Impaired Tissue/Skin Integrity (Wound Care) Nursing Diagnosis & Care Plans

Skin is the patient's first barrier, and when it breaks you are managing infection risk, pain, nutrition, and the slow work of healing all at once. This guide covers the assessment, diagnoses, goals, and interventions you use at the bedside for wounds and compromised skin integrity, from pressure injuries to burns.

What is Tissue Integrity?

The integumentary system is the body's frontline defense. Skin, cornea, subcutaneous tissue, and mucous membranes block threats from the outside, and in a healthy patient those defenses hold. Physical trauma, thermal and chemical injury, infection, poor nutrition, fluid imbalance, and altered circulation can all breach them.

Most breaks heal well. Some never close and the body fills the gap with connective tissue instead. Left untreated, a break in tissue integrity invites local or systemic infection and can progress to necrosis.

Other contributors include age, weight loss, poor nutrition and hydration, too much moisture or too little, smoking, and anything that limits blood flow. Frequent bathing, prolonged UV exposure, and wet-work occupations also compromise the skin. The result ranges from itching, pain, and disfigurement to allergy and secondary infection, and the burden climbs with age.

What is Wound Care?

A wound is a disruption of the normal structure and function of skin and soft tissue. An acute wound heals on schedule through the expected stages. A chronic wound is physiologically stalled. Healing is a complex process pushed forward or held back by external and internal factors, and your job, with the rest of the team, is to manage those factors and give the wound the best environment to close.

Phases of Wound Healing

Injured skin heals through four phases: hemostasis, inflammatory, proliferative, and maturation.

• Hemostasis. Platelets release growth factors that recruit cells to start repair. This phase lasts up to 60 minutes depending on severity.
• Inflammatory. Vasodilation lets white blood cells move into the wound and clean the wound bed. You see edema, erythema, and exudate.
• Proliferative. Beginning within a few days, this phase covers epithelialization, angiogenesis, collagen formation, and contraction. Epithelialization builds new epidermis and granulation tissue. Angiogenesis starts as capillaries develop in the wound 24 hours after injury, delivering oxygen and nutrients. Collagen gives the wound strength, and the wound begins to contract as the phase ends.
• Maturation. Collagen keeps building to strengthen the wound. A wound typically heals in 4 to 5 weeks and usually leaves a scar that softens, flattens, and pales over about 9 months.

Types of Wound Healing

Wounds heal by primary, secondary, or tertiary intention.

• Primary intention. The wound is sutured, stapled, glued, or otherwise closed and heals beneath the closure. This is how clean-edged lacerations and surgical incisions heal. Closed edges are described as approximated.
• Secondary intention. The edges cannot be brought together, so the wound fills from the bottom up with granulation tissue. Pressure injuries and chainsaw injuries are examples, and they carry a higher infection risk.
• Tertiary intention. The wound stays open or is reopened, often for severe infection, and is closed later once the infection clears. Expect delayed healing and more scar tissue.

Causes

Common related factors for impaired skin integrity:

• Physical trauma. Car accidents, sports injuries, cuts, and blunt trauma.
• Thermal factors. Extreme heat or cold producing burns or frostbite.
• Chemical injury. Drug reactions or contact with harmful chemicals.
• Infection. Pathogens invading and damaging tissue.
• Nutritional imbalances. Poor intake of nutrients needed for skin health and repair.
• Fluid imbalances. Dehydration or fluid overload that compromises skin moisture and elasticity.
• Altered circulation. Conditions such as pressure injuries that cut blood flow to the skin.
• Age. Thinner, less elastic skin that breaks down more easily.
• Weight loss. Reduced cushioning over bony areas.
• Poor nutrition and hydration. Inadequate fuel for healthy skin.
• Excessive moisture or dryness. Maceration or cracking.
• Personal hygiene behaviors. Frequent bathing or harsh cleansers that strip natural oils.

Signs and Symptoms

Common defining characteristics:

• Pain or abnormal sensation in the affected area.
• Inflammation. Redness, swelling, heat, and pain.
• Cutaneous lesions. Abrasions, lacerations, or ulcers.
• Loss of cutaneous substance. Breaks that may expose underlying tissue.
• Skin and tissue color changes. Red, purplish, or black discoloration.
• Swelling around the injury. Edema signaling fluid accumulation.
• Pruritic skin. Itching that drives scratching and further damage.
• Dry, scaly skin.
• Thin, fragile skin prone to tears.
• Exudate or drainage, clear, bloody, or purulent.
• Delayed wound healing.
• Necrosis. Dead tissue in or around the wound.
• Erythema and edema around the wound.

Nursing Care Plans and Management

Wound care and skin integrity are core nursing work. Prompt, correct management promotes healing and prevents complications. Build the plan around the specific wound, the patient's overall health, and their preferences, with attention to wound assessment, interdisciplinary collaboration, patient education, and evidence-based practice.

