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Fundamentals of Nursing NUR 101

2. Chapter 6. Skin Integrity and wound Care. 3. Types of Wounds . Intentional or unintentional .Open or closed.A cute or chronic.Partial thickness, full-thickness, complex.. 4. Principles of Wound Healing . Intact skin is the first line of defense against microorganisms.Surgical asepsis is used in caring for a wound.The body responds systematically to trauma of its parts.An adequate blood supply is essential for normal body response to injury.Normal healing is promoted when wound is free 23

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Fundamentals of Nursing NUR 101

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    1. 1 Fundamentals of Nursing (NUR 101) Prepared by Nabeel Al-Mawajdeh RN.Mcs. King Saud University- Aflaj College

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    3. 3 Types of Wounds Intentional or unintentional . Open or closed. A cute or chronic. Partial thickness, full-thickness, complex.

    4. 4 Principles of Wound Healing Intact skin is the first line of defense against microorganisms. Surgical asepsis is used in caring for a wound. The body responds systematically to trauma of its parts. An adequate blood supply is essential for normal body response to injury. Normal healing is promoted when wound is free of foreign material. The extent of damage and the persons state of health affects wound healing. Response to wound is more effective if proper nutrition is maintained.

    5. 5 Phases of Wound Healing Inflammatory. Proliferative. Remodeling.

    6. 6 Inflammatory Phase Begins at time of injury. Prepares wound for healing: Hemo-stasis (blood clotting) occurs Vascular and cellular phase of inflammation

    7. 7 Proliferative Phase Phase begins within 2 to 3 days of injury and may last up to 2 to 3 weeks. New tissue is built to fill wound space through action of fibroblasts. Capillaries grow across wound. Thin layer of epithelial cells forms across wound. Granulation tissue forms foundation for scar tissue development.

    8. 8 Remodeling Phase Begins about 3 weeks after injury to possibly 6 months. Collagen is remodeled. New collagen tissue is deposited. Scar becomes a flat, thin, white line.

    9. 9 Factors Affecting Wound Healing Age children and healthy adults heal more rapidly. Circulation and oxygenation adequate blood flow is essential. Nutritional status healing requires adequate nutrition. Wound condition specific condition of wound affects healing. Smoking delay healing. Some medications corticosteroid drug and postoperative radiation therapy delay healing.

    10. 10 Wound Complications Infection. Hemorrhage. Dehiscence and evisceration. Fistula formation.

    11. 11 Wound Assessment Inspection for sight and smell. Palpation for appearance, drainage, and pain. Sutures, drains or tube, manifestation of complications .

    12. 12 Signs of Wound Infection Wound is swollen. Wound is deep red in color. Wound feels hot on palpation. Drainage is increased and possibly purulent . Foul odor may be noted . Wound edges may be separated with dehiscence present.

    13. 13 Purposes of Wound Dressings Provide physical , psychological , and aesthetic comfort. Remove necrotic tissue . Prevent, eliminate , or control infection . Absorb drainage . Maintain a moist wound environment . Protect wound from further injury . Protect skin surrounding .

    14. 14 Bedsores ( Pressure Ulcers ) A bed sore or pressure sore is an ulcer occurring on the skin of any bed ridden patients . Particularly over bony prominences or where two skin surfaces press against each other. due to pressure, circulation becomes slow and finally death of tissues occurs .

    15. 15 Common sites liable to get bed sore Occiput . Scapula. Hips. Elbow. Ears.

    16. 16 Stages of Pressure Ulcers Stage 1 non- blanch able erythema of intact of intact skin . Stage 2 partial-thickness skin loss. Stage 3 full-thickness skin loss; not involving underlying fascia. Stage 4- full-thickness skin loss with extensive destruction.

    17. 17 Patients Prone to Pressure Sores Bed ribbon patients. Obese patients . Very thin patients. Patients in traction. Patients in complete bed rest. Diabetic patients.

    18. 18 Signs /Symptoms of Bedsore Redness, heat, and discomfort in the area. Area become cold to touch. Area become blue. Gangrene formation. Sloughing and infection.

    19. 19 Causes of Bedsore Pressure. Friction. Moisture.

    20. 20 Prevention of Bedsore Find out and detect the patients who are prone to bedsores. Daily observation of the rubber rings. Stimulate circulation . Relive pressure by: Moving the patient in bed, changing position every 2 hours. Avoid the use of rubber rings. Use abed cradle to take the weight off the linen. Use pillows between legs. Early ambulation of the patient.

    21. 21 The End

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