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Care of the Patient with an Integumentary Disorder and Surgical Wound Care
Care of the Patient with an Integumentary Disorder and Surgical Wound Care
Module BChapter 3 and Chapter 13
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Overview of Anatomy and Physiology
Skin covers the outside of the bodyMain function:
HomeostasisProtection
Functions of the skinProtectionTemperature regulationVitamin D synthesis
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Figure 43-1
Structures of the skin.
(From Thibodeau, G.A., Patton, K.T. [2005], The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
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Basic Structure of the Skin
EpidermisThe outer layer of the skinNo blood supplyComposed of stratified squamous epitheliumDivided into layers: stratum germinativum, pigment-
containing layer, stratum corneumDermis
“True skin”Contains blood vessels, nerves, oil glands, sweat
glands, and hair folliclesSubcutaneous layer
Connects the skin to the musclesComposed of adipose and loose connective tissue
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Basic Structure of the Skin
Appendages of the skinSudoriferous glands—sweat glandsCeruminous glands—secrete cerumen
(earwax)Located in the external ear canal
Sebaceous glands—“oil glands”Secrete sebum
Hair Composed of modified dead epidermal tissue,
mainly keratinNails
Composed mainly of keratin
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Assessment of the Skin
Inspection and palpationAsk the patient about:
Recent skin lesions or rashesWhere the lesions first appearedHow long the lesions have been present
Recent skin color changesExposure to the sun without sunscreenFamily history of skin cancer
Observe the skin colorAssess any skin lesions
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Assessment of the SkinInspection and palpation (continued)
Assess for rashes, scars, lesions, or ecchymoses Assess temperature and textureInspect nails for normal development, color,
shape, and thicknessInspect hair for thickness, dryness, or dullnessInspect mucous membranes for pallor or
cyanosisAssess the ceruminous and sebaceous gland for
overactivity or underactivityAssessment of dark skin
Assess lips and mucous membranes
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Chief ComplaintWhen skin lesions
foundExact locationLengthWidthGeneral
appearanceName
Make sure all information is documented
Assess Chief Complaint:Provocative/
palliativeQuality/quantityRegionSeverityTime
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Psychosocial AssessmentMay affect body image and self-
esteemAssess coping abilitiesNurse’s attitude should be
nonjudgmental, warm, and acceptingProvide consistent informationInclude family in treatment planProvide positive feedback
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Bacterial Disorders of the Skin
CellulitisPotentially serious infection of the skinEtiology/pathophysiology
Streptococci and Staphylococcus aureusHaemophilus influenza type B {more common in
children}Diagnostic TestsMedical Management/nursing interventions:
AntibioticsPatient teaching
Prognosis
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Cellulitis
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Bacterial Disorders of the Skin
Folliculitis, furuncles, carbuncles, and felonsEtiology/pathophysiology
Folliculitis Infected hair follicle
Furuncle (boil) Infection deep in hair follicle; involves surrounding
tissueCarbuncle
Cluster of furunclesFelons
Infected soft tissue under and around an area
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Bacterial Disorders of the Skin
Folliculitis, furuncles, carbuncles, and felons (continued)Clinical manifestations/assessment
Pustule EdemaErythemaPainPruritus
Diagnostic testsPhysical examCulture of drainage
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Bacterial Disorders of the Skin
Folliculitis, furuncles, carbuncles, and felons (continued)Medical management/nursing interventions
Warm soaks 2-3 times per day (promote suppuration)
May require surgical incision and drainageTopical antibiotic cream or ointmentMedical asepsis
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furuncle carbuncle
Felon
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Fungal Infections of the Skin
DermatophytosesEtiology/pathophysiology
Microsporum audouinii major fungal pathogenTinea capitis
o Ringworm of the scalpTinea corporis
o Ringworm of the bodyTinea cruris
o Jock itchTinea pedis (most common)
o Athlete’s foot
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Fungal Infections of the Skin
Dermatophytoses (continued)Clinical manifestations/assessment
Tinea capitisErythematous around lesion with pustules around
the edges and alopecia at the siteTinea corporis
Flat lesions—clear center with red border, scaliness, and pruritus
Tinea crurisBrownish-red lesions in groin area, pruritus, skin
excoriationTinea pedis
Fissures and vesicles around and below toes
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Fungal Infections of the Skin
Dermatophytoses (continued)Diagnostic tests
Visual inspectionUltraviolet light for tinea capitis
Infected hair becomes fluorescent (blue-green)Medical management/nursing interventions
Griseofulvin—oralAntifungal soaps and shampoosTinactin or DesenexKeep area clean and dryBurrow's solution (tinea pedis)
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Figure 43-7
