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Skin Integrity & Wound Assessment Guide

Diabetic Foot, Wound Dressings & Skin Care for GCC Nurses

GCC Clinical Reference 2025

Skin Assessment

🧠 Skin Anatomy Quick Review

Epidermis — 5 Layers (superficial to deep)

  1. Stratum corneum — dead keratinised cells, barrier function
  2. Stratum lucidum — thick skin only (palms/soles), clear layer
  3. Stratum granulosum — keratohyalin granules, waterproofing begins
  4. Stratum spinosum — prickle cells, immune Langerhans cells
  5. Stratum basale — mitotic layer, melanocytes, stem cells

Dermis

  • Papillary dermis (superficial, loose connective tissue)
  • Reticular dermis (deep, dense irregular connective tissue)
  • Contains collagen, elastin, blood/lymph vessels, nerves

Hypodermis (Subcutis)

  • Adipose tissue — insulation, energy reserve, cushioning
  • Anchors skin to underlying fascia and muscle

Skin Appendages

  • Hair follicles — thermoregulation, sensation
  • Sebaceous glands — sebum secretion, skin barrier lipid protection; open into hair follicles
  • Eccrine sweat glands — thermoregulation, widespread over body
  • Apocrine sweat glands — axillae, groin; odour production post-puberty
  • Nails — protection, proprioception; nail plate arises from nail matrix
🔎 Systematic Skin Assessment

Colour

  • Pallor reduced blood flow, anaemia, shock
  • Erythema inflammation, infection, burn — blanches on pressure if vascular
  • Jaundice yellow tinge — sclera, mucous membranes; liver/biliary disease
  • Cyanosis blue tinge — central (lips, tongue) or peripheral (fingers) — hypoxia or poor perfusion
  • Pigmentation changes hyperpigmentation (post-inflammatory, Addison's), hypopigmentation (vitiligo), mottling (livedo reticularis)

Temperature

  • Warm: normal, fever, inflammation
  • Hot: local infection, cellulitis, thrombophlebitis
  • Cool/cold: poor circulation, arterial insufficiency, hypothermia
  • Use dorsum of hand for best thermal sensitivity

Moisture

  • Dry/xerotic: flaking, scaling, fissuring — very common in GCC dry climate
  • Moist: incontinence, wound exudate, skin folds (intertrigo risk)
  • Diaphoretic: profuse sweating — pain, sepsis, hypoglycaemia, anxiety

Turgor

  • Pinch test: dorsal hand or sternum in elderly
  • Normal: skin returns immediately on release
  • Tent sign: skin remains tented >2 seconds — dehydration, malnutrition, ageing (note: poor turgor is normal in elderly)
  • Also assess for pitting oedema (1+ to 4+)

Integrity

  • Intact: no breaks, no lesions
  • Macerated: white, soft, wrinkled skin — prolonged moisture exposure
  • Erythematous: redness present — assess for blanchability
  • Excoriated: superficial loss from scratching/friction
  • Ulcerated: full thickness skin loss

Documentation

  • Site (use anatomical terms or body diagram)
  • Size (length × width in cm)
  • Colour, borders, distribution, pattern
  • Associated symptoms: pruritus, pain, burning
  • Onset, duration, progression, precipitants
📄 Skin Lesion Terminology

Primary Lesions (arise from normal skin)

LesionDefinition
MaculeFlat colour change <1 cm (e.g. freckle)
PatchFlat colour change >1 cm (e.g. vitiligo)
PapuleRaised solid <1 cm (e.g. wart)
PlaqueRaised solid >1 cm, flat top (e.g. psoriasis)
VesicleFluid-filled <1 cm (e.g. herpes simplex)
BullaFluid-filled >1 cm (e.g. friction blister)
PustulePus-filled (e.g. acne, folliculitis)
NoduleSolid >1 cm, extends into dermis (e.g. lipoma)
WhealTransient raised oedema (e.g. urticaria)

Secondary Lesions (evolve from primary lesions)

