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Alterations in Physical Integrity. Types of Wounds Wound: disruption of normal anatomical structure and FX that results from pathological processes beginning.

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Presentation on theme: "Alterations in Physical Integrity. Types of Wounds Wound: disruption of normal anatomical structure and FX that results from pathological processes beginning."— Presentation transcript:

1 Alterations in Physical Integrity

2 Types of Wounds Wound: disruption of normal anatomical structure and FX that results from pathological processes beginning internally or externally to the involved organ(s). (p. 1551)

3 Classification of Wounds Intentional vs. Unintentional Intentional: Usually the result of therapy. Occur under aseptic conditions. Wound edges: usually smooth/clean Unintentional: Occurs unexpectedly. Occurs under unsterile conditions. Wound edges: sometimes jagged.

4 Open vs. Closed Open: Involves a break in the skin or mucous membranes. Wound edges are not closed. If drainage system in place, it is an open system. Closed Involves no break in skin integrity. Wound edges are closed. Wound edges are closed. If drainage system is in place, it is a closed system.

5 Acquisition Incision: Wound made with a sharp instrument. Puncture/Perforating: Penetrating wound in which a foreign object enters/exits an internal organ. Contusion: Closed wound caused by a blow to the body by blunt object. Laceration: Tearing apart of tissues. Wound has irregular edges. Abrasion: Superficial wound. Scraping, rubbing of skins surface. Penetrating: Wound involving a break in epidermal skin layer, as well as dermis and deeper tissues or organs.

6 Contamination Clean wounds: Closed surgical wound not entering GI, respiratory, genital, uninfected urinary tract, or oropharyngeal cavity. Contaminated wounds Open, traumatic, accidental wound. Surgical wound involving a break in aseptic technique. Clean-contaminated wounds: Surgical wound entering GI, respiratory, genital, uninfected urinary tract, or oropharyngeal cavity under controlled conditions. Dirty or infected wounds: Any wound that does not properly heal and grows organisms. Old traumatic wound, surgical incision into a area infected.

7 Acute: Wound that proceeds through an orderly and timely reparative process. Acute: Wound that proceeds through an orderly and timely reparative process. Chronic: Wound that fails to proceed through an orderly and timely reparative process. Chronic: Wound that fails to proceed through an orderly and timely reparative process. Superficial: Wound that involves only epidermal layer of skin. Superficial: Wound that involves only epidermal layer of skin.

8 Stages of Wound Healing Regeneration:The process of tissue renewal Defensive stage (Inflammatory Phase/Reaction) (hemostasis, inflammation, cell migration & epithelialization) Defensive stage (Inflammatory Phase/Reaction) (hemostasis, inflammation, cell migration & epithelialization)

9 Reconstructive stage (Proliferative Phase/Regeneration) Filling in of the wound with new connective or granulation tissue Filling in of the wound with new connective or granulation tissue the closing of the top of the wound by epitheliazation. the closing of the top of the wound by epitheliazation.

10 Maturative stage (Maturation Phase /Remodeling) May take more than a year. Collagen scar continues to reorganize and gain strength for several months. Usu. scar tissue has fewer pigmented cells and has a lighter color than normal skin.

11 Classification of Wound Healing Primary Intention Wounds that heal with little tissue loss. Wounds that heal with little tissue loss. The skin wedges are approximated. The skin wedges are approximated. Risk of infection is low. Risk of infection is low. Healing occurs quickly: Healing occurs quickly: drainage stops by day 3 of closure, wound is epitheliazed by day 4, wound is epitheliazed by day 4, inflammation is present up to day 5, healing edge is present by day 9.

12 Classification of Wound Healing Secondary Intention Wound edges do not approximate. Wound is left open until it becomes filled by scar tissue. Chance of infection is greater.Inflammatory phase is often chronic Wound filled with granulation tissue (a form of connective tissue that has a more abundant blood supply than collagen. Scarring is greater.

13 Classification of Wound Healing Tertiary Intention There is a time delay between the time of the injury and the approximation of the wound edges. Attempt by surgeon to allow for effective drainage and cleansing of a clean-contaminated or contaminated wound. Not closed until all evidence of edema and wound debris has been removed. Dressing is used to protect.

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15 Wound Drainage Serous: Clear, watery Sanguineous: Hemorrhagic. Specify color. Serosanguinous: pink to light red in color. Thinner than sanguineous. Purulent: thick drainage that is often yellow-green in color.

