NLE Integumentary & Skin Integrity — Skin Integrity and Wound CareStudy Notes

The integumentary system consists of three primary layers, each with distinct structure and function. The **epidermis** is the outermost, avascular (lacking blood vessels) layer composed of stratified squamous epithelial cells. Its main function is to provide a physical barrier against pathogens and prevent fluid loss. The **dermis** lies beneath the epidermis and is highly vascular, containing blood vessels, nerves, hair follicles, sebaceous glands, and sweat glands. This layer provides strength and elasticity through collagen and elastic fibers. The **subcutaneous tissue** (or hypodermis) is the deepest layer, composed of loose connective tissue and adipose (fat) tissue that provides insulation, shock absorption, and energy storage. Intact skin protects against infection, regulates temperature through perspiration and vasoconstriction/vasodilation, maintains fluid balance, and provides sensory information about the environment. When skin integrity is compromised, all these functions are at risk. **Pressure Injury Pathophysiology:** A pressure injury (formerly called a pressure ulcer or decubitus ulcer) is localized damage to skin and underlying soft tissue, typically over bony prominences, resulting from sustained pressure or a combination of pressure with shear forces. The mechanism is straightforward: when external pressure exceeds capillary closing pressure (approximately 32 mmHg) for a prolonged period, blood flow to that tissue is occluded. Without oxygen and nutrients, cells become ischemic (oxygen-deprived) and undergo necrosis (cell death). The longer the pressure application and the higher the pressure intensity, the faster tissue damage occurs. Conversely, even low pressure applied continuously over hours can cause damage. **Contributing Factors to Pressure Injury Development:** - **Pressure intensity and duration** — High pressure for a short duration or low pressure over a long duration can both cause injury. - **Shear force** — Occurs when the skeleton (bone) moves or slides relative to the skin surface, which remains fixed. For example, when the head of the bed is elevated too high, the skeleton slides downward while friction keeps the skin in place, creating internal tissue damage. This is particularly damaging in the sacral region. - **Friction** — The mechanical rubbing of skin against surfaces (e.g., dragging a patient across bed linen), which abrades the epidermis. - **Moisture** — Incontinence, perspiration, and wound drainage macerate (soften and break down) the skin, increasing susceptibility to breakdown. Moisture-associated skin damage (MASD) is a distinct entity from pressure injury but equally important to prevent. - **Immobility** — Patients unable to reposition themselves are at highest risk; those with spinal cord injury, advanced dementia, or sedation cannot respond to normal pain signals that prompt position changes. - **Sensory deficits** — Patients with diabetes (neuropathy), spinal cord injury, or stroke cannot feel pressure or pain, so they do not naturally shift weight. - **Poor nutrition** — Deficiency in protein, calories, vitamin C (necessary for collagen synthesis), and zinc delays healing and weakens skin resistance. Albumin levels below 3.5 g/dL significantly increase risk. - **Advanced age** — Skin becomes thinner, loses elasticity, and has reduced dermal blood flow; older adults also often have multiple comorbidities and poor nutritional status. - **Reduced tissue perfusion** — Conditions like heart failure, anemia, hypotension, or peripheral vascular disease reduce oxygen and nutrient delivery. - **Other factors** — Corticosteroid use, immunosuppression, diabetes with poor glycemic control, and chronic conditions (renal failure, cancer) impair healing and increase risk. **High-Risk Anatomical Sites:** Pressure injuries develop most commonly over bony prominences where soft tissue is compressed between bone and an external surface. In **supine patients**, the **sacrum and coccyx** are the highest-risk sites (accounting for ~40% of all pressure injuries), followed by the **heels**. The **ischial tuberosities** are the primary site in **sitting patients**, while the **greater trochanters** and **elbows** are at risk in any position. The **occiput** is a common site in bedridden or unconscious patients. Less common sites include the ears, knees, and ankles. Understanding these sites is essential for directing preventive efforts.

Accurate staging of pressure injuries is essential for communication, documentation, treatment planning, and quality monitoring. The **National Pressure Ulcer Advisory Panel (NPUAP)** and **National Pressure Injury Advisory Panel (NPIAP)** established a standardized staging system based on the **depth of tissue destruction**. It is critical to understand that staging describes what you see at the time of assessment and is determined by the **deepest visible tissue layer involved**. **CRITICAL RULE: Pressure injuries are NEVER reverse-staged.** If a Stage 4 pressure injury heals, it is documented as a "healing Stage 4," never downgraded to Stage 2 or 3. This maintains accurate documentation of the maximum depth of tissue damage that occurred. **Stage 1 Pressure Injury:** - **Definition:** Intact skin with **non-blanchable erythema** (redness that does not blanch or turn white when you apply and release finger pressure). - **Characteristics:** Localized area usually over a bony prominence; may include changes in skin color, temperature (warmer or cooler than surrounding area), firmness (induration), or sensation (pain, itching). - **In darkly pigmented skin:** Blanching may not be visible. Look for color that differs from surrounding skin, areas of persistent red, blue, or purple discoloration, or changes in skin temperature or firmness. - **Clinical significance:** Stage 1 is a **warning sign** of impending tissue damage; the skin is still intact, so there is no open wound, but the tissue beneath is already ischemic. - **Management:** Aggressive prevention measures, immediate pressure relief, increase repositioning frequency, optimize nutrition, and monitor closely for progression. **Stage 2 Pressure Injury:** - **Definition:** **Partial-thickness** skin loss with exposed **dermis**. The skin is broken, but the wound does not extend through the full thickness. - **Appearance:** A **shallow open ulcer** with a red-pink wound bed (this pink color is healthy granulation tissue beneath), or an **intact or ruptured serum-filled blister** (the fluid is clear or yellowish serum, not purulent). - **Key finding:** **No slough or eschar** is visible at the base; you can see only the dermis. - **Clinical significance:** This is the first stage with actual tissue loss and an open wound, so infection risk increases. Stage 2 injuries are often painful because nerve endings in the dermis are exposed. - **Management:** Clean wound care, maintain moist wound bed, protect from further pressure and trauma, monitor for signs of infection, and apply appropriate dressing (usually hydrocolloid or transparent film). **Stage 3 Pressure Injury:** - **Definition:** **Full-thickness** skin loss in which **subcutaneous fat is visible**, but the deepest layers (bone, tendon, muscle, ligament, cartilage) are **NOT** exposed. - **Appearance:** The wound has a crater-like appearance; the base may contain yellow or tan slough (dead tissue) or black eschar (dried dead tissue), but the underlying support structures are not visible. Undermining (tissue destruction under intact skin edges, creating a pocket) and tunneling (a narrow passageway from the main wound) are common. - **Clinical significance:** Full-thickness wound; healing is slower because it must occur by granulation and epithelialization from the base up. High risk for infection and complications. - **Management:** Thorough wound assessment including measurements and documentation of undermining/tunneling; likely referral to wound care specialist; careful debridement of slough/eschar; moist dressing; frequent monitoring. **Stage 4 Pressure Injury:** - **Definition:** **Full-thickness** skin and tissue loss with **exposed bone, tendon, muscle, ligament, or cartilage** directly visible or palpable (you can feel it with a sterile probe). - **Appearance:** The wound is deep and involves structures beyond subcutaneous fat. Slough and/or eschar, undermining, and tunneling are often extensive. The wound may appear deceptively shallow on the surface if covered with eschar, but probing may reveal a deep cavity beneath. - **Clinical significance:** Most severe stage of pressure injury. **Highest risk for osteomyelitis** (bone infection) because bone is directly exposed to contamination. Requires aggressive specialized wound care, often including surgical debridement. Healing is prolonged and may require skin grafting. - **Management:** Immediate referral to wound care team and likely surgeon; systemic antibiotics if signs of infection; meticulous wound care; nutritional support; frequent reassessment. **Unstageable Pressure Injury:** - **Definition:** **Full-thickness** skin and tissue loss in which the **base is completely obscured by slough and/or eschar**, so you **cannot determine the true depth** and therefore cannot assign a stage (it could be Stage 3 or 4). - **Appearance:** Thick layer of yellow slough or black/brown eschar covering the entire base of the wound. - **Management approach:** Debride the slough/eschar (via autolytic, enzymatic, mechanical, or sharp debridement methods) until the true depth is visible, then stage accordingly. **EXCEPTION:** If the eschar is **stable** (dry, adherent, intact, without surrounding erythema, edema, or signs of fluctuance/fluid collection) on an **ischemic limb or heel**, do **NOT** remove it because it serves as a natural protective cover for ischemic tissue. Removing it exposes necrotic tissue to infection without improving healing potential. - **Documentation:** Write "Unstageable" until debridement is complete, then update to the appropriate stage. **Deep Tissue Pressure Injury (DTI):** - **Definition:** An area of **intact or non-intact skin** with localized **persistent non-blanchable deep red, maroon, or purple discoloration** or a **blood-filled blister**, resulting from damage to underlying soft tissue from pressure/shear. - **Characteristics:** The discoloration does not blanch. The skin may or may not be broken. May present as a clear or blood-filled blister. Can appear similar to a Stage 1 but the color is darker (deep purple/maroon, not bright red), indicating deeper tissue involvement. - **Clinical significance:** Indicates significant subcutaneous damage; may evolve rapidly to reveal the true extent of injury (underlying Stage 3 or 4) even with optimal treatment. Prognosis is often worse than similarly-staged surface injuries. - **Management:** Aggressive pressure relief, frequent monitoring for progression, wound assessment and care once the true extent is revealed. **Suspected Deep Tissue Pressure Injury (SDTI):** If you suspect DTI but are not certain, document as "Suspected DTI" and monitor closely for changes. **Documentation Best Practice:** Document the stage, location (e.g., "sacrum"), dimensions in centimeters (length × width × depth), presence of slough/eschar/granulation, exudate characteristics, signs of infection, and a photograph (with patient consent) if available. Use terms like "healing Stage 3" to show progression, and never downgrade an injury even if it improves.