LesionDefinition
ScaleShedding dead epidermal cells (e.g. psoriasis, tinea)
CrustDried exudate — serum, blood, pus (e.g. impetigo)
ErosionPartial thickness epidermal loss — heals without scar
UlcerFull thickness skin loss — heals with scar
FissureLinear crack through epidermis/dermis (e.g. heel fissure)
AtrophyThinning of epidermis or dermis (e.g. steroid-induced)
ScarFibrous tissue replacing normal skin after wound healing
LichenificationThickened leathery skin from chronic rubbing
🌞 GCC-Specific Skin Considerations
Melanin-Rich Skin: Erythema is harder to detect visually. Use tactile assessment — palpate for localised warmth, bogginess, induration. Assess colour changes relative to the patient's baseline skin tone. Use lighting that minimises shadows.
Xerosis (Dry Skin): Extremely common in GCC due to low humidity and air conditioning. Results in pruritus, scaling, fissuring. Emollient protocols are essential: apply within 3 minutes of bathing (soak and seal), use fragrance-free products, avoid soap-based cleansers.
Sun Exposure: Despite cultural sun-protective clothing, photodermatitis, actinic keratosis and skin cancer risk remain significant in the region. UV Index regularly exceeds 11 (extreme) in Gulf summer months. Fair-skinned expatriate workers are at elevated risk.
Healthcare Worker Hand Dermatitis: Irritant contact dermatitis from frequent hand hygiene is extremely prevalent. Assess hands at every shift change. Use alcohol-based hand rub preferentially over soap and water where safe. Apply moisturising cream after hand washing and at end of shift.

Wound Assessment

📋 Wound Classification

By Aetiology

Acute Wounds

  • Surgical: intentional incision, healing by primary intention (sutured, approximated edges)
  • Traumatic: lacerations, abrasions, degloving injuries
  • Burns: thermal, chemical, electrical, radiation

Chronic Wounds (healing impaired >4 weeks)

  • Pressure injury — bony prominences, sacrum, heels
  • Venous leg ulcer — medial malleolus region
  • Arterial ulcer — toes, bony prominences
  • Diabetic foot ulcer — plantar surface, pressure points
  • Malignant wound — fungating tumour

By Healing Intention

  • Primary intention: wound edges approximated (sutures, staples, tissue glue) — minimal scar
  • Secondary intention: wound left open to granulate and epithelialise — larger scar, slower healing
  • Tertiary (delayed primary): wound left open briefly then closed — used in contaminated wounds

By Depth

Superficial: Epidermis only involved. Painful, red, moist. No dermis exposed. Heals by epithelialisation. Example: superficial burn (1st degree), minor abrasion.
Partial Thickness: Epidermis + part of dermis involved. Very painful (nerve endings exposed), blistering possible. Heals by re-epithelialisation from hair follicles and wound edges. Example: superficial partial-thickness burn, skin tear.
Full Thickness: Entire dermis and beyond — may extend into subcutaneous fat, fascia, muscle or bone. May be painless (nerve endings destroyed). Requires granulation and epithelialisation or grafting. Example: stage 3/4 pressure injury, deep burn.
📏 MEASURE Wound Assessment Tool
Use this interactive form to document wound assessment. Print or copy findings into the patient chart.
M
Measure — wound dimensions
E
Exudate — amount and type
A
Appearance — wound bed tissue type (estimate % of each)
Note: hypergranulation = overgrowth above wound edge level — requires treatment
S
Suffering — pain assessment
U
Undermining — tunnelling/undermining measurement
R
Re-evaluate — comparison to previous assessment
E
Edge — wound margin assessment
⏳ Wound Healing Phases
Haemostasis
0–10 min
Inflammation
0–5 days
Proliferation
4–21 days
Maturation
21 days–2 years

Haemostasis (Immediate)

  • Vasoconstriction, platelet plug formation
  • Coagulation cascade — fibrin clot
  • Platelet degranulation releases growth factors (PDGF, TGF-β)

Inflammation (0–5 days)

  • Vasodilation, increased permeability
  • Neutrophils (first responders — bacterial killing), then macrophages (debridement, orchestrate healing)
  • Signs: redness, warmth, swelling, pain — normal in acute wounds
  • Chronic wounds stuck in inflammation = no progression

Proliferation (4–21 days)

