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

2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wounds Skin –Largest organ –Primary defense against infection Wound –Disruption in integrity of body tissue

3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiology of Wound Healing Defensive phase –Hemostasis and inflammatory –Lasts three to four days Reconstructive phase –Proliferative –Lasts two to three weeks (continued)

4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiology of Wound Healing Maturation phase –Continues up to two years or more Types of healing: –Primary intention –Secondary intention –Tertiary intention (continued)

5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiology of Wound Healing Kinds of wound drainage: –Serous Serum –Purulent Pus –Hemorrhagic Blood

6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Factors Affecting Wound Healing Hemorrhage –Persistent bleeding Infection –Bacterial wound contamination (continued)

7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Factors Affecting Wound Healing Dehiscence –Separation of wound edges Evisceration –Protruding viscera through wound

8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Classification Cause of wounds –Intentional Occurs during treatment or therapy –Unintentional Unanticipated Result of trauma or accident Greater risk for infection (continued)

9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Classification Cleanliness of wounds –Clean Intentional No inflammation –Clean-contaminated Intentional Involves alimentary, respiratory, genitourinary, and oropharyngeal tracts (continued)

10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Classification Cleanliness of wounds –Contaminated Open, traumatic, and intentional Nonpurulent inflammation –Dirty and infected Traumatic Purulent drainage (continued)

11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Classification Wagner ulcer grade classification Classification by thickness of skin loss Red-yellow-black (RYB) classification system

12. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Assessment –Health history Aggravating factors Alleviating factors Personal and social history Functional ability assessment –Physical examination (continued)

13. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Assessment –Wound assessment –Location –Size –General appearance and drainage –Pain –Laboratory data (continued)

14. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Diagnosis –NANDA statements Impaired skin integrity Impaired tissue integrity Risk for infection Acute pain Disturbed body image Deficient knowledge (continued)

15. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Planning and outcome identification –NOC for wounds: Wound healing –Primary intention Wound healing –Secondary intention –Collaboration (continued)

16. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Implementation –Initiate emergency measures –Provide comfort measures –Cleanse wound –Dress wound –Monitor drainage of wound (continued)

17. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Implementation –Provide suture care –Check bandages, binders, and slings –Administer heat and cold therapy (continued)

18. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Wound Healing and the Nursing Process Evaluation –Ongoing process –Skin integrity Maintenance Improvement –Revisions

19. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers Lesions caused by unrelieved pressure and ischemia –Results in damage to underlying tissue

20. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiology of Pressure Ulcers Pressure over time Loss of oxygen to tissue Death of tissue Other forces: –Shearing –Friction

21. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Risk Factors for Pressure Ulcers Immobility Inactivity Incontinence Malnutrition Decreased mental status Diminished sensation Age-related changes

22. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers and the Nursing Process Assessment –Stage I Nonblanchable erythema of intact skin –Stage II Partial thickness skin loss Epidermis or dermis (continued)

23. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers and the Nursing Process Assessment –Stage III Full-thickness skin loss Subcutaneous tissue –Stage IV Full-thickness skin loss Extensive damage to muscle, bone, or supporting structures (continued)

24. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers and the Nursing Process Diagnosis –Similar to wounds Disturbed body image Risk for social isolation Situation low self-esteem related to disturbed body image (continued)

25. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers and the Nursing Process Planning and outcome identification –Similar to wounds Individualized Address: –Overall physical condition –Stage of wound –Client’s risk factors Teaching (continued)

26. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers and the Nursing Process Implementation –Monitor nutritional status –Ensure proper hygiene and skin care –Debride –Provide proper positioning –Employ support surfaces –Employ complementary therapies (continued)

27. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pressure Ulcers and the Nursing Process Evaluation –Consider: Physical signs of healing Status of pressure ulcer Client’s adaptation