Alterations in physical integrity
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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.

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Alterations in Physical Integrity

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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



  • Acute: Wound that proceeds through an orderly and timely reparative process.

  • Chronic: Wound that fails to proceed through an orderly and timely reparative process.

  • Superficial: Wound that involves only epidermal layer of skin.

Stages of Wound HealingRegeneration:The process of tissue renewal

  • Defensive stage (Inflammatory Phase/Reaction) (hemostasis, inflammation, cell migration & epithelialization)

Reconstructive stage

(Proliferative Phase/Regeneration)

  • Filling in of the wound with new connective or granulation tissue

  • the closing of the top of the wound by epitheliazation.

Maturative stage (Maturation Phase /Remodeling)

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.

Classification of Wound Healing

Primary Intention

  • Wounds that heal with little tissue loss.

  • The skin wedges are approximated.

  • Risk of infection is low.

  • Healing occurs quickly:

    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.

Classification of Wound Healing

Secondary Intention

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.

Classification of Wound Healing

Tertiary Intention

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.

Wound Drainage

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.

Factors affecting Wound Healing

Factors Inhibiting Wound Healing: Elderly

Factors Inhibiting Wound Healing: Elderly

Complications of Wound Healing

  • Hemorrhage

  • Dehiscence

  • Evisceration

  • Infection

  • Fistulas

Nursing Process for Wound Management

Untreated Wounds – basic first aide

Treated Wounds – prescribed per M.D. or wound care nurse.

Wound Care Protocol

Wound Assessment

  • Appearance

  • Drainage (penrose, J-P drain, Hemovac)

  • Swelling & Induration

  • Pain

  • Temperature

Sequential signs of primary wound healing:

  • Absence of bleeding

  • Inflammation

  • Granulation tissue

  • Scar formation

  • Reduction in scar size

Lab Data


Hgb, Hct

BUN, Albumin

Wound cultures

MD promotes wound healing

RN provides:

  • Ongoing wound assessment

  • Aseptic wound care according to MD specifications

  • Documentation of wound status

  • Keeps MD apprised of wound status as appro.

To promote healing/prevent complications…

  • Adequate nutrition

  • Prevent wound stress/trauma



    abdominal distention

  • Prevent wound infection

Factors Affecting Wound Care

  • Type of wound

  • Size

  • Drainage/exudate

  • Open vs. closed

  • Wound location

  • MD orders

  • Presence of complications

Drain management

  • Open vs. closed

  • Monitor drainage

  • Universal precautions, aseptic technique

Penrose Drain

Open Drainage System

Jackson Pratt Drain

Close Drainage system


Drainage Collection Bag (T-tubes)

Close Drainage System



Hot/cold applications

Pressure ulcerPressure sore, Decubitus Ulcer

  • Epidermis:

    Stratum corneum

    stratum basale

  • Dermis

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)





Risk Factors for Skin Breakdown

Impaired Sensory input

Impaired motor fx

Alteration in LOC

Orthopedic devices

Any equipment

Shearing Force







Impaired peripheral circulation

Age (elderly)


Contributing Factors

Evaluation Tools

Classification of Pressure Ulcers

Stage I

(no skin loss)

Stage I

(no skin loss)

Stage II

(Shallow crater – involves epidermis and/or dermis)

Stage II

Shallow crater – involves epidermis and/or dermis)

Stage III

(Full thickness involving damage/necrosis of subc. Tissue. Does not extend down through underlying fascia)

Stage III or IV

Four Stages of Ulcers

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