  • Angiogenesis — new capillary formation
  • Fibroblast migration — collagen type III deposition
  • Granulation tissue formation (red, moist, granular)
  • Epithelialisation — keratinocytes migrate across wound surface
  • Wound contraction — myofibroblasts

Maturation / Remodelling (21 days–2 years)

  • Collagen type III replaced by type I (stronger)
  • Cross-linking increases tensile strength
  • Maximum strength: ~80% of normal skin (never 100%)
  • Scar matures — fades, flattens; hypertrophic/keloid if excess collagen

Factors Impairing Wound Healing

Diabetes mellitus Malnutrition / low protein Wound infection / biofilm Peripheral oedema Corticosteroids / immunosuppressants Smoking / nicotine Poor tissue perfusion Advanced age Anaemia Zinc / vitamin C deficiency Hypoxia Radiation damage

Diabetic Foot & Ulcer Types

GCC Context: The UAE, Saudi Arabia, Kuwait and Bahrain rank among the highest globally for diabetes prevalence (18–25% of population). Diabetic foot ulcers and lower limb amputations represent a major public health burden in the region. Proactive foot screening is a nursing priority.
🦷 Diabetic Foot Ulcer (DFU)

Risk Factors

  • Peripheral neuropathy — loss of protective sensation (LOPS) — inability to feel injury
  • Peripheral arterial disease (PAD) — ischaemia impairs healing
  • Foot deformity — claw toe, Charcot foot — abnormal pressure distribution
  • Previous ulceration or amputation — highest risk marker
  • Visual impairment — unable to inspect own feet
  • Poorly fitting footwear — friction, pressure points
  • Prolonged diabetes duration and poor glycaemic control

Assessment Tools

  • 10-g monofilament: LOPS if unable to feel at ≥4 of 10 plantar sites
  • 128 Hz tuning fork: vibration sensation at hallux
  • Ankle reflexes
  • Probe-to-bone test: positive = osteomyelitis strongly suspected (sensitivity 89%, specificity 85%)
  • ABI (Ankle-Brachial Index): Normal 0.9–1.3 | <0.9 = arterial disease | >1.3 = falsely elevated (calcified vessels — common in diabetes; use toe-brachial index)

Infection Signs (IDSA Criteria)

At least 2 of: localised warmth, erythema, tenderness/pain, swelling, purulent discharge
  • Erythema extending >2 cm from wound = moderate infection
  • Systemic features (fever, leucocytosis, hyperglycaemia) = severe infection — requires urgent admission
  • Positive probe-to-bone or exposed bone = osteomyelitis until proven otherwise
  • MRI is gold standard for osteomyelitis diagnosis

Offloading (Critical for Healing)

  • Total Contact Cast (TCC) — gold standard for plantar DFU, non-removable
  • Removable Cast Walker (CAM boot) — less effective if removed by patient
  • Therapeutic footwear / custom orthoses — prevention and maintenance
  • Bed rest / wheelchair — for non-ambulant patients
📈 Wagner Diabetic Foot Classification
0
At Risk / Pre-ulcer
No open lesion. Callus, deformity, neuropathy. Intact skin.
Preventive care
1
Superficial Ulcer
Full thickness ulcer, not into tendon, capsule, or bone.
Wound care + offload
2
Deep Ulcer
Penetrates to tendon, capsule, or bone. No abscess/osteomyelitis yet.
Vascular review
3
Deep + Infection
Deep ulcer with osteomyelitis, abscess, or septic arthritis.
IV antibiotics + surgical
4
Partial Gangrene
Gangrenous forefoot or portion of foot. Localised necrosis.
Urgent surgical
5
Extensive Gangrene
Whole foot gangrene. Major amputation required.
Amputation
🔨 Ulcer Type Comparison
Feature Venous Leg Ulcer Arterial Ulcer Diabetic Foot Ulcer Pressure Injury
Location Medial gaiter (above medial malleolus) Toes, foot, bony prominences Plantar surface, metatarsal heads, toes Sacrum, heels, ischium, occiput
Wound edges Irregular, sloping Punched-out, well-defined Callused margins, punched-out Defined, may be undermined
Wound bed Shallow, granulating, ruddy Pale, grey, necrotic, dry Variable — may be neuropathic (pink) or ischaemic (pale) Variable per stage
Exudate Heavy Minimal / none Variable Variable
Pain Aching, relieved by elevation Severe, worse at night/elevation, rest pain Often painless (neuropathy) Present unless spinal cord injury/neuropathy
Surrounding skin Lipodermatosclerosis, haemosiderin, varicosities, oedema Hairless, shiny, atrophic, cool, pale/dusky Callus, dry skin, deformity Erythema, induration, maceration
ABI Normal (>0.9) or mildly reduced Reduced (<0.9, often <0.5) May be falsely elevated (>1.3) — calcified vessels N/A
Key treatment Compression bandaging (multilayer, 4-layer) — NOT if ABI <0.6 Revascularisation (bypass/angioplasty) before wound healing possible Offloading, glycaemic control, debridement Pressure redistribution, repositioning, NPUAP staging
SAFETY: Never apply compression bandaging to a limb with ABI <0.6 or clinical signs of arterial insufficiency — it can cause critical ischaemia and limb loss.

