Skin Integrity Management

Skin Integrity

• Turning and repositioning: Turn patients at least every 2 hours to prevent pressure injuries, elevate the head of the bed no more than 30 degrees to decrease shear effects, position the patient laterally at 30 degrees when side-lying to avoid direct pressure on bony prominences, place pillows between the knees for side-lying, position legs with pillows so that heels "float" off the mattress, limit chair use to 2 hours or less, and provide assistance to patients who are unable to change positions independently.
• Pressure-reducing mattresses: Use support surfaces like overlays, replacement mattresses, and specialty beds to redistribute the body's weight.
• Cleaning and drying: Keep skin dry from urine, stool, wound drainage, and moisture, apply skin barrier as needed, and change wet/soiled gowns and sheets frequently.
• Wound dressings: Choose dressings according to the wound type and healing goals, moisten gauze dressings with saline before removal to prevent trauma, use moist-to-dry dressings for debridement, and apply pressure dressings for bleeding wounds.

Heat and Cold Therapy Actions

• Moist Compress Application: Soak sterile gauze or linen in a sterile solution, place over the wound/injury, and cover with towels or a waterproof pad to maintain warmth or cold for the prescribed time.
• Moist Soak Application: Place the extremity completely in the solution, maintain the temperature of the solution by covering the container and extremity, and keep the solution warm or cold by changing the solution or adding to it as needed (about every 10 minutes). Dry the extremity completely.
• Sitz Bath Application: Soak the perineum/pelvic area for 20 minutes, adjust the temperature according to facility protocol, and use a chair, tub, or toilet attachment. Monitor the perineal area for complications.
• Aquathermia Application: Obtain pad and control unit, place pad around the extremity, and turn on the control unit.
• Hot/Cold Pack Application: Follow manufacturer instructions for commercial packs, fill noncommercial ice bags with water or crushed ice, remove air before closing, and do not place heat or cold pack directly on the skin, placing a small washcloth between the skin and pack.

Wound Cleansing and Irrigation

• Cleaning agent selection: Use a cleaning agent that balances cleaning and trauma to the wound bed, avoid Dakin's solution, povidone-iodine, acetic acid, and hydrogen peroxide because they can damage healing cells, and use normal saline 0.9% for wound cleaning.
• Wound Drain Cleaning: Clean the drain in a circular motion from close to the drain outward using a new cleansing gauze for each movement, place a specially prepared 4" x 4" dressing around the drain, and apply ABD pads and tape.

Negative Pressure Wound Therapy (NPWT)

• Application: Clean and pat dry wound and surrounding skin, apply skin barrier protectant, cut foam to fit the wound, apply a transparent occlusive dressing over foam and extend 2 inches out, cut a hole in the dressing if there is not a precut center hole, place suction tubing in the center hole without the tubing touching the wound bed, apply another transparent dressing over both the tubing and the first dressing, apply the suction tubing to the canister, discard gloves and wash hands, and turn on the unit.
• Documentation: Document wound assessment, characteristics of drainage, dressing type, pressure setting, and patient response to NPWT

Malignant, Traumatic, and Surgical Wounds

• Dressing Care: Keep dressing dry and intact, assess and change dressings as needed or in accordance with healthcare provider instructions or facility policies, and assess and measure the wound inspecting the skin for abrasions, edema, discoloration, or exposed wound edges prior to applying bandages or binders.
• Drainage Care: Assess drainage characteristics and monitor and clean drains as needed.

Nasogastric (NG) Tube Management

• Tube Selection: Choose the smallest lumen tube effective for intended use, and select a Levin or Salem Sump tube for stomach decompression or enteral feedings.
• Tube Insertion and Care: Insert using clean technique, lubricate the naris, provide frequent mouth care, and change soiled tape or securement devices.
• Positioning: Do not reposition the NG tube if the patient has undergone gastric surgery to avoid disrupting the suture line.
• Water Use: Use purified or sterile water for flushing and medication preparation, and use sterile water for reconstituting powdered formula and for all procedures involving immunocompromised patients.

Nutrition

• High-Protein Foods: Offer foods high in protein, including meat, milk, eggs, cheese, beans, nuts, and seeds.
• Vitamins C and A: Provide foods high in vitamins C and A, such as oranges, citrus fruit, strawberries, kiwi, broccoli, peppers, tomatoes, carrots, apricots, sweet potatoes, and dark yellow or orange vegetables.
• Zinc and Copper: Offer food high in zinc and copper, like high-protein foods and molasses.
• Fluids: Encourage fluid intake to increase fluid consumption.
• Patient Input: Ask for the patient's input on favorite foods and completion of diet requests.
• Consultations: Consult with a dietitian/nutritionist as needed.
• Monitoring: Monitor albumin and prealbumin levels.

Pressure Injuries

• Prevention: Use Braden Scale or Norton Scale to assess risk for pressure injuries, do not massage pressure injuries, and suggest fluid intake.