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Chapter 37

Chapter 37. Skin Integrity and Wound Healing. Wounds. Skin Largest organ Primary defense against infection Wound Disruption in integrity of body tissue. Physiology of Wound Healing. Defensive phase Hemostasis and inflammatory Lasts three to four days Reconstructive phase Proliferative

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Chapter 37

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  1. Chapter 37 Skin Integrity and Wound Healing

  2. Wounds • Skin • Largest organ • Primary defense against infection • Wound • Disruption in integrity of body tissue

  3. Physiology of Wound Healing • Defensive phase • Hemostasis and inflammatory • Lasts three to four days • Reconstructive phase • Proliferative • Lasts two to three weeks (continued)

  4. Physiology of Wound Healing • Maturation phase • Continues up to two years or more • Types of healing: • Primary intention • Secondary intention • Tertiary intention (continued)

  5. Physiology of Wound Healing • Kinds of wound drainage: • Serous • Serum • Purulent • Pus • Hemorrhagic • Blood

  6. Factors Affecting Wound Healing • Hemorrhage • Persistent bleeding • Infection • Bacterial wound contamination (continued)

  7. Factors Affecting Wound Healing • Dehiscence • Separation of wound edges • Evisceration • Protruding viscera through wound

  8. Wound Classification • Cause of wounds • Intentional • Occurs during treatment or therapy • Unintentional • Unanticipated • Result of trauma or accident • Greater risk for infection (continued)

  9. Wound Classification • Cleanliness of wounds • Clean • Intentional • No inflammation • Clean-contaminated • Intentional • Involves alimentary, respiratory, genitourinary, and oropharyngeal tracts (continued)

  10. Wound Classification • Cleanliness of wounds • Contaminated • Open, traumatic, and intentional • Nonpurulent inflammation • Dirty and infected • Traumatic • Purulent drainage (continued)

  11. Wound Classification • Wagner ulcer grade classification • Classification by thickness of skin loss • Red-yellow-black (RYB) classification system

  12. Wound Healing and the Nursing Process • Assessment • Health history • Aggravating factors • Alleviating factors • Personal and social history • Functional ability assessment • Physical examination (continued)

  13. Wound Healing and the Nursing Process • Assessment • Wound assessment • Location • Size • General appearance and drainage • Pain • Laboratory data (continued)

  14. Wound Healing and the Nursing Process • Diagnosis • NANDA statements • Impaired skin integrity • Impaired tissue integrity • Risk for infection • Acute pain • Disturbed body image • Deficient knowledge (continued)

  15. Wound Healing and the Nursing Process • Planning and outcome identification • NOC for wounds: • Wound healing • Primary intention • Wound healing • Secondary intention • Collaboration (continued)

  16. Wound Healing and the Nursing Process • Implementation • Initiate emergency measures • Provide comfort measures • Cleanse wound • Dress wound • Monitor drainage of wound (continued)

  17. Wound Healing and the Nursing Process • Implementation • Provide suture care • Check bandages, binders, and slings • Administer heat and cold therapy (continued)

  18. Wound Healing and the Nursing Process • Evaluation • Ongoing process • Skin integrity • Maintenance • Improvement • Revisions

  19. Pressure Ulcers • Lesions caused by unrelieved pressure and ischemia • Results in damage to underlying tissue

  20. Physiology of Pressure Ulcers • Pressure over time • Loss of oxygen to tissue • Death of tissue • Other forces: • Shearing • Friction

  21. Risk Factors for Pressure Ulcers • Immobility • Inactivity • Incontinence • Malnutrition • Decreased mental status • Diminished sensation • Age-related changes

  22. Pressure Ulcers and the Nursing Process • Assessment • Stage I • Nonblanchable erythema of intact skin • Stage II • Partial thickness skin loss • Epidermis or dermis (continued)

  23. Pressure Ulcers and the Nursing Process • Assessment • Stage III • Full-thickness skin loss • Subcutaneous tissue • Stage IV • Full-thickness skin loss • Extensive damage to muscle, bone, or supporting structures (continued)

  24. Pressure Ulcers and the Nursing Process • Diagnosis • Similar to wounds • Disturbed body image • Risk for social isolation • Situation low self-esteem related to disturbed body image (continued)

  25. Pressure Ulcers and the Nursing Process • Planning and outcome identification • Similar to wounds • Individualized • Address: • Overall physical condition • Stage of wound • Client’s risk factors • Teaching (continued)

  26. Pressure Ulcers and the Nursing Process • Implementation • Monitor nutritional status • Ensure proper hygiene and skin care • Debride • Provide proper positioning • Employ support surfaces • Employ complementary therapies (continued)

  27. Pressure Ulcers and the Nursing Process • Evaluation • Consider: • Physical signs of healing • Status of pressure ulcer • Client’s adaptation

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