Nursing Problem Priorities

1. Wound assessment. Assess by type, cause, and characteristics to guide treatment and maximize healing.
2. Effective wound care. Quality care speeds healing, cuts complications, readmissions, length of stay, and cost.
3. Suture and staple removal. Correct timing and technique prevent complications from a wound that has not yet healed.
4. Drain management. Check the site and drain through the shift to confirm function and catch leaks.
5. Burn wound care. Manage burns to prevent deterioration.
6. Pressure injury management. Prevent and treat early; pressure injuries cause pain, raise morbidity and mortality, and drive up cost.
7. Patient and caregiver education. Bring the patient and caregivers into the healing process and help them prevent complications.

Nursing Assessment

Assess the skin and wound thoroughly: measure dimensions, evaluate the wound bed, look for infection, and check the surrounding skin. This assessment drives your choice of dressings, cleansers, and adjunctive therapy.

A break in tissue integrity shows up as:

• A site that is hot and tender to touch
• Damaged or destroyed tissue (cornea, mucous membranes, integumentary, subcutaneous)
• Local pain and protectiveness toward the site
• Skin and tissue color changes (red, purplish, black)
• Swelling around the initial injury
• Pruritic skin
• Dry, scaly skin
• Thin, fragile skin

Nursing Diagnosis

After assessment, form nursing diagnoses around the patient's specific condition and your clinical judgment. Diagnostic labels vary by setting; the priority is matching the plan to the patient's needs. Examples:

• Impaired Skin Integrity related to prolonged pressure on bony prominences as evidenced by redness and nonblanchable areas on the sacrum and heels, with pain on repositioning secondary to CVA.
• Impaired Skin Integrity related to friction and shear from frequent repositioning.
• Impaired Skin Integrity related to insufficient nutritional intake as evidenced by delayed wound healing and dry, flaky skin.

Nursing Goals

Expected outcomes:

• The patient reports altered sensation or pain at the site of tissue impairment.
• The patient understands the plan to heal tissue and prevent injury.
• The patient describes how to protect and heal the tissue, including wound care.
• The patient's wound shrinks and shows increased granulation tissue.

Nursing Interventions and Actions

1. Skin and Wound Assessment

Visual examination of the skin and the description of any lesions drive the diagnosis and guide treatment.

Determine the etiology (acute or chronic wound, burn, dermatologic lesion, pressure ulcer, leg ulcer). Knowing the cause is what lets you pick the right interventions. Systemic disease changes the picture: diabetes compromises skin structure and function, foot deformity and gait problems build callus and raise ulcer risk, and dermatologic disease affects the skin directly, from inflammation to tumors.

Assess the site and its condition. Redness, swelling, pain, burning, and itching point to inflammation and the immune response to local trauma. Repeated irritation can harden the skin as a protective response, the way friction thickens the stratum corneum on the foot.

Assess wound characteristics: type, location, color, size, drainage, and odor. Do a thorough exam for existing wounds and gauge breakdown risk with the Braden Scale.

• Type. Abrasions, lacerations, burns, surgical incisions, pressure injuries, skin tears, arterial ulcers, or venous ulcers. The type drives the intervention.
• Location. Document precisely; a body diagram helps.
• Size. Measure regularly to track whether the wound is growing or shrinking. Length runs head-to-toe, width laterally.
• Degree of tissue injury. Classify as partial-thickness or full-thickness. Stage pressure injuries.
• Color of the wound base. Healthy granulation is pink or red. Dark red granulation, white or yellow slough, and brown or black necrotic tissue signal trouble.
• Drainage. Document color, consistency, and amount at every dressing change. Amount runs scant, small, moderate, or copious; type is serosanguineous, sanguineous, serous, or purulent.

Assess for fever. Fever is a systemic sign of inflammation and may mean infection. Pyrogens stimulate the hypothalamus to raise the temperature set point.

Assess pain. Pain is part of inflammation, but its severity does not always track tissue damage. Skin tears hurt because dermal nerve endings are exposed, while a diabetic foot ulcer may be nearly painless from neuropathy.

Monitor the site at least once daily for color change, redness, swelling, warmth, pain, or other signs of infection. A break in the skin lets bacteria in, and a local infection can progress to systemic infection, sepsis, and limb- or life-threatening infection.

Monitor the periwound skin. The skin at the wound edges tells you about healing. For wounds closing by primary intention, document whether the edges are well-approximated or showing signs of dehiscence.

Monitor skin care practices: soap and cleanser type, water temperature, and how often the skin is cleansed. Repeated or prolonged exposure to water and irritants such as surfactants, solvents, oils, urine, or stool raises skin surface pH, strips natural moisturizing factors, and disrupts the lipid barrier. Overbathing does the same.

