SKIN INTEGRITY AND WOUND CARE

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