Unit 3
Chapter 32: Skin Integrity and
Wound Care
Wound Assessment
Learning Objectives
• Integrate knowledge from the liberal arts; behavioral, social, and
biological sciences; and nursing science when making practice
judgments during the provision and management of safe holistic care for
diverse adult clients and their families.
• Perform all nursing procedures safely.
• Accurately assess and document the condition of wounds.
• Describe developmental and other factors that may affect skin integrity
Case Study
You are a visiting nurse caring for a 32year-old writer who became paraplegic as
a result of a motorcycle accident 1 year
ago. He is recovering from a subsequent
depression; your visits are to monitor his
emotional outlook and also encourage his
hygienic self-care and offer strategies for
success.
Review of General Skin
Assessment
INSPECTION
PALPATION
Case Study
cont…
Upon assessment, we
learn that the patient has
an indwelling catheter
connected to a leg bag
and is incontinent of
stool. You are monitoring
a red spot on his left
buttocks, which has
progressed to a pressure
injury.
Assessment of a wound
• Inspection of wound bed
• Inspection of periwound
• Measurements
• Vital signs including pain
Types of
drainage
• Serous
• Serousanguinous
• Sanguinous
• Purulent
Tunneling
vs.
undermining
Granulation/
Slough/
Eschar
Signs and
symptom of
infection
• Swelling/ edema
• Redness
• Warm to touch
• Increased drainage
• Smell
• Increased temperature
• Increased WBC
Practice
Time!!!
Assess this wound
Assess this
wound
Assess this
wound