NLE Integumentary & Skin Integrity — Skin Integrity and Wound CareSummary

The skin consists of three distinct layers: (1) the **epidermis**—the outermost, avascular layer composed of stratified squamous epithelium that provides the first barrier and contains melanocytes; (2) the **dermis**—the middle, highly vascularized layer containing blood vessels, nerves, hair follicles, sebaceous and sweat glands, and fibroblasts that produce collagen for strength and elasticity; and (3) the **subcutaneous tissue (hypodermis)**—the innermost layer of adipose tissue and connective tissue that provides insulation, shock absorption, and energy storage. Intact skin protects against microbial invasion, regulates temperature through vasodilation and perspiration, maintains fluid and electrolyte balance, provides sensory perception, and synthesizes vitamin D.

A **pressure injury** is localized damage to skin and underlying soft tissue, usually over bony prominences, resulting from sustained pressure and/or pressure combined with shear. The mechanism is ischemia: sustained external pressure exceeding capillary closing pressure (approximately 32 mmHg) occludes blood flow, cutting off oxygen and nutrients to tissue; hypoxic and ischemic tissue becomes necrotic. **Contributing factors** include: (1) **pressure intensity and duration**—high pressure for short periods or low pressure for prolonged periods; (2) **shear**—occurs when the skeleton slides (e.g., when head of bed is elevated too high and the patient slides down) but skin remains fixed, causing internal tissue damage; (3) **friction**—abrades the epidermis (e.g., rubbing against sheets); (4) **moisture**—incontinence, perspiration, and wound drainage macerate skin and reduce resistance to breakdown (distinct from pressure injury but overlapping in etiology); (5) **immobility**—inability to reposition reduces pressure relief; (6) **advanced age**—skin loses elasticity and subcutaneous fat; (7) **poor nutrition**—protein-calorie malnutrition, low albumin, vitamin C and zinc deficiencies impair collagen synthesis and immune function; (8) **impaired sensation**—inability to feel pain prevents the patient from shifting position; (9) **reduced tissue perfusion**—diabetes, cardiovascular disease, anemia, and smoking compromise microcirculation. **Common sites** include sacrum and coccyx (highest risk in supine patients), heels, ischial tuberosities, greater trochanters, elbows, and occiput.

The National Pressure Ulcer Advisory Panel (NPUAP) and National Pressure Injury Advisory Panel (NPIAP) provide the internationally recognized staging system used in the Philippines. Staging describes the **depth of tissue destruction** and is determined by the **deepest visible tissue layer involved**. **Stage 1** presents as **intact skin** with **non-blanchable erythema** (redness that does not blanch/turn white when pressed) over a bony prominence; in darkly pigmented skin, the area may appear purple, dark maroon, or differ in temperature or firmness. **Stage 2** involves **partial-thickness skin loss** with exposed **dermis**, appearing as a shallow open ulcer with a red-pink wound bed, or as an **intact or ruptured serum-filled blister**; no slough or deeper tissue is visible. **Stage 3** is **full-thickness skin loss** where **subcutaneous fat may be visible**, but bone, tendon, and muscle are **not** exposed; slough and/or eschar may be present but do not obscure the depth; undermining and tunneling may occur. **Stage 4** involves **full-thickness** loss of skin and tissue with **exposed or directly palpable bone, tendon, muscle, ligament, or cartilage**; often accompanied by slough, eschar, undermining, and tunneling; highest risk for **osteomyelitis**. **Unstageable** wounds have a base **obscured by slough or eschar**, making the true depth indeterminate; once necrotic tissue is removed, the wound will be classified as Stage 3 or 4. **Exception:** stable (dry, adherent, intact, without erythema or fluctuance) eschar on an **ischemic limb or heel** should **not** be removed—it serves as the body's natural protective cover. **Deep Tissue Pressure Injury (DTI)** presents as **intact or non-intact skin** with a localized area of **persistent non-blanchable deep red, maroon, or purple discoloration**, or a **blood-filled blister**, indicating damage to underlying soft tissue from shear or pressure; DTI may rapidly evolve to reveal full-thickness loss even with treatment.

