NLE Integumentary & Skin Integrity — Skin Integrity and Wound CareDetailed Explanation

Anatomy and Physiology of the Skin

The skin is composed of three primary layers, each with distinct structures and functions that are critical to understanding how and why skin breakdown occurs. **Epidermis** — The outermost, avascular layer. It contains keratinocytes (provide waterproofing), melanocytes (provide pigmentation), Langerhans cells (immune defense), and Merkel cells (touch sensation). Because it is avascular, it depends on the dermis below for nutrient diffusion. This is clinically important: when epidermal breakdown occurs (Stage 2 pressure injury), the wound is painful because nerve endings in the dermis are now exposed. **Dermis** — The middle, vascular layer. It contains blood vessels, lymphatics, nerve endings, hair follicles, sebaceous glands (oil), and sweat glands (eccrine and apocrine). Collagen and elastin fibers give the skin its strength and elasticity. Aging causes collagen loss, thinning the dermis and increasing pressure injury risk in elderly Filipino patients — a major concern in Philippine public hospitals where older patients may have prolonged bed rest. **Subcutaneous Tissue (Hypodermis)** — The deepest layer, composed of adipose (fat) and loose connective tissue. It provides cushioning, insulation, and energy storage. When a pressure injury reaches this layer, it is at least a Stage 3. **Functions of the skin** (memorize with the acronym **PIRATES**): - **P**rotection from microorganisms, UV radiation, and chemical injury - **I**mmune surveillance (Langerhans cells) - **R**egulation of temperature (vasodilation/vasoconstriction, sweating) - **A**bsorption of fat-soluble vitamins (Vitamin D synthesis) - **T**actile sensation (pain, pressure, temperature, touch) - **E**xcretion of waste (sweat contains urea and salts) - **S**ensory perception **Capillary Closing Pressure** — A key concept for pressure injury pathophysiology: normal capillary closing pressure is approximately **32 mmHg**. When external pressure exceeds this value — as occurs when a patient lies on a bony prominence — capillary blood flow is occluded. If this continues for more than 1–2 hours, tissue ischemia and cell death occur, resulting in a pressure injury.

Pressure Injury Staging (NPUAP/NPIAP System)

