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*SAFETY PROTECTION/

*SAFETY PROTECTION/. SKIN INTEGRITY. WOUND CLASSIFICATION. An intentional wound An unintentional wound An open wound A closed wound. PHASES OF WOUND HEALING. Inflammatory phase Fibroplasia (proliferation) phase Maturation (remolding) phase. WOUND HEALING PROCESSES. Primary healing

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*SAFETY PROTECTION/

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  1. *SAFETY PROTECTION/ SKIN INTEGRITY

  2. WOUND CLASSIFICATION • An intentional wound • An unintentional wound • An open wound • A closed wound

  3. PHASES OF WOUND HEALING • Inflammatory 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 • PATIENTS HEALTH/OVERALL CONDITION

  6. WOUND COMPLICATIONS • HEMORRHAGE • DEHISCENCE • EVISCERATION • INFECTION

  7. PSYCHOLOGICAL EFFECTS OF WOUNDS • Pain • Anxiety &Fear • Alterations in body image

  8. ASSESSING THE WOUND • INSPECTION • PALPATION • DRAINAGE • PAIN • SUTURES, STAPLES, DRAINS, TUBES, AND MANIFESTATIONS OF COMPLICATIONS

  9. DIAGNOSING IN WOUND CARE • SKIN INTEGRITY IMPAIRMENT • RISK FOR SKIN INTEGRITY • RISK FOR INFECTION • BODY IMAGE DISTURBANCE

  10. PLANNING: Expected outcomes for pressure ulcers • Patient will: participate in the prescribed treatment to promote healing • Patient will demonstrate progressive healing of the pressure ulcer • Develop no new areas of skin breakdown

  11. IMPLEMENTING WOUND CARE • Teaching for home care of a wound to patient and/or care giver • Implementing every two hour position change schedule • Use of positioning devices for protection and comfort

  12. PRESSURE ULCERS: • PATHOLOGY OF ULCER DEVELOPMENT: • ISCHEMIA • FRICTION • SHEARING FORCE

  13. FACTORS EFFECTING PRESSURE ULCER DEVELOPING • MOBILITY & IMMOBILITY • NUTRITION & HYDRATION • MOISTURE ON THE SKIN • MEMTAL STATUS • AGE

  14. PRESSURE ULCER STAGING • STAGE ONE – non-blanchable erythema of intact skin; the heralding lesion of skin ulceration • STAGE TWO – partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater

  15. PRESSURE ULCER STAGING CON’T. • Stage Three; full thickness skin loss involving epidermis and. The ulcer is superficial and presents clinically as a deep crater with or without undermining of adjacent tissue. • Stage Four; full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure (a.g., tendon, joint capsule)

  16. ASSESSING THE RISK FOR OR ACTUAL PRESSURE ULCER Hx of skin problems trauma, chronic debilitating disease, immobility, age integumentary status, musculoskeletal status nutritional status, HMG/HMT, serum albumin, psychosocial status

  17. DIAGNOSING PRESSURE ULCERS • Risk for impaired skin integrity • Risk for impaired tissue integrity • Risk for infection • Impaired bed mobility • Altered tissue perfusion • Pain • Altered nutrition; less than body requirements

  18. EVALUATING PRESSURE ULCER CARE • Demonstrate progressive healing • Improved overall physical condition • Remains free of infection at any pressure ulcer site • Responds effectively to the teaching strategies and plans • Communicates need for additional support

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