Systematic wound assessment is the foundation of wound care management and involves: (1) **location and size**—precisely document anatomical location, measure length (longest dimension), width (widest dimension perpendicular to length), and depth (using a sterile applicator or probe); assess for **undermining** (tissue destruction under intact skin edges, measured in centimeters and documented by clock position—12 o'clock typically toward the patient's head) and **tunneling/sinus tracts** (tissue destruction extending beyond the main wound opening); (2) **wound bed tissue**—classify as **granulation** (beefy red, moist, healthy, indicates healing), **slough** (yellow, tan, stringy, nonviable tissue), or **eschar** (black or brown necrotic/devitalized tissue); (3) **exudate**—assess amount (none, scant, light, moderate, copious) and type: **serous** (clear, watery), **sanguineous** (bloody, bright red), **serosanguineous** (pink-tinged, mix of serous and blood), or **purulent** (thick, yellow-green, foul-smelling, indicates infection); (4) **wound edges and periwound skin**—inspect for epithelialization (pink edge indicating new skin), maceration (pale, waterlogged appearance from excess moisture), erythema (redness suggesting inflammation or infection), induration (hardness, sign of cellulitis), and skin breakdown; (5) **signs of infection**—increased erythema, warmth, edema, purulent drainage, foul odor, increased pain, fever, and increasing wound size; note that **bacterial colonization is universal in chronic wounds, but bacterial load (quantity) determines clinical significance**—signs of increasing bacterial burden indicate infection requiring intervention.

Wounds heal by three types of intention, each with distinct timelines and outcomes: (1) **Primary intention (primary closure)**—surgical wounds with well-approximated, clean edges (e.g., a sutured abdominal incision); minimal tissue loss, fastest healing (7–10 days for suture removal, complete healing in weeks to months), least scarring, and lowest infection risk. (2) **Secondary intention**—wounds with significant tissue loss left open to heal by granulation from the wound base upward and inward epithelialization from the edges (e.g., a Stage 3 or 4 pressure injury, infected wound left open for drainage); slower healing (weeks to months or longer for large wounds), prominent scarring, and higher infection risk. (3) **Tertiary intention (delayed primary closure)**—a wound initially left open (to allow drainage, clear infection, or assess viability) and closed surgically after several days; balances infection control with cosmetic outcome. The **four phases of wound healing** are sequential and often overlap: (1) **Hemostasis (immediate)**—instantaneous; vasoconstriction and platelet aggregation form a clot to stop bleeding. (2) **Inflammatory phase (days 1–4)**—vasodilation increases blood flow, causing erythema and warmth; histamine release increases vascular permeability; phagocytes (neutrophils, then macrophages) migrate to the wound and remove debris, bacteria, and dead tissue; this phase is characterized by edema, warmth, pain, and exudate—**all expected and necessary for healing**; do not confuse with infection. (3) **Proliferative phase (days 4–21)**—fibroblasts proliferate and synthesize collagen, forming provisional matrix; angiogenesis (new blood vessel formation) brings oxygen and nutrients; granulation tissue (red, bumpy, vascular tissue) fills the wound; epithelial cells migrate from edges and appendages over the granulation tissue (epithelialization). (4) **Maturation/remodeling phase (day 21 to 1–2 years)**—collagen is remodeled and cross-linked by lysyl oxidase; tensile strength gradually increases, though a healed wound achieves only approximately 70–80% of original tissue strength; scar tissue remodels and may fade; this phase is lengthy and may continue for up to 2 years.

