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