Accurate and thorough wound assessment is the foundation of effective wound care. A complete assessment documents all relevant factors and serves as the baseline for monitoring healing progress. Reassess wounds at each dressing change or at least weekly if dressings remain in place longer. **Location and Size:** - **Document the location** clearly, using anatomical landmarks (e.g., "sacrum," "left heel," "right anterior shin") or body regions. - **Measure dimensions in centimeters** (not inches, as the metric system is standard in the Philippines and NLE): length (longest dimension), width (perpendicular to length), and **depth** (using a sterile applicator or ruler to measure from the surface to the deepest point at the wound base). Record as "L × W × D cm." - **Assess for undermining** — tissue destruction under intact skin edges, creating a cavity or pocket. Use a sterile applicator (cotton swab or sterilized probe) gently inserted under the skin edge to determine how far the cavity extends. Document the depth and use **clock position** to indicate location (imagine the patient's head is at 12 o'clock; document "undermining 2 cm at 3 o'clock"). - **Assess for tunneling or sinus tracts** — narrow passageways that extend from the main wound into surrounding tissue. Use the same method as undermining; gently probe, measure depth, and document clock position. Tunneling can extend far from the visible wound and harbor bacteria if not addressed. - **Serial measurements and photographs** (with patient consent) help track healing or deterioration over time. **Wound Bed Tissue Assessment:** - **Granulation tissue** — Healthy, beefy red (bright red to pink) color due to abundant blood vessels; granular or bumpy texture. This tissue is living, regenerating tissue and indicates normal healing in the proliferative phase. It should bleed slightly when wiped with a gauze (the bleeding indicates good perfusion). This is what you want to see in a healing wound. - **Slough** — Nonviable (dead) tissue that is yellow, tan, or gray in color with a stringy, moist appearance. It represents devitalized tissue that must be removed to promote healing and prevent infection. Slough is not the same as exudate; it is actual tissue. - **Eschar** — Nonviable tissue that is black, brown, or dark in color with a dry, leathery appearance. Also called dry necrotic tissue. Must be removed except when stable on a heel or ischemic limb (see Stage 4 and Unstageable discussion). - **A healthy wound bed should be mostly granulation tissue with minimal slough or eschar.** - Wounds with excessive slough or eschar need debridement; assess the entire wound base at each assessment. **Exudate Assessment:** - **Amount:** - **None** — No drainage, wound bed is dry. - **Scant** — Minimal drainage, barely visible on the dressing. - **Moderate** — Visible drainage on the dressing but the dressing is not saturated. - **Copious** — Heavy drainage; the dressing may be soaked through and require frequent changes. - **Type:** - **Serous** — Clear, pale yellow, watery drainage; normal and indicates adequate blood flow (contains water, electrolytes, proteins but no blood cells or bacteria); often seen in early inflammatory phase. - **Sanguineous** — Bright red, bloody drainage; indicates active bleeding; usually seen immediately after injury or with dressing changes that cause trauma. - **Serosanguineous** — Pink or light red color; mixture of serous and sanguineous; common in healing wounds with good perfusion. - **Purulent** — Thick, yellow, yellow-green, or greenish drainage with a foul odor; indicates bacterial infection and requires immediate intervention (wound culture, antimicrobial dressing, possible systemic antibiotics, and physician notification). - **Bacterial load vs. contamination:** All wounds are contaminated (exposed to bacteria), but not all are infected. Infection is diagnosed by clinical signs (increased pain, erythema, warmth, edema, purulent drainage, foul odor, fever) and often confirmed by wound culture. High bacterial load (>10^5 bacteria per gram of tissue) delays healing and is considered "critically colonized" even if clinical signs are mild. **Wound Edges and Periwound Skin:** - **Edges:** Are they sharp and defined, or are they rolled inward (rolled edges), undermined, or macerated (softened and whitened from moisture)? Rolled edges may indicate chronic wound; undermining suggests tissue damage laterally. - **Periwound skin** (skin surrounding the wound, ~2–5 cm out): Assess for **maceration** (white, soggy appearance from moisture), **erythema** (redness), **induration** (hardness or firmness), **edema** (swelling), **excoriation** (breakdown from irritant drainage or harsh dressings), or **dry, flaky skin**. These findings guide dressing selection. - Maceration → need to reduce moisture or improve drainage. - Erythema and edema → may indicate infection or friction from dressing edges; may need dressing adjustment or antimicrobial treatment. - Excoriation → need barrier cream or different dressing material. - Dry skin → may need skin care or hydrating lotion (avoid greasy products under dressings as they impair adhesion). **Signs of Infection (Local and Systemic):** - **Local signs:** Increased erythema and edema extending beyond the periwound area, warmth, purulent drainage (thick, yellow-green with foul odor), foul odor in general (even without visible purulent drainage), increasing pain or new pain (different from baseline wound pain), and wound breakdown (previously healing wound that suddenly worsens). - **Systemic signs:** Fever (temperature >38.5°C or >101.3°F), increased white blood cell count, malaise, anorexia, or delayed healing. - **In older adults or immunocompromised patients:** Fever may be absent; watch for behavioral changes, confusion, or lethargy. - **Action:** If infection is suspected, culture the wound (aerobic and anaerobic), notify the physician, initiate antimicrobial dressing if appropriate, and ensure appropriate systemic antibiotic therapy if prescribed. Monitor closely for signs of spreading infection (cellulitis, abscess, or sepsis). **Wound Assessment Documentation Format (Example):** "Pressure injury, Stage 3, sacrum. Dimensions: 5 cm length × 4 cm width × 2 cm depth. Wound bed: 70% beefy-red granulation tissue, 20% yellow slough, 10% areas of undermining at 2 and 4 o'clock extending 1 cm. Exudate: moderate, serosanguineous. Edges: well-defined, no rolled edges. Periwound skin: mild erythema within 1 cm of edges, no maceration, no edema. Pain: 4/10 at rest, 6/10 with dressing change. No signs of infection. Last dressing change: 2 days ago. Plan: continue alginate dressing for drainage, reposition q2h, assess for pain management, monitor for slough for possible enzymatic debridement."