The National Pressure Injury Advisory Panel (NPUAP, now renamed NPIAP) classification system is the gold standard for staging pressure injuries. Each stage describes the **depth of tissue destruction**. The NLE heavily tests this topic — you must be able to identify stages from clinical descriptions and choose the correct nursing action. **Critical Rule #1: Stage by the DEEPEST visible tissue layer involved.** **Critical Rule #2: NEVER reverse-stage a healing wound.** A Stage 4 injury that is healing is documented as 'Healing Stage 4,' never downgraded to Stage 2 or 3. --- **Stage 1 — Non-Blanchable Erythema, Intact Skin** - Skin is INTACT. - Localized area of non-blanchable erythema (redness that does NOT turn white when pressed). - Usually over a bony prominence. - In dark skin tones: may appear as a different color (purple, violet, darker), warmer, firmer, or boggy compared to surrounding tissue. - **Clinical tip:** Use a glass slide or your fingertip to check blanching. If the skin stays red, it is Stage 1. **Stage 2 — Partial-Thickness Skin Loss** - Skin is OPEN (or has an intact/ruptured blister). - Involves epidermis and part of the dermis — **PARTIAL-THICKNESS loss**. - Appears as a shallow, open wound with a **red-pink wound bed** (dermis exposed). - OR: an **intact or ruptured serum-filled (clear) blister**. - NO slough, necrotic tissue, or visible deep structures. - **Clinical tip:** Stage 2 looks like a 'scraped knee' — shallow, red, moist. The blister is filled with clear (serous) fluid — NOT blood (blood-filled blisters suggest DTI). **Stage 3 — Full-Thickness Skin Loss** - FULL-THICKNESS loss: epidermis AND full dermis are gone. - **Subcutaneous fat MAY be visible** but bone, tendon, muscle, and ligament are NOT exposed. - Slough (yellow/tan stringy tissue) and/or eschar (black/brown necrotic tissue) may be present. - Undermining and tunneling may be present. - **Depth varies by location:** In areas with little subcutaneous tissue (nose, ear, occiput, malleolus), a Stage 3 may be shallow. In areas with thick fat layers (buttocks), a Stage 3 may be very deep. **Stage 4 — Full-Thickness Skin and Tissue Loss** - Most severe classified stage. - **Bone, tendon, muscle, ligament, or cartilage is EXPOSED or directly palpable.** - High risk for **osteomyelitis** (bone infection) — a serious complication requiring long-term antibiotics or surgery. - Slough, eschar, undermining, and tunneling are commonly present. - **Clinical tip:** If you can touch bone or see muscle/tendon, it is Stage 4. **Unstageable — Depth Unknown** - Full-thickness loss where the wound base is **OBSCURED by slough or eschar** — you cannot see how deep it goes. - Cannot be staged until the slough/eschar is removed. - Once debrided, it will be classified as Stage 3 or Stage 4. - **CRITICAL EXCEPTION:** Do NOT debride **stable, dry, adherent, intact eschar on the heel or an ischemic limb** — it acts as the body's natural biological cover and removing it can cause life-threatening complications. A heel with stable dry eschar should be assessed but left intact. **Deep Tissue Pressure Injury (DTPI/DTI)** - Intact OR non-intact skin. - Localized area of **persistent non-blanchable deep red, maroon, or purple discoloration**. - OR: a **blood-filled blister** (key differentiator from Stage 2 which has a serum/clear blister). - Results from damage to DEEPER soft tissue (muscle, fat) from pressure/shear — the surface looks okay but the damage is inside. - May evolve rapidly — the patient may present with what looks like Stage 1–2, but within days it can 'open up' to reveal a Stage 3 or 4. - Common on the heel. --- **Common Bony Prominences at Risk (by position):** - **Supine:** Sacrum, coccyx, heels, occiput, scapulae, elbows - **Sitting/Semi-Fowler's:** Ischial tuberosities (the 'sitting bones') - **Side-lying:** Greater trochanter, lateral malleolus, medial knee - **Prone:** Knees, toes, anterior iliac spine, cheeks, ears