Multiple intrinsic and extrinsic factors delay or impair healing: (1) **advanced age**—thinned dermis, reduced collagen synthesis, slower cell turnover, and diminished immune response; (2) **malnutrition**—protein-calorie malnutrition limits fibroblast proliferation and collagen synthesis; **vitamin C deficiency** impairs cross-linking of collagen and immune function; **zinc deficiency** impairs epithelialization and immune response; **iron deficiency** limits oxygen-carrying capacity; (3) **diabetes and poor glycemic control**—hyperglycemia impairs leukocyte migration and phagocytosis, increases infection risk, and damages microvascular circulation; (4) **impaired tissue perfusion**—cardiovascular disease, peripheral vascular disease, anemia, and hypoalbuminemia reduce oxygen delivery; (5) **smoking**—nicotine causes vasoconstriction, reducing blood flow; carbon monoxide decreases oxygen saturation; smoking impairs immune function; (6) **corticosteroids and immunosuppressive medications**—suppress inflammatory response and immune function, delaying healing; (7) **infection**—increased bacterial burden (biofilms) produces enzymes and toxins that destroy tissue and consume oxygen; (8) **moisture imbalance**—excessive moisture (maceration) weakens tissue; excessive dryness impairs epithelialization; (9) **chronic stress and poor sleep**—impair immune function and cortisol regulation; (10) **chronic diseases** such as end-stage renal disease, liver disease, and cancer; (11) **radiation therapy**—damages blood vessels and fibroblasts.

**Prevention is the highest priority** because most pressure injuries are preventable. Evidence-based prevention includes: (1) **Risk assessment and monitoring**—use a validated tool such as the **Braden Scale** on admission and regularly thereafter (at least weekly in acute settings); the Braden Scale assesses six subscales: sensory perception (ability to respond to pressure-related discomfort), moisture (degree of skin exposure to moisture), activity (degree of physical activity), mobility (ability to change and control body position), nutrition (food intake pattern), and friction/shear (degree to which skin moves against support surfaces); **lower total scores indicate higher risk** (score ≤ 18 generally indicates high risk, but cutoff varies by setting and population; follow institutional protocol). (2) **Repositioning**—the cornerstone of prevention: reposition bedbound patients at least every **2 hours** using a **repositioning schedule** documented in the care plan; reposition chairbound patients every **1 hour**; for active patients, teach independent position shifting every 15 minutes; use the **30-degree lateral tilt** (rather than direct side-lying on the trochanter, which concentrates pressure) or supine with alternate semi-Fowler positions. (3) **Reduce shear and friction**—keep head of bed at **≤ 30 degrees** when possible (high Fowler increases shear as patient slides); use a **draw sheet** to facilitate repositioning without friction; avoid dragging patients; use a **trapeze** or **assist device** to help patients self-reposition. (4) **Pressure redistribution surfaces**—for high-risk patients, use pressure-redistribution mattresses or cushions: **foam mattresses** for standard risk, **alternating-pressure mattresses** (which inflate and deflate sections cyclically) or **low-air-loss mattresses** for high risk; ensure proper fit and function; **do not use a standard hospital mattress for a Stage 2 or higher pressure injury**—escalate to specialized surface. (5) **Offload heels**—place a **pillow under the calves** so heels float and have no contact with the mattress (not a rolled towel under the heel, which still applies pressure); alternatively, use a heel protector device designed for offloading. (6) **Skin care and moisture management**—cleanse skin **daily** and after incontinence with **pH-balanced, gentle cleansers** (avoid harsh soaps); pat dry thoroughly; apply **moisture-barrier cream or ointment** to incontinent areas to prevent maceration; manage incontinence promptly; **do not massage over bony prominences**—this was previously recommended but is now contraindicated because it can cause deep tissue damage. (7) **Nutrition and hydration optimization**—ensure adequate protein (1.25–1.5 g/kg/day), calories, vitamin C (500–1000 mg daily), and zinc; involve a **registered dietitian (RD)** for high-risk patients; monitor intake and output; hydrate appropriately. (8) **Patient and caregiver education**—teach about risk factors, importance of repositioning, nutrition, skin inspection, and reporting changes; involve family in prevention, especially for home-bound patients in rural or resource-limited settings.

