1. Chapter 38 Skin Integrity and Wound Care

2. Types of Wounds Intentional or unintentional Open or closed
Acute or chronic
Partial thickness, full-thickness, complex

3. Principles of Wound Healing
Intact skin is the first line of defense against microorganisms.
Surgical asepsis is used in caring for a wound.
The body responds systematically to trauma of any of its parts.
An adequate blood supply is essential for normal body response to injury.
Normal healing is promoted when wound is free of foreign material.

4. Principles of Wound Healing (continued)
The extent of damage and the person’s state of health affects wound healing.
Response to wound is more effective if proper nutrition is maintained.

5. Phase of Wound Healing
Inflammatory
Proliferative
Remodeling

6. Inflammatory Phase Begins at time of injury Prepares wound for healing
Hemostasis (blood clotting) occurs
Vascular and cellular phase of inflammation

7. Proliferative Phase
Phase begins within 2 to 3 days of injury and may last up to 2 to 3 weeks.
New tissue is built to fill wound space through action of fibroblasts.
Capillaries grow across wound.
Thin layer of epithelial cells forms across wound.
Granulation tissue forms foundation for scar tissue development.

8. Remodeling Phase
Final stage of healing begins about 3 weeks after injury to possibly 6 months.
Collagen is remodeled
New collagen tissue is deposited.
Scar becomes a flat, thin, white line.

9. Factors Affecting Wound Healing
Age — children and healthy adults heal more rapidly
Circulation and oxygenation — adequate blood flow is essential
Nutritional status — healing requires adequate nutrition
Wound condition – specific condition of wound affects healing
Health status — corticosteroid drugs and postoperative radiation therapy delay healing

10. Wound Complications Infection Hemorrhage Dehiscence and evisceration
Fistula formation

11. Psychological Effects of Wounds
Pain
Anxiety
Fear
Change in body image

12. Wound Assessment Inspection for sight and smell
Palpation for appearance, drainage, and pain
Sutures, drains or tube, manifestation of complications

13. Presence of Infection Wound is swollen. Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated with dehiscence present.

14. Assessment of Wound Drainage
Serous
Sanguineous
Purulent

15. Purposes of Wound Dressings
Provide physical, psychological, and aesthetic comfort
Remove necrotic tissue
Prevent, eliminate, or control infection
Absorb drainage
Maintain a moist wound environment
Protect wound from further injury
Protect skin surrounding wound

16. Types of Wound Dressings
Telfa
Gauze dressings
Transparent dressings

17. Color Classification of Open Wounds
R = red — proliferative stage of healing; reflect color of normal granulation
Y = yellow — characterized by oozing; need to be cleansed
B = black — covered with thick eschar; require debridement
Mixed wounds — contain components or RY&B wounds

18. Types of Bandages Roller bandages Circular turn Spiral turn
Figure-of-eight turn
Recurrent-stump bandage

19. Types of Binders Straight — used for chest and abdomen
T-binder — used for rectum, perineum, and groin area
Sling — used to support an arm

20. Factors Affecting the Response to Hot and Cold Treatments
Method and duration of application
Degree of heat and cold applied
Patient’s age and physical condition
Amount of body surface covered by the application

21. Effects of Applying Heat
Dilates peripheral blood vessels
Increases tissue metabolism
Reduces blood viscosity and increases capillary permeability
Reduces muscle tension
Helps relieve pain

22. Effects of Applying Cold
Constructs peripheral blood vessels
Reduces muscle spasms
Promotes comfort

23. Devices to Apply Heat Hot water bags or bottles Electric heating pads
Aquathermia pads
Heat lamps
Heat cradles
Hot packs
Moist heat
Sitz baths
Warm soaks

24. Devices to Apply Cold Ice bags Cold packs Hypothermia blankets
Moist cold

25. Topics for Home Care Teaching
Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination

26. Factors Affecting Pressure Ulcer Development
Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders

27. Mechanisms in Pressure Ulcer Development
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood vessels

28. Stages of Pressure Ulcers
Stage I — non-blanchable erythema of intact skin
Stage II — partial-thickness skin loss
Stage III — full-thickness skin loss; not involving underlying fascia
Stage IV — full-thickness skin loss with extensive destruction

29. Norton and Braden scales
Nursing history
Physical assessment

30. Measurement of a Pressure Ulcer
Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract

31. Cleaning a Pressure Ulcer
Clean with each dressing change.
Use careful, gentle motions to minimize trauma.
Use 0.9% normal saline solution to irrigate and clean the ulcer.
Report any drainage or necrotic tissue.

32. Dressing the Pressure Ulcer
Keep ulcer tissue moist and surrounding skin dry.
Place moist dressings only on the wound surface.
Use dressing that absorbs exudate but maintains moist environment.
Use skin sealant or moisture-barrier ointment on surrounding skin.
Secure dressing with the least amount of tape possible.
Use wet-to-dry dressings for debridement, when ordered.
Pack wound cavities loosely with dressing material.