Assess the overall condition of the skin for baseline data. Healthy skin has good turgor, feels warm and dry, is free of breaks and rashes, and refills capillaries in under 6 seconds. Older patients are high-risk because their skin is less elastic, drier, and thinner.

Assess for a history of AIDS or other immune problems. Kaposi sarcoma is an early HIV-related finding. It first appears as purple, red, or brown spots or lesions, flat (patches), slightly raised (plaques), or as nodules, usually on the legs or face but also on mucous membranes of the mouth, throat, eye, and eyelids.

Assess for prior radiation therapy. Radiated skin is thin, friable, and poorly perfused. Radiation causes stasis or occlusion of small vessels and damages fibroblasts.

Evaluate the patient's strength to move (shift weight while sitting, turn in bed, move bed to chair). Immobility is the single biggest risk factor for breakdown. A patient who cannot reposition will develop tissue damage unless caregivers move them often.

Assess for fecal or urinary incontinence. Stool enzymes break down skin, and urea in urine converts to caustic ammonia within minutes. Diapers and pads speed breakdown, starting with erythema and tenderness and progressing to skin loss, often with a secondary fungal rash.

Assess for edema. Skin stretched over edematous tissue is at risk. Venous stasis in the legs blocks oxygen and nutrient delivery, leading to stasis dermatitis, hemosiderin deposits, dryness, stiffening, and a high risk for leg ulceration.

Assess for environmental moisture (wound drainage, high humidity). Moisture macerates skin. The four types of moisture-associated skin damage are incontinence-associated dermatitis, intertriginous dermatitis, periwound, and peristomal.

Assess for dermatitis or chemical irritant exposure. Irritants inflame the skin, causing redness, itching, and sometimes blisters. Excessive use of cleansing and care products raises skin surface pH and destroys corneocytes and the lipid layers of the stratum corneum.

Assess for pruritus or mechanical trauma. Both disrupt the barrier. Systemic disease can cause pruritus ranging from mild to disabling, sometimes with normal-appearing skin and sometimes with secondary lesions such as excoriations, prurigo nodules, lichen simplex chronicus, or secondary infection.

Watch for itching and scratching. Scratching opens lesions and raises infection risk. Pruritus is usually a primary skin disorder, but when no skin cause is found, look for a systemic or neuropathic one.

Assess for long-term steroid use and other drug causes of breakdown. Steroids leave skin papery and fragile, reduce inflammation, inhibit epithelialization, and lower collagen production. Hydroxyurea can cause nonhealing ulcers, and chemotherapy reduces wound matrix formation, collagen, and contraction.

Identify factors that affect healing. Local factors act directly on the wound: blood flow and tissue oxygenation, infection, foreign body, and venous insufficiency. Systemic factors reflect overall health: nutrition, mobility, stress, diabetes, age, obesity, medications, alcohol, and smoking.

Monitor labs that affect healing. Low hemoglobin means less oxygen reaching the wound. Elevated WBC means infection. High glucose and HbA1c mean poorly controlled diabetes. A positive wound culture confirms infection and identifies the organism and the antibiotics it responds to.

2. Providing Effective Skin and Wound Care

The most important intervention is preventing the hazard in the first place. When skin is highly vulnerable during severe illness or immobility, add measures to keep the environment safe. Good skin and wound care lowers the risk of worsening breakdown and complications.

Promoting skin integrity

Clean, dry, and moisturize the skin twice daily or as needed for incontinence or sweating, especially over bony prominences. Avoid hot water. If powder is needed, use medical-grade cornstarch, not talc, which can injure the lungs. Lipophilic leave-on products raise epidermal moisture and ease dry skin, and regular application matters more than the specific formula.

Massage only around the affected area to boost perfusion. Massaging a reddened area directly damages the skin. Avoid massage over open wounds, fragile skin, infection, or significant inflammation.

For incontinence, implement a management plan to keep urine and stool off the skin. Options include absorbent pads, breathable film with a pad, and a review of toileting technique, plus a containment or continence system when appropriate.

Tell the patient not to rub or scratch. Provide gloves or trim the nails as needed. Rubbing causes abrasions and breakdown that open the door to infection.

Assess nutritional status, including weight, weight loss, and serum albumin. Poor intake raises breakdown risk and slows healing. An albumin under 2.5 g/dL is a grave sign of severe protein depletion and high breakdown risk. Track hemoglobin, prealbumin, and weight weekly.

Discuss the role of nutrition: fluids, protein, vitamins B and C, iron, and calories. Ascorbic acid is needed for tissue healing, along with vitamin A, B vitamins, zinc, and sulfur.

Encourage a diet of 2,000 to 3,000 kcal/day, more with increased metabolic demand. A high-protein, high-calorie diet, protein supplements, and iron preparations support healing and a positive nitrogen balance, which matters because pressure injuries form faster and resist treatment in malnourished patients.

