutrition and hydration (protein, calories, vitamin C, zinc)
• Use Braden Scale risk assessment (lower score = higher risk) on admission and regularly

Relationship To Central

Primary nursing intervention per RA 9173 scope

Concept

Wound Cleaning and Debridement

Sub Concepts

• Clean with normal saline (avoid cytotoxic agents)
• Avoid routine hydrogen peroxide or povidone-iodine on granulating wounds
• Debride nonviable tissue: Autolytic, enzymatic, mechanical, sharp/surgical
• Exception: Do NOT remove stable, dry, adherent eschar on heels or ischemic limbs (natural protective cover)
• Remove slough and eschar from other wound sites
• Maintain clean technique for chronic wounds; sterile technique for acute/surgical wounds

Relationship To Central

Essential principles for optimal healing environment

Concept

Dressing Selection and Moist Wound Care

Sub Concepts

• Transparent film (Tegaderm): Stage 1, superficial, secondary dressing
• Hydrocolloid (DuoDERM): Stage 2-3 with light-to-moderate exudate, supports autolytic debridement, stays 3-7 days
• Hydrogel: For dry wounds, supports autolytic debridement, soothing for painful wounds
• Foam: Absorbs moderate-to-heavy exudate, good padding
• Alginate: Heavy exudate and deep/tunneling wounds, hemostatic
• Antimicrobial (silver, iodine, honey): Critically colonized or infected wounds
• Negative-pressure wound therapy (NPWT/VAC): Large Stage 3/4 wounds
• Keep wound bed moist; keep periwound skin dry

Relationship To Central

Maintains optimal wound environment for healing

Concept

Ostomy Care and Peristomal Skin Protection

Sub Concepts

• Healthy stoma: Red-pink, moist, slightly raised
• Emergency signs: Dusky, pale, dark, purple, or black stoma (ischemia)
• Mild stoma bleeding is normal (vascular tissue)
• Ileostomy output: Liquid to pasty, enzyme-rich (high peristomal breakdown risk)
• Cut wafer/barrier 1-2 mm larger than stoma to prevent effluent contact
• Cleanse peristomal skin with water only; pat dry
• Apply skin barriers as needed
• Change appliance every 3-7 days or when leaking
• Monitor for dehydration and electrolyte loss (ileostomy)
• Teach dietary considerations and peristomal complication signs

Relationship To Central

Specialized wound/stoma management preventing skin complications

Concept

Nursing Diagnoses (NANDA-I)

Sub Concepts

• Impaired skin integrity related to pressure, shear, friction, moisture
• Risk for impaired skin integrity
• Impaired tissue integrity related to pressure injury or wound
• Acute or chronic pain related to wound or healing process
• Risk for infection related to break in skin integrity
• Deficient fluid volume related to excessive wound drainage or ostomy output
• Imbalanced nutrition: Less than body requirements
• Deficient knowledge regarding wound care, ostomy management, or prevention

Relationship To Central

Framework for systematic nursing care planning

Concept

Complications and Emergency Management

Sub Concepts

• Local infection and cellulitis
• Abscess formation
• Osteomyelitis (Stage 4 over bone)
• Sepsis and systemic infection
• Marjolin ulcer (malignant transformation of chronic wound)
• Peristomal complications: Dermatitis, stomal retraction, prolapse, stenosis
• Dusky/black stoma = emergency (ischemia); notify provider immediately

Relationship To Central

Consequences of untreated or advanced wounds requiring urgent intervention

Concept

Patient and Family Teaching

Sub Concepts

• Repositioning schedules and technique
• Daily skin inspection over bony prominences
• Moisture management and incontinence care
• Nutrition and hydration importance for healing
• Proper handwashing and dressing technique
• Signs of infection to report immediately
• Ostomy appliance changes and skin care
• Output monitoring and dietary modifications
• When to contact healthcare provider

Relationship To Central

Empowerment for self-care and prevention in home/community setting

Concept

Legal and Ethical Considerations (RA 9173)

Sub Concepts

• Documentation accuracy in pressure injury staging
• Never reverse-stage wounds (legal documentation requirement)
• Informed consent for treatment and teaching
• Patient autonomy in ostomy management decisions
• Reporting unsafe care or facility negligence
• Maintaining confidentiality of patient information
• Duty to prevent harm (non-maleficence) through evidence-based prevention