Tinea capitis. (From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
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Tinea corporis
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Tinea cruris
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<>
Tinea pedis
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Inflammatory Disorders of the Skin
Contact dermatitisEtiology/pathophysiology
Direct contact with agents of hypersensitivityDetergents, soaps, industrial chemicals, plants
Clinical manifestations/assessmentBurningPainPruritusEdemaPapules and vesicles
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Inflammatory Disorders of the Skin
Contact dermatitisDiagnostic tests
Health historyIntradermal skin testingElimination diets
Medical management/nursing interventionsRemove causeBurrow's solutionCorticosteroids to lesionsCold compressesAntihistamines (Benadryl)
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Inflammatory Disorders of the Skin
Dermatitis venenata, exfoliative dermatitis, anddermatitis medicamentosaEtiology/pathophysiology
Dermatitis venenata: Contact with certain plants Exfoliative dermatitis: Infestation of heavy metals,
antibiotics, aspirin, codeine, gold, or iodineDermatitis medicamentosa: Hypersensitivity to a
medication Clinical manifestations/assessment
Mild to severe erythema and pruritusVesiclesRespiratory distress (especially with medicamentosa)
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Inflammatory Disorders of the Skin
Dermatitis venenata, exfoliative dermatitis, anddermatitis medicamentosa (continued)Medical management/nursing interventions
All dermatitisColloid solution, lotions, and ointmentsCordicosteroids
Dermatitis venenataThoroughly wash affected areaCool, wet compressesCalamine lotion
Dermatitis medicamentosaDiscontinue use of drug
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Inflammatory Disorders of the Skin
UrticariaEtiology/pathophysiology
Allergic reaction (release of histamine in an antigen-antibody reaction)
Drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold
Clinical manifestations/assessmentPruritusBurning painWheals
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Inflammatory Disorders of the Skin
Urticaria (continued)Diagnostic tests
Health historyAllergy skin test
Medical management/nursing interventionsIdentify and alleviate causeAntihistamine (Benadryl)Therapeutic bathEpinephrineTeach patient possible causes and prevention
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Inflammatory Disorders of the Skin
AngioedemaEtiology/pathophysiology
Form of urticariaOccurs only in subcutaneous tissueSame offenders as urticariaCommon sites: eyelids, hands, feet, tongue, larynx, GI,
genitalia, or lips
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Inflammatory Disorders of the Skin
Angioedema (continued)Clinical manifestations/assessment
Burning and pruritusAcute pain (GI tract)Respiratory distress (larynx)Edema of an entire area (eyelid, feet, lips, etc.)
Medical management/nursing interventionsCold compressesAntihistamines, epinephrine, corticosteroids
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Inflammatory Disorders of the Skin
Eczema (atopic dermatitis)Etiology/pathophysiology
Allergen causes histamine to be released and an antigen-antibody reaction occurs
Primarily occurs in infantsClinical manifestations/assessment
Papules and vesicles on scalp, forehead, cheeks, neck, and extremities
Erythema and dryness of areaPruritus
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Inflammatory Disorders of the Skin
Eczema (atopic dermatitis) (continued)Diagnostic tests
Health history (heredity)Diet eliminationSkin testing
Medical management/nursing interventionsReduce exposure to allergenHydration of skinTopical steroidsLotions—Eucerin, Alpha-Keri, Lubriderm, or Curel 3-4
times/day
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Inflammatory Disorders of the Skin
Acne vulgarisEtiology/pathophysiology
Occluded oil glandsAndrogens increase the size of the oil gland
Influencing factorsDietStressHeredityOveractive hormones
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Inflammatory Disorders of the Skin
Acne vulgaris (continued)Clinical manifestations/assessment
Tenderness and edema Oily, shiny skinPustulesComedones (blackheads)Scarring from traumatized lesions
Diagnostic testsInspection of lesionBlood samples for androgen level
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Inflammatory Disorders of the Skin
Acne vulgaris (continued)Medical management/nursing interventions
Keep skin cleanKeep hands and hair away from areaWash hair dailyWater-based makeupTopical therapy
Benzoyl peroxide, vitamin A acids, antibiotics, sulfur-zinc lotions
Systemic therapyTetracycline, isotretinoin (Accutane)
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Inflammatory Disorders of the Skin
PsoriasisEtiology/pathophysiology
NoninfectiousSkin cells divide more rapidly than normal
Clinical manifestations/assessmentRaised, erythematous, circumscribed, silvery, scaling
plaquesLocated on scalp, elbows, knees, chin, and trunk
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Inflammatory Disorders of the Skin
Psoriasis (continued)Medical management/nursing interventions
Topical steroidsKeratolytic agents
Tar preparationsSalicylic acidReduces shedding of the outer layer of skin
PhotochemotherapyPUVA
o Oral psoraleno Ultraviolet light
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Figure 43-10
Psoriasis.