Understanding the type and phase of wound healing guides expectations for healing timelines and appropriate interventions. The way a wound heals depends on the amount of tissue loss and how the wound is managed. **Three Types of Wound Healing by Intention:** **Primary Intention (Primary Closure):** - **Definition:** The edges of the wound are brought together and held in place with sutures, staples, or adhesive. The wound heals by restoration of continuity with minimal tissue loss. - **Characteristics:** Clean, surgical wounds with well-approximated edges; minimal tissue loss; wounds heal from the inside out, then the outside in. - **Timeline:** Fastest healing; epithelialization occurs within 7–10 days; tensile strength reaches ~70% of original at 3 weeks, but continues to increase for months. Full closure occurs relatively quickly. - **Scarring:** Minimal; results in a thin line scar. - **Examples:** A simple laceration closed immediately, a surgical incision with approximated edges, a minor cut with clean edges brought together with adhesive. - **Nursing role:** Keep the wound clean and dry; monitor for signs of infection (increasing pain, purulent drainage, fever); remove sutures/staples at appropriate time per protocol (typically 7–10 days for most areas, 14 days for areas under tension like the legs). **Secondary Intention (Healing by Granulation):** - **Definition:** The wound is left open to heal naturally from the base upward. Tissue is regenerated through epithelialization and contraction; this is slower and results in significant scarring. - **Characteristics:** Wounds with substantial tissue loss (such as pressure injuries, large traumatic wounds, burns, infected wounds left to drain); edges are not approximated; healing occurs by filling the wound with granulation tissue, which is then covered by epithelial tissue. - **Timeline:** Much slower than primary intention; can take weeks to months depending on size and depth. A Stage 3 pressure injury may take 4–6 months or longer to heal completely. - **Scarring:** More significant; the wound contracts (the edges move inward) as fibroblasts shorten, which helps reduce the area to be covered but results in contracture (permanent tightening of tissue). In areas like joints, contracture can limit movement. - **Examples:** Pressure injuries, full-thickness burns, open traumatic wounds, infected surgical wounds that are left open to drain. - **Nursing role:** Facilitate moist wound healing with appropriate dressings, support granulation tissue development, optimize nutrition and perfusion, manage pain, prevent infection, reposition to relieve pressure, and monitor for complications. Secondary intention wounds are at higher risk for infection and complications because they are open for a long time. **Tertiary Intention (Delayed Primary Closure):** - **Definition:** The wound is initially left open (often to allow drainage of infection, to ensure all devitalized tissue is removed, or to allow swelling to subside), and then closed surgically at a later time when conditions are optimal. - **Characteristics:** The wound heals by secondary intention initially, but then before complete healing, the edges are approximated with sutures. - **Timeline:** Longer than primary intention but shorter than true secondary intention, because closure occurs before the wound must be fully epithelialized. - **Examples:** A traumatic wound contaminated with dirt or debris, left open for initial cleaning and observation, then closed after 3–5 days; an infected surgical wound left open to drain and debride, then closed once infection is controlled. - **Nursing role:** Manage the wound as open (appropriate dressing, moisture balance, infection control) during the initial phase; prepare the patient for planned surgical closure; ensure suture removal at appropriate intervals post-closure. **The Four Phases of Wound Healing:** Wound healing is a dynamic process that occurs in overlapping phases. Understanding these phases helps predict what to expect and when: **Phase 1: Hemostasis (Immediate – Minutes)** - **Definition:** The immediate response to injury; stopping bleeding through clot formation. - **Mechanisms:** - **Vasoconstriction** — Blood vessels constrict to reduce blood flow to the injured area (initial response, temporary). - **Platelet aggregation** — Platelets adhere to the exposed tissue and to each other, forming a platelet plug. - **Blood coagulation cascade** — Fibrin threads form, trapping blood cells and forming a stable clot (the scab). - **Clinical appearance:** Bright red bleeding, then darkening as the clot forms and dries (especially visible in open wounds). - **Duration:** Minutes to hours as the clot sets. - **Nursing action:** Apply direct pressure to control bleeding; do not disturb the forming clot. **Phase 2: Inflammatory Phase (Days 1–4, Can Extend to 7 Days)** - **Definition:** The body's response to injury characterized by inflammation, which is necessary for healing but also manifests as erythema, edema, warmth, and pain. - **Key cellular processes:** - **Vasodilation** — Blood vessels dilate to increase blood flow to the area (causing redness and warmth). - **Increased vascular permeability** — Fluid leaks into tissue (causing edema/swelling). - **Leukocyte infiltration** — White blood cells (neutrophils first, then macrophages) migrate into the wound to clean up bacteria and dead tissue through phagocytosis (eating debris). - **Cytokine release** — Inflammatory mediators signal and coordinate the immune and healing response. - **Clinical signs:** **Expected and normal** inflammation = erythema (redness), warmth, edema (swelling), exudate (drainage), and pain. These are **not signs of infection** at this stage; they are signs of normal healing. - **Important distinction:** Pain and signs of inflammation in the first few days are normal. However, if inflammation increases substantially after day 3–4, or if purulent drainage develops, infection should be suspected. - **Macrophages:** By about day 3–4, macrophages become the dominant cell type; they continue cleanup and begin releasing growth factors that stimulate the next phase. - **Nursing actions:** Expect and do not be alarmed by inflammation; ensure the wound is clean; support the immune response with adequate nutrition, hydration, and rest; manage pain; monitor for signs of infection (excessive purulent drainage, fever, spreading erythema). **Phase 3: Proliferative Phase (Days 4–21, Can Extend to Day 30)** - **Definition:** The phase in which new tissue is actively synthesized and the wound begins to fill and close. This is the longest phase for large wounds. - **Key cellular processes:** - **Fibroblast proliferation and collagen deposition** — Fibroblasts migrate into the wound and synthesize **collagen**, the primary structural protein of the new tissue. Collagen gives tensile strength and structure. - **Angiogenesis** — New blood vessels form to supply the growing tissue (neovascularization). The new blood vessels appear as **beefy-red granulation tissue**. - **Epithelialization** — Epithelial cells at the wound edges migrate inward to cover the wound surface. This occurs simultaneously with granulation tissue formation. - **Wound contraction** — For wounds healing by secondary intention, the edges begin to move inward (myofibroblasts contract), reducing the wound area. This can be significant: a 4 × 4 cm wound may reduce by 0.5–1 mm per day through contraction. Contracture is beneficial (it reduces the wound area) but can become problematic if it limits joint movement. - **Clinical appearance:** The wound fills with beefy-red, granular-appearing **granulation tissue**; the wound bed is moist and bleeds slightly if touched; exudate is serosanguineous (pink) and moderate; the wound edges appear to be shrinking; if edges are approximated (primary intention), new skin begins to form over the incision. - **Factors promoting proliferative phase:** Moist environment, good perfusion and oxygenation, adequate nutrition (protein, vitamin C, zinc), growth factors, and absence of infection. - **Factors delaying proliferative phase:** Infection, dry environment, poor perfusion, malnutrition, corticosteroid use, advanced age, and chronic disease. - **Nursing actions:** Maintain a moist wound environment with appropriate dressings; ensure good perfusion and oxygenation (position to avoid pressure, administer supplemental oxygen if needed); support nutrition; manage pain; prevent infection; avoid cytotoxic cleaning agents that harm new tissue; avoid massage over the wound which can traumatize new blood vessels. **Phase 4: Maturation/Remodeling Phase (Day 21 to Up to 1–2 Years)** - **Definition:** The phase in which collagen is remodeled and reorganized, tensile strength increases, and the wound achieves its final appearance and strength. - **Key processes:** - **Collagen remodeling** — The disorganized collagen laid down during proliferation is remodeled into organized fibers aligned with the direction of stress. This increases tensile strength. - **Angiogenesis resolution** — Some new blood vessels regress as tissue perfusion becomes normal; the beefy red color of granulation gradually fades to pink and then to the color of normal skin. - **Epithelial maturation** — The new epithelium thickens and strengthens. For a healed incision, the scar matures from red/purple to pale and flat. - **Scar tissue formation** — The wound is closed, but scar tissue has different properties than original skin: it lacks hair follicles, sweat glands, and some sensory function; it is less elastic; and it remains slightly weaker than original tissue. - **Timeline:** Can take 12–24 months for complete remodeling, especially for large wounds or those in older adults. - **Final tensile strength:** A healed wound reaches only **70–80% of the original tissue's tensile strength** — it is stronger but never quite as strong as uninjured tissue. - **Clinical appearance:** The wound is closed; scar is flat, pale, and increasingly less noticeable; edema resolves; sensation gradually returns (though never fully); flexibility improves as collagen continues to remodel. - **Patient concerns:** Some patients expect the scar to completely disappear, but this is unrealistic. Explain that scars continue to improve over months but will always be visible to some degree. - **Nursing actions:** Reassure the patient that continued scar improvement is normal; protect the healing scar from sun exposure (UV light darkens scars); teach gentle range-of-motion exercises if the wound is near a joint to prevent contracture; manage itching (a sign of collagen remodeling) with lotions or prescribed antihistamines; refer to scar management specialists (dermatology, plastic surgery) if the scar becomes hypertrophic (thick, raised) or if contracture limits function. **Factors That Impair Healing (Critical to Know for NLE):** **Systemic factors:** - **Advanced age** — Slower healing due to reduced cell division, decreased collagen synthesis, slower angiogenesis, and often accompanied by comorbidities and poor nutrition. - **Poor nutrition** — Protein-calorie malnutrition, vitamin C deficiency (impairs collagen synthesis and immune function), zinc deficiency (essential for cell division and protein synthesis), iron deficiency (limits oxygen transport). Albumin <3.5 g/dL significantly increases risk. - **Diabetes and hyperglycemia** — Impairs immune function, reduces blood flow, delays collagen synthesis, and increases infection risk. Tight glycemic control (target HbA1c <7%) improves healing. - **Impaired perfusion** — Heart failure, anemia, hypotension, peripheral vascular disease, or any condition reducing oxygen/nutrient delivery. Wounds in areas of poor perfusion (e.g., diabetic ulcers on the foot) heal slowly. - **Infection** — High bacterial load delays healing; systemic infection (sepsis) is life-threatening. - **Smoking** — Vasoconstriction reduces blood flow; impairs immune function; increases infection risk. Smoking cessation improves healing within days. - **Corticosteroid use and immunosuppression** — Decreases immune response, impairs collagen synthesis, and slows healing. Weigh risks vs. benefits; cannot always be discontinued. - **Chronic diseases** — Renal failure (uremia impairs healing, often accompanies malnutrition), cancer (protein loss, immunosuppression), liver disease (impaired protein synthesis), and chronic obstructive pulmonary disease (reduced oxygenation). **Local factors:** - **Infection or high bacterial load** — Delays healing, increases inflammation, impairs angiogenesis. - **Dry wound bed** — Prevents epithelialization; cells cannot migrate across a dry surface. - **Excess exudate** — Maceration of surrounding skin; increased infection risk. - **Tissue trauma during care** — Harsh cleaning, dressing removal that traumatizes fragile new tissue, massage that disrupts blood vessels. - **Foreign bodies or devitalized tissue** — Prolongs inflammatory phase as the body tries to eliminate them. **Nursing assessment:** At each wound assessment, consider these factors and ask: "What is prolonging healing here?" If a wound is not progressing as expected, investigate these factors and address modifiable ones (nutrition, infection control, dressing selection, pressure relief, smoking cessation, glycemic control).