**Wound cleaning** removes dead tissue, bacteria, and debris, promoting healing and preventing infection. **Clean wounds with normal saline** (0.9% sodium chloride)—the gold standard for chronic and acute wounds; saline is isotonic, does not damage healthy tissue, and is cost-effective. **Avoid cytotoxic agents** on granulating tissue: hydrogen peroxide (effervesces and damages new tissue), povidone-iodine (Betadine) solutions (stains and can be toxic to fibroblasts), and harsh antiseptics cause pain and impair healing. **Gentle irrigation** using a syringe or wound wash bottle at low pressure (≤ 8 PSI) effectively removes debris without traumatizing tissue; high-pressure irrigation can drive bacteria into tissue. **Debridement** is the removal of nonviable (dead) tissue, slough, and eschar. Four methods exist: (1) **Autolytic debridement**—the body's own enzymes (in moisture) break down dead tissue; achieved by keeping the wound moist with occlusive dressings; slowest method but gentlest. (2) **Enzymatic debridement**—topical enzyme products (e.g., collagenase, papain-urea) applied directly to necrotic tissue chemically break down collagen and dead tissue; faster than autolytic; useful for large areas of eschar. (3) **Mechanical debridement**—wet-to-dry dressings (moist gauze applied, allowed to dry, then removed, pulling away loose debris) or irrigation; effective but potentially painful and nonselective (can remove healthy tissue); less commonly used now due to development of better alternatives. (4) **Sharp/surgical debridement**—performed by physician, nurse practitioner, or trained clinician using scalpel or laser; removes large amounts of necrotic tissue rapidly; necessary for infected or heavily necrotic wounds; most selective method. **Exception:** Do **not** remove **stable, dry, intact, adherent eschar** on the **heel or an ischemic limb**—this eschar serves as a natural protective dressing; removing it exposes underlying tissue to infection and fluid loss.

The **moist wound-healing principle** is foundational: wounds healed in a **moist environment epithelialize 2–3 times faster** than those left to air-dry. Moisture allows epithelial cells to migrate horizontally over the wound bed; in a dry environment, cells must burrow down through the scab, delaying healing. The goal is to **maintain a moist wound bed while keeping the periwound (surrounding) skin dry and protected**—a balance. Dressing selection depends on wound characteristics, primarily **moisture level and exudate amount**. Key dressings used in the Philippines and tested on the NLE include: (1) **Transparent film dressings** (e.g., Tegaderm, OpSite)—thin, adhesive, waterproof polymeric films; allow visualization of the wound; maintain moisture; used for Stage 1, superficial wounds, minor abrasions, and as secondary dressings over gauze; **not suitable for heavy exudate** (will cause maceration); can remain 5–7 days if not soiled; easy to apply and remove. (2) **Hydrocolloid dressings** (e.g., DuoDERM, Comfeel)—occlusive wafers composed of gelatin, pectin, and carboxymethylcellulose; absorb light-to-moderate exudate and form a gel, maintaining moisture; ideal for Stage 2 and shallow Stage 3 pressure injuries; support autolytic debridement; can remain 3–7 days; less suitable for heavily exuding or infected wounds; may have an odor upon removal (normal). (3) **Hydrogel dressings** (amorphous or sheet forms, e.g., Aquasorb, Intrasite)—high water content (70–90%); **add moisture to dry wounds**; support autolytic debridement; soothing for painful wounds; used on shallow to moderate-depth wounds; require a secondary dressing; need frequent changes (daily to every 2 days) as they evaporate. (4) **Foam dressings** (e.g., Mepilex, Lyofoam)—composed of polyurethane foam; absorb **moderate-to-heavy exudate** while maintaining moisture; provide cushioning and pressure relief; used on Stage 3 and Stage 4 wounds with moderate exudate, around tubes and drains, and on sacral areas for pressure offloading; can remain 3–7 days depending on exudate; not ideal for very wet wounds. (5) **Alginate dressings** (e.g., Kaltostat, Tegagen)—derived from seaweed (brown algae); highly **absorbent**, ideal for **heavy exudate**; can be used as a rope or sheet to **pack deep or tunneling wounds**; support hemostasis (help stop bleeding); absorb exudate and convert to a gel; require a secondary dressing; change when saturated (typically 1–7 days). (6) **Antimicrobial dressings**—contain **silver, iodine (cadexomer iodine), or honey (Manuka honey)**; used for critically colonized or infected wounds, Stage 4 wounds with signs of infection, or when clinical signs of infection appear; silver dressings may inhibit growth of resistant organisms; iodine dressings help manage odor; honey dressings have antibacterial and anti-inflammatory properties; duration varies (follow product guidelines). (7) **Negative-pressure wound therapy (NPWT/wound VAC)**—a pump applies controlled negative pressure (typically -125 mmHg) through a sponge placed in the wound, removing exudate and reducing edema; promotes granulation and epithelialization; used for large Stage 3 and Stage 4 wounds, traumatic wounds, surgical site infections, and post-surgical open wounds; requires precise fitting and regular monitoring; expensive but highly effective; contraindicated in necrotic wounds (must debride first), wounds with exposed bone or blood vessels, and malignancy.

