1. SKIN INTEGRITY AND WOUND CARE
SKIN AND SKIN BREAKDOWN

2. WOUND CLASSIFICATION:
AN INTENTIONAL WOUND
UNINTENTIONAL WOUNDS
AN OPEN WOUND
AN CLOSED WOUND

3. PHASES OF WOUND HEALING
INFLAMATORY PHASE
FIBROPLASIA (Proliferation )phase
Maturation (remolding) phase

4. WOUND HEALING PROCESSES
PRIMARY HEALING
SECONDARY HEALING
TERTIARY HEALING

5. FACTORS AFFECTING WOUND HEALING
AGE
CIRCULATION & OXYGENATION
WOUND CONDITION
OVERALL PATIENT HEALTH

6. WOUND COMPLICATIONS INFECTION: Purulent Drainage Increased Drainage
Pain
Redness
Swelling
Increased Body Temperature
Increased White Blood Cell Count (WBC)

7. DEHISCENCE OR EVISCERATION DEFINE EACH:
Patients at greatest risk for these complications Include:
Obese or malnourished
Have infected wounds
Excessive coughing
Vomiting or straining

8. 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

9. PSYCHOLOGICAL EFFECTS OF WOUNDS
PAIN
ANXIETY AND FEAR
ALTERATION IN BODY IMAGE

10. ASSESSING THE WOUND Inspection Sight Smell Palpation Appearance
Drainage
Pain

11. DIAGNOSING IN WOUND CARE
Altered skin integrity
Risk for infection
Pain
Delayed surgical recovery
Body image disturbance

12. 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

13. IMPLEMENTING WOUND CARE
Promote wound healing
Prevent further injury
Prevent alterations in skin integrity
Prevent infections
Promote physical and emotional comfort
Facilitate coping

14. 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

15. EVALUATING WOUND CARE Evaluating is based on the expected outcome (EO)
No complications
Wound is progressing through the healing stages

16. PRESSURE ULCERS: PATHOLOGY OF ULCER DEVELOPMENT: External Pressure
Friction
Shearing Forces

17. FACTORS AFFECTING PRESSURE ULCER DEVELOPING
Mobility
Immobility
Nutrition
Hydration
Moisture on the skin
Mental status
Age

18. PRESSURE ULCER STAGING
Stage I
Stage II
Stage III
Stage IV

19. ASSESSING THE RISK FOR:PRESSURE ULCERS
Nursing history
Physical assessment pg.933
Mobility
Nutrition
Incontinence
Use of Braden scale pg.936

20. ASSESSING: “ACTUAL” PRESSURE ULCER
1st sign of pressure =“blanching” (local anemia, is called “ischemia”)
Ischemia is rapid followed by hyperemia when pressure is relieved.

21. DIAGNOSING PRESSURE ULCERS
Impaired Skin Integrity*
The stage of the ulcer is a factor in determining the nursing diagnosis
Stage 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*

22. PLANNING EXPECTED OUTCOMES FOR PRESSURE ULCERS
Patient participation
Demonstrate progression in healing of the ulcer
Demonstrate increase in body wt. and muscle size
Remain free of infection at the wound site
Develop no new areas of skin breakdown
Demonstrate self-care measures necessary to prevent development of a pressure ulcer

23. IMPLEMENTING INTERVENTIONS TO PREVENT PRESSURE ULCERS:
Protecting the skin from external mechanical forces
Teach patient and caregivers about prevention
Pressure ulcer care
Cleaning the pressure ulcer
Dressing the pressure ulcer
Controlling infection
Providing care when surgical intervention is necessary

24. Evaluate Pressure Ulcer Care
Had the patient and caregiver participated effectively in prevention and treatment
Prevention of additional skin breakdown
Demonstrated progressive healing of pressure ulcer
Remained free of infection
Improved overall physical condition