**Prevention of pressure injuries is a fundamental responsibility of all nurses.** According to the Philippine Nursing Act of 2002 (RA 9173), nurses are accountable for providing safe care and preventing complications. The Joint Commission has identified pressure injury prevention as a patient safety priority, and incidence and prevalence of hospital-acquired pressure injuries are quality indicators in Philippine healthcare facilities. **Most pressure injuries are preventable** with evidence-based interventions. **Risk Assessment:** Begin with a validated risk assessment tool on admission and regularly (at least weekly, more frequently for high-risk patients). The **Braden Scale** is widely used and recommended by the NPIAP: **Braden Scale Components (each scored 1–4, lower is worse):** - **Sensory perception** — Can the patient perceive and respond to pressure-related discomfort? (Patients with neurological deficits, unconsciousness, or sedation score low.) - **Moisture** — Is the patient's skin exposed to moisture from incontinence, perspiration, or wound drainage? (Constant moisture increases risk.) - **Activity** — What is the patient's mobility level? (Bedbound or chairbound scores lower than ambulatory.) - **Mobility** — Can the patient change positions independently? (Immobilized or dependent on assistance scores lower.) - **Nutrition** — Is nutritional intake adequate? (Poor intake or intake of inadequate protein scores lower; assess albumin, recent weight loss.) - **Friction/Shear** — Is the patient at risk for friction or shear injury? (Patients who slide in bed or need assistance to move score higher.) **Braden Scale Interpretation:** - **15–23** = Low risk (but older adults, those with diabetes, or those in intensive care may require interventions even with scores in this range). - **13–14** = Moderate risk → implement preventive measures. - **10–12** = High risk → intensive preventive measures. - **≤9** = Very high risk → aggressive, comprehensive interventions. **CRITICAL RULE: A LOWER Braden Score = HIGHER RISK.** Do not confuse the scale; a score of 9 is much higher risk than a score of 23. **Prevention Interventions (Organized by Level of Intervention):** **Level 1: Universal Precautions (For All Patients)** 1. **Skin inspection and assessment** - Inspect the entire skin daily, especially over bony prominences (sacrum, heels, ischial tuberosities, greater trochanters, elbows, occiput). - In darkly pigmented skin, look for color differences, temperature changes, and firmness—not just redness. - Document findings and report any concerns (erythema, warmth, induration) to the charge nurse or physician. - Teach patients and families to inspect skin and report changes. 2. **Moisture management** - Keep skin clean and dry. - Manage incontinence promptly: use absorbent pads or briefs that wick moisture away from skin; change soiled bedding and clothing immediately (do not wait for scheduled changes). - Use **pH-balanced cleansers** (not harsh soaps with heavy oils or lotions). - Pat skin dry gently; do not rub. - Apply **moisture-barrier creams** (e.g., zinc oxide, petroleum jelly, or commercial products) to areas prone to incontinence-related damage (buttocks, perineum, lower abdomen) to protect the skin from prolonged contact with urine or stool. - Manage perspiration and wound drainage similarly. - **Important:** Do not apply moisturizers or creams under dressings or on areas where adhesive dressings will be applied, as they impair adhesion. 3. **Optimal nutrition and hydration** - Ensure adequate intake of protein (1.2–1.5 g/kg/day for wound healing), calories, vitamin C (75–100 mg/day for healing), zinc (11–15 mg/day), and iron. - Monitor weight weekly; report unintentional loss (goal is maintenance or modest gain for healing). - Monitor albumin; if <3.5 g/dL, involve dietitian for supplementation. - Ensure adequate fluid intake (unless contraindicated); dehydration increases skin fragility. - For patients with swallowing difficulty, ensure appropriate diet consistency and consider nutritional supplements or feeding support. - Involve the dietitian for high-risk patients (elderly, malnourished, diabetic, post-operative). **Level 2: Pressure Relief and Repositioning (For All Bedridden/Chairbound Patients)** 1. **Repositioning schedule** - **Bedbound patients: reposition every 2 hours.** Use a written repositioning schedule posted at the bedside so all staff follow the same schedule. Include positions: supine, right lateral, left lateral, prone (if tolerated). Alternate positions to distribute pressure across different body surfaces. - **Chairbound patients: reposition or have them shift weight every 1 hour.** If the patient is able, teach them to do weight shifts every 15 minutes by lifting their buttocks or leaning forward/side-to-side. - **Document repositioning** times in the chart or on a repositioning record to ensure accountability. - **Use a log or turning sheet** visible at the bedside; some facilities use alarms on pressure-relieving beds that alert staff when repositioning is due. 2. **Proper positioning techniques** - **Avoid direct pressure on bony prominences.** When lying on the side, place the patient at a 30-degree lateral tilt (not 90 degrees directly on the trochanter). Support the patient with pillows to maintain this angle. - **Float the heels** — Use a pillow or foam wedge under the calf so the heel is suspended off the bed and does not contact any surface. This is one of the most effective preventive measures for heel pressure injuries. - **Support the head** with a single pillow to avoid excessive pressure on the occiput and upper cervical spine. Avoid multiple pillows that can cause excessive neck flexion. - **Keep the head of the bed at 30 degrees or lower** when possible and when not contraindicated by the patient's condition (e.g., respiratory distress, gastroesophageal reflux). High elevation increases shear force on the sacrum. If the patient has gastroesophageal reflux or aspiration risk, consult with the physician for the lowest safe HOB angle. - **Avoid direct contact of skin with bed rails or hard surfaces.** Use padding if necessary. 3. **Use of pressure-redistribution surfaces** - These surfaces reduce pressure by distributing body weight over a larger area or by actively relieving pressure: - **Foam mattresses** — Static; reduces pressure compared to a standard hospital mattress; inexpensive and adequate for low-to-moderate risk patients. - **Alternating-pressure air mattresses** — Cyclic inflation/deflation of air cells that alternately relieves pressure; suitable for high-risk patients; more expensive and require electricity and monitoring for air leaks. - **Low-air-loss mattresses** — Air is continuously circulated through the mattress to reduce moisture and heat, and to reduce pressure; excellent for high-risk and very high-risk patients; expensive; often available in intensive care units. - **Gel or water mattresses** — Distribute pressure; less commonly used now due to weight and maintenance issues. - **Specialized positioning devices** — Pressure-relieving cushions for chairs, pillows, and wedges. - **IMPORTANT:** A pressure-relieving surface is a **supplement to repositioning, not a replacement.** Even on a specialized mattress, repositioning every 2 hours is still required. - **Do NOT use donut cushions or ring cushions** — These were historically used to relieve pressure on a specific area but are now recognized as harmful because they increase pressure around the edges of the ring and can compromise tissue perfusion. Avoid them. **Level 3: Skin Care and Maintenance of Integrity** 1. **Do NOT massage over bony prominences.** This was previously recommended but is now contraindicated; massage can cause deep tissue damage (ischemia and damage to subcutaneous vessels) and may increase risk of Deep Tissue Pressure Injury. 2. **Manage friction and shear** - Use a **turn sheet** (a draw sheet placed under the patient) to lift and reposition the patient rather than dragging them across the bed. - Use **lateral slide sheets** or transfer aids to reduce friction during transfers. - Teach the patient to use the bed trapeze (an overhead bar) to lift themselves and reduce dragging. - Reduce friction by using **low-friction bed linen** or **talc-free powder** (though talc-free is important for respiratory reasons; powder is not essential). - For patients with excessive perspiration, use moisture-wicking fabrics. 3. **Continence management** - Address the underlying cause of incontinence (urinary tract infection, medication side effect, mobility limitation, cognitive impairment) rather than simply accepting incontinence. - Use **prompted voiding** (asking the patient at regular intervals if they need to void) or **scheduled toileting** for patients with cognitive impairment. - If catheterization is necessary, use it for the shortest duration possible and maintain meticulous catheter care. - Use **absorbent pads or briefs** that minimize contact with skin; change immediately when soiled. - Apply barrier creams to protect skin from urine and stool. 