An **ostomy** is a surgically created opening (stoma) through the abdominal wall that diverts stool or urine. Types include: (1) **Colostomy**—diverts colon contents (stool); output ranges from solid to pasty depending on the location (right/ascending colon = liquid; left/descending/sigmoid = formed; sigmoid colon = most predictable); (2) **Ileostomy**—diverts small intestine (ileum) contents; output is liquid to pasty and **rich in digestive enzymes**, making peristomal skin especially vulnerable to breakdown; output is continuous and copious; (3) **Urostomy** (ileal conduit, cutaneous ureterostomy)—diverts urine through an opening; output is continuous; risk of skin breakdown and infection. A **healthy stoma** appears **red-pink, moist, and slightly raised above skin level**. **Report immediately** if the stoma is **dusky, pale, dark, purple, or black**—these signs indicate **ischemia** and tissue death, which is a medical emergency requiring immediate physician notification. **Mild bleeding** when cleaning is normal and expected (the stoma is highly vascular). **Peristomal skin protection** is central to ostomy care: (1) **Cut the wafer/barrier opening** to fit the stoma **snugly—approximately 1–2 mm larger than the stoma diameter**; an **opening that is too large** exposes peristomal skin to effluent, causing chemical dermatitis and breakdown; an **opening that is too tight** can constrict the stoma, causing ischemia; use a **stoma measuring tool** or template; (2) **Cleanse peristomal skin** with **water only** (avoid soaps with oils or lotions that reduce adhesion of the barrier or appliance); for ileostomy output rich in enzymes, gentle cleansing followed by thorough drying is essential; pat dry, do not rub; (3) **Apply skin barriers** as needed—protective rings (washer-type barriers), barrier wipes, or paste to fill in skin irregularities and protect against leakage; (4) **Change the appliance** (pouch and wafer) every **3–7 days** or when leaking; do **not wait for leakage to occur**—if leakage is evident, change immediately to prevent skin damage; empty the pouch when it is **one-third to one-half full** to prevent weight and bulging that compromises the seal; (5) **Monitor for peristomal complications**: **erythema** (redness, often due to allergic contact dermatitis or leakage), **itching and burning** (sign of skin breakdown or candidiasis), **ulceration and nodules**, and **candidiasis** (white, cottage-cheese-like appearance); report to healthcare provider if complications develop; (6) For **ileostomy** specifically, monitor for **dehydration and electrolyte loss** (liquid output leads to sodium and potassium loss); teach adequate **fluid intake** (at least 1.5–2 L daily) and include **foods rich in sodium and potassium** (bananas, potatoes, broth, sports drinks); also teach that certain foods (e.g., nuts, seeds, popcorn, corn) and high-fiber foods may cause blockage in ileostomy; (7) **Teach independence** before discharge—patient should be competent in appliance changes, skin care, output monitoring, and recognition of complications before leaving the hospital.