Dressing Selection & Products

Guiding Principle: The ideal wound dressing maintains a moist wound environment, absorbs excess exudate without desiccating the wound, provides thermal insulation, is non-adherent to wound tissue, and is cost-effective. Dressing selection is driven by wound type, exudate level, infection status, and wound bed preparation goals (TIME framework: Tissue, Infection/Inflammation, Moisture, Edge).
🩹 Dressing Selection by Wound Type & Exudate
Wound Condition Dressing Category Examples (GCC-available) Notes
Low exudate + granulating Hydrocolloid, Film dressing, Thin foam Duoderm, Tegaderm, Mepilex Lite, Comfeel Autolytic debridement in hydrocolloid. Film for shallow, low-risk wounds. Change every 3–7 days.
Moderate exudate Foam dressing, Hydrofibre Mepilex, Allevyn, Aquacel (CMC hydrofibre), Biatain Foam absorbs and maintains moist environment. Aquacel forms gel over wound. Change every 2–4 days.
High exudate Alginate, Super-absorbent polymer Kaltostat, Sorbsan, Drymax Extra, Eclypse Alginate from seaweed — haemostatic properties. Convert to gel on contact with exudate. May require secondary dressing.
Infected wound Silver-containing, Iodine, DACC-coated Mepilex Ag, Aquacel Ag, Inadine (povidone-iodine), Iodoflex, Sorbact (DACC) Silver — broad-spectrum antimicrobial. Iodine — use limited duration (max 3 months). Sorbact — physical binding of bacteria, no chemical agent. Review need every 2 weeks.
Sloughy / necrotic Hydrogel (autolytic), Enzymatic, Sharp debridement Intrasite Gel, Purilon, collagenase (Santyl), Iruxol Hydrogel rehydrates necrotic tissue for autolytic debridement. Enzymatic cleaves necrotic collagen. Sharp debridement fastest — requires trained practitioner. Cover with secondary dressing.
Cavity wounds Alginate ribbon, Hydrofibre ribbon, Foam filler Kaltostat Rope, Aquacel ribbon, Allevyn Cavity Lightly fill cavity — do NOT pack tightly. Overpacking impairs healing and can mask abscess formation.
Hypergranulation Topical steroid, Pressure foam Triamcinolone acetonide paste, Silver nitrate (chemical cautery — clinical use only), Mepilex with pressure Hypergranulation (proud flesh) — tissue overgrown above wound edge, inhibits epithelialisation. Treat cause (infection? foreign body? friction?). Topical steroid short course reduces overgrowth.
Burns Silicone contact layer, Antimicrobial Mepitel One, Mepitel Ag, Mepilex Transfer, Aquacel Ag Burn Silver sulfadiazine (Flamazine) — falling out of favour due to cytotoxicity to fibroblasts, obscures wound. Silicone products now preferred. Refer burns >10% TBSA, full thickness, face/hands/genitalia.
🔧 Negative Pressure Wound Therapy (NPWT / VAC)

Mechanism

  • Applies sub-atmospheric (negative) pressure through foam or gauze interface
  • Removes excess exudate and oedema fluid
  • Promotes granulation tissue formation
  • Reduces bacterial load
  • Draws wound edges together (mechanical deformation)
  • Stimulates angiogenesis via microdeformation