Wound Assessment

Comprehensive wound assessment is the foundation of the nursing process in wound care. A thorough assessment guides diagnosis, planning, and selection of appropriate interventions. In the NLE context, you must know what to assess, how to document it, and what findings indicate complications. **Components of a Complete Wound Assessment:** **1. Location** - Describe using anatomical landmarks (e.g., 'over the right sacrum,' 'right lateral malleolus'). - Note the position of highest-risk areas by patient position. **2. Size — The 'LWD' Rule** - **Length** (head-to-toe direction, in centimeters) - **Width** (side-to-side direction, in centimeters) - **Depth** (deepest point, using a sterile cotton-tipped applicator) - Document as: L × W × D (e.g., 4 cm × 3 cm × 1.5 cm) **3. Undermining and Tunneling** - **Undermining**: Tissue destruction beneath INTACT skin edges — the wound is larger under the skin than it appears on the surface. Measured by inserting a sterile applicator under the wound edge and measuring the extent. - **Tunneling (sinus tract)**: A narrow channel or passage extending from the wound. Documented by clock position (e.g., 'tunneling at 6 o'clock, 2 cm deep'). **4. Wound Bed Tissue — The 'COLOR' Code** - **Red/Granulation tissue**: Beefy red, cobblestone-like, HEALTHY. Indicates healing. Handle gently — granulation tissue bleeds easily. - **Yellow/Slough**: Stringy, yellow or tan, moist, NONVIABLE tissue. Must be debrided for healing to proceed. - **Black/Eschar**: Hard or soft, black or brown, NECROTIC tissue. Must be debrided (EXCEPT stable heel/ischemic limb eschar). - **Pink/Epithelialization**: New pink, shiny skin growing from the wound edges — indicates wound is closing. This is the goal. **5. Exudate (Wound Drainage)** - **Amount**: None, scant, moderate, copious - **Type**: - **Serous**: Clear, watery, thin — normal in early healing - **Sanguineous**: Bloody — normal after debridement or injury to granulation tissue - **Serosanguineous**: Pink (mixture of serous and blood) — normal in early healing - **Purulent**: Thick, yellow, green, or brown, opaque, may have foul odor — INFECTION **6. Wound Edges and Periwound Skin** - **Maceration**: Waterlogged, white, soft skin from excess moisture — the wound is too wet; dressing needs adjustment. - **Erythema**: Redness around wound — may indicate inflammation or infection. - **Induration**: Hardness of periwound tissue — sign of infection. - **Epibole**: Rolled, thickened wound edges that have overgrown — may need debridement to allow healing. - **Epithelialization**: New skin growing inward from wound edges — a positive healing sign. **7. Signs of Wound Infection (The '5 Wound Infection Indicators')** - Increased **erythema** (spreading redness beyond wound edge) - **Warmth** (localized heat) - **Edema** (swelling) - **Purulent drainage** (pus) - **Pain** (worsening or new onset) - PLUS: Foul **odor**, systemic signs (**fever**, increased WBC, elevated ESR) - **CRITICAL:** A wound can be critically colonized (high bacterial load but no systemic signs) or infected (systemic signs). A wound that does not progress despite optimal care for 2–4 weeks should be assessed for biofilm or infection. **Wound Assessment Documentation Example:** 'Stage 3 pressure injury, right sacrum. Measures 5 cm × 4 cm × 2 cm. Wound bed: 70% yellow slough, 30% granulation tissue. Moderate amount of serosanguineous exudate. Undermining noted at 9 o'clock, 1.5 cm. Periwound skin intact, mild erythema noted. No foul odor. Patient reports pain rated 4/10.'

