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Skin Integrity and Wound Care

Tatiana A Gamboa

Benjamín Leon School of Nursing, Miami Dade College

NUR1025L: Fundamentals of Nursing Clinical

Professor Patricia McCrink

July 17, 2022

Skin Integrity and Wound Care

This essay will discuss skin integrity and wound care. A pressure injury is localized damage to the skin and

underlying soft tissue. The injury can present as intact skin or blister or an open ulcer and may be painful the

injury occurs because of intense and or prolonged pressure or pressure in combination with sheer (Edsberg et

al., 2016). Shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle and

bone are stationary (Bryant, 2016; Potter et al., 2021). Pressure ulcers (PUs), also known as pressure injuries,

bedsores, or decubitus ulcers, are foreseeable and preventable adverse events, for residents in residential aged

care facilities (RACFs) who are unable to feel local pressure and/or those with limited mobility (Wei et al.,

2020). A breach in skin function poses the onset of wounds in vulnerable patients. With high-risk skin injuries

commonly acquired in care homes and post-operative surgery, the need for high-quality and effective wound

management is evident. A nurse can achieve optimal skin function through preventative techniques.

Patient Description

A 65-year-old female was found by her husband after a fall and was rushed to the emergency department. She

was admitted with complaints of weakness, confusion, and right lower leg and foot pain. Her past medical

history includes mild dementia, Parkinson's disease, anxiety, and hypothyroidism. It was later found that the

patient suffered a fracture to the right tibia and fibula and surgery was requested right away. However, surgery

was delayed by four hours for several reasons. After the procedure, she was admitted to the orthopedic floor
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with orders to follow the post-intramedullary nailing procedure standing protocol. The hospital's "Alteration in

Skin Integrity" protocol required an air mattress for any patient with a score of less than 18. Although the

admitting nurse ordered a medical air mattress overlay for the patient, the hospital did not have any available. A

request for a mattress was placed with an outside vendor. However, due to non-communication, the patient did

not receive the bed until day three when the injury on the sacrum was in stage four, therefore failing to comply

with the hospital's protocol for after surgery (Affinity Insurance Services, 2021).

Patient Care

In the following nine months, the patient suffered from infections, debridement, and anemia all related to a

sacral ulcer. The patient died ten months after her fall. The family of the deceased filed a malpractice claim

against the hospital and seven registered nurses (Affinity Insurance Services, 2021). Upon investigation, several

errors were found. After reviewing the file, the operating room skin assessments were incomplete, as well as

any documentation of the position aides. The nurses failed to reposition the patient every two hours throughout

her stay. All the nurses involved did not seek administration or the person next in the chain of command to

resolve the vendor issue of obtaining that bed. This nursing staff failed to put this post-operative patient as a

priority.

Analysis

A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development, repositioning

interests are based on patient assessment (Potter et al., 2021). For this patient, frequent position changes alone
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were not going to suffice, this patient needed that air mattress to prevent shear in the sacral area. When a patient

is admitted with impaired skin integrity, it is imperative that during assessments a nurse should consider all

elements as they build and create a discharge plan. The nurses involved also failed to obtain the patient's

perception by not asking questions about their pain level and discomfort. Asking a patient if they are content

with their care can lead to follow-up questions or statements that can lead to the next action for care.

Observation of a patient is important, but the priority should be a physical examination. Assessment for tissue

pressure damage includes visual and tactile inspection of the skin perform a baseline assessment to determine

the patient's normal skin characteristics and any actual or potential areas of breakdown (Nix, 2016; Potter et al.,

2021). Skin tears must be assessed and documented regularly according to healthcare practice and policy.

Evidence-based wound care principles should guide the treatment of skin tears (LeBlanc & Baranoski, 2011).

The Braden Scale is the most widely used risk assessment tool for pressure injuries and is in the WOCN

guidelines (2016) as a valid tool to use for pressure injury risk assessment (Wei et al., 2020). The Braden Scale

for predicting the risk of pressure ulcers, which is based on seven risk factors and measures six subscales

(sensory perception, activity, mobility, moisture, nutrition, and friction/shear), was developed by Braden and

Bergstrom (Potter et al., 2021). It might be concluded that a specialized pressure ulcer risk assessment scale is

needed for every special clinical setting if healthcare professionals want a better predictive capacity. Pressure

Ulcers are difficult to treat and may lead to impaired skin integrity, resulting in increased morbidity, prolonged

hospital stays, increased medical expenses, and decreased quality of life (Wei et al., 2020).

Summary
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In conclusion, nursing care is based on patients' identified needs and priorities. When caring for patients who

have impaired skin integrity, information gathered from patients is used to understand the risk to skin integrity.

It is important to use a valid and reliable assessment tool to categorize pressure ulcer risk groups, identify high-

risk patients, and implement appropriate intervention programs for the prevention of pressure ulcers (Wei et al.,

2020). Goals should be set and frequently evaluated. Nurses should report needs for additional consultations for

high-risk patients. Nurses should consult with the interprofessional team regarding changes and wound care

regimens. (Potter et al., 2021). Healthcare professionals involved in the care of patients with skin tears must be

willing and able to work together toward positive patient outcomes. (LeBlanc & Baranoski, 2011). Failure to

follow up results in substantial consequences and possibly the patient's life.

Reflection

In retrospect, I learned from this assignment that to provide exceptional care, I need to brainstorm and

implement preventative actions simultaneous to physical care. My aha moment was finding that advocacy is

how I can get what I need for my patient. With this new information, I have gathered that collaborating with the

team and using protocols is the recipe for a successful treatment. This has changed me because becoming aware

of the consequences of the research I have done I plan on being more conscientious. It has impacted me and for

the future, I place on finding a balance between the work expected of me and the extra step I need to seek to

provide quality care. In the future when I am in the field, I will do my best to speak up for my patients and get

them the full care they are rightfully entitled to. A nurse's duty is admired, and it is one that I hope to fulfill.
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References

Affinity Insurance Services. (2021). Nurse case study: Failure to follow policies on Skin integrity.

https://www.nso.com/Learning/Artifacts/Legal-Cases/Failure-to-follow-established-policies-and-

procedures-on-skin-integrity

LeBlanc, K; Baranoski, S. (2011). Skin tears: State of the science. Advances in Skin and Wound Care, 24(9), 2–

15. https://doi.org/10.1097/01.asw.0000405316.99011.95

Potter, P. A., Perry, A. G., Stockert, P. A.; Hall, A. (2021). Fundamentals of Nursing (10th ed.). Elsevier

Wei, M., Wu, L., Chen, Y., Fu, Q., Chen, W., & Yang, D. (2020). Predictive validity of the Braden Scale for

pressure ulcer risk in critical care: A meta‐analysis. Nursing in Critical Care, 25(3), 165–170.

https://doi.org/10.1111/nicc.12500
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