SKIN INTEGRITY AND WOUND CARE
SKIN AND SKIN BREAKDOWN
WOUND CLASSIFICATION:
AN INTENTIONAL WOUND
UNINTENTIONAL WOUNDS
AN OPEN WOUND
AN CLOSED WOUND
PHASES OF WOUND HEALING
INFLAMATORY PHASE
FIBROPLASIA (Proliferation )phase
Maturation (remolding) phase
WOUND HEALING PROCESSES
PRIMARY HEALING
SECONDARY HEALING
TERTIARY HEALING
FACTORS AFFECTING WOUND HEALING
AGE
CIRCULATION & OXYGENATION
WOUND CONDITION
OVERALL PATIENT HEALTH
WOUND COMPLICATIONS
INFECTION: Purulent Drainage Increased Drainage Pain Redness Swelling Increased Body Temperature Increased White Blood Cell Count
(WBC)
DEHISCENCE OR EVISCERATION DEFINE EACH:
Patients at greatest risk for these complications Include:
Obese or malnourishedHave infected woundsExcessive coughingVomiting or straining
HEMMORHAGE
Occurrences may be due to:Slipped sutures
A dislodged clot from stress at the suture line or operative site
Infection
Erosion of a blood vessel by a foreign body such as a drain
PSYCHOLOGICAL EFFECTS OF WOUNDS
PAIN
ANXIETY AND FEAR
ALTERATION IN BODY IMAGE
ASSESSING THE WOUND
Inspection
Sight
Smell
Palpation
Appearance
Drainage
Pain
DIAGNOSING IN WOUND CARE
Altered skin integrity
Risk for infection
Pain
Delayed surgical recovery
Body image disturbance
PLANNING EXPECTED OUTCOMES FOR WOUND CARE
Facilitating the patients return to health
Providing interventions that facilitate wound healing
Reduce the risk for complications
Promote psychosocial adaptation
IMPLEMENTING WOUND CARE
Promote wound healing
Prevent further injury
Prevent alterations in skin integrity
Prevent infections
Promote physical and emotional comfort
Facilitate coping
TEACHING FOR HOME CARE OF A WOUND
Explain the terminology
Identify risk factors
Explain where and how pressure ulcers develop
Describe various prevention strategies and options
EVALUATING WOUND CARE
Evaluating is based on the expected outcome (EO)
No complications
Wound is progressing through the healing stages
PRESSURE ULCERS:
PATHOLOGY OF ULCER DEVELOPMENT:
External Pressure
Friction
Shearing Forces
FACTORS AFFECTING PRESSURE ULCER DEVELOPING
Mobility
Immobility
Nutrition
Hydration
Moisture on the skin
Mental status
Age
PRESSURE ULCER STAGING
Stage I
Stage II
Stage III
Stage IV
ASSESSING THE RISK FOR:PRESSURE ULCERS
Nursing history
Physical assessment pg.933
MobilityNutritionIncontinence Use of Braden scale pg.936
ASSESSING: “ACTUAL” PRESSURE ULCER
1st sign of pressure =“blanching” (local anemia, is called “ischemia”)
Ischemia is rapid followed by hyperemia when pressure is relieved.
DIAGNOSING PRESSURE ULCERS
Impaired Skin Integrity*
The stage of the ulcer is a factor in determining the nursing diagnosisStage I and II pressure = superficial skin damage. Stage III and IV pressure ulcer = full thickness skin loss and damage to underlying tissue
Impaired Tissue Integrity is more appropriate*
PLANNING EXPECTED OUTCOMES FOR PRESSURE ULCERS
Patient participationDemonstrate progression in healing of the ulcerDemonstrate increase in body wt. and muscle sizeRemain free of infection at the wound siteDevelop no new areas of skin breakdownDemonstrate self-care measures necessary to prevent development of a pressure ulcer
IMPLEMENTING INTERVENTIONS TO PREVENT PRESSURE ULCERS:Protecting the skin from external mechanical
forcesTeach patient and caregivers about
preventionPressure ulcer careCleaning the pressure ulcerDressing the pressure ulcerControlling infectionProviding care when surgical intervention is
necessary
Evaluate Pressure Ulcer Care
Had the patient and caregiver participated effectively in prevention and treatmentPrevention of additional skin breakdownDemonstrated progressive healing of pressure ulcerRemained free of infectionImproved overall physical condition