Types and Phases of Wound Healing

Understanding how wounds heal helps nurses select the right interventions, recognize complications, and set realistic goals for patients and families. Wound healing involves specific types of intention and sequential phases. --- **TYPES OF WOUND HEALING INTENTION:** **1. Primary Intention (First Intention)** - Clean surgical wounds with well-approximated (closed/sutured) edges. - Minimal tissue loss. - Fastest healing, least scarring, lowest infection risk. - Example: A clean appendectomy incision closed with sutures or staples. - The edges are held together, so the wound heals from side to side. **2. Secondary Intention** - Wounds with SIGNIFICANT tissue loss, left OPEN to heal. - Heal by granulation from the BASE UP and sides IN (bottom to top, inside out). - Slower, more scarring, higher infection risk. - Example: A Stage 3 pressure injury, an abscess that was drained and left open. - These wounds require frequent dressing changes and wound care. **3. Tertiary Intention (Delayed Primary Closure)** - Wound initially left OPEN (often to allow drainage or treat infection), then SURGICALLY CLOSED later. - Used when a wound is too contaminated to close immediately. - Example: An infected abdominal wound left open for several days, then sutured once infection is controlled. --- **PHASES OF WOUND HEALING:** **Phase 1 — Hemostasis (Immediate, first minutes to hours)** - Goal: STOP BLEEDING. - Vasoconstriction occurs immediately. - Platelet aggregation and fibrin clot formation seal the wound. - A scab (dried clot) forms on the surface. - Key players: Platelets, thrombin, fibrin. **Phase 2 — Inflammatory Phase (Days 1–4)** - Goal: CLEAN THE WOUND. - Vasodilation occurs (reversal of vasoconstriction) → brings blood, nutrients, and immune cells to the wound. - Signs: Redness (rubor), warmth (calor), swelling (tumor), pain (dolor) — these are NORMAL and EXPECTED. - White blood cells (neutrophils first, then macrophages) phagocytose bacteria and debris. - Macrophages are the 'directors' of healing — they release growth factors that initiate the next phase. - Key players: Neutrophils, macrophages, histamine, bradykinin. - NURSING ALERT: Do not confuse the NORMAL signs of inflammation with infection. Infection typically presents on Day 3–5 with purulent drainage, spreading erythema, and systemic signs. **Phase 3 — Proliferative Phase (Days 4–21)** - Goal: FILL AND COVER THE WOUND. - Three key processes: 1. **Granulation**: Fibroblasts migrate and lay down COLLAGEN (Type III initially). New capillaries grow into the wound (angiogenesis). This forms granulation tissue — the beefy red, cobblestone-like tissue that fills the wound from the base up. 2. **Wound Contraction**: Myofibroblasts pull wound edges together, reducing wound size. 3. **Epithelialization**: Epithelial cells migrate from wound edges to resurface the wound. This is the final step in the proliferative phase — the wound surface is covered with new, fragile skin. - Key players: Fibroblasts, myofibroblasts, epithelial cells. **Phase 4 — Maturation/Remodeling Phase (Day 21 to up to 1–2 years)** - Goal: STRENGTHEN THE WOUND. - Type III collagen is replaced by stronger Type I collagen. - The scar remodels — becomes flatter, paler, and stronger over time. - A healed wound reaches only **70–80% of its original tensile strength** — it will NEVER be as strong as intact skin. - Hypertrophic scars and keloids can form in some patients (more common in patients with darker skin tones, including many Filipinos — clinically relevant NLE context). - Key players: Fibroblasts, collagen Type I. --- **FACTORS THAT IMPAIR WOUND HEALING** (memorize for NLE): - **Poor nutrition**: Protein, Vitamin C (collagen synthesis), zinc (cell division and immune function) - **Diabetes mellitus**: Hyperglycemia impairs phagocytosis and perfusion; peripheral neuropathy reduces sensation - **Impaired circulation**: Peripheral arterial disease, venous insufficiency - **Infection**: Bacterial load prolongs inflammation and delays proliferation - **Age**: Elderly patients have slower healing, thinner skin, reduced immune response - **Medications**: Corticosteroids suppress inflammation (needed for healing) and impair collagen synthesis - **Smoking**: Nicotine causes vasoconstriction, reducing oxygen delivery to tissues - **Moisture imbalance**: Too dry (slows epithelialization) or too wet (causes maceration)