Untreated or poorly managed wounds can develop serious **local and systemic complications**. **Local complications** include: (1) **Infection**—wounds are contaminated with bacteria, but infection occurs when bacterial load exceeds the tissue's ability to contain it; signs include increased erythema around the wound, purulent exudate (thick, yellow-green discharge), foul odor, increased pain, fever, warmth, and swelling; critical for nurses to recognize and report for timely intervention; (2) **Cellulitis**—spreading inflammation of dermis and subcutaneous tissue characterized by erythema, warmth, edema, and pain; may progress to abscess (localized collection of pus) or systemic infection; (3) **Osteomyelitis**—bone infection, most common with Stage 4 pressure injuries over bone (sacrum, ischial tuberosities); manifests as fever, bone tenderness, purulent drainage from the wound, and elevated inflammatory markers; diagnosed via bone culture and imaging; requires prolonged antibiotic therapy and, often, surgical debridement; devastating if not treated; (4) **Abscess**—localized collection of pus walled off by granulation tissue and fibrin; presents as a pocket of fluctuance; may require drainage (incision and drainage procedure); (5) **Fistula or sinus tract**—abnormal passages connecting the wound to other tissues or the skin surface; may result from infection or incomplete healing; detected by probing with a sterile applicator; (6) **Malignant transformation (Marjolin ulcer)**—rare but serious complication of chronic, longstanding wounds (typically pressure injuries lasting > 30 years); squamous cell carcinoma develops within the ulcer; presents as change in wound appearance, increased pain, or new nodule; requires biopsy and surgical resection. **Systemic complications** include: (1) **Sepsis**—systemic inflammatory response to infection with bacterial translocation into bloodstream; manifests as fever, tachycardia, tachypnea, altered mental status, hypotension, and organ dysfunction; life-threatening and requires ICU care, broad-spectrum antibiotics, and supportive measures; (2) **Septic shock**—further deterioration with profound hypotension and end-organ failure; mortality high even with treatment.

Using the nursing process and NANDA-I (North American Nursing Diagnosis Association–International) taxonomy, common nursing diagnoses for patients with skin integrity problems and wounds include: (1) **Impaired Skin Integrity** (NANDA-I 00046)—defined as alteration in epidermis and/or dermis; related to pressure, shear, moisture, immobility, malnutrition, or infection; goals include maintaining or restoring skin integrity and preventing pressure injury formation. (2) **Risk for Pressure Injury** (NANDA-I 00249)—high-risk patients with factors such as immobility, poor nutrition, or advanced age; nursing interventions focus on prevention (repositioning, pressure redistribution, nutrition optimization, skin care). (3) **Impaired Tissue Integrity** (NANDA-I 00044)—damage to mucous membrane, subcutaneous tissue, muscle, tendon, bone, cartilage, joint capsule, and/or ligament; applies to Stage 3 and Stage 4 pressure injuries, surgical wounds, and traumatic injuries; goals include tissue repair and prevention of further damage. (4) **Acute Pain** (NANDA-I 00132)—related to tissue trauma, inflammation, or infection; goals include pain relief and comfort; interventions may include analgesics (per protocol), topical anesthetics, gentle handling, and dressing changes at optimal times. (5) **Risk for Infection** (NANDA-I 00004)—in patients with open wounds, poor nutrition, or immunosuppression; interventions include sterile technique, monitoring for signs of infection, and teaching about hygiene. (6) **Deficient Knowledge** (NANDA-I 00161)—regarding wound care, prevention, ostomy management, or nutrition; goals include patient/family understanding and competence in self-care; teaching is essential before discharge. (7) **Disturbed Body Image** (NANDA-I 00118)—may occur in patients with large wounds, ostomy, or disfiguring pressure injuries; goals include acceptance and adaptation; support and counseling are important. Care planning prioritizes **Maslow's hierarchy of needs**: preventing tissue necrosis and infection (physiological safety) takes precedence over comfort or knowledge; maintaining mobility to prevent further skin breakdown is a priority; and psychosocial needs (body image, self-care) are addressed as the patient stabilizes.