Settings

  • Standard: −125 mmHg continuous
  • Intermittent: −125 mmHg on/off (more stimulation, less tolerated)
  • Instillation (NPWTi-d): combines NPWT with instillation of saline or antiseptic solution — for heavily contaminated/infected wounds
  • Dressing change every 48–72 hours (or per manufacturer)

Indications

  • Complex wounds — dehisced surgical, traumatic
  • Diabetic foot wounds (Wagner 2–3)
  • Open abdomens (temporary abdominal closure)
  • Skin grafts (bolster dressing to improve take)
  • Pressure injuries stage 3–4
  • Sternal wound dehiscence post-cardiac surgery

Contraindications

  • Untreated osteomyelitis
  • Malignancy within the wound
  • Non-enteric / unexplored fistulae
  • Necrotic tissue with eschar (debride first)
  • Exposed vessels, nerves, anastomoses (relative — use with caution and interposing layer)
📊 GCC Product Availability Notes

Widely Available in GCC Hospitals

  • Mepilex / Mepilex Border / Mepilex Ag (Molnlycke)
  • Allevyn / Allevyn Gentle Border (Smith+Nephew)
  • Aquacel / Aquacel Ag / Aquacel Foam (ConvaTec)
  • Duoderm CGF (ConvaTec)
  • Tegaderm (3M)
  • Intrasite Gel (Smith+Nephew)
  • Inadine povidone-iodine (Systagenix)
  • Kaltostat alginate (ConvaTec)

May Require Pharmacy/Procurement Order

  • Sorbact (DACC-coated, Abigo)
  • Collagenase (Santyl, Iruxol)
  • Eclypse / Drymax super-absorbents
  • NPWTi-d systems (Acelity)
  • Speciality silicone burn dressings
  • Larval therapy (maggot debridement) — rarely used in GCC
Formulary availability varies between MOH, private, and military hospital systems. Always check local formulary before prescribing or planning care.

Common Skin Conditions & Quiz

🏥 Healthcare-Associated Skin Conditions

Incontinence-Associated Dermatitis (IAD)

KEY DISTINCTION: IAD is NOT a pressure injury. IAD is a moisture-associated skin damage — it lacks depth, the distribution follows the moisture exposure pattern (perineum, gluteal cleft, inner thighs), and it presents as superficial, bright red erythema.
  • Caused by urinary and/or faecal incontinence — chemical irritants (ammonia, bile salts, faecal proteases)
  • Presentation: bright red, superficial, diffuse, no depth, may have erosion/blistering
  • Affected areas: perineum, perianal area, gluteal fold, inner thighs, scrotum
  • Risk: secondary fungal superinfection (satellite lesions = candidiasis)

IAD Management — Structured Skin Care

  • Cleanse: pH-balanced no-rinse cleanser — avoid soap (alkaline, disrupts barrier)
  • Moisturise: emollient after cleansing
  • Protect: barrier cream/paste — zinc oxide 20–40%, dimethicone, cyanoacrylate film — apply at every incontinence episode
  • Manage incontinence cause if possible (toileting programme, containment products)

Moisture-Associated Skin Damage (MASD) vs Pressure Injury

FeatureMASD / IADPressure Injury
CauseMoisture/chemical irritantPressure/shear
DepthSuperficial — no depthHas depth (stages 2–4)
LocationFollows moisture exposureOver bony prominence
EdgesDiffuse, irregularDefined
ColourBright red, uniformVaries by stage
PainBurning, itchingDeep aching, pressure

Medical Device Related Skin Injury (MDRSI)

  • Caused by: oxygen masks, ET tube holders, nasogastric tubes, urinary catheters, orthopaedic devices, compression stockings
  • Prevention: foam padding/protectors at device contact points, regular repositioning of device, correct sizing, daily skin inspection under devices
  • Document device, location, inspection findings at every shift

Skin Tears (STAR Classification)

  • Common in elderly, anticoagulated, or corticosteroid-treated patients
  • Category 1: flap present, can cover >75% of wound — realign flap
  • Category 2: flap present but covers <75% — partial loss
  • Category 3: flap absent — complete skin tear loss
  • Management: clean, realign flap if possible, non-adherent dressing (silicone, soft silicone), emollients for prevention, consider protective sleeves/clothing
💊 Common Dermatology Conditions

