Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Lesson Plan
Chapter 31, Skin Integrity and Wound Care
Goals of the Lesson:
Cognitive: Students will be able to discuss the processes involved in wound healing and list factors that affect it. They will be able to identify patients at risk for pressure ulcer
development, explain the method of staging of pressure ulcers, and provide nursing interventions to prevent pressure ulcers. Students will be able to accurately assess and
document the condition of wounds, implement appropriate dressing changes for different kinds of wounds, and provide information to patients and caregivers for self-care of
wounds at home. They will be able to apply hot and cold therapy effectively and safely.
Learning Objectives:
The lesson plan for each objective starts on the next page.
31.1 Discuss the processes involved in wound healing..................................................................................................................................................................................................... 2
31.2 Identify factors that affect wound healing................................................................................................................................................................................................................. 5
31.3 Identify patients at risk for pressure ulcer development. .......................................................................................................................................................................................... 7
31.4 Describe the method of staging of pressure ulcers. ................................................................................................................................................................................................... 9
31.5 Accurately assess and document the condition of wounds. .................................................................................................................................................................................... 12
31.6 Provide nursing interventions to prevent pressure ulcers. ....................................................................................................................................................................................... 14
31.7 Implement appropriate dressing changes for different kinds of wounds. ................................................................................................................................................................ 18
31.8 Provide information to patients and caregivers for self-care of wounds at home. .................................................................................................................................................. 21
31.9 Apply hot and cold therapy effectively and safely. ................................................................................................................................................................................................. 22
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Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.1 Discuss the processes involved in wound healing.
Lecture Outline
Content
 Discuss the anatomy and
physiology of the integumentary
system and how the state of a
person’s health and therapeutic
treatments have a direct effect on
the condition of the skin.
 Teach your students how wounds
occur (mechanical forces or
physical injury). Discuss types of
wounds (intentional,
unintentional, open and closed,
acute and chronic, partial
thickness, full thickness,
complex) and their causes.
 Make sure your students
understand the physiology of
wound healing and can describe
the four phases of wound healing
(hemostasis, inflammatory,
proliferation, maturation).
Brainstorm with the class to
develop a list of the
characteristics of each phase.
 Discuss the interventions that
help support the healing process
of a wound.
Text
page
955–
963
PPT
slide
2–20
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Figures
Pre-Lecture Quizzes
Written Assignments
31-1 A cross-section
of normal skin, p.
957, PPT slide 5
True/False
 Wounds that heal by
tertiary intention are
wounds left open for
several days to allow
edema or infection to
resolve or fluid to drain.
 Granulation tissue forms
the foundation for scar
tissue development during
the proliferation phase of
wound healing.
Visit a health care
facility to assess and
document the condition
of a patient recovering
from a serious wound.
Write a brief report
discussing the process
of wound healing, the
factors that affect this
process, and the
condition of the wound
assessed.
Discussion Topics
Test Generator
Questions
Tables
31-1 Functions of the
Skin, p. 958
31-2 Factors Placing
an Individual at Risk
for Skin Alterations,
p. 959
31-3 Types of
Wounds, p. 961
Boxes
31-1 Principles of
Wound Healing,
p. 962
Reflective Practice:
Cultivating QSEN
Competencies
Challenge to Ethical
and Legal Skills,
pp. 956–957
Focus on the Older
Adult
Nursing Strategies to
Address Age-Related
Page 2 of 22
Copyright © 2015 Wolters Kluwer
Compare and contrast the
healing process (including
factors that will affect that
process) between the following
two patients: An elderly
patient who presented with a
stage I pressure ulcer last week
and a 25-year-old with an
abdominal stab wound that was
surgically repaired 2 days ago.
Case Studies
You are a nurse in a medical–
surgical unit in a hospital
caring for a 27-year-old
professional football player
who underwent surgery to
repair a compound fracture of
Use the test generator
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questions related
specifically to this
objective.
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*Study Guide
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
Changes in Skin,
p. 960
his femur. The surgery went
smoothly and you are
responsible for his
postoperative care after he
returns from PACU.
 What is his skin’s role in
preventing infection
before surgery?
 Describe how you would
expect his wound to heal.
 Indicate factors that could
affect the healing of his
surgical wound.
 For which complications
would you monitor his
wound?
 Outline signs and
symptoms that might
indicate his wound is
infected. In what time
frame might they appear?
Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Concepts in Action
Animations