4. **Environmental control** - Maintain room temperature and humidity at comfortable levels to minimize perspiration. - Keep beds clean and dry; change wet or soiled bedding immediately. - Ensure adequate ventilation. **Level 4: Education and Staff/Family Involvement** 1. **Staff education** - All nursing and nursing assistant staff must understand pressure injury prevention and staging. - Use the Braden Scale and other risk tools appropriately. - Understand that prevention is always preferred to treatment. - Reinforce that pressure injuries are largely **preventable** and are often considered indicators of the quality of care. 2. **Patient and family education** - Explain the risk of pressure injuries and how they develop. - Teach patients the importance of movement and repositioning; explain that they should not remain in one position for more than 2 hours. - Teach skin inspection: look for red areas that do not blanch, warmth, or hardness, especially over bony areas. - Teach families to assist with repositioning, skin care, and nutrition. - Involve patients in their care plan and encourage them to report discomfort or areas of concern. **Special Considerations for High-Risk Populations:** - **Elderly patients:** Use lower Braden scores as a threshold for intervention (even scores of 18–20 warrant preventive measures in older adults); optimize nutrition; manage chronic conditions; monitor closely. - **Intensive care patients:** High-risk due to immobility, sedation, mechanical ventilation, and illness severity; may require specialized pressure-relieving surfaces even if Braden score is not very low. - **Diabetic patients:** High risk for foot and heel pressure injuries due to sensory neuropathy; extra vigilance for heel flotation and daily foot inspection. - **Patients with spinal cord injury:** Complete sensory loss below the injury level; require aggressive prevention (specialized mattress, frequent repositioning, skin inspection by the patient or caregiver, wheelchair cushion management). - **Palliative/end-of-life patients:** While preventing pressure injuries is still a goal, comfort becomes the priority. Discuss realistic goals with the patient and family; continued repositioning may conflict with comfort goals. Document the care plan and family understanding. **Documenting Prevention Efforts:** Documentation is crucial for demonstrating that appropriate prevention measures were implemented. Chart: - **Braden Scale score** and date of assessment; note any recent changes in status that warmed or lowered the risk score. - **Pressure-relieving surface** in use and any adjustments made. - **Repositioning times** (document each time or use a repositioning record). - **Skin assessments** and any findings (erythema, warmth, induration); location and appearance. - **Nutrition and fluid intake** summary (adequate, fair, poor); involvement of dietitian. - **Patient and family education** provided (topic, date, patient/family response). - **Any barriers to prevention** (e.g., "patient refusal to reposition," "difficult to keep heels off mattress," "limited access to specialized mattress") and actions taken to address them. This documentation demonstrates accountability and helps coordinate care across shifts and settings.

**Evidence-Based Wound Cleaning:** Proper wound cleaning removes bacteria, debris, and old dressing material, creating an optimal environment for healing. However, **harsh or cytotoxic cleaning agents damage new tissue and impair healing.** **Best Practice: Use Normal Saline (0.9% NaCl)** - Normal saline is isotonic, non-irritating, and safe for all types of wounds, including those with healthy granulation tissue. - Use at room temperature or slightly warm (warmth does not significantly improve outcomes but is comfortable for the patient). - Pour or spray saline gently over the wound to irrigate; avoid high-pressure irrigation (>15 psi) which can force bacteria into deeper tissue layers. - For wounds with thick exudate or debris, you may use gentle swabbing with a sterile gauze soaked in saline. **Agents to AVOID on Granulating Wounds:** - **Hydrogen peroxide (H₂O₂)** — Foaming action can remove bacteria and debris but also damages granulation tissue and collagen-producing fibroblasts. Do not use routinely on granulating wounds; it may be acceptable for initial cleansing of heavily contaminated wounds but is not for regular use. - **Povidone-iodine (Betadine®)** — Has antimicrobial properties but is cytotoxic to fibroblasts and epithelial cells. Not recommended for routine wound cleaning, especially on healthy granulation tissue. If iodine is required (for specific bacterial coverage), use on infected wounds and discontinue once infection is controlled. - **Acetic acid** — Some protocols recommend it for wounds with Pseudomonas, but it is acidic and can damage tissue; use judiciously and only when Pseudomonas is confirmed. - **Soap** — Contains oils and detergents that strip protective skin oils and can irritate wound tissues; not appropriate for wounds. - **Alcohol-based products** — Drying and cytotoxic; avoid. **Clean vs. Sterile Technique:** - **Chronic wounds** (pressure injuries, diabetic ulcers, venous ulcers) in stable, non-infected state are managed with **clean technique** in outpatient/home settings. This includes hand hygiene, clean (not sterile) gloves, and clean (not necessarily sterile) dressings and supplies. Clean technique is safe because the wound is not in a critical state and the risk of introducing pathogenic bacteria is low. - **Acute wounds** (post-operative incisions, traumatic wounds, acute lacerations) and **infected wounds** require **sterile technique** in hospital settings. Use sterile gloves, sterile supplies, and aseptic technique to prevent infection introduction. - **Facility policy** varies; follow your institution's protocol, which may specify sterile technique for all dressing changes even in chronic wounds. **Wound Bed Moisture Balance:** The goal is to **maintain a moist wound bed while keeping the periwound skin dry.** This is the "sweet spot" for healing: - **Moist wound bed** (optimal environment) — Facilitates epithelialization, reduces pain, allows migration of epithelial cells and fibroblasts; promotes granulation tissue formation; allows for autolytic debridement of slough. - **Dry wound bed** — Impairs epithelialization (cells cannot migrate across a dry surface); painful; delays healing; may cause eschar formation. - **Overly wet wound bed** — Causes maceration of periwound skin (breakdown from excess moisture); creates environment conducive to bacterial overgrowth; requires frequent dressing changes. **Match the dressing to the wound's moisture and tissue needs** (see dressing types below). **Frequency of Dressing Changes:** - Change dressings as needed based on the amount of exudate and the dressing capacity: - **Light exudate:** may change every 3–7 days depending on dressing type. - **Moderate exudate:** every 2–3 days or per dressing instructions. - **Heavy exudate:** every 24–48 hours or when dressing is approaching saturation. - **Before leakage occurs** — Do not wait for the dressing to leak before changing; leakage indicates the dressing can no longer contain the exudate and continued use allows bacteria and exudate to contact surrounding skin. - **Follow manufacturer recommendations** for each specific dressing product. - **Assess the periwound skin** at each change; if maceration is present, change more frequently or select a dressing with better absorbency or moisture management. **Basic Dressing Change Procedure:** 1. **Wash hands** and don gloves. 2. **Carefully remove the old dressing** by gently peeling it back; if it adheres, use saline to loosen it. Do not cause trauma to the fragile new tissue. 3. **Assess the wound** (see "Wound Assessment" section for details): measure, document tissue type, exudate, signs of infection, periwound skin condition. 4. **Clean the wound** with normal saline using gentle irrigation or swabbing. Do not use harsh agents. 5. **Pat dry** the periwound skin (the surrounding ~2 cm); avoid getting the dressing directly on exudative drainage. 6. **Apply antimicrobial or topical products** if ordered (e.g., enzymatic debridement agent, silver dressing for infection). 7. **Apply the appropriate dressing** based on wound characteristics and product instructions. 8. **Secure the dressing** with tape or other means to keep it in place without excessive tightness. 9. **Label the dressing** with the date and time of change (some facilities use the nurse's initials). 10. **Document** the wound assessment findings and dressing applied in the patient's chart. --- **Dressing Selection by Wound Type and Exudate Level:** **1. Transparent Film Dressings (e.g., Tegaderm®, OpSite®)** - **Composition:** Thin, transparent, adhesive plastic film with acrylic adhesive; waterproof but allows oxygen permeability. - **Characteristics:** - Allows visualization of the wound without removing the dressing (great for monitoring). - Maintains moisture; promotes autolytic debridement (softening and liquefying of slough through enzyme action in the moist environment). - Creates a warm, moist microenvironment that enhances epithelialization. - Non-absorbent; suitable for **dry or minimally draining wounds only**. - Adhesive may irritate sensitive skin or cause damage if removed improperly. - **Indications:** - **Stage 1 pressure injuries** (intact skin, no open wound; protects from friction and further breakdown). - **Shallow, clean Stage 2 wounds** with minimal to no drainage (if drainage develops, switch to more absorbent dressing). - **Superficial lacerations or abrasions** after initial healing begins. - **Protective dressing** over pressure areas to prevent friction damage. - **Secondary dressing** over other dressings to secure and waterproof. - **Frequency of change:** **3–7 days** or when integrity is compromised (wrinkled, loose, or moisture is visible under the film). If moisture accumulates under the film (creating a pool), change sooner to prevent maceration. - **Do NOT use for:** Heavy exudate wounds, infected wounds (opacity of film makes assessment difficult), or patients allergic to acrylic adhesive. **2. Hydrocolloid Dressings (e.g., DuoDERM®, Comfeel®)** - **Composition:** Gelatin, pectin, and polyurethane in a waterproof, adhesive film backing; when exposed to exudate, the gelatin component absorbs moisture and forms a gel. - **Characteristics:** - Absorbs light-to-moderate exudate (absorptive capacity: typically 0.5–1 oz per dressing). - Maintains a moist wound environment; promotes autolytic debridement. - Occlusive (sealed) design prevents bacterial entry and reduces odor. - Waterproof; patient can shower or bathe with the dressing in place. - Non-adherent to healthy granulation tissue (changes should be gentle and easy). - May produce a characteristic dark, viscous gel-like drainage (decomposing gelatin component) that may be mistaken for purulent drainage; assess for other signs of infection. - Creates a warm, moist microenvironment ideal for healing. - Can remain in place **3–7 days** before changing (depending on exudate and manufacturer recommendations). - **Indications:** - **Stage 2 pressure injuries** (excellent choice for this stage). - **Shallow Stage 3 pressure injuries** with light-to-moderate exudate (not suitable if deep