Relationship To Central

Professional accountability in Philippine nursing practice

To

Pressure Injury Pathophysiology

From

Skin Anatomy and Physiology

Strength

strong

Relationship

Understanding the three skin layers (epidermis, dermis, subcutaneous tissue) explains how sustained pressure leads to ischemia and tissue damage at different depths

To

Pressure Injury Staging

From

Pressure Injury Pathophysiology

Strength

strong

Relationship

The mechanism of tissue damage (ischemia) directly determines the depth of injury and therefore the stage classification

To

Nursing Diagnoses

From

Pressure Injury Staging

Strength

strong

Relationship

Accurate staging guides selection of appropriate NANDA diagnoses such as Impaired Skin Integrity or Impaired Tissue Integrity

To

Dressing Selection

From

Wound Assessment

Strength

strong

Relationship

Systematic assessment of exudate level, wound bed tissue, and infection status directly determines which dressing type is most appropriate

To

Factors Impairing Healing

From

Wound Healing Phases

Strength

strong

Relationship

Understanding each phase reveals specific points where nutritional deficiencies, infection, or poor perfusion can interrupt normal progression

To

Pressure Injury Staging

From

Pressure Injury Prevention

Strength

moderate

Relationship

Effective prevention strategies, when implemented consistently, prevent progression from Stage 1 to higher stages

To

Pressure Injury Prevention

From

Patient and Family Teaching

Strength

strong

Relationship

Patient and caregiver education directly enables execution of prevention strategies in hospital and community settings

To

Wound Healing Phases

From

Wound Assessment

Strength

moderate

Relationship

Assessment findings (granulation tissue presence, epithelialization) indicate which healing phase is occurring and guide interventions

To

Complications and Emergency Management

From

Ostomy Care and Peristomal Skin Protection

Strength

strong

Relationship

Failures in ostomy care techniques lead to specific complications (peristomal dermatitis, ulceration) or stoma ischemia emergencies

To

Pressure Injury Prevention

From

High Risk Sites

Strength

strong

Relationship

Identifying high-risk anatomical locations (sacrum, heels, ischial tuberosities) allows targeted, site-specific prevention measures

To

Pressure Injury Prevention

From

Braden Scale Risk Assessment

Strength

strong

Relationship

Braden Scale score stratifies risk level and guides intensity and frequency of prevention interventions

To

Wound Healing Phases

From

Wound Cleaning and Debridement

Strength

moderate

Relationship

Appropriate wound preparation (removing nonviable tissue, using normal saline) optimizes conditions for inflammatory and proliferative phases

To

Factors Impairing Healing

From

Contributing Factors

Strength

strong

Relationship

Many factors contributing to pressure injury development (poor nutrition, reduced perfusion, advanced age) also impair wound healing

To

Wound Healing Phases

From

Dressing Selection

Strength

moderate

Relationship

Dressing choice supports phase-specific needs: hydrogel for inflammatory phase debridement, foam for proliferative phase exudate management

To

Complications and Emergency Management

From

Signs of Infection

Strength

strong

Relationship

Recognition of infection signs (purulent drainage, fever, increased pain) enables early intervention preventing cellulitis, abscess, or sepsis

To

Pressure Injury Staging

From

Legal and Ethical Considerations

Strength

moderate

Relationship

RA 9173 and documentation standards require accurate staging that is never reverse-staged, ensuring legal compliance and continuity of care

To

Patient and Family Teaching

From

Legal and Ethical Considerations

Strength

moderate

Relationship

Informed consent and patient autonomy principles require comprehensive teaching about wound care, ostomy management, and prevention options

To

Emergency Management

From

Stoma Assessment

Strength

strong

Relationship

Recognition of dusky, dark, or black stoma indicates ischemia requiring immediate provider notification and possible surgical intervention

To

Dressing Selection

From

Peristomal Skin Protection

Strength

moderate

Relationship

Ostomy barrier wafers are specialized dressings selected based on stoma size, pouch type, and peristomal skin condition

To

Patient and Family Teaching

From

Pressure Injury Prevention

Strength

strong

Relationship

Prevention education empowers patients and families to recognize pressure areas, maintain positioning, and participate actively in prevention