Nursing Management and Pressure Injury Prevention

Prevention is the highest priority in pressure injury management. The majority of pressure injuries are preventable with systematic, evidence-based nursing care. The nursing process guides all interventions. --- **STEP 1 — RISK ASSESSMENT: THE BRADEN SCALE** The Braden Scale is the most widely used validated tool for pressure injury risk assessment. It is required on admission to all Philippine DOH-accredited hospitals and should be repeated regularly (e.g., every 24–48 hours, or with any significant change in condition). The Braden Scale assesses SIX subscales (remember with **'SMA-MNF'**): 1. **S**ensory Perception — ability to respond to pressure-related discomfort (1=completely limited to 4=no impairment) 2. **M**oisture — degree of skin moisture exposure (1=constantly moist to 4=rarely moist) 3. **A**ctivity — degree of physical activity (1=bedfast to 4=walks frequently) 4. **M**obility — ability to change and control body position (1=completely immobile to 4=no limitations) 5. **N**utrition — usual food intake pattern (1=very poor to 4=excellent) 6. **F**riction and Shear — (1=problem to 3=no apparent problem) **Total Score Interpretation:** - **Score 23**: No risk (maximum possible) - **Score 15–18**: Mild risk - **Score 13–14**: Moderate risk - **Score 10–12**: High risk - **Score ≤ 9**: Very high risk - **CRITICAL RULE: LOWER score = HIGHER RISK** --- **STEP 2 — PREVENTION INTERVENTIONS:** **Repositioning:** - Bedbound patients: Reposition AT LEAST every **2 hours** (or more frequently if high risk). - Chairbound patients: Reposition every **1 hour** (or teach the patient to do independent weight shifts every **15 minutes** if able). - Use a **30-degree lateral tilt** (not 90-degree side-lying which directly loads the trochanter) — alternate right side, back, left side in sequence. - Keep the **Head of Bed (HOB) at or below 30 degrees** whenever possible and when not clinically contraindicated. Higher HOB angles increase shear forces on the sacrum. - Use foam wedges, pillows, and positioning aids to maintain positions. **Heel Protection:** - Heels are the SECOND most common site for pressure injuries after the sacrum in supine patients. - Use pillows under the calves to **'float the heels'** — the heels must be completely off the mattress surface. - Commercial heel protectors can be used SUPPLEMENTALLY but do not replace positioning. - Inspect heels at every repositioning. **Pressure-Redistribution Surfaces:** - Upgrade the mattress for at-risk patients: - **Foam mattresses** (reactive, static) — for low-moderate risk - **Alternating-pressure mattresses** — alternating air cells redistribute pressure - **Low-air-loss mattresses** — for high-risk patients or existing Stage 3/4; reduces moisture and heat - **Turning frames and specialty beds** — for highest-risk patients **Moisture Management:** - Moisture (from incontinence, sweat, wound drainage) is a RISK FACTOR for pressure injury AND a distinct entity — Moisture-Associated Skin Damage (MASD). - Manage incontinence promptly: use incontinence briefs, skin sealants, and consider a urinary catheter or bowel management system for severe, uncontrolled incontinence. - Use **pH-balanced cleansers** (not regular soap, which disrupts the skin's acid mantle). - Apply **moisture-barrier creams** (e.g., zinc oxide, petrolatum-based products) to protect perianal and perisacral skin. - **DO NOT massage over bony prominences** — this causes deep tissue damage from friction and capillary disruption. **Nutrition and Hydration:** - Optimize protein intake (1.2–1.5 g/kg/day for at-risk patients). - Ensure adequate calories, Vitamin C, and zinc. - Consult a dietitian for high-risk or malnourished patients. - Encourage adequate hydration — dehydration reduces skin turgor and perfusion. --- **WOUND CARE PRINCIPLES:** **Wound Cleansing:** - Use **NORMAL SALINE** (NSS) as the primary cleansing solution for most wounds. - AVOID cytotoxic agents (hydrogen peroxide, full-strength povidone-iodine/Betadine, Dakin's solution at full strength) on granulating wounds — they DESTROY new granulation tissue and fibroblasts, delaying healing. - Exception: Povidone-iodine or Dakin's may be used SHORT-TERM on heavily infected wounds as ordered. - Gently irrigate — do not scrub granulation tissue. **Debridement — Removing Nonviable Tissue:** Nonviable tissue (slough, eschar) delays healing and provides a medium for bacterial growth. Methods: 1. **Autolytic debridement**: Using the body's own enzymes under a moisture-retentive dressing (hydrocolloid, hydrogel). Slowest but most selective and painless. Good for non-infected wounds. 2. **Enzymatic debridement**: Applying topical enzymes (e.g., collagenase/Santyl) to chemically dissolve necrotic tissue. More effective than autolytic alone. 3. **Mechanical debridement**: Wet-to-dry dressings (controversial — non-selective, may remove healthy tissue), wound irrigation, pulsatile lavage. Wet-to-dry is no longer recommended for granulating wounds. 4. **Sharp/Surgical debridement**: Using scalpel, scissors, or curette to cut away necrotic tissue. Fastest, most effective, but requires skill (advanced nursing practice or physician). Used for large amounts of necrotic tissue or urgent infection. **Moist Wound Healing:** - The evidence-based principle: **Moist wounds epithelialize up to 50% FASTER than dry wounds.** - Maintain a MOIST wound bed while PROTECTING the periwound skin from excess moisture. - Avoid letting wounds dry out (do not use dry gauze or air exposure for open wounds). **Wound Technique:** - Use STERILE technique for acute/surgical wounds. - Use CLEAN technique for chronic wounds (pressure injuries, venous ulcers) per policy.