undermining or significant drainage). - **Diabetic foot ulcers** and other chronic wounds with moderate exudate. - **Clean, non-infected wounds** during proliferative phase. - **Contraindications:** Heavily draining wounds, infected wounds, or wounds with significant slough or eschar (cannot allow for drainage and necrotic tissue removal). - **Caution:** Do NOT use on areas prone to friction or where the dressing might loosen; hydrocolloids adhere best to clean, dry skin. **3. Hydrogel Dressings (e.g., Curaflex®, Tegagel®, Aquasorb®)** - **Composition:** Water-based polymer (up to 96% water) in a non-adhesive sheet or amorphous (unstructured) form; looks like a water-based gel. - **Characteristics:** - **Hydrating agent:** Donates moisture to dry wounds; rehydrates dehydrated tissue. - Soothing and cooling; reduces pain in painful wounds. - Promotes autolytic debridement of slough and necrotic tissue. - Minimally absorbent; does NOT absorb exudate (in fact, it absorbs moisture and swells). - Non-adhesive (requires secondary dressing to secure). - Useful for wounds with minimal or no drainage. - Requires more frequent changes if wound is draining (every 24 hours or when gel is diluted by wound exudate). - **Indications:** - **Dry pressure injuries** that need rehydration and debridement (especially with dry slough or eschar in early stages). - **Painful wounds** where the cooling and soothing properties are beneficial. - **Wounds undergoing autolytic debridement** where a moist environment is needed. - **Donor sites** (areas where skin is removed during skin grafting) for comfort. - **Contraindications:** Heavily draining or infected wounds (hydrogel will become diluted and lose effectiveness); wounds with macerated periwound skin (the hydrating property will worsen maceration). **4. Foam Dressings (e.g., Allevyn®, PolyMem®, Mepilex®)** - **Composition:** Polyurethane or polyethylene foam with an adhesive backing; may have additional layers (top moisture-barrier layer, absorptive middle, hydrophobic back). - **Characteristics:** - Absorbent of **moderate-to-heavy exudate** (absorptive capacity: typically 0.5–3 oz per dressing depending on size and product). - Provides cushioning and pressure redistribution; excellent for pressure areas. - Maintains a moist wound environment. - Conformable; adapts to wound shape. - Waterproof backing prevents strike-through (exudate saturating through to the outside). - Reduces pain and trauma with dressing changes. - Suitable for **3–7 days** depending on exudate and product. - Some products (e.g., PolyMem®) are non-adherent and do not require a secondary dressing. - Some products require a secondary dressing to secure them. - **Indications:** - **Moderate-to-heavy exudate wounds:** excellent for this use. - **Pressure injuries** (Stages 2–4) with moderate exudate. - **Leg ulcers** and other chronic wounds. - **Post-operative wounds** with moderate drainage. - **High-risk pressure areas** where padding and pressure relief are beneficial. - **Contraindications:** Minimally draining wounds (foam will be excessive and may over-absorb and dry the wound); very deep wounds with tunneling may require packing dressings for better contact. **5. Alginate Dressings (e.g., Kaltostat®, Seasorb®, AlgiSite®)** - **Composition:** Fibers derived from brown seaweed (kelp) that contain sodium alginate; when exposed to wound exudate (containing sodium and calcium ions), the alginate converts to a gel. - **Characteristics:** - **Highly absorbent:** Can absorb **up to 20 times its weight** in exudate; excellent for heavy drainage. - Excellent for **packing** deep, tunneling, or undermined wounds; conforms to wound shape and fills dead space. - Maintains a moist wound environment; promotes hemostasis (alginate's ion exchange can help control bleeding). - Fibers dissolve into gel form as they absorb exudate; removal is easy and typically painless (gel flushes out with irrigation). - Provides mild antimicrobial properties; can deodorize wounds with foul odor. - Suitable for **2–3 days** depending on exudate; heavily exuding wounds may require daily changes. - Available as ribbons (for packing) or sheets (for flat wounds). - **Indications:** - **Heavy exudate wounds:** primary indication. - **Deep, tunneling, or undermined pressure injuries** (Stages 3–4): alginate ribbon is packed into the cavity for maximum contact. - **Post-operative wounds** with high drainage. - **Leg ulcers** and diabetic foot ulcers with heavy drainage. - **Control of oozing/bleeding:** alginate's hemostatic properties help. - **Contraindications:** Minimally draining or dry wounds (alginate requires exudate to work effectively; in a dry wound, it may stick and cause trauma on removal); wounds requiring transparent visualization; patients allergic to seaweed. - **Important:** Alginate requires a secondary dressing to secure it. **6. Antimicrobial Dressings (Silver, Iodine, Honey-Based)** Used for wounds with **critical colonization** (high bacterial load) or **active infection**: **Silver-containing dressings (e.g., Acticoat®, SilverGel®, Aquacel Ag®)** - **Mechanism:** Silver ions disrupt bacterial cell membranes and inhibit replication; broad-spectrum antimicrobial activity. - **Indications:** Infected wounds or wounds with high bacterial load; critically colonized wounds. - **Duration:** Per product instructions (typically 3–7 days); change sooner if saturated or signs of infection worsen. - **Caution:** Avoid prolonged use; discontinue once infection is controlled to minimize resistance development. Silver can stain surrounding skin temporarily (blue-gray discoloration). **Iodine-containing dressings (e.g., Iodoform gauze, Iodine-impregnated pads)** - **Mechanism:** Iodine is antimicrobial; kills bacteria and some fungi. - **Indications:** Infected wounds; critically colonized wounds. **Not for routine use on healthy granulation tissue** (see earlier caution on povidone-iodine). - **Duration:** Per protocol, typically 1–3 days. - **Caution:** Assess for iodine allergy; check thyroid function in patients on prolonged iodine use (rare but possible). **Honey-based dressings (e.g., Manuka honey products, Medihoney®)** - **Mechanism:** Raw or medical-grade honey has antimicrobial properties (hydrogen peroxide produced as honey metabolizes), promotes autolytic debridement, and has anti-inflammatory properties. - **Indications:** Infected or critically colonized wounds; some evidence for chronic wounds like diabetic ulcers. - **Duration:** Per product; typically 3–7 days. - **Caution:** Ensure product is medical-grade (not raw honey from food); assess for allergy to bee products. **7. Specialty Dressings** **Negative-Pressure Wound Therapy (NPWT / Wound VAC - Vacuum-Assisted Closure)** - **How it works:** A sealed dressing with an attached tube is placed over the wound; a pump applies negative pressure (gentle suction), which removes exudate, reduces edema, improves blood flow, and promotes granulation tissue formation. - **Indications:** - **Large Stage 3 and Stage 4 pressure injuries** (especially those with high exudate). - **Chronic diabetic foot ulcers** that are not responding to conventional therapy. - **Post-operative wounds** with high drainage. - **Traumatic wounds** with large tissue loss. - **Grafted areas** (protects and promotes graft "take"). - **Benefits:** Accelerates healing; reduces pain; allows for less frequent dressing changes; promotes granulation tissue; can reduce infection. - **Drawbacks:** Expensive (significant cost, often requiring insurance pre-authorization); requires equipment maintenance; cannot be used with certain dressings or topical agents; patient mobility may be limited. - **Caution:** Contraindicated if there is active infection or osteomyelitis (must be treated first); requires close monitoring and regular dressing changes. - **Nursing role:** Ensure the seal is intact (air leaks reduce effectiveness); monitor the canister (when full, exudate is measured for output tracking); ensure prescribed suction level is maintained; assess wound at each change; watch for signs of maceration or complications. **Enzymatic Debridement Agents (e.g., Papain-urea, Collagenase)** - **How they work:** Enzymatic agents selectively break down collagen or necrotic proteins, facilitating removal of slough and eschar. - **Indications:** Wounds with significant slough or eschar that are not candidates for sharp debridement (e.g., patient on anticoagulants, poor perfusion, or patient preference). - **Application:** Apply directly to necrotic tissue; cover with a secondary dressing; monitor and reapply per protocol until necrotic tissue is removed. - **Caution:** Do NOT apply to healthy granulation tissue (these agents are non-selective and will digest healthy tissue too); protect surrounding skin with a barrier. Enzymatic debridement is slow compared to surgical debridement but is safer for certain patients. **Dressing Selection Summary Table** (Quick Reference): | Dressing Type | Exudate Level | Wound Type | Key Feature | Change Frequency | |---------------|---------------|-----------|-------------|------------------| | Transparent film | Minimal | Stage 1, superficial, clean | Visualization | 3–7 days | | Hydrocolloid | Light-moderate | Stage 2, shallow Stage 3 | Autolytic debridement | 3–7 days | | Hydrogel | Minimal | Dry wounds, painful wounds | Rehydration, comfort | Daily or per saturation | | Foam | Moderate-heavy | Pressure areas, moderate exudate | Cushioning, absorption | 3–7 days | | Alginate | Heavy, deep | Deep wounds, tunneling, Stage 3–4 | Packing, high absorption | 2–3 days or daily | | Silver dressing | Heavy + infected | Infected/critically colonized | Antimicrobial | Per product | | NPWT | Heavy | Large wounds, non-responsive | Suction, granulation promotion | Per protocol | **Key Principle:** **The goal is to match the dressing to the wound's moisture level and tissue needs.** Assess the wound, consider the amount and type of exudate, the presence of slough/eschar/granulation, and the periwound skin condition. Then select the dressing that will maintain a moist wound bed while protecting the periwound skin. As the wound heals and exudate changes, the dressing may need to be changed to a different type.