Encourage hydration of 2,000 mL/day unless restricted. Adequate hydration keeps skin turgid, moist, and resilient. Watch patients with limited cardiovascular reserve.

Collaborate with a dietitian to identify and correct deficiencies, especially when a wound is healing poorly.

Providing wound care

Provide wound care matched to the etiology. Dressings range from wet or dry gauze to topical creams, hydrocolloids, and vapor-permeable membranes such as Tegaderm, with an eye patch or hard shield for corneal injury. The dressing replaces the skin's protective function during healing.

Perform hand hygiene before setting up supplies and after wound care. It prevents the cross-contamination that delays healing.

Use sterile dressing technique to lower infection risk: sterile field, gloves, supplies, dressing, and instruments, chosen to fit the wound, the dressing procedure, the goal of care, and agency policy.

Premedicate for dressing changes when manipulating deep or extensive wounds will hurt. Give pain medication before the scheduled change.

Cleanse with an appropriate solution at each dressing change, using products compatible with wound tissue. Normal saline is the gentlest, delivered by syringe or commercial cleanser. Avoid hydrogen peroxide, betadine, and acetic acid, which are cytotoxic.

Plan debridement when necrotic tissue (eschar or slough) is present and consistent with the patient's goals. Wounds do not heal over necrotic tissue. Leave a dry heel eschar in place until vascular status is confirmed.

Maintain appropriate moisture. Dressings should keep the bed moist to build granulation tissue, but heavy exudate needs an absorbent dressing such as alginate or hydrofiber to prevent maceration.

Pack deep or tunneling wounds to keep the bed moist and fill dead space, using saline-moistened sterile gauze or hydrogel-impregnated dressings that lift out cleanly without tearing fragile granulation tissue.

Control odor. When a wound is malodorous, talk to the provider about dressing-change frequency, cleansers, and the need for topical antimicrobials or debridement. Room deodorizers help after changes.

Protect the periwound skin. Heavy drainage or misused moist dressings macerate the surrounding skin. Apply dressings to keep the bed moist while protecting the edges with barrier creams, protective wipes, or barrier wafers.

Administer antibiotics as ordered. IV antibiotics may be needed, but wound infections are often managed well with topical agents. A core goal of wound care is keeping bacteria and contaminants off the wound base.

• Polyhexamethylene biguanide (PHMB). Binds the acidic membrane components of bacteria, dissolving the cell with no surviving organisms to build resistance. Combined into gauze and foam, it suits healable surface wounds with exudate.
• Silver. An ionized antibacterial that attacks cell membranes, organelles, and DNA, so resistance is uncommon. Best for healable wounds with critical colonization, often combined with alginates, hydrofibers, foams, and hydrogels.
• Iodine. Blocks bacterial efflux pumps, disrupts respiration, alters DNA, and denatures proteins. Povidone-iodine and cadexomer iodine are the common slow-release iodophors. Check thyroid function at intervals for large wounds or extended use, since iodine dressings can induce hypothyroidism or hyperthyroidism.
• Methylene blue and crystal violet foam dressings. Two agents in a low-release foam create a redox environment that inhibits bacterial growth. The polyvinyl alcohol foam needs partial hydration to bind surface slough and provide autolytic debridement.
• Honey. Used in wounds for centuries for its antibacterial and anti-inflammatory action; its acidic pH and high sugar load make the wound hostile to bacteria. Use medical-grade honey, not food honey, which can carry bacterial spores.

Wrap blisters with gauze or apply a hydrocolloid dressing to keep pathogens out. Sterile gauze is changed at least daily; a hydrocolloid acts as an occlusive barrier.

Take wound swabs at dressing changes when new infection signs appear, per agency policy, and discuss culture and antibiotics with the provider.

Assist with a wound vac. This device uses special foam, a film seal, and suction to pull fluid out and draw the wound edges together. It is usually worn 24 hours a day during healing.

Apply advanced topical therapy when a wound stalls.

• Topical growth factor. A platelet-derived growth factor that stimulates fibroblast proliferation and granulation. Used for neuropathic diabetic ulcers and wounds reaching the subcutaneous tissue or deeper; applied once daily to the wound bed.
• Acellular extracellular matrices. Nonliving allogenic, xenographic, or synthetic tissue that speeds healing with less scarring. For partial- and full-thickness, burn, traumatic, and surgical wounds.
• Placental tissue allografts. Derived from amnion/chorion membrane or umbilical cord, they deliver growth factors and are antimicrobial and anti-inflammatory. Applied directly to acute, chronic, and nonhealing wounds.
• Cell-based therapies. Deliver growth factors with viable cells on bioabsorbable matrices, as epidermal, dermal, or bilayer products. For partial- and full-thickness, chronic nonhealing, and burn wounds.

