Skin Integrity and Wound Care Chapter 47 Skin Integrity and Wound Care Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Skin Structure: epidermis and dermis Function Mosby items and derived items © 2005 by Mosby, Inc.

Pressure Ulcers: Pathogenesis Pressure intensity Pressure duration Tissue tolerance Mosby items and derived items © 2005 by Mosby, Inc.

Risk for Pressure Ulcer Development Impaired sensory perception Impaired mobility Alteration in level of consciousness Shear Friction Moisture Mosby items and derived items © 2005 by Mosby, Inc.

Classification of Pressure Ulcers Stage I: persistent red, blue, or purple tones; no open skin areas Stage II: partial-thickness skin loss; presents as an abrasion or blister Mosby items and derived items © 2005 by Mosby, Inc.

Classification of Pressure Ulcers (cont'd) Stage III: full-thickness skin loss with damage or necrosis of subcutaneous tissue; presents as a deep crater Stage IV: full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, other structures Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Wound Classification Skin integrity: open, closed, acute,chronic Cause: intentional, unintentional Severity of injury: superficial, penetrating, perforating Mosby items and derived items © 2005 by Mosby, Inc.

Wound Classification (cont'd) Cleanliness: clean, clean-contaminated, contaminated, infected, colonized Descriptive qualities: laceration, abrasion, contusion Mosby items and derived items © 2005 by Mosby, Inc.

Process of Wound Healing Primary intention Secondary intention Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Wound Repair Partial thickness: inflammatory response, epithelial proliferation and migration, reestablishment of epidermal layers Full thickness: inflammatory phase, proliferative phase, and remodeling Mosby items and derived items © 2005 by Mosby, Inc.

Complications of Wound Healing Hemorrhage—shock Infection Dehiscence Evisceration Fistula formation Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Wounds Nutrition Tissue perfusion Infection Age Mosby items and derived items © 2005 by Mosby, Inc.

Psychosocial Impact of Wounds Body image Social resources Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Assessment Skin: color, temperature, turgor, integrity Risk for pressure ulcers: Norton and Braden scales Nutritional status Exposure of skin to body fluids Pain Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Traumatic Wounds Wounds: emergency setting Abrasions Lacerations Punctures Appearance Amount of bleeding Size Mosby items and derived items © 2005 by Mosby, Inc.

Assessment of Wounds in a Stable Setting Appearance: size, healing Character of drainage: serous, sanguineous, serosanguineous, purulent Drains Mosby items and derived items © 2005 by Mosby, Inc.

Wounds: Stable Setting (cont'd) Closures: staples, sutures Palpation of wound Wound cultures: aerobic, anaerobic Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Nursing Diagnoses Risk for infection Imbalanced nutrition: less than body requirements Pain Impaired skin integrity Impaired tissue integrity Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Planning Goals and outcomes Wound improvement within 2 weeks No further skin breakdown Increase in caloric intake by 10% Setting priorities Continuity of care Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Health Promotion Prevention of pressure ulcers Skin care Positioning Use of support surfaces Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Acute Care Management of pressure ulcers and wounds Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Wound Management Prevent and manage infection Cleanse the wound Remove nonviable tissue Manage exudate Mosby items and derived items © 2005 by Mosby, Inc.

Wound Management (cont'd) Protect the wound Client education Nutritional support Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. First Aid for Wounds Control of bleeding Cleansing Application of topical growth factors Protection Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Dressings Purpose Types: gauze, wet-to-dry, Telfa, transparent, hydrocolloid, hydrogel, foam, alginate Changing or reinforcing dressings Packing a wound: wound VAC Securing the dressing Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Dressing Changes Administer required analgesic Explain steps of procedure to client Gather all necessary supplies Prepare sterile field, as indicated Remove old dressing, assess area, and provide necessary care using appropriate aseptic technique Answer client’s questions and document care provided Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Wound Care Cleansing skin and drain sites Wound irrigations Suture/staple care and removal Drainage evacuation Comfort measures Mosby items and derived items © 2005 by Mosby, Inc.

Application of Bandages and Binders Inspect underlying skin Cover exposed wounds Assess condition of dressings Assess skin of areas distal to bandage Use appropriate technique to apply Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Hot and Cold Therapy Assessment for temperature tolerance Bodily responses to heat and cold Local effects of heat and cold Factors influencing tolerance Choice of moist or dry Compresses, packs, soaks, sitz baths, aquathermia pad Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Evaluation Client care Client expectations Mosby items and derived items © 2005 by Mosby, Inc.