An **ostomy** is a surgically created opening (stoma) that diverts bodily waste (stool or urine) to the exterior of the body, bypassing the normal anatomical route. Ostomies are created when the normal pathway is obstructed, diseased, or non-functional. **Types of Ostomies:** **Fecal Diversions:** - **Colostomy** — Stoma created from the colon; diverts stool. The output consistency depends on the location of the stoma in the colon: - **Ascending colostomy** (rare; right-sided) — Output is liquid to pasty, similar to ileostomy, because the ascending colon does not yet absorb significant water. - **Transverse colostomy** — Output is pasty to semi-formed; inconsistent due to the nature of the transverse colon. - **Descending or sigmoid colostomy** (most common) — Output is formed, similar to normal stool; more predictable; many patients can achieve continence with proper diet and timing. - **Ileostomy** — Stoma created from the small intestine (ileum); the output is liquid to pasty and is continuous (no predictable pattern like a sigmoid colostomy). Ileostomy effluent is rich in digestive enzymes and is much more irritating to the skin than colostomy output. - **Other fecal diversions:** Continent ileostomy (Kock pouch), ileoanal pouch (J-pouch) — less common but important to recognize; patient has continence or improved continence. **Urinary Diversions:** - **Urostomy** — Diverts urine from the kidneys and bladder through a surgically created stoma into a pouch; created when the bladder is removed or non-functional. Output is urine (continuous, sterile at the stoma, but quickly colonized). **Stoma Assessment — Critical Indicators:** **Healthy Stoma Characteristics:** - **Color:** Red to pink, similar to the inside of the mouth (highly vascular tissue). - **Shape and texture:** Slightly raised above the skin surface (~1–2 cm), with a smooth surface. Some stomas are rounded, others more oval. - **Moisture:** Moist (secretes mucus), actively functioning (passing stool or urine). - **Size:** Varies but typically 2–5 cm in diameter; size may vary slightly over time due to swelling or changes in bowel function. - **Bleeding:** **Mild bleeding when cleaning is NORMAL** — the stoma is highly vascular. The tissue should not bleed spontaneously, but light oozing or minimal bleeding with gentle cleaning or if the patient bumps the stoma is expected. **EMERGENCY Signs — Stoma Ischemia (Requires Immediate Physician Notification):** - **Dusky, pale, dark, purple, or black stoma** — Indicates **ischemia** (loss of blood supply) and is a medical emergency. The stoma tissue is dying. This requires immediate surgical evaluation; may require surgical revision if the ischemia is severe. - **Bleeding that does not stop** — Excessive or uncontrolled bleeding is abnormal; report immediately. - **Foul, putrid odor** — May indicate tissue necrosis; report. - **Complete absence of output** — Possible bowel obstruction; report. Respond immediately by notifying the surgeon or attending physician; do not delay in documenting "dusky stoma" in a routine chart note. This is urgent. **Peristomal Skin Care — The Foundation of Ostomy Management:** The **peristomal skin** (skin immediately surrounding the stoma) is under constant threat of breakdown due to: - **Continuous exposure to effluent** (stool or urine) which is acidic and contains enzymes that digest skin. - **Irritation from dressing/wafer materials** in sensitive individuals. - **Moisture from perspiration, drainage, or humidity**. - **Friction from pouch movement**. **The goal is to keep the peristomal skin intact, dry, and healthy.** **Best Practice Peristomal Skin Care:** 1. **Cleanse with water only.** Use lukewarm tap water and gentle friction to remove old adhesive, effluent, and old skin barrier. **Avoid soaps with oils or lotions** — these leave a residue that impairs the adhesion of the new wafer and barrier products. Some facilities use commercial skin cleansers specifically designed for ostomy care (alcohol-free, pH-balanced), which are acceptable. 2. **Pat dry thoroughly.** Use a soft cloth or paper towel; do not rub harshly. The skin must be completely dry before applying new adhesive barrier (adhesive cannot stick to wet skin). 3. **Assess the peristomal skin** at each pouch change: - **Healthy:** Intact, same color as surrounding skin, no irritation or breakdown. - **Erythema (redness)** — Slight redness within 1 cm of the stoma is common and usually resolves with proper barrier application; significant erythema extending beyond 1 cm or spreading outward suggests irritation or infection (candidiasis—a yeast infection common in moist ostomy environment). - **Excoriation (breakdown, erosion)** — Raw or weeping areas; indicates effluent is contacting skin. Immediately improve the fit of the wafer/barrier and increase change frequency. - **Itching or burning** — Usually indicates skin irritation or fungal infection; report if severe or not resolving with better barrier fit. - **Swelling (edema) around the stoma** — Can indicate inflammation or infection; assess for other signs. 4. **Apply skin barrier as needed:** - **Skin barrier paste or powder** — Applied to any eroded or irritated areas to protect and promote healing. - **Hydrocolloid strips or rings** — Can be placed around the stoma (with a hole cut for stoma) to protect skin and improve the seal. - These products are often placed under the wafer (the main adhesive backing of the pouch) to enhance protection and fit. 5. **Cut the wafer opening to fit the stoma precisely:** - **Measure the stoma diameter** using a ruler or the measuring guide that comes with many pouch systems. - **Cut the opening 1–2 mm LARGER than the stoma diameter** (this allows for slight swelling while protecting most of the surrounding skin). - **Too large an opening** = exposed skin gets damaged by effluent; **too small** = risk of injuring the stoma by compression. - Many pouches come with pre-sized openings or with a template for cutting; follow the manufacturer's guide. - **Re-measure monthly** and adjust as needed; stoma size can change, and a poorly fitting wafer leads to leakage and skin damage. 6. **Apply the wafer properly:** - Ensure the peristomal skin is clean, dry, and free of powder or lotion residue. - Some patients benefit from a **skin sealant** (thin protective film applied to skin before the wafer) to further protect against irritation; others find it unnecessary. - Center the stoma in the wafer opening; press down firmly from the center outward to ensure good adhesion and to eliminate air pockets. - Smooth out wrinkles to create a complete seal. 7. **Attach the pouch:** - Most modern pouches are drainable (can be emptied without removing the entire pouch) or closed pouch (must be removed and replaced). - For **drainable pouches:** Ensure the drain/outlet is secure and directed downward for gravity drainage. Empty when ~1/3 to 1/2 full to prevent leakage (full pouches weigh more and are more likely to loosen). - Ensure the pouch is positioned comfortably and securely; some patients use an elastic belt or adjustable strap for additional support. **Frequency of Pouch/Wafer Changes:** - **Do not change every day** — Frequent changes irritate the skin and strip adhesive. - **Typical frequency:** Every **3–7 days** depending on: - **Type of output** — Ileostomy output is liquid and more erosive; pouches may need changing every 3–4 days. Colostomy output is more formed and less erosive; pouches may last 5–7 days. - **Adhesive quality** — Some adhesives last longer. - **Skin condition** — If the peristomal skin is irritated, change the pouch sooner to inspect and treat the skin. - **Leakage** — Change immediately if leakage occurs; do not wait. - **Patient preference and activity level** — Some patients prefer daily changes for cleanliness/comfort; balance this with skin health. - **Patient should change the pouch BEFORE leakage occurs.** Leakage indicates the adhesive has failed and the pouch can no longer contain the output. Continuing to wear a leaking pouch damages the peristomal skin. **Special Considerations for Ileostomy:** **Ileostomy output characteristics:** - **Consistency:** Liquid to pasty; continuous and unpredictable (unlike a sigmoid colostomy which is more predictable). - **Volume:** Typically 400–600 mL/day, but can vary with diet and fluid intake. - **Enzymes:** Rich in digestive enzymes (especially bile salts and enzymes from the pancreas and small intestine) which are **highly irritating to the skin** and can cause breakdown within hours if exposed. - **Content:** May be partially digested food, liquid stool, and secretions. **Nursing considerations for ileostomy patients:** 1. **Peristomal skin:** More prone to breakdown than colostomy sites due to enzyme-rich output. **Extra vigilance is required.