Comprehensive patient and family education is essential for preventing complications, promoting healing, and ensuring independent self-care. Teaching content includes: (1) **Pressure injury prevention** (for at-risk patients and family caregivers)—importance of repositioning, demonstration of proper techniques (30-degree lateral tilt, using draw sheets), skin inspection daily (teach patients to inspect their own skin or have a family member do so, paying special attention to bony prominences), and reporting any areas of redness that do not blanch. (2) **Nutrition and hydration**—importance of adequate protein, calories, and fluids for healing; consultation with a registered dietitian if hospitalized; understanding that healing requires "building blocks" (protein) and nutrients. (3) **Skin and wound care at home**—handwashing before and after care, clean technique (for chronic wounds) versus sterile technique (per healthcare provider instruction), wound cleaning procedures, dressing changes, recognition of normal versus abnormal drainage, signs of infection (increased redness, warmth, pus, odor, pain, fever), and when to contact the healthcare provider. (4) **Activity and mobility**—importance of moving and changing positions to prevent recurrence; for patients able to move independently, teach repositioning every 15 minutes; for bedridden patients, emphasize the need for caregiver assistance every 2 hours. (5) **For ostomy patients specifically**—appliance changes (demonstration and return demonstration), skin care, pouch emptying and disposal, dietary considerations (fiber, fluids, foods causing gas or odor), and signs of complications requiring healthcare provider contact; many patients benefit from **ostomy support groups** for emotional support and peer learning. (6) **General adaptation and coping**—recognizing that chronic wounds or ostomies can affect self-image and quality of life; teaching adaptation strategies; information about resources, support groups, and professional counseling if needed.

The Philippines has a tiered healthcare delivery system (RA 9173 and RA 7875 define the National Health System structure): **primary health care** is delivered through barangay health stations and rural health units (RHUs); **secondary care** through district and city hospitals; **tertiary care** through regional and specialty hospitals. Challenges to skin integrity and wound care in the Philippine context include: (1) **Resource limitations in rural areas**—RHUs may lack specialized dressings, pressure-redistribution surfaces, or NPWT equipment; nurses must improvise safely using available materials (e.g., foam, locally available barriers) and prioritize prevention over treatment; (2) **Limited specialist access**—wound care specialists may be unavailable outside tertiary centers; nurses must function as wound experts and educate community health workers; (3) **Reliance on family caregiving**—many patients are cared for at home; family teaching is crucial, and the nurse must assess family capacity and provide simplified, culturally appropriate instructions; (4) **Nutritional challenges**—malnutrition is prevalent in some communities; wound healing is compromised; community nurses must counsel on affordable, locally available protein sources; (5) **Infection control in austere settings**—ensuring clean/sterile technique with limited resources requires creativity and adherence to basic principles (handwashing, disinfection); (6) **Cultural considerations**—traditional healing practices may coexist with biomedical care; nurses must respect these while advocating for evidence-based wound care; (7) **Compliance challenges**—patients may not prioritize prevention or self-care; culturally sensitive communication and education strategies tailored to the community are essential. Nurses in the Philippines play a vital role in disseminating evidence-based skin integrity and wound care knowledge and preventing preventable complications across all healthcare levels.