Foundations of Nursing: Skin Integrity and Wound Care

Introduction

• Skin: Largest organ, protects against pathogens, sensory organ, synthesizes vitamin D.
• Wound Healing: Complex process influenced by various factors.
• Clinical Judgement: Essential for assessing skin integrity and planning care.

Skin Structure

• Epidermis: Outer layer with stratum corneum (thin, protective, allows absorption/evaporation).
• Dermis: Inner layer, provides strength, contains connective tissue.
• Aging: Alters skin, increasing vulnerability.

Pressure Injuries

• Terminology: Pressure injury replaces terms like bedsore.
• Causes: Develops over bony prominences due to pressure, shear.
• Risk Factors: Decreased mobility, sensory perception, incontinence, poor nutrition.
• Prevention: Early identification, prevention strategies.
• Assessment: Staged from 1 (redness) to 4 (deep tissue exposure).

Case Study: Mr. Omar Ahmed

• Background: 76-year-old with pneumonia, weight loss, diabetes, hypertension.
• Risks: Limited mobility, sensation issues, nutritional deficiencies.
• Management: Pressure relief strategies, wound care, nutritional support.

Wound Types & Classification

• Closed Wounds: Skin intact, underlying damage (e.g., contusions).
• Open Wounds: Skin and tissues exposed, risk of infection.
• Healing Intentions:
  • Primary: Edges approximated, low infection risk.
  • Secondary: Tissue loss, open until filled by scar tissue.
  • Tertiary: Delayed closure to monitor infection.

Factors Affecting Wound Healing

• Nutrition: Deficiencies impair healing.
• Oxygenation: Critical for cell functions.
• Infection: Prolongs healing phases.
• Age: Alters physiological processes.

Nursing Process in Wound Care

• Assessment: Risk factors, wound characteristics, client expectations.
• Diagnosis: Based on assessment data (e.g., impaired skin integrity).
• Planning & Implementation: Tailor interventions to client needs.
• Evaluation: Reassess wounds, adjust care plans.

Prevention and Management

• Skin Care: Gentle cleaning, moisture barriers.
• Positioning: Regular repositioning, support surfaces.
• Education: Client and caregiver training.

Dressings and Interventions

• Dressing Selection: Based on wound phase.
• Packing & Debridement: Ensures proper healing environment.
• Advanced Therapies: Negative pressure wound therapy for complex cases.

Heat and Cold Therapy

• Applications: Used for pain relief, circulation, edema.
• Precautions: Assess client condition, contraindications.

Conclusion

• Critical Thinking: Essential for effective wound management.
• Ongoing Education: Key for both healthcare providers and families.