Alterations in Physical Integrity. Types of Wounds. Wound: disruption of normal anatomical structure and FX that results from pathological processes beginning internally or externally to the involved organ(s). (p. 1551). Classification of Wounds. Open vs. Closed. Acquisition. Contamination.
Alterations in Physical Integrity
Wound: disruption of normal anatomical structure and FX that results from pathological processes beginning internally or externally to the involved organ(s). (p. 1551)
May take more than a year.
Collagen scar continues to reorganize and gain strength for several months.
Usu. scar tissue has fewer pigmented cells and has a lighter color than normal skin.
drainage stops by day 3 of closure,
wound is epitheliazed by day 4,
inflammation is present up to day 5,
healing edge is present by day 9.
Wound edges do not approximate.
Wound is left open until it becomes filled by scar tissue.
Chance of infection is greater.Inflammatory phase is often chronic
Wound filled with granulation tissue (a form of connective tissue that has a more abundant blood supply than collagen.
Scarring is greater.
There is a time delay between the time of the injury and the approximation of the wound edges.
Attempt by surgeon to allow for effective drainage and cleansing of a clean-contaminated or contaminated wound.
Not closed until all evidence of edema and wound debris has been removed.
Dressing is used to protect.
Serous: Clear, watery
Sanguineous: Hemorrhagic. Specify color.
Serosanguinous: pink to light red in color. Thinner than sanguineous.
Purulent: thick drainage that is often yellow-green in color.
Untreated Wounds – basic first aide
Treated Wounds – prescribed per M.D. or wound care nurse.
Wound Care Protocol
Open Drainage System
Close Drainage system
Drainage Collection Bag (T-tubes)
Close Drainage System
Tissue Ischemia: local absence of blood flow/major reduction in blood flow
Blanching: Normal red tones of light-skinned client are absent. Does not occur in clients with darkly pigmented skin.
Darkly pigmented skin: Skin that remains unchanged (does not blanch) when pressure is applied over a boney prominence – irrespective of the client’s race or ethnicity.
Normal Reactive Hyperemia: Visible effect of localized vasodilatation, the body’s normal response to lack of blood flow to the underlying tissue. Area blanches with fingertip pressure. Lasts less than 1 hour.
Abnormal reactive hyperemia: Excessive vasodilatation and induration in response to pressure. The skin appears bright pink to red. Lasts more than 1 hour to 2 weeks after the removal of the pressure. Does not blanch.
Characteristics of Intact Dark Skin that might alert nurses to the potential for pressure ulcers (p. 1546)
Impaired Sensory input
Impaired motor fx
Alteration in LOC
Impaired peripheral circulation
(no skin loss)
(no skin loss)
(Shallow crater – involves epidermis and/or dermis)
Shallow crater – involves epidermis and/or dermis)
(Full thickness involving damage/necrosis of subc. Tissue. Does not extend down through underlying fascia)