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Chapter 47

Skin Integrity and Wound Care

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Skin

• Structure: epidermis and dermis

• Function

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Pressure Ulcers: Pathogenesis

• Pressure intensity

• Pressure duration

• Tissue tolerance

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Risk for Pressure Ulcer Development

• Impaired sensory perception

• Impaired mobility

• Alteration in level of consciousness

• Shear

• Friction

• Moisture

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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

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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

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Wound Classification

• Skin integrity: open, closed, acute,chronic

• Cause: intentional, unintentional

• Severity of injury: superficial, penetrating, perforating

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Wound Classification (cont'd)

• Cleanliness: clean, clean-contaminated, contaminated, infected, colonized

• Descriptive qualities: laceration, abrasion, contusion

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Process of Wound Healing

• Primary intention

• Secondary intention

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Wound Repair

• Partial thickness: inflammatory response, epithelial proliferation and migration, reestablishment of epidermal layers

• Full thickness: inflammatory phase, proliferative phase, and remodeling

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Complications of Wound Healing

• Hemorrhage—shock

• Infection

• Dehiscence

• Evisceration

• Fistula formation

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Factors Influencing Wounds

• Nutrition

• Tissue perfusion

• Infection

• Age

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Psychosocial Impact of Wounds

• Body image

• Social resources

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Assessment

• Skin: color, temperature, turgor, integrity

• Risk for pressure ulcers: Norton and Braden scales

• Nutritional status

• Exposure of skin to body fluids

• Pain

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Assessment of Traumatic Wounds

• Wounds: emergency setting– Abrasions– Lacerations– Punctures

• Appearance– Amount of bleeding– Size

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Assessment of Wounds in a Stable Setting

• Appearance: size, healing

• Character of drainage: serous, sanguineous, serosanguineous, purulent

• Drains

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Wounds: Stable Setting (cont'd)

• Closures: staples, sutures

• Palpation of wound

• Wound cultures: aerobic, anaerobic

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Nursing Diagnoses

• Risk for infection

• Imbalanced nutrition: less than body requirements

• Pain

• Impaired skin integrity

• Impaired tissue integrity

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Planning

• Goals and outcomes– Wound improvement within 2 weeks– No further skin breakdown– Increase in caloric intake by 10%

• Setting priorities

• Continuity of care

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Implementation: Health Promotion

• Prevention of pressure ulcers – Skin care– Positioning– Use of support surfaces

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Implementation: Acute Care

• Management of pressure ulcers and wounds

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Wound Management

• Prevent and manage infection

• Cleanse the wound

• Remove nonviable tissue

• Manage exudate

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Wound Management (cont'd)

• Protect the wound

• Client education

• Nutritional support

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First Aid for Wounds

• Control of bleeding

• Cleansing

• Application of topical growth factors

• Protection

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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

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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

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Wound Care

• Cleansing skin and drain sites

• Wound irrigations

• Suture/staple care and removal

• Drainage evacuation

• Comfort measures

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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

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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

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Evaluation

• Client care

• Client expectations