Dressing Selection

Selecting the appropriate wound dressing is a critical nursing decision that directly affects wound healing outcomes. The guiding principle is: **match the dressing to the wound's moisture needs and tissue condition.** The golden rule is to **keep the wound bed moist and the periwound skin dry.** Dressings are classified by their moisture properties and primary function. --- **TRANSPARENT FILM DRESSINGS** - Examples: Tegaderm, Op-Site - Properties: Thin, clear, adherent, semipermeable (allows oxygen and water vapor through, but keeps liquid water and bacteria out) - Best for: **Stage 1** injuries, superficial wounds, skin tears, IV site protection, and as a SECONDARY dressing over other dressings - Allows wound VISUALIZATION without removing the dressing - NOT for: Heavy exudate (it collects under the film), infected wounds, or fragile periwound skin - Change: Every 3–7 days or when seal is broken **HYDROCOLLOID DRESSINGS** - Examples: DuoDERM, Comfeel - Properties: Occlusive; contain gel-forming agents (carboxymethylcellulose) that absorb light exudate and create a moist healing environment; support AUTOLYTIC DEBRIDEMENT - Best for: **Stage 2** and **shallow Stage 3** with light-to-moderate exudate; clean wounds with slough to be debrided autolytically - The dressing turns into a gel-like substance as it absorbs exudate — this is NORMAL, not infection (nurses must educate patients about this) - NOT for: Heavy exudate, infected wounds, or deep cavities - Change: Every 3–7 days or when seal is broken or leaking **HYDROGEL DRESSINGS** - Examples: Intrasite Gel, Curasol (sheet or amorphous forms) - Properties: Water-based or glycerin-based; ADDS MOISTURE to the wound; soothing and cooling - Best for: **DRY wounds**, necrotic wounds needing autolytic debridement, painful wounds (e.g., radiation burns, partial-thickness burns) - Amorphous hydrogel: Applied directly into wound bed or onto gauze - Sheet hydrogel: Applied over superficial wounds - NOT for: Heavily exuding wounds (will over-moisten) - Change: Every 1–3 days depending on exudate level **FOAM DRESSINGS** - Examples: Mepilex, Allevyn, PolyMem - Properties: Highly absorbent, provides cushioning and thermal insulation - Best for: **Moderate-to-heavy exudate** wounds, pressure areas (cushioning), Stage 2–3 wounds with significant drainage - Can be used as primary or secondary dressing - NOT for: Dry wounds (will dehydrate the wound bed further) - Change: Every 2–5 days or when saturated **ALGINATE DRESSINGS** - Examples: Kaltostat, Sorbsan, Aquacel (hydrofiber, similar properties) - Properties: Derived from SEAWEED; highly absorbent (can absorb up to 20× their weight in fluid); form a soft gel on contact with exudate; can be used as PACKING for deep wounds and tunnels - Best for: **Heavy exudate** wounds, deep or tunneling wounds that need packing, wounds with some bleeding (calcium ions aid hemostasis) - Remove by irrigating with NSS — the gel rinses away easily - NOT for: Dry or minimally exuding wounds (will dry out the wound bed) - Change: Every 1–3 days depending on exudate **ANTIMICROBIAL DRESSINGS** - Examples: Silver-containing dressings (Aquacel Ag, Mepilex Ag), Iodosorb (iodine), Medihoney (manuka honey) - Properties: Contain antimicrobial agents that reduce bacterial load - Best for: Critically colonized or infected wounds, wounds not progressing despite optimal care - Silver is broad-spectrum (including MRSA); honey creates osmotic/acidic environment hostile to bacteria - NOT for: Routine use on clean, uninfected wounds — reserve for infected/at-risk wounds - Change: Per manufacturer's recommendation (often every 2–7 days) **NEGATIVE PRESSURE WOUND THERAPY (NPWT / Wound VAC)** - Examples: V.A.C. (Vacuum-Assisted Closure) by KCI, PICO (single-use) - Properties: Uses controlled negative pressure (suction) applied through a foam or gauze dressing sealed with an adhesive drape; removes excess exudate and edema, reduces bacterial load, mechanically stimulates granulation tissue formation - Best for: Large **Stage 3/4** pressure injuries, complex surgical wounds, diabetic foot ulcers, wound dehiscence - CONTRAINDICATED in: Untreated osteomyelitis, malignancy in the wound, unexplored fistulas, necrotic wound with eschar - Monitor: Amount and color of drainage in the canister; maintain airtight seal; assess pain - Change: Foam dressing changed every 48–72 hours (or per order/protocol) --- **QUICK REFERENCE: DRESSING SELECTION GUIDE** - **Dry wound (needs moisture)** → Hydrogel - **Light exudate** → Hydrocolloid or Transparent Film - **Moderate-to-heavy exudate** → Foam - **Heavy exudate / deep cavity / tunneling** → Alginate - **Infected/critically colonized** → Antimicrobial (Silver, Honey, Iodine) - **Large Stage 3/4, complex wound** → NPWT/Wound VAC - **Visualization needed** → Transparent Film - **Autolytic debridement** → Hydrocolloid or Hydrogel