(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
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MalignanciesThree most common:
MelanomaBasal cell carcinomaSquamous cell carcinoma
Mnemonic:ASYMMETRYBORDERSCOLORDIAMETERELEVATEDFEELING
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Tumors of the SkinBasal cell carcinoma
Skin cancerCaused by frequent contact with chemicals,
overexposure to the sun, radiation treatmentMost common on face and upper truckFavorable outcome with early detection and
removalSquamous cell carcinoma
Firm, nodular lesion; ulceration and indurated margins
Rapid invasion with metastasis via lymphatic system
Sun-exposed areas; sites of chronic irritationEarly detection and treatment are important
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Tumors of the SkinMalignant melanoma
Cancerous neoplasmMelanocytes invade the epidermis, dermis, and
subcutaneous tissueGreatest risk
Fair complexion, blue eyes, red or blond hair, and freckles
TreatmentSurgical excisionChemotherapy
Cisplatin, methotrexate, dacarbazine
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Figure 43-16
Basal cell carcinoma.
(From Belcher, A. E. [1992]. Cancer nursing. St. Louis: Mosby.)
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Figure 43-17
Squamous cell carcinoma.
(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
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Figure 43-18
The ABCDs of melanoma.
(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
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Stage I
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Stage II
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Stage III
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Stage IV
Chapter 13
Surgical Wound Care
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Wound ClassificationWounds Classified According to
CauseIncision or puncture
Severity of InjuryAmount of Contamination
Clean, clean-contaminated, contaminated, and dirty or infected
Skin Integrity
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Wound HealingPhases of Wound Healing
HemostasisTermination of bleedingBegins as soon as the injury occurs
Inflammatory PhaseAn initial increase in blood elements and water flow
out of the blood vessel into the vascular spaceCauses cardinal signs and symptoms of
inflammation: erythema, heat, edema, pain, and tissue dysfunction
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Wound HealingPhases of Wound Healing
Reconstruction PhaseCollagen formation occursa glue-like protein
substance that adds tensile strength to the wound and tissue.
Appearance changes to an irregular, raised, purplish, immature scar.
Wound dehiscence most frequently occurs during this phase.
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Wound HealingPhases of Wound Healing
Maturation PhaseFibroblasts begin to exit the wound.The wound continues to gain strength, although
healed wounds rarely return to the strength the tissue had before surgery.
Keloids may form during this phase.
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Wound HealingProcess of Wound Healing
Primary IntentionWound is made surgically with little tissue loss.Skin edges are close together.Minimal scarring results.It begins during the inflammatory phase of healing.
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Wound HealingProcess of Wound Healing
Secondary IntentionHealing occurs when skin edges are not close
together or when pus has formed.If wound has purulent exudates, the surgeon
provides a means for its release via drainage system or by packing the wound.
The necrotized tissue decomposes and escapes.The cavity begins to fill with granulation tissue.The amount of granulation tissue required depends
on the size of the wound; scarring is greater in a larger wound.
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Wound HealingTertiary Intention
Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together.
Occurs when a contaminated wound is left open and sutured closed after the infection is controlled or a primary wound becomes infected, is opened, allowed to granulate, and then sutured.
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Figure 13-1
Types of wound healing. A, Primary intention.
B, Secondary intention. C, Tertiary intention.
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)
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Wound HealingFactors that Affect Healing
Nutritional NeedsIf the patient cannot tolerate food or fluids, total
parenteral nutrition or nasogastric feedings can be provided.
Because patients may not be able to tolerate large meals or solid foods, dietary services can provide small frequent feedings.
FluidsOffer hourly; encourage 2000 to 2400 ml in 24
hours.
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Wound HealingFactors that Affect Healing
Rest and ActivityThe nurse assists the patient to achieve a balance
between time to rest to facilitate healing and activity to decrease venous stasis.
When the patient is confined to bed, moving one body section at a time should be encouraged.
