Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 37 Skin Integrity and Wound...

Chapter 37

Skin Integrity and Wound Healing

Wounds

• Skin– Largest organ

– Primary defense against infection

• Wound– Disruption in integrity of body tissue

Physiology of Wound Healing

• Defensive phase– Hemostasis and inflammatory

– Lasts three to four days

• Reconstructive phase– Proliferative

– Lasts two to three weeks

(continued)

• Maturation phase– Continues up to two years or more

• Types of healing:– Primary intention

– Secondary intention

– Tertiary intention

(continued)

• Kinds of wound drainage:– Serous

• Serum

– Purulent• Pus

– Hemorrhagic• Blood

Factors Affecting Wound Healing

• Hemorrhage– Persistent bleeding

• Infection– Bacterial wound contamination

(continued)

Factors Affecting Wound Healing

• Dehiscence– Separation of wound edges

• Evisceration– Protruding viscera through wound

Wound Classification

• Cause of wounds– Intentional

• Occurs during treatment or therapy

– Unintentional• Unanticipated

• Result of trauma or accident

• Greater risk for infection

(continued)

• Cleanliness of wounds– Clean

• Intentional

• No inflammation

– Clean-contaminated• Intentional

• Involves alimentary, respiratory, genitourinary, and oropharyngeal tracts

(continued)

• Cleanliness of wounds– Contaminated

• Open, traumatic, and intentional

• Nonpurulent inflammation

– Dirty and infected• Traumatic

• Purulent drainage

(continued)

• Wagner ulcer grade classification

• Classification by thickness of skin loss

• Red-yellow-black (RYB) classification system

Wound Healing and the Nursing Process

• Assessment– Health history

• Aggravating factors

• Alleviating factors

• Personal and social history

• Functional ability assessment

– Physical examination

(continued)

• Assessment– Wound assessment

– Location

– Size

– General appearance and drainage

– Pain

– Laboratory data

(continued)

• Diagnosis– NANDA statements

• Impaired skin integrity

• Impaired tissue integrity

• Risk for infection

• Acute pain

• Disturbed body image

• Deficient knowledge

(continued)

• Planning and outcome identification– NOC for wounds:

• Wound healing– Primary intention

• Wound healing– Secondary intention

– Collaboration

(continued)

• Implementation– Initiate emergency measures

– Provide comfort measures

– Cleanse wound

– Dress wound

– Monitor drainage of wound

(continued)

• Implementation– Provide suture care

– Check bandages, binders, and slings

– Administer heat and cold therapy

(continued)

• Evaluation– Ongoing process

– Skin integrity• Maintenance

• Improvement

– Revisions

Pressure Ulcers

• Lesions caused by unrelieved pressure and ischemia– Results in damage to underlying tissue

Physiology of Pressure Ulcers

• Pressure over time

• Loss of oxygen to tissue

• Death of tissue

• Other forces:– Shearing

– Friction

Risk Factors for Pressure Ulcers

• Immobility• Inactivity• Incontinence• Malnutrition

• Decreased mental status

• Diminished sensation

• Age-related changes

Pressure Ulcers and the Nursing Process

• Assessment– Stage I

• Nonblanchable erythema of intact skin

– Stage II• Partial thickness skin loss

• Epidermis or dermis

(continued)

• Assessment– Stage III

• Full-thickness skin loss

• Subcutaneous tissue

– Stage IV• Full-thickness skin loss

• Extensive damage to muscle, bone, or supporting structures

(continued)

• Diagnosis– Similar to wounds

• Disturbed body image

• Risk for social isolation

• Situation low self-esteem related to disturbed body image

(continued)

• Planning and outcome identification– Similar to wounds

• Individualized

• Address:– Overall physical condition

– Stage of wound

– Client’s risk factors

• Teaching

(continued)

• Implementation– Monitor nutritional status

– Ensure proper hygiene and skin care

– Debride

– Provide proper positioning

– Employ support surfaces

– Employ complementary therapies

(continued)

• Evaluation– Consider:

• Physical signs of healing

• Status of pressure ulcer

• Client’s adaptation

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 37 Skin Integrity and Wound...

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