Transcript Chapter 48 Skin Integrity and Wound Care
Chapter 48 Skin Integrity and Wound Care
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Scientific Knowledge Base: Skin
Dermal-epidermal junction Separates dermis and epidermis Epidermis Top layer of skin Dermis Inner layer of the skin Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 2
Pressure Ulcers
Pressure ulcer Pressure sore, decubitus ulcer, or bed sore Pathogenesis Pressure intensity Blanching Pressure duration Tissue tolerance Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 3
Risk Factors for Pressure Ulcer Development
Impaired sensory perception Alterations in LOC Impaired mobility Shear Friction Moisture Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 4
Classification of Pressure Ulcers
Stage I Intact skin with nonblanchable redness Stage II Partial-thickness skin loss involving epidermis, dermis, or both Stage III Full-thickness tissue loss with visible fat Stage IV Full-thickness tissue loss with exposed bone, muscle, or tendon Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 5
Classification Wound healing Repair Complications
Wounds
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Nursing Knowledge Base
Prediction and prevention of pressure ulcers Norton Scale • Physical and mental condition, activity, mobility, and continence Braden Scale • Sensory perception, moisture, activity, mobility, nutrition, and friction and shear Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 7
Factors Influencing Pressure Ulcer Formation and Wound Healing
Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 8
Assessment
Skin Presence of ulcers Mobility Nutrition and fluid status Pain Existing wounds, appearance, character Wound culture Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 9
Nursing Diagnosis and Planning
The assessment will reveal important information regarding the client’s status.
Use NANDA-I –approved diagnoses. Write client goals and outcomes specific to the client’s needs.
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Implementation
Health promotion Topical skin care • Protect bony prominences, skin barriers for incontinence.
Positioning • Turn every 1 to 2 hours as indicated.
Support surfaces • Decrease the amount of pressure exerted over bony prominences.
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Acute Care
Wound management Debridement • Mechanical, autolytical, chemical, or surgical/sharp Nutrition Client education Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 12
Dressings
Dry or moist Gauze Hydrocolloid Protects the wound from surface contamination Hydrogel Maintains a moist surface to support healing Wound V.A.C.
Uses negative pressure to support healing Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 13
Dressings
Changing
Know type of dressing, placement of drains, and equipment needed.
Securing
Tape, ties, or binders
Comfort measures
Carefully remove tape.
Gently cleanse the wound.
Administer analgesics before dressing change.
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Wound Cleansing
Cleansing Apply noncytotoxic solution.
Irrigation Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle Suture Care Consult health care facility policy.
Drainage Evacuation Portable units that exert a safe, constant, low-pressure vacuum to remove and collect drainage Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 15
Bandages and Binders
Bandages Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin Binder application Breast, abdominal, sling Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 16
Heat and Cold Therapy
Assessment for temperature tolerance Bodily responses to heat and cold Factors influencing heat and cold tolerance Education Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 17
Evaluation
Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals.
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