3. Suture and Staple Removal

Sutures are thread, wire, or other material used to close tissue; they may be absorbable or nonabsorbable. Staples are stainless steel and require a sterile extractor for removal. Timing depends on how well the wound has healed and the extent of surgery. Remove sutures too early and the wound can dehisce.

Remove the dressing and assess the wound before removing sutures. Leave sutures in long enough to support internal tissues. Watch the wound line for separation during removal and stop if there is any concern. If the wound is well-healed, all sutures can come out at once.

Irrigate before removing sutures with sterile normal saline to clear debris and exudate, reduce contamination risk, and loosen dried blood and crusted exudate. Commercial cleansers also work.

Cut under the knot, as close to the skin as possible. Never cut both ends, or you cannot remove the suture from below. Do not pull the contaminated top of the suture through the tissue. Point any blade away from the patient.

Remove remaining sutures only if the wound is well-approximated. Take out alternate sutures first, then the rest once approximation is confirmed, which may be days or weeks later.

Apply Steri-Strips if separation occurs or at each removed staple site. If the wound separates, stop, apply Steri-Strips, notify the provider, and dress or leave open to air. Steri-Strips support wound tension, reduce scarring, and let the wound heal by primary intention.

Place the staple extractor under the staple without pulling up while depressing the handle. The closed handle bends the staple's two ends out of the skin. Then gently rock the staple side to side to remove it.

Keep the handle closed and move the extractor away from the skin once both ends are visible, releasing the staple onto sterile gauze. This avoids premature removal, pressure on the wound, and scratching the skin.

4. Drain Management

Drains remove postoperative drainage, prevent infection, and support healing. Check the site and drain regularly to confirm function and rule out leakage.

Monitor placement of tubes, catheters, and devices, and assess the skin under securing tape. Feeding tubes, IV lines, chest tubes, and other percutaneous tubes cause pressure, friction, and shear damage.

Perform hand hygiene before and after drain management and don nonsterile gloves and goggles or a face shield as needed. PPE limits microorganism transmission and protects against body-fluid exposure.

Remove the spout plug using sterile technique, opening it away from your face to avoid a splash. Keep the plug sterile to prevent cross-contamination; breaking the vacuum lets the reservoir expand.

Compress the drain after emptying it. Set the container on a hard surface, tilt it away from your face, and flatten it with one hand. Squeeze out the air before closing the spout to reestablish the vacuum.

Secure the device and check patency and placement. Position the reservoir below the wound so gravity assists drainage, and leave enough slack in the tubing to allow movement without tension on the insertion site.

Remove drainage tubing with a swift, steady pull, grasping it firmly. Slight resistance is normal; if resistance is strong, stop, cover the site, and call the provider. Confirm the drain tip is intact and smooth after removal, and send it to the lab if agency policy requires.

Cleanse the old drain site with aseptic technique and cover it with a sterile dressing to prevent contamination and infection.

Collaborate with a wound, ostomy, and continence nurse (WOCN) for product selection, education, and a prevention plan. Refer to a wound care specialist for delayed healing or chronic wounds.

5. Management of Burn Wounds

Most burns are small. Patients with small burns do well in an outpatient setting as long as the burn spares critical areas such as the face, hands, genitals, and feet. When in doubt, coordinate outpatient care with the burn unit, whose team can help you reach the best result.

Assessment of burn injuries

Evaluate the burn patient using the ABCs. Use the American College of Surgeons Advanced Trauma Life Support primary survey, focused on airway, gas exchange, and circulation. Assess the airway first; early recognition of impending compromise and prompt intubation can be lifesaving.

Assess the extent and location of the burn. Examine the cornea in facial burns before lid swelling blocks the exam. Large injuries trigger a systemic response from skin barrier loss, vasoactive mediators, and infection.

Estimate burn size accurately, since it drives treatment and transfer decisions. The most accurate method is the age-specific Lund-Browder chart, which adjusts for body proportions; you draw the burn on a figure and calculate body surface area from the matching table.

Use the rule of nines as the adult alternative. It is less accurate in children, whose proportions differ. For irregular or scattered burns, the patient's palm without the fingers represents 0.5% of body surface.

Determine burn depth, which is routinely underestimated early because the wound changes over the following days. Serial exams help. Depth is classified first through fourth degree.

• First-degree burns are red, dry, and painful. Many burns first called first-degree are actually superficial second-degree, sloughing the next day.
• Second-degree burns are red, wet, and very painful, with widely varying depth, healing, and scarring.
• Third-degree burns are leathery, dry, insensate, and waxy. They will not heal except by contraction and limited epithelial migration, leaving unstable cover.
• Fourth-degree burns involve subcutaneous tissue, tendon, or bone. Even an experienced examiner struggles to gauge depth early.

Assess for burn wound infection. Local signs include a partial-thickness injury converting to full-thickness, worsening surrounding cellulitis, eschar separation, and tissue necrosis. Burn cellulitis shows as erythema, induration, warmth, and tenderness around the wound or eschar.