Ostomy Skin Care

An ostomy is a surgically created opening (stoma) from an internal organ to the body surface. Nurses play a central role in ostomy care, patient education, and peristomal skin management. Understanding stoma types, healthy vs. emergency stoma appearance, and peristomal skin care principles is essential for the NLE. --- **TYPES OF OSTOMIES:** **1. Colostomy** - Diversion of the COLON through the abdominal wall - Output: Formed to semi-formed stool (especially sigmoid colostomy — closer to the rectum, so more formed) - Sites: Sigmoid (most common), descending, transverse, or ascending colon - May be TEMPORARY (e.g., after bowel resection for cancer, to rest the bowel) or PERMANENT (e.g., after abdominoperineal resection) **2. Ileostomy** - Diversion of the ILEUM (last part of the small intestine) through the abdominal wall - Output: LIQUID TO PASTY stool — the large intestine is bypassed, so water is not absorbed - High in DIGESTIVE ENZYMES — this is why ileostomy output is VERY IRRITATING to the skin and causes rapid peristomal breakdown if it contacts the skin - The pouch may need emptying when **ONE-THIRD to ONE-HALF FULL** (liquid content expands quickly) - Patients are at HIGH RISK for: Dehydration and electrolyte imbalances (Na+, K+), especially in hot weather or with illness. Filipino ileostomy patients should increase oral fluid intake (2–3 L/day) and consume electrolyte-rich foods. **3. Urostomy (Ileal Conduit)** - Diversion of URINE through the abdominal wall using a segment of ileum - Output: URINE — continuous flow - Pouch needs emptying every 2–4 hours (or when one-third full) - Patients are at risk for URINARY TRACT INFECTION (ascending infection from stoma) --- **HEALTHY STOMA APPEARANCE:** - **Color**: Red to pink, like the inside of the mouth (buccal mucosa) - **Texture**: Moist (mucous membrane) - **Shape**: Round or oval - **Projection**: Slightly raised above skin level (especially ileostomy — the spout helps direct effluent into the pouch) - **Bleeding**: MILD bleeding when gently cleaning the stoma is NORMAL (the stoma is very vascular — rich in capillaries) **EMERGENCY STOMA FINDINGS — REPORT IMMEDIATELY:** - **Dusky, pale, dark, purple, or BLACK stoma** = ISCHEMIA / NECROSIS — this is a SURGICAL EMERGENCY - The stoma should be monitored every 4–8 hours post-operatively and at every appliance change - A dusky/cyanotic stoma may indicate vascular compromise from: tight appliance, retraction, or internal vascular problem - **Report immediately to the surgeon** — this may require surgical revision **Other Stoma Complications to Monitor:** - **Prolapse**: Stoma extends abnormally far out (telescoping) - **Retraction**: Stoma retracts below skin level — increases leak risk - **Stenosis**: Narrowing of the stoma opening — may need dilation - **Hernia**: Bulging around the stoma base --- **PERISTOMAL SKIN CARE:** The peristomal skin is the skin surrounding the stoma. Protecting it is the TOP PRIORITY in ostomy care. **Wafer/Barrier Fitting — The 1–2 mm Rule:** - Cut the wafer/skin barrier opening to fit **~1–2 mm larger than the stoma diameter** - TOO LARGE an opening = stoma effluent contacts the skin → skin breakdown (especially with ileostomy) - TOO TIGHT an opening = constricts the stoma → ischemia and mucosal injury - Use a stoma measuring guide to accurately measure the stoma, especially in the first 6–8 weeks post-surgery (the stoma will SHRINK as edema resolves post-operatively) **Skin Cleansing:** - Clean peristomal skin with **WATER** (plain or with mild, fragrance-free soap, RINSED COMPLETELY) - AVOID soaps with oils, lotions, or moisturizers — these REDUCE the adhesive's ability to stick, causing leaks - Pat dry — do NOT rub (friction damages fragile peristomal skin) **Barrier Products:** - Apply skin barrier rings, paste, or powder as needed to protect skin and fill gaps - Apply skin sealant/barrier film before the wafer to protect perforated or damaged skin **Appliance Change Schedule:** - Change every **3–7 days** (or per manufacturer's recommendation) - Do NOT wait for leakage before changing — leakage = skin breakdown - Change when: Pouch is one-third to one-half full (to prevent weight from pulling on the seal), there is leaking, odor despite intact pouch, or the skin barrier is lifting **Peristomal Skin Complications:** - **Contact dermatitis / Peristomal dermatitis**: Erythema, itching, erosion from effluent contact → re-fit wafer, use skin barrier - **Candidiasis (fungal infection)**: Satellite lesions, rash extending to skin folds → antifungal powder (nystatin), ensure skin is dry before applying wafer - **Mechanical injury**: Skin stripping from too-frequent appliance changes or improper removal → use adhesive remover, be gentle - **Pseudoverrucous lesions**: Wart-like growths from chronic moisture exposure --- **ILEOSTOMY-SPECIFIC NURSING PRIORITIES:** 1. **Dehydration risk**: Liquid output can be 1–2 L/day or more. Teach patients to drink 2–3 L of fluid daily and increase fluid intake during illness, hot weather, or heavy activity. 2. **Electrolyte loss**: Sodium and potassium are lost in ileostomy output. Teach patients to include electrolyte-rich foods: bananas, coconut water (widely available in the Philippines — an excellent potassium and electrolyte source), sports drinks, broth. 3. **Medication absorption**: Enteric-coated or extended-release medications may pass through without being absorbed — report to the physician; may need alternative formulations.