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Surgical WoundSelection of the site for the surgical wound is
based onTissue or organ involvedNature of injury or disease processProcess of inflammation or infectionStrength of the siteIf a drainage system is required, the position of
the drain may also influence the placement of the incision.
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Surgical WoundThe surgeon’s goal is to enter the cavity
involved, repair the injured or diseased area, and minimize trauma as quickly as possible.
Many options are available to the surgeon for closing the surgical incision.Sutures, staples, Steri-Strips, butterfly strips,
and transparent sprays and filmsBinder or bandage used to support the incision
of secure dressings without the use of adhesive materials
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Figure 13-5
Wound closure with staples.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Figure 13-6
Steri-Strips placed over incision for closure.
(From Potter, P.A., Perry, A.G. [2003]. Basic nursing: Essentials for practice. [5th ed.]. St. Louis: Mosby.)
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Figure 13-4
Sutures. A, Interrupted, or separate. B, Continuous. C, Blanket. D, Retention.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Surgical WoundThe nurse should inspect dressings every 2
to 4 hours for the first 24 hours.On the day of surgery, most wounds will have
sanguineous or serosanguineous exudates.As the exudate subsides, it becomes serous. Because pressure to the surgical wound
retards bleeding, wounds are usually covered by a gauze dressing.
The nurse should inspect both the dressing or incisional area and the area under the patient; exudate follows the flow of gravity.
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Care of the IncisionSurgical wounds, because they are
aseptically created, generally heal well and quickly.
Incision CoveringsGauze
Permits air to reach the woundSemiocclusive
Permits oxygen but not air impurities to passOcclusive
Permits neither air nor oxygen to pass
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Figure 13-2
Types of dressings.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Care of the IncisionRemoving Dressings
Care is taken to avoid accidental removal or displacement of underlying drains.
An analgesic may need to be given at least 30 minutes before exposing a wound.
Sutured, clean wounds may not be dressed after surgery or dressing may be removed within 24 hours postoperatively to allow air circulation.
Sterile technique is followed whenever the wound or dressing is handled.
A gown, mask, and protective goggles are worn if soiling or splashing of wound exudate is expected.
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Care of the IncisionDry Dressings
May be chosen for management of a wound with little exudate/drainage
Protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing
Most commonly used for abrasions and nondraining postoperative incisions
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Care of the IncisionWet-to-Dry Dressing
Primary purpose is to mechanically debride a wound.
The moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris.
As the dressing dries, it adheres to the wound and debrides it when the dressing is removed.
Commonly used wetting agents are normal saline and lactated Ringer’s solution, acetic acid, sodium hypochlorite solution, povidone-iodine, and antibiotic solutions.
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Care of the IncisionTransparent Dressings
Self-adhesive transparent film is a synthetic permeable membrane that acts as a temporary secondary skin.
AdvantagesAdheres to undamaged skin to contain exudates and
minimize wound contaminationServes as a barrier to external fluids and bacteria
yet still allows the wound to breathePromotes a moist environment that speeds
epithelial cell growthPermits visualization of the wound
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Care of the IncisionIrrigations
Wound cleansing and irrigation is accomplished using sterile or clean technique.
Cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, or whirlpool.
Fluid retention is avoided by positioning the patient on his or her side to encourage the flow of the irrigant away from the wound.
Promote wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar.
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Care of the IncisionIrrigations
Solutions used for irrigations include warm water, saline, or mild detergents.
Principles of Basic Wound IrrigationCleanse in a direction from the least contaminated
area to the most contaminated area.When irrigating, all of the solution flows from the
least contaminated area to the most contaminated area.
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Complications of Wound HealingImpaired wound healing requires accurate
observation and ongoing interventions.Situation can be life-threatening.Recognizing the seriousness of signs and
symptoms is vital throughout the patient’s recovery phase.
Wound bleedingBleeding may indicate a slipped suture,
dislodged clot, coagulation problem, or trauma to blood vessels or tissue.
If internal hemorrhage occurs, the dressing may be dry while the abdominal cavity collects blood.
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Complications of Wound HealingDehiscence
Wound layers separate.Patient may say that something has given way.It may result after periods of sneezing, coughing,
or vomiting.It may be preceded by serosanguineous drainage.Patient should remain in bed and receive nothing
by mouth, be told not to cough, and be reassured.
The nurse should place a warm, moist sterile dressing over the area until the physician evaluates the site.
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Complications of Wound HealingEvisceration
Abdominal organs protrude through an opened incision.
Patient is to remain in bed, and the wound and contents should be covered with warm, sterile saline dressings.