Emergency burn management

Remove the source of flames. If clothing is on fire, have the patient drop and roll, or smother the flames with a blanket, rug, or coat. Tell an older adult or someone with limited mobility to stop, sit, and pat to avoid musculoskeletal injury.

Cool the burn. Once the flames are out, briefly soak the burned area and adherent clothing with cool water to stop the burning. Never apply ice, wrap the patient in ice, or use cold soaks longer than a few minutes; it worsens tissue damage and risks hypothermia.

Remove restrictive objects. Take off clothing right away, leaving adherent clothing in place once cooled, and remove all jewelry and piercings before rapidly developing edema causes constriction.

Cover the wound quickly to limit bacterial contamination, hold body temperature, and reduce pain by keeping air off the surface. Any clean, dry cloth works as an emergency dressing. Do not apply ointments, salves, medication, or any material other than the dressing.

Irrigate chemical burns immediately. At home, brush off the chemical, remove clothing, and rinse every contacted area under continuous running water, in the shower or any other source.

Wound cleaning and dressing

Cleanse and dress the wound gently and regularly, usually removing accumulated exudate and topical medication daily. The patient can clean a small burn with lukewarm tap water and mild soap, and soaking the dressing in lukewarm water eases removal.

Choose dressing materials to fit the patient. Most outpatient topicals use a viscous carrier that prevents desiccation and broadens antibacterial coverage to reduce colonization. A gauze wrap limits soiling and protects the wound.

Manage pain at every dressing change. For most patients, an oral narcotic 30 to 60 minutes before a planned change gives adequate control. Because most dressings are occlusive, pain between changes is usually controlled without narcotics.

Wet dressings thoroughly with sterile normal saline before removal to loosen adherents and reduce pain. After removal, gently clean the wound, inspect for infection, pat dry, and redress.

Modify dressings for splints and positioning devices. After topical agents, cover the wound with several layers of dry dressing, lighter over joints to preserve mobility. Apply circumferential dressings distally to proximally to move excess fluid back to central circulation.

Assist with excision and grafting for full-thickness burns. Early excision and closure change the natural history of the injury and prevent wound sepsis. Burns over 40% TBSA may need staged procedures, and when autograft is exhausted, temporary closure uses human allograft or other materials.

Medication administration

Apply topical antibacterials as indicated. The goal is an agent effective against gram-positive and gram-negative organisms and fungi, able to penetrate eschar without systemic toxicity, affordable, easy to apply and remove, and able to reduce dressing frequency, pain, and nursing time.

• Silver. Broad antibacterial spectrum, painless on application.
• Aqueous 0.5% silver nitrate. Broad coverage including fungi, but leaches electrolytes.
• Mafenide acetate. Broad spectrum and the best eschar penetration.
• Petrolatum. Bland and nontoxic.
• Debriding enzymes. Useful in selected partial-thickness wounds.

Assist with the application of membranes as appropriate. Membranes provide transient physiologic wound closure: protection from mechanical trauma, skin-like vapor transmission, and a barrier to bacteria.

• Porcine xenograft. Adheres to the wound coagulum and controls pain well.
• Split-thickness allograft. Vascularizes and gives durable temporary closure.
• Hydrocolloid dressings. A vapor and bacteria barrier that absorbs exudate.
• Impregnated gauzes. A vapor and bacteria barrier that still allows drainage.
• Acticoat. A nonadherent dressing delivering low-concentration silver for antisepsis.
• Biobrane. A synthetic bilaminate that lets fibrovascular tissue grow into the inner layer and acts as a temporary barrier.
• Transcyte. A synthetic bilaminate with allogenic fibroblasts in the inner layer and an outer temporary barrier.
• Alloderm. Cell-free allogenic human dermis requiring an immediate thin overlying autograft.
• Integra. A scaffold for the neodermis requiring a delayed thin autograft.

Surgical management of burns

Assist with debridement as indicated to remove devitalized tissue and eschar for grafting and healing, and to clear tissue contaminated by bacteria and foreign bodies. There are four types:

• Natural debridement. Devitalized tissue separates on its own as bacteria liquefy the collagen holding the eschar, over weeks to months.
• Mechanical debridement. Surgical tools, dressing changes, and wound cleaning remove eschar and debris. Wet-to-dry dressings are avoided in burns because they strip viable cells with the necrotic tissue.
• Chemical debridement. Topical enzymatic agents loosen eschar. Because they lack antimicrobial action, pair them with topical antibacterials.
• Surgical debridement. Early excision with early closure is one of the most important factors in surviving a major burn. Done once the patient is hemodynamically stable and edema has decreased, the wound is ideally covered immediately with a graft and dressing.