A Braden score of 9 is near the lowest possible (6 = completely limited in all subscales) and indicates extremely high pressure injury risk. In the nursing process, this ASSESSMENT finding directly leads to multiple NURSING DIAGNOSES (Risk for Impaired Skin Integrity, Impaired Urinary Elimination, Imbalanced Nutrition: Less than Body Requirements) and PLANNING immediate, high-priority INTERVENTIONS. In a Philippine hospital, this score should trigger documentation in the patient's care plan and reporting to the physician for medical orders supporting prevention (e.g., specialty mattress order, dietitian referral).

This multi-part clinical scenario tests integration of ostomy assessment knowledge. The key teaching points are: (1) Normal stoma appearance (red, moist) vs. emergency (dark/purple/black); (2) Wafer must be 1–2 mm larger — not more — to prevent peristomal dermatitis; (3) New colostomy output characteristics in the post-operative period and when to escalate. These are all commonly tested in the NLE medical-surgical nursing section.

This problem targets the highest-yield NLE exception rule in pressure injury management: stable heel eschar in patients with ischemic/PAD limbs must NOT be debrided. This is tested almost every board exam cycle. Removing eschar from a heel with poor perfusion converts a covered, stable wound into an open, non-healing, infection-prone ulcer — a life-threatening complication. The correct nursing action is to offload the heel, monitor the eschar, and report any changes in its characteristics to the physician.

This practice problem integrates wound assessment, dressing selection, and nursing documentation — all critical NLE competencies. The choice of alginate is justified by: moderate-to-high exudate and a 3 cm deep cavity that needs packing (alginate forms a gel that fills the cavity and absorbs exudate). The foam secondary dressing provides additional absorption and protection. Documentation under RA 9173 must include: complete wound assessment findings, interventions performed, patient response, education provided, and the nurse's signature with license number — this is a legal record of nursing practice.

This problem tests the most commonly missed concept about the Braden Scale: it is an INVERSE scale where lower scores indicate higher risk. A score of 23 is the maximum (lowest risk), and a score of 6 is the minimum (highest risk). In triage-type NLE questions asking nurses to prioritize multiple patients, the patient with the LOWEST Braden score receives the HIGHEST priority for pressure injury prevention interventions.