The surgeon is notified immediately.This is a medial emergency, and the wound
requires surgical repair.
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Complications of Wound HealingWound Infection
Surgical wound becomes contaminated.CDC labels a wound “infected” when it
contains purulent (pus) drainage.A patient with an infected wound displays a
fever, tenderness, and pain at the wound; edema; and an elevated WBC count.
Purulent drainage has an odor and is brown, yellow, or green, depending on the pathogen.
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Exudate/DrainageExudate
Fluid, cells, or other substances that have slowly exuded from cells or blood vessels through small pores or breaks in the cell membrane
DrainageRemoval of fluids from a body cavity, wound,
or other source of discharge through one or more method
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Exudate/DrainageSerous
Clear, watery fluid that has been separated from its solid elements
SanguineousFluid that contains blood
SerosanguineousThin and red; composed both of serum and
bloodIf the tissue is infected, exudate/drainage may
be brown-green purulent.Exudate/drainage from organs has its own
particular color. (Bile from the liver and gallbladder is green-brown.)
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D. Sanguineous: • Bright red:
indicates active bleeding
B. Purulent: • Thick, yellow, green,
tan, or brownC. Serosanguineous:
• Pale, red, watery: mixture of serous and sanguineous
A. Serous: • Clear, watery plasma
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 111
Exudate/DrainageThe type and amount produced depend on
the tissue and organs involved.More than 300 ml in the first 24 hours
should be treated as abnormal.When patients first ambulate, a slight
increase may occur.Assess
Color, amount, consistency, and odorIt may be contained either in a drainage
system or on a dressing.
Maintaining Oxygenation
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Oxygen TherapyGoal:
Prevent or relieve hypoxiaPatient with impaired tissue oxygenation can
benefit from controlled oxygen therapyConsidered a drug:
Need an order to administerColorless, odorless, tasteless gas that does
not burn/explodeIf combined with other factors can support
combustion and igniteInitiated by respiratory therapist
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Oxygen Delivery SystemRoom air: 21%
Nasal Cannula: 22 – 45% (1-6 L)Effective for low oxygen concentration
Simple Mask:25 – 60% (6 – 10 L)Delivers oxygen concentrations up to 60%
Partial Non-Rebreather:35 – 60% (8 – 12 L)Flaps stays open; valves allows expired carbon dioxide to leave
the maskNon-rebreather:
80 – 95% (10 – 15 L)Delivers highest possible oxygen concentration without
intubation
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OxygenBest position for respiratory distress:
FowlersSemi-fowlers
Assess for signs of hypoxia/respiratory distress:Apprehension, anxiety, restlessnessDecreased level of consciousness, decrease
ability to concentratePallor, cyanosis, dyspneaMay require humidification due to drying out
effects of oxygen
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Pulse OximetryNoninvasive method to determine oxygen
saturationDetect within 6 secondsOxygen saturation: 90 – 100%
Needed to adequately replenish oxygen in plasma
<90% need oxygen<70% life threatening
If questionable, the physician will order an arterial blood gas (ABG)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 117
Pulse OximetryDon’t use:
On an extremity with a blood cuff or arterial catheter in place
Place probe over a pulsating vascular bedProtect from direct sunlightAvoid excessive movementHypothermia, Hypotension, vasoconstriction
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Clearing the AirwayGather your equipmentAssess need for suctioning
Gurgling respirationsRestlessnessVomitus in mouthDrooling
Explain procedureCoughing, sneezing, or gagging
Position:Conscious: Semi-fowlers with head dto one side
Promotes drainage
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Clearing the AirwayPosition:
Conscious: Semi-fowlers with head to one sidePromotes drainage of secretionsFacilitates insertion of suction catheter
Unconscious:Side-lying facing nurse
Common vacuum settings for wall suction units:110-150 mm Hg
Common catheter settings:12-16 French
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 120
Oropharygneal SuctioningYankauer:
Clean glovesEncourage to cough
NasopharyngealSterileLength of insertion: 10 cm
Nasotracheal Suction:Length of insertion: 20-24 cm
Limit suction to 10-15 secondsAllow 1-2 minutes of rest betweenAdminister oxygen if neededProvide mouth care after suctioning
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 121
Collection of SpecimenNasal:
Ask patient to blow nose to clear nasal passages of mucus that contains resident bacteria
Throat:Obtain before starting antibioticsIf antibiotics already started, notify labCollect before mealtime or one hour after
eating
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 122
Emergency Procedures
AirwayBreathingCirculation
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