16 Factors affecting Wound Healing Compromised host Stress Nutrition Patient teaching Obesity Hospital in-patient time Medications (immunosuppressants) Blood sugar

17 Factors Inhibiting Wound Healing: Elderly Diminished epidermal cell activity After age of 50 cell renewal time is increased by one third. Epithelial cell renewal takes 30 or more days for the elderly. SLOWS Healing… Atrophy and Thinning of both skin layers Both layers are thinner and flatter. The thinning of the epidermis reduces the skins natural barriers. Weakening in the epidermis and dermis attachment. The epidermis can slide – precipitates skin tears.

18 Factors Inhibiting Wound Healing: Elderly Impaired immune function of skin cells Increases the risk of infection Hypodermics is decreased (insulator of the skin) Little subcutaneous padding over bony prominences. More at risk for skin breakdown and heat stroke. Loss in the amt. of collagen Decreased skin turgor Greater risk for shearing and tearing injuries.

19 Complications of Wound Healing Hemorrhage Hemorrhage Dehiscence Dehiscence Evisceration Evisceration Infection Infection Fistulas Fistulas

20 Nursing Process for Wound Management Untreated Wounds – basic first aide Treated Wounds – prescribed per M.D. or wound care nurse. Wound Care Protocol

21 Wound Assessment Appearance Appearance Drainage (penrose, J-P drain, Hemovac) Drainage (penrose, J-P drain, Hemovac) Swelling & Induration Swelling & Induration Pain Pain Temperature Temperature

22 Sequential signs of primary wound healing: Absence of bleeding Absence of bleeding Inflammation Inflammation Granulation tissue Granulation tissue Scar formation Scar formation Reduction in scar size Reduction in scar size

23 Lab Data WBC Hgb, Hct BUN, Albumin Wound cultures

24 MD promotes wound healing RN provides: Ongoing wound assessment Ongoing wound assessment Aseptic wound care according to MD specifications Aseptic wound care according to MD specifications Documentation of wound status Documentation of wound status Keeps MD apprised of wound status as appro. Keeps MD apprised of wound status as appro.

25 To promote healing/prevent complications… Adequate nutrition Adequate nutrition Prevent wound stress/trauma Prevent wound stress/traumavomitingcoughing abdominal distention Prevent wound infection Prevent wound infection

26 Factors Affecting Wound Care Type of wound Type of wound Size Size Drainage/exudate Drainage/exudate Open vs. closed Open vs. closed Wound location Wound location MD orders MD orders Presence of complications Presence of complications

27 Drain management Open vs. closed Open vs. closed Monitor drainage Monitor drainage Universal precautions, aseptic technique Universal precautions, aseptic technique

28 Penrose Drain Open Drainage System

29 Jackson Pratt Drain Close Drainage system

30 Hemovacs Close Drainage System Drainage Collection Bag (T-tubes)

31 Sutures….Staples…. Hot/cold applications

32 Pressure ulcer Pressure sore, Decubitus Ulcer Epidermis: Epidermis: Stratum corneum stratum basale Dermis Dermis

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34 Tissue Ischemia: local absence of blood flow/major reduction in blood flow Blanching: Normal red tones of light- skinned client are absent. Does not occur in clients with darkly pigmented skin. Darkly pigmented skin: Skin that remains unchanged (does not blanch) when pressure is applied over a boney prominence – irrespective of the clients race or ethnicity.

35 Normal Reactive Hyperemia: Visible effect of localized vasodilatation, the bodys normal response to lack of blood flow to the underlying tissue. Area blanches with fingertip pressure. Lasts less than 1 hour. Abnormal reactive hyperemia: Excessive vasodilatation and induration in response to pressure. The skin appears bright pink to red. Lasts more than 1 hour to 2 weeks after the removal of the pressure. Does not blanch.

36 Characteristics of Intact Dark Skin that might alert nurses to the potential for pressure ulcers (p. 1546) ColorTemperatureTouchAppearance

37 Risk Factors for Skin Breakdown Impaired Sensory input Impaired motor fx Alteration in LOC Orthopedic devices Any equipment

38 Contributing Factors Shearing Force FrictionEdemaAnemiaCachexiaObesityInfection Impaired peripheral circulation Age (elderly) Nutrition

39 Evaluation Tools

40 Classification of Pressure Ulcers I Nonblanchable erythema of the intact skin. II Partial-thickness skin loss involving epidermis and /or dermis. III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. IV Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.

41 Stage I (no skin loss)

42 Stage I (no skin loss)

43 Stage II (Shallow crater – involves epidermis and/or dermis)

44 Stage II Shallow crater – involves epidermis and/or dermis)

45 Stage III (Full thickness involving damage/necrosis of subc. Tissue. Does not extend down through underlying fascia)

46 Stage III or IV

47 Four Stages of Ulcers


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