Cellulitis

  • Acute spreading bacterial infection of dermis and subcutaneous tissue
  • Usually Streptococcus pyogenes or Staphylococcus aureus
  • Presentation: warm, tender, expanding erythema; systemic features (fever, rigors, tachycardia)
  • Mark erythema border with pen to monitor progression
  • Treatment: IV flucloxacillin (or cefazolin) for systemic; oral flucloxacillin / cefalexin for mild. MRSA risk: consider vancomycin / linezolid
  • Elevate limb. Review blood glucose (hyperglycaemia impairs response)

Herpes Zoster (Shingles)

  • Reactivation of varicella-zoster virus (VZV) in dorsal root ganglia
  • Presentation: prodromal pain → dermatomal vesicular rash (unilateral, does not cross midline)
  • Contagious (contact/airborne) until lesions fully crusted over
  • Isolation: Airborne + contact precautions for immunocompromised patients (standard contact for immunocompetent)
  • Treatment: Aciclovir 800 mg 5x/day for 7 days — start within 72 hours of rash onset
  • Ophthalmic zoster (forehead/nose tip = Hutchinson's sign) — urgent ophthalmology referral to prevent sight loss
  • Postherpetic neuralgia: gabapentin, amitriptyline, topical lidocaine

Scabies

  • Infestation by Sarcoptes scabiei mite
  • Presentation: intense pruritus worse at night, linear burrows in finger webs, wrists, areolae, genitalia
  • Crusted (Norwegian) scabies in immunocompromised — highly contagious, thick hyperkeratotic lesions
  • Treatment: Permethrin 5% cream — apply to whole body (neck to toe) overnight × 2 applications 1 week apart. Treat all household contacts simultaneously regardless of symptoms
  • Launder clothing, bedding at 60°C or bag for 72 hours
  • Contact precautions until 24 hours post-treatment
  • Itch may persist 2–6 weeks post-treatment (hypersensitivity reaction) — does not mean treatment failure

Psoriasis

  • Chronic immune-mediated inflammatory skin condition
  • Presentation: well-demarcated erythematous plaques with silver-white scale; extensor surfaces, scalp, nails
  • Koebner phenomenon: psoriasis developing at sites of skin trauma — important in wound care context
  • Nail changes: pitting, onycholysis, subungual hyperkeratosis
  • Associated: psoriatic arthritis (30%), cardiovascular risk, metabolic syndrome
  • Nursing role: topical corticosteroids, emollients, patient education, psychological support
🧠 Knowledge Check — 10 MCQ Quiz

1. A wound that is 3 cm long, 2 cm wide, and 1 cm deep involves subcutaneous fat but does not reach muscle. How should this wound be classified by depth?

2. A diabetic patient has a foot ulcer probed during assessment — the probe contacts bone. This finding is most consistent with:

3. A patient with a venous leg ulcer has an ABI of 0.55. What is the safest compression therapy decision?

4. Which dressing choice is most appropriate for a moderately exuding, non-infected granulating wound on the lower leg?

5. A bedridden patient develops a bright red, superficial, diffuse rash in the perineal and inner thigh area. The skin is intact but erythematous and the patient is incontinent of urine and faeces. The most accurate diagnosis is:

6. A patient with cellulitis of the left lower leg has been marked with a skin pen to monitor erythema. After 4 hours, the erythema has spread 2 cm beyond the marked border and the patient develops a fever of 39.2°C. The most appropriate next action is:

7. A patient presents with intensely itchy linear burrows between finger webs and on the wrists, worse at night. Which treatment and infection control measure is correct?

8. During MEASURE wound assessment, undermining is noted at the 3 o'clock position measuring 2.5 cm. Which action best describes correct documentation?

9. Which of the following is a CONTRAINDICATION to negative pressure wound therapy (NPWT)?

10. A nurse assessing an elderly patient with dark skin tone notices an area on the sacrum that feels warmer and slightly boggy compared to surrounding tissue, but there is no obvious colour change. The best interpretation and action is: