Summary

The epidermis, dermis, and hypodermis are the three distinct layers of the skin. The epidermis is the outermost portion and is made up of stratified epithelial cells. The dermis is the second layer of skin that consists of elastic connective tissue made up of collagen. The bottom layer, the hypodermis or subcutaneous tissue, anchors the skin to the underlying tissues. The functions of the skin include protection, thermoregulation, sensation, absorption, elimination, and vitamin D production. These functions each play a major role in maintaining health and homeostasis of a person. The skin has psychosocial effects and serves to aid in identification. Assessment findings may vary among cultures and ethnicities, developmental levels, and age groups.

Normal healthy skin is based on the age, ethnicity, genetics, and health condition of the patient. Patients are at risk of impaired skin integrity if they have risky lifestyle and behavioral factors (e.g., poor nutrition, activity levels, sexuality, illicit drug use, body piercings, tattoos). State of health (e.g., illnesses, medications, mobility status) and genetic (e.g., vitiligo, acne, melanoma, psoriasis, eczema) factors may also pose a risk. Common skin disorders include bacterial infections, viral infections, fungal infections, inflammatory reactions, and skin cancers. Common bacterial infections of the skin include impetigo, folliculitis, carbuncles, and cellulitis. Viral skin infections include herpes simplex, herpes zoster, and verruca. Common fungal skin infections include tinea that affects the feet and toes, beard, body, groin, and scalp. Parasitic skin infections include pediculosis that affects the body, scalp, and groin, and scabies. Inflammatory skin reactions include eczema, seborrheic dermatitis, urticaria, acne vulgaris, psoriasis, and SLE. Skin cancer has three main types: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. People with impaired skin integrity may need to make lifestyle modifications to promote healing. Nurses must take age-related and cultural factors into consideration when developing a plan of care and educating patients, their family members, or their caregivers to promote skin health.

Wounds are classified in several ways and include intentional or unintentional wounds (treatment and therapy or accidental), open or closed wounds (break in the skin or under the skin layers), acute or chronic wounds (follow normal healing process or healing is delayed and does not follow normal healing process), pressure injuries, and friction and shear. Pressure injuries are localized ischemic lesions of the skin and underlying tissue caused by external pressure that impairs blood and lymph flow. Friction and shear are mechanical forces that tear and injure blood vessels and can contribute to the development of pressure injuries.

Risk factors for pressure injury development include exposure to excessive moisture, malnutrition and dehydration, lack of mobility, and cognitive factors. Moisture weakens the skin integrity and makes it more susceptible to breakdown and infection. Malnourishment leads to cell damage, inadequate perfusion, and lack of padding for bony prominences. People who have mobility issues or are bedridden are unable to adjust themselves in response to pressure and are often in one position for a prolonged period of time. Those with altered mental status and who have decreased awareness (e.g., unconsciousness, sedation, dementia) are at risk because they are less likely to recognize and respond to the discomfort from pressure.

Depending on the extent of damage, pressure injuries are assessed and classified as stages one through four and as deep tissue or unstageable. A stage I pressure injury is characterized by localized nonblanchable erythema of intact skin. Stage II pressure injuries are characterized by partial-thickness skin loss involving the epidermis or dermis. Stage III pressure injuries are characterized by full-thickness skin loss in which the adipose, granulation, and deeper tissues are visible and may have a presence of slough or eschar. Stage IV pressure injuries are characterized by full-thickness skin loss with extensive destruction, necrosis, and exposed or palpable fascia, tendon, ligament, muscle, cartilage, and bone. Slough and eschar are often visible along with epibole, undermining, and/or tunneling. Deep-tissue pressure injuries are characterized by persistent, nonblanchable areas of intact skin that have maroon, deep red, or purple discoloration. Pressure injuries are classified as unstageable if they have full-thickness skin or tissue loss with excessive slough or eschar that obscures the extent of the damage.

Wound management encompasses many nursing interventions that are essential for promoting healing and tissue regeneration. To effectively manage wounds, nurses must understand the phases of wound healing, factors affecting wound healing, psychological effects of wounds, complications affecting wound healing, and the nurse’s role in wound care management. Wounds are healed by primary, secondary, or tertiary intention. Wound healing can be broken down into the following phases: hemostasis, inflammatory phase, proliferation phase, and maturation. Several factors may influence the speed of wound healing and may be localized or systemic. Localized factors are those factors that occur directly in the wound (i.e., desiccation, maceration, trauma, edema, infection). Systemic factors are not related to the wound itself. These factors take place throughout the body (i.e., age, venous insufficiency, poor oxygenation, obesity, diabetes, medications, smoking and alcohol use). Wounds and pressure injuries cause stress and emotional challenges caused by pain, fear, disruption to activities of daily living, and an altered body image that can have a significant effect on an affected person’s self-identity and mental well-being. There are several events that can interfere with wound healing and cause complications. Infection, hemorrhage, dehiscence and evisceration, and fistulas can increase the risk of death or generalized illness, increase healthcare costs, and prolong the need for healthcare interventions. The nursing role includes assessment and documentation, positioning, dressing care, drain care, suture and staple care, cleaning, debridement, administering growth factors, heat and cold therapy, wound care education and health promotion, and teaching the patient to perform self-care at home. Other therapies that the nurse may be required to assist with include hyperbaric oxygen therapy and surgery. It is essential that nurses understand their role in wound care management to effectively implement interventions within their scope of practice.