6. Management of Pressure Injuries

Once a pressure injury develops, treat it immediately. Treatments have included specialty mattresses, ointments, creams, solutions, dressings, ultrasonography, ultraviolet heat lamps, sugar, and surgery. Choose the strategy based on the stage of the wound and the goal of treatment.

Assessment and classification of pressure injuries

Classify pressure injuries by the extent of tissue damage, using the National Pressure Injury Advisory Panel (NPIAP) staging:

• Stage I. Nonblanchable erythema signaling potential ulceration.
• Stage II. Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis.
• Stage III. Full-thickness loss with damage to or necrosis of subcutaneous tissue down to but not through fascia; a deep crater with or without undermining.
• Stage IV. Full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures such as tendons and joint capsules.
• Unstageable. Full-thickness loss obscured by slough or eschar, so the depth cannot be confirmed.
• Deep tissue pressure injury. Intact or non-intact skin with persistent nonblanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.

Check the bony prominences: sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, and the back of the head. Skin stretched tautly over bone is at higher risk because capillaries are compressed between bone and a hard surface. Pressure areas look red on light skin and red, blue, or purple on darker skin.

Evaluate awareness of pressure sensation. People normally shift off pressure areas every few minutes, even in sleep. A patient who cannot feel it does nothing, so pressure on skin capillaries continues until ischemia sets in.

Use a validated risk-assessment tool.

• Acute care: Assess every 24 to 48 hours, or sooner if the patient changes. Measure and document size to track changes and guide treatment.
• Long-term care: Assess on admission, weekly for four weeks, then quarterly and whenever the resident changes.
• Braden Scale. A widely used tool with six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, each rated 1 to 4, from completely limited to no impairment.
• Norton Scale. Rates physical condition, mental condition, activity, mobility, and incontinence; the five subscales total 5 to 20, with a lower score meaning higher risk.

Assess shear and friction. Elevating the head of the bed shears the body's weight onto the sacrum. Friction comes from heels or elbows rubbing linen and from dragging the patient up in bed without a lift sheet. Shear happens when tissue layers slide over each other, stretching and tearing the vessels passing through subcutaneous tissue.

Assess the surface the patient spends the most time on, a mattress for the bedridden or a cushion for wheelchair users. These patients need a pressure-reduction or pressure-relief device. The first step in healing is identifying the cause, and specialty surfaces can keep tissue pressures below 32 mm Hg.

Use a risk tool to assess immobility-related risk for patients with limited mobility:

• Level 4. No limitations. Makes major, frequent position changes without help.
• Level 3. Slightly limited. Makes frequent slight changes independently.
• Level 2. Very limited. Makes occasional slight changes but cannot make frequent or significant ones independently.
• Level 1. Completely immobile. Makes no position changes without help.

Monitor continence and minimize skin exposure to incontinence, perspiration, and wound drainage. Urine and stool make the skin erythematous and can erode the dermis and epidermis, with damage occurring within 10 to 15 minutes of contact.

Pay special attention to high-risk areas: bony prominences, skin folds, sacrum, and heels. Pressure is greatest at the bony prominence and decreases toward the periphery.

Assess for risk factors. Immobility, impaired sensation or cognition, decreased perfusion, poor nutrition, friction and shear, increased moisture, and age-related skin changes all drive pressure injuries.

Provide relief from pressure

Check every 2 hours for proper placement of footboards, restraints, traction, casts, or other devices, and assess skin integrity. Beyond regular turning, small shifts such as repositioning an ankle, elbow, or shoulder matter. Inspect the skin at each position change and relieve pressure if redness, heat, or discomfort appears.

Use pillows, foam wedges, and pressure-reducing devices to redistribute pressure. A pillow or heel protector floats the heels off the bed when supine. Pillows above and below the sacrum offload it, and a small rolled towel or sheepskin under a shoulder or hip restores blood flow.

Keep the head of the bed at the lowest elevation possible to reduce shear and friction. The recumbent position is preferred to semi-Fowler because it spreads body weight over more surface area. Watch for the patient migrating down the bed, especially with the head elevated.

Match pressure-relieving devices to the level of risk:

• Low-risk patients: a dense foam mattress overlay at least 5 inches thick. Egg-crate mattresses under 4 to 5 inches thick do not relieve pressure, trap moisture, and create a false sense of security. Foam is light and maintenance-free but retains moisture and heat.
• Moderate-risk patients: a water mattress or static or dynamic air mattress. Dynamic devices alternate inflation and deflation; static devices stay inflated with gel, foam, water, or air. Water mattresses are easy to clean but heavy and leak-prone, and gel mattresses resist puncture but are expensive.
• High-risk patients or those with stage III or IV injuries (or stage II with multiple risk factors): low-air-loss beds or air-fluidized therapy. Low-air-loss beds allow head elevation and transfers but are noisy, expensive, and restrict mobility. Air-fluidized therapy supports the patient's weight below capillary closing pressure but makes getting out of bed hard.

Encourage ambulation when the patient is able. Movement offloads the skin. After wound closure, get ambulatory patients up with assistance as soon as possible, but delay strenuous activity about 6 weeks.

Improve sensory perception. Stimulate awareness of self and environment, encourage participation in self-care, and support active compensation for lost sensation.

Proper patient positioning

Do not position the patient on the impaired site. If ordered, turn and reposition at least every 2 hours and transfer carefully. Repositioning is the cornerstone of prevention and treatment and continues every 2 hours even with a specialty surface.

Have the patient shift every 15 minutes and change chair-bound positions every hour. Sitting pressure over the sacrum can exceed 100 mm Hg, and any pressure above the roughly 32 mm Hg that closes capillaries causes ischemia. The patient can push up on the armrests to lift the buttocks, push up one side at a time, or shift side to side.

Implement a turning schedule limiting any one position to 2 hours or less for bedbound patients. Turning every 2 hours is the key to preventing breakdown. Keep the head of the bed at 30 degrees or less to prevent sliding, and rotate the patient laterally, prone, and dorsally unless a position is not tolerated or is contraindicated.

Promote interventions that improve tissue perfusion. Activity, exercise, and repositioning all help. Avoid massaging erythematous areas, which damages capillaries and deep tissue. Elevate edematous parts to promote venous return.

Medical management of pressure injuries

Prepare the patient for hyperbaric oxygen therapy. Topical oxygen at increased pressure or a hyperbaric chamber promotes healing by stimulating new vascular growth and preserving damaged tissue.

Administer muscle relaxants for spasticity or prepare for surgery. Control spasticity with diazepam, baclofen, or dantrolene sodium. Patients refractory to medication may be candidates for neurosurgical ablation, and flexion contractures may need surgical release.

Provide oral nutritional supplementation as recommended. Malnutrition is one of the few reversible contributors to pressure injuries. Oral supplements enriched with arginine, vitamin C, and zinc improve healing and may lower the risk of developing injuries.

Surgical management of pressure injuries

Prepare the patient for surgery as indicated when the injury is extensive, complicated, or unresponsive to treatment. Procedures include debridement, incision and drainage, bone resection, and skin grafting. Osteomyelitis is a common complication of stage IV wounds.

Assist with urinary or fecal diversion when needed to optimize healing, since many of these patients are incontinent and their wounds are contaminated daily.

Prepare the patient for reconstruction to improve hygiene and appearance, resolve osteomyelitis and sepsis, reduce fluid and protein loss, and prevent future malignancy. Stage III and IV injuries often need flap reconstruction.

7. Patient and Caregiver Education

Teaching the patient and caregivers puts them in control of wound cleaning, dressing changes, and prevention, so they can carry out self-care and contribute to healing.

Teach proper nutrition, hydration, and ways to maintain tissue integrity. Malnutrition is reversible, and adequate caloric intake improves healing.

Teach skin and wound assessment and how to spot infection, complications, and healing. Early detection prevents serious problems. Local infection shows as redness, warmth, and tenderness, often with purulent, malodorous drainage.

Teach wound care: handwashing, cleansing, dressing changes, and applying topical medication. Cleanse and pat the area dry, apply medication while the skin is moist, cover with plastic if recommended, and seal the edges with an elastic bandage, dressing, or paper tape.

Teach when to notify the provider or nurse, including new signs of infection, which prompt an order for a wound culture, and any concern about a chronic wound or its dressing.

Tell the patient and caregiver not to repeatedly raise the head of the bed, and to use a trapeze or lift sheet to move the patient. Friction from rubbing heels and elbows on linen and shear from an elevated head of bed both drive breakdown.

Teach the causes of pressure. Pressure injuries track directly with the duration of immobility; sustained pressure leads to small-vessel thrombosis, tissue necrosis, and an injury.

Reinforce turning, mobility, and ambulation. When a person is immobile, pressure builds against the skin and subcutaneous tissue from the mattress, chair, or cast.

Teach proper skin care. Prevent continuous moisture with meticulous hygiene, paying attention to skin folds under the breasts, arms, groin, and between the toes. Lubricate with a bland lotion to keep skin soft, and avoid drying agents and powders.

Teach routine inspection of pressure areas. When sensation is reduced, the patient and caregivers inspect potential pressure areas every morning and evening, using a mirror if needed.

Reinforce checking diapers and incontinence pads in immobile patients. Pads pull moisture off the skin only if checked regularly and changed when soiled; used poorly, they worsen maceration and cause dermatitis.

Alert caregivers to environmental factors that contribute to pressure injuries, such as wrinkled sheets or tubes pressing on the skin, and have them remove the source.

Ensure a strong support system at home. Avoiding recurrent and new ulceration is a lifelong responsibility, and education on pressure avoidance should start in the hospital and continue at home.