** Poor fit of the wafer or infrequent changes quickly lead to severe skin damage. 2. **Pouch emptying:** Empty the pouch when it is ~1/3 to 1/2 full (not when completely full) to prevent: - Leakage from overfilling and poor seal. - Weight pulling on adhesive and loosening the wafer. - Patient discomfort from bulky pouch. 3. **Dehydration risk:** Because the ileostomy output is liquid, there is significant **fluid and electrolyte loss**. Ileostomy patients are at risk for: - **Dehydration** — Output is primarily water; excessive output can lead to low blood volume and dehydration, especially if fluid intake is inadequate. - **Electrolyte imbalances** — Loss of sodium, potassium, chloride, and bicarbonate. Potassium and sodium loss can cause weakness, muscle cramps, and arrhythmias. - **Risk of acute kidney injury** — In severe dehydration or high-output ileostomy (>1000 mL/day). **Prevention:** Counsel ileostomy patients to: - Drink **adequate fluid** (at least 1500–2000 mL/day, more in hot weather or with high activity; individualize based on output). - Consume adequate **sodium and potassium** (table salt in food, salty snacks, potassium-rich foods like bananas if diet is otherwise controlled). - Monitor **urine output and color** (dark urine indicates dehydration). - Report **signs of dehydration:** dizziness, weakness, decreased urine output, dark urine, dry mouth. - Report **high-output ileostomy** (>1000–1200 mL/day) to the healthcare provider; may indicate obstruction, infection, or diet issues and may require intervention (medications to thicken output, dietary changes, fluid/electrolyte supplementation). 4. **Dietary considerations:** - **Ileostomy patients can eat most foods,** but some foods increase output or cause gas: - **Increase output:** Fruits, vegetables high in fiber, spicy foods, alcohol, caffeine. - **Cause gas:** Beans, cruciferous vegetables, carbonated beverages, chewing gum (artificial sweeteners). - Patients learn through experience which foods they tolerate; encourage them to keep a **food/output diary** initially. - **Stress:** Stress and emotions can increase bowel motility and output; teach stress management. 5. **Medication absorption:** The **ileostomy bypasses the colon**, where much water reabsorption (and some medication absorption) normally occurs. Additionally, **enteric-coated medications** are designed to dissolve in the colon, not the small intestine. Counsel patients: - **Liquid or chewable medications are preferred** over tablets or enteric-coated forms (pills may pass through unabsorbed). - **Monitor medication effectiveness** and report to the healthcare provider if usual doses seem ineffective. - **Timing:** Take medications at least 30 minutes to 1 hour before or after meals to maximize absorption. **Special Considerations for Colostomy (especially Sigmoid):** - **Sigmoid colostomy output** is often formed (like normal stool) and may be predictable, occurring at specific times (e.g., after meals or specific times of day). - **Some patients achieve continence:** With proper diet, timing, and management, many sigmoid colostomy patients can regulate bowel function and may not need to wear a pouch full-time. They may use a small cap or dressing over the stoma between evacuations. - **Output consistency varies** with diet; solid foods produce more formed output; liquid/spicy foods may loosen it. - **Odor control:** Use odor-eliminating products (pouches with charcoal filters, deodorant sprays or drops) as needed. - **Irrigation:** Some patients learn **colostomy irrigation** (inserting water through the stoma to trigger bowel evacuation), which can help control output timing and improve continence. This is more commonly used with sigmoid colostomies. **Complications of Ostomy (Recognition and Action):** 1. **Peristomal dermatitis** — Inflammation and breakdown of surrounding skin due to poor barrier fit or effluent exposure. **Action:** Improve wafer fit, increase change frequency, apply protective barrier products, assess for candidiasis (fungal infection common in moist environment; treat with antifungal powder or cream), and educate patient on proper care. 2. **Stomal ischemia** — Described above; **EMERGENCY.** Immediate physician notification required. 3. **Stomal retraction** — Stoma sinks inward (retracts) below the skin level. Risk: Effluent pools on the skin rather than flowing into the pouch; skin damage results. **Cause:** Usually occurs months after surgery due to scarring or weight gain. **Action:** Use a convex wafer (curved to create a slight bulge that protrudes the stoma) to help direct output into the pouch; may require surgical revision if severe. 4. **Stomal prolapse** — The stoma becomes elongated and protrudes excessively (like a small finger protruding from the abdomen). Usually painless but concerning to the patient. **Risk:** The elongated stoma can become kinked, causing obstruction; trauma if caught in clothing. **Action:** Teach patient to protect the stoma; surgical revision may be needed if prolapse is severe or symptomatic. 5. **Stomal stenosis** — The stoma opening becomes narrowed due to scar tissue formation. **Risk:** Obstruction of output, constipation, abdominal discomfort. **Action:** Teach dietary modifications; may require dilation or surgical revision if severe. 6. **Parastomal hernia** — A bulge develops beside the stoma due to weakness in the abdominal wall at the stoma site. Usually painless but may cause discomfort or fitting problems for the pouch. **Management:** Support with a special hernia belt or abdominal binder; surgery may be offered if causing significant problems. **Patient and Family Education for Ostomy:** Before discharge, ensure the patient demonstrates competence in: 1. **Pouch/wafer change** — Correct technique, including measuring the stoma, cutting the opening, and applying the wafer; the ability to recognize and address fit problems. 2. **Emptying a drainable pouch** — Holding it over the toilet, opening the drain, and ensuring complete drainage before closing. 3. **Skin assessment** — Recognizing normal healthy stoma vs. signs of complications (erythema, excoriation, dusky color). 4. **Supplies and ordering** — Where to obtain supplies, how to order, and insurance coverage. 5. **Activity and lifestyle** — Reassure that most activities are possible (swimming, exercise, intimate relationships); advise on clothing choices (loose clothing may be more comfortable, especially when new to ostomy) and on managing ostomy during social situations. 6. **Diet and fluids** — Especially important for ileostomy: adequate hydration and sodium/potassium intake; keeping a food diary initially. 7. **When to call the healthcare provider:** - **Stoma color changes** (pale, dark, dusky, black). - **Severe skin irritation or breakdown**. - **Continuous bleeding from the stoma** (small amount of oozing is normal). - **Obstruction symptoms** — No output for 4–6 hours (depends on usual pattern), abdominal pain, nausea/vomiting. - **High-output ileostomy** (>1000 mL/day) — May indicate obstruction, infection, or need for dietary/medication adjustment. - **Signs of dehydration** — Dizziness, weakness, dark urine, decreased output. - **Significant odor changes** — May indicate infection or obstruction. 8. **Support resources** — Provide information on **ostomy support groups** (local hospital groups, American Ostomy Association, regional patient organizations) and **ostomy nurse specialists** (enterostomal therapy nurses, also called ET nurses or WOCN — Wound Ostomy Continence Nurses) who can provide expert guidance and troubleshooting. **Documentation:** At each assessment, document: - **Stoma appearance** (color, size, moisture, any bleeding) - **Peristomal skin condition** (intact, erythema, excoriation, other findings) - **Pouch system in use** (brand, style, size of opening, date last changed) - **Output characteristics** (amount, consistency, color, odor) - **Patient/family ability to manage pouch change** (independent, assisted, requires training) - **Complications or concerns** (and actions taken) - **Patient education provided** (topics, date, response) This documentation ensures continuity of care and identifies any urgent issues requiring intervention.