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Chapter 37
Skin Integrity and Wound Healing
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Wounds
• Skin– Largest organ
– Primary defense against infection
• Wound– Disruption in integrity of body tissue
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Physiology of Wound Healing
• Defensive phase– Hemostasis and inflammatory
– Lasts three to four days
• Reconstructive phase– Proliferative
– Lasts two to three weeks
(continued)
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Physiology of Wound Healing
• Maturation phase– Continues up to two years or more
• Types of healing:– Primary intention
– Secondary intention
– Tertiary intention
(continued)
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Physiology of Wound Healing
• Kinds of wound drainage:– Serous
• Serum
– Purulent• Pus
– Hemorrhagic• Blood
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Factors Affecting Wound Healing
• Hemorrhage– Persistent bleeding
• Infection– Bacterial wound contamination
(continued)
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Factors Affecting Wound Healing
• Dehiscence– Separation of wound edges
• Evisceration– Protruding viscera through wound
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Wound Classification
• Cause of wounds– Intentional
• Occurs during treatment or therapy
– Unintentional• Unanticipated
• Result of trauma or accident
• Greater risk for infection
(continued)
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Wound Classification
• Cleanliness of wounds– Clean
• Intentional
• No inflammation
– Clean-contaminated• Intentional
• Involves alimentary, respiratory, genitourinary, and oropharyngeal tracts
(continued)
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Wound Classification
• Cleanliness of wounds– Contaminated
• Open, traumatic, and intentional
• Nonpurulent inflammation
– Dirty and infected• Traumatic
• Purulent drainage
(continued)
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Wound Classification
• Wagner ulcer grade classification
• Classification by thickness of skin loss
• Red-yellow-black (RYB) classification system
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Wound Healing and the Nursing Process
• Assessment– Health history
• Aggravating factors
• Alleviating factors
• Personal and social history
• Functional ability assessment
– Physical examination
(continued)
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Wound Healing and the Nursing Process
• Assessment– Wound assessment
– Location
– Size
– General appearance and drainage
– Pain
– Laboratory data
(continued)
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Wound Healing and the Nursing Process
• Diagnosis– NANDA statements
• Impaired skin integrity
• Impaired tissue integrity
• Risk for infection
• Acute pain
• Disturbed body image
• Deficient knowledge
(continued)
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Wound Healing and the Nursing Process
• Planning and outcome identification– NOC for wounds:
• Wound healing– Primary intention
• Wound healing– Secondary intention
– Collaboration
(continued)
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Wound Healing and the Nursing Process
• Implementation– Initiate emergency measures
– Provide comfort measures
– Cleanse wound
– Dress wound
– Monitor drainage of wound
(continued)
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Wound Healing and the Nursing Process
• Implementation– Provide suture care
– Check bandages, binders, and slings
– Administer heat and cold therapy
(continued)
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Wound Healing and the Nursing Process
• Evaluation– Ongoing process
– Skin integrity• Maintenance
• Improvement
– Revisions
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Pressure Ulcers
• Lesions caused by unrelieved pressure and ischemia– Results in damage to underlying tissue
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Physiology of Pressure Ulcers
• Pressure over time
• Loss of oxygen to tissue
• Death of tissue
• Other forces:– Shearing
– Friction
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Risk Factors for Pressure Ulcers
• Immobility• Inactivity• Incontinence• Malnutrition
• Decreased mental status
• Diminished sensation
• Age-related changes
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Pressure Ulcers and the Nursing Process
• Assessment– Stage I
• Nonblanchable erythema of intact skin
– Stage II• Partial thickness skin loss
• Epidermis or dermis
(continued)
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Pressure Ulcers and the Nursing Process
• Assessment– Stage III
• Full-thickness skin loss
• Subcutaneous tissue
– Stage IV• Full-thickness skin loss
• Extensive damage to muscle, bone, or supporting structures
(continued)
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Pressure Ulcers and the Nursing Process
• Diagnosis– Similar to wounds
• Disturbed body image
• Risk for social isolation
• Situation low self-esteem related to disturbed body image
(continued)
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Pressure Ulcers and the Nursing Process
• Planning and outcome identification– Similar to wounds
• Individualized
• Address:– Overall physical condition
– Stage of wound
– Client’s risk factors
• Teaching
(continued)
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Pressure Ulcers and the Nursing Process
• Implementation– Monitor nutritional status
– Ensure proper hygiene and skin care
– Debride
– Provide proper positioning
– Employ support surfaces
– Employ complementary therapies
(continued)
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Pressure Ulcers and the Nursing Process
• Evaluation– Consider:
• Physical signs of healing
• Status of pressure ulcer
• Client’s adaptation