Skin Integrity and Wound Care - Concept Map
Maintaining Skin Integrity and Managing Wounds to Prevent Complications and Promote Healing
Related concepts
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Concept connections
- Skin Anatomy and PhysiologyPressure Injury PathophysiologyUnderstanding the three skin layers (epidermis, dermis, subcutaneous tissue) explains how sustained pressure leads to ischemia and tissue damage at different depths
- Pressure Injury PathophysiologyPressure Injury StagingThe mechanism of tissue damage (ischemia) directly determines the depth of injury and therefore the stage classification
- Pressure Injury StagingNursing DiagnosesAccurate staging guides selection of appropriate NANDA diagnoses such as Impaired Skin Integrity or Impaired Tissue Integrity
- Wound AssessmentDressing SelectionSystematic assessment of exudate level, wound bed tissue, and infection status directly determines which dressing type is most appropriate
- Wound Healing PhasesFactors Impairing HealingUnderstanding each phase reveals specific points where nutritional deficiencies, infection, or poor perfusion can interrupt normal progression
- Pressure Injury PreventionPressure Injury StagingEffective prevention strategies, when implemented consistently, prevent progression from Stage 1 to higher stages
- Patient and Family TeachingPressure Injury PreventionPatient and caregiver education directly enables execution of prevention strategies in hospital and community settings
- Wound AssessmentWound Healing PhasesAssessment findings (granulation tissue presence, epithelialization) indicate which healing phase is occurring and guide interventions
- Ostomy Care and Peristomal Skin ProtectionComplications and Emergency ManagementFailures in ostomy care techniques lead to specific complications (peristomal dermatitis, ulceration) or stoma ischemia emergencies
- High Risk SitesPressure Injury PreventionIdentifying high-risk anatomical locations (sacrum, heels, ischial tuberosities) allows targeted, site-specific prevention measures
- Braden Scale Risk AssessmentPressure Injury PreventionBraden Scale score stratifies risk level and guides intensity and frequency of prevention interventions
- Wound Cleaning and DebridementWound Healing PhasesAppropriate wound preparation (removing nonviable tissue, using normal saline) optimizes conditions for inflammatory and proliferative phases
- Contributing FactorsFactors Impairing HealingMany factors contributing to pressure injury development (poor nutrition, reduced perfusion, advanced age) also impair wound healing
- Dressing SelectionWound Healing PhasesDressing choice supports phase-specific needs: hydrogel for inflammatory phase debridement, foam for proliferative phase exudate management
- Signs of InfectionComplications and Emergency ManagementRecognition of infection signs (purulent drainage, fever, increased pain) enables early intervention preventing cellulitis, abscess, or sepsis
- Legal and Ethical ConsiderationsPressure Injury StagingRA 9173 and documentation standards require accurate staging that is never reverse-staged, ensuring legal compliance and continuity of care
- Legal and Ethical ConsiderationsPatient and Family TeachingInformed consent and patient autonomy principles require comprehensive teaching about wound care, ostomy management, and prevention options
- Stoma AssessmentEmergency ManagementRecognition of dusky, dark, or black stoma indicates ischemia requiring immediate provider notification and possible surgical intervention
- Peristomal Skin ProtectionDressing SelectionOstomy barrier wafers are specialized dressings selected based on stoma size, pouch type, and peristomal skin condition
- Pressure Injury PreventionPatient and Family TeachingPrevention education empowers patients and families to recognize pressure areas, maintain positioning, and participate actively in prevention
Diagrams
Skin Integrity and Wound Care Concept Map
Comprehensive mind map displaying all key concepts in Skin Integrity and Wound Care, organized by major topic areas including anatomy, pressure injury pathophysiology and staging, wound assessment and healing, prevention strategies, dressing selection, ostomy management, and patient teaching. This hierarchical map shows how each concept relates to the central theme of maintaining skin integrity and promoting optimal wound healing outcomes.
Pressure Injury Assessment and Staging Decision Tree
Systematic decision tree guiding nurses through pressure injury assessment and staging. Begins with skin integrity assessment, progresses through visual and tactile examination, and leads to accurate staging (Stage 1-4, Unstageable, or Deep Tissue Injury). Each stage branches to appropriate nursing actions. This flowchart aligns with NPUAP/NPIAP guidelines and reflects the NLE testing approach.
Wound Healing Phases and Timeline
Timeline illustrating the four sequential phases of normal wound healing with specific timeline durations. Shows the progression from immediate hemostasis through inflammatory, proliferative, and maturation phases. Identifies typical manifestations at each phase and displays factors that either accelerate or impair progression. Particularly valuable for understanding expected wound characteristics and recognizing delayed healing requiring intervention.
Dressing Selection Algorithm Based on Wound Characteristics
Evidence-based algorithm for selecting appropriate wound dressings based on systematic assessment of exudate level, wound bed condition, depth, and infection status. Guides nurses through decision points to choose from transparent film, hydrogel, hydrocolloid, foam, alginate, antimicrobial, or negative-pressure options. Emphasizes the principle of maintaining moist wound bed while keeping periwound skin dry. Includes monitoring and reassessment steps.
Pressure Injury Prevention Protocol for Immobilized Patients
Comprehensive prevention protocol for pressure injuries in immobilized patients, aligned with evidence-based standards and NLE expectations. Integrates Braden Scale risk stratification to guide intensity of prevention measures. Addresses positioning, pressure redistribution, skin care, nutrition, and monitoring. Emphasizes key prevention principles: repositioning frequency by patient mobility status, heel offloading, HOB positioning to reduce shear, and avoidance of harmful practices like massage over prominences.
Stoma Health Status Assessment and Action Framework
State diagram showing the stoma health assessment framework and decision pathways. Illustrates the progression from healthy stoma through concerning signs to potential emergency situations. Maps normal stoma characteristics (red-pink, moist), warning signs (pale, dusky, mottled), and critical emergency signs (dark purple, black) indicating ischemia. Includes branching paths for different complications (retraction, prolapse, peristomal skin issues) and associated nursing actions. Critical for rapid assessment and appropriate escalation of care.
Ostomy Appliance Management and Peristomal Skin Protection
Step-by-step procedural flowchart for ostomy appliance changes and peristomal skin protection. Addresses the critical nursing action of cutting the barrier opening 1-2 mm larger than the stoma to prevent effluent contact with skin. Emphasizes water-only cleansing and complete drying. Includes decision points for responding to common peristomal complications (erythema, itching, maceration, ulceration) with appropriate interventions. Essential procedure for preventing peristomal skin breakdown and maintaining ostomy function.
Wound Healing Phase Distribution Timeline
Pie chart illustrating the relative duration distribution of the four wound healing phases. Shows that while hemostasis is immediate, the inflammatory phase occupies a brief period (days 1-4), the proliferative phase is the main active healing period (days 4-21), and maturation extends for months to years. This visualization helps nurses understand that most active tissue rebuilding occurs during proliferation, while maturation continues long after a wound appears healed, affecting wound strength and durability.