Hemostasis
Wound Healing
Journal Article
Medical Adhesives and Patient
Safety Consensus Statements
for the Assessment,
Prevention, and Treatment of
Adhesive-Related Skin
Page 3 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
Injuries. Journal of the
Dermatology Nurses'
Association.
Spanish-English Audio
Glossary
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Page 4 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.2 Identify factors that affect wound healing.
Lecture Outline
Content
Text
page
 Discuss the factors that affect
963–
wound healing (age, circulation
966
to and oxygenation of tissues,
nutritional status, condition of the
wound, immunosuppression,
medications, overall patient
health).
 Review the complications that
may occur with wound healing
(infection, hemorrhage,
dehiscence and evisceration,
fistula formation) and the
psychological effects of wounds
on the patient (pain, anxiety, fear,
impact on activities of daily
living, change in body image).
Page 5 of 22
Copyright © 2015 Wolters Kluwer
PPT
slide
21–27
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Figures
Pre-Lecture Quizzes
Written Assignments
31-2 Wound
Fill-in-the-Blank
complications, p. 965,  The partial or total
PPT slide 26
separation of wound layers
is known as
31-3 Fistula, p. 966
________________, the
result of excessive stress
Focus on the Older
on wounds that are not
Adult
healed.
Nursing Strategies to
Address Age-Related Discussion Topics
Changes in Wound
Compare and contrast the
Healing, p. 964
healing process (including
factors that will affect that
process) between the following
two patients: An elderly
patient who presented with a
stage I pressure ulcer last week
and a 25-year-old with an
abdominal stab wound that was
surgically repaired 2 days ago.
Visit a health care
facility to assess and
document the condition
of a patient recovering
from a serious wound.
Write a brief report
discussing the process
of wound healing, the
factors that affect this
process, and the
condition of the wound
assessed.
Group Assignments
Interview experienced
nurses in various health
care settings about their
experience with caring
for patients with
pressure ulcers. Then,
answer the following
List all the physical factors you related questions and
share your findings in a
can think of that can affect
class discussion:
wound healing, and provide a
strategy to facilitate healing for  What types of
each factor.
patients may be
predisposed to the
Case Studies
condition?
You are a nurse in a medical–
 What factors
surgical unit in a hospital
contribute to the
caring for a 27-year-old
development of
professional football player
pressure ulcers?
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
who underwent surgery to
repair a compound fracture of
his femur. The surgery went
smoothly and you are
responsible for his
postoperative care after he
returns from PACU.
 What is his skin’s role in
preventing infection
before surgery?
 Describe how you would
expect his wound to heal.
 Indicate factors that could
affect the healing of his
surgical wound.
 For which complications
would you monitor his
wound?
 Outline signs and
symptoms that might
indicate his wound is
infected. In what time
frame might they appear?
Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Spanish-English Audio
Glossary




What treatment do
you find most
effective?
How do you
attempt to prevent
pressure ulcers in
your patients?
Have you
incorporated any
new methods for
treating pressure
ulcers in your care
plan?
What is the
psychological effect
of pressure ulcers
on the patient?
Test Generator
Questions
Use the test generator
software to identify
questions related
specifically to this
objective.
*Adaptive Learning
Powered by prepU
Individualized, adaptive
learning through
quizzing and
remediation is available
for this chapter.
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Page 6 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.3 Identify patients at risk for pressure ulcer development.
Lecture Outline
Content
Text
page
 Make sure your students
966–
understand pressure ulcer
968
formation and the underlying
causes of pressure ulcers. Review
the factors that place patients at
risk for pressure ulcers (aging
skin, chronic illnesses,
immobility, malnutrition, fecal
and urinary incontinence, altered
level of consciousness, spinal
cord and brain injuries,
neuromuscular disorders).
 Discuss the mechanisms that
contribute to pressure ulcer
development including external
pressure, friction, and shearing
forces.
Page 7 of 22
Copyright © 2015 Wolters Kluwer
PPT
slide
28–29
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Figures
Pre-Lecture Quizzes
Written Assignments
31-4 Common sites
Fill-in-the-Blank
for development of
 A __________ ulcer, a
pressure ulcers, p. 967
localized area of injury to
the skin, may develop
31-5 Shearing forces
when soft tissue is
can occur when a
compressed between a
patient is moved
bony prominence and an
carelessly or slides
external surface.
down in bed, p. 967
 Patients who are pulled,
rather than lifted, when
Boxes
being moved up in bed or
31-2 Risk Factors for
from the bed to the chair
Pressure Ulcer
are at risk for injury from
Development, p. 968
____________ forces.
Visit a health care
facility to assess and
document the condition
of a patient recovering
from a serious wound.
Write a brief report
discussing the process
of wound healing, the
factors that affect this
process, and the
condition of the wound
assessed.
Group Assignments
Interview experienced
nurses in various health
care settings about their
Outline strategies to prevent
experience with caring
pressure ulcer development in
for patients with
patients.
pressure ulcers. Then,
answer the following
Case Studies
You are a visiting nurse caring related questions and
share your findings in a
for a 32-year-old writer who
class discussion:
became paraplegic as a result
of a motorcycle accident 1 year  What types of
patients may be
ago. He is recovering from a
predisposed to the
subsequent depression; your
condition?
visits are to monitor not only
his emotional outlook but also  What factors
contribute to the
to encourage his hygienic selfdevelopment of
care and offer strategies for his
pressure ulcers?
Discussion Topics
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
success. He wears a leg bag
and is incontinent of stool. You
are monitoring a red spot on
his left buttock, which has
progressed to a pressure ulcer
in which subcutaneous fat is
visible.
 Outline the mechanisms
that contributed to the
development of the
pressure ulcer.
 What specific assessments
should be performed to
prevent formation of
pressure ulcers?
 How would you stage his
pressure ulcer?
 Indicate the information
that would be included in
an assessment of his
wound.
 Identify appropriate
outcomes for this patient’s
plan of care.




What treatment do
you find most
effective?
How do you
attempt to prevent
pressure ulcers in
your patients?
Have you
incorporated any
new methods for
treating pressure
ulcers in your care
plan?
What is the
psychological effect
of pressure ulcers
on the patient?
Test Generator
Questions
Use the test generator
software to identify
questions related
specifically to this
objective.
Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Spanish-English Audio
Glossary
*Adaptive Learning
Powered by prepU
Individualized, adaptive
learning through
quizzing and
remediation is available
for this chapter.
*Study Guide
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Page 8 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.4 Describe the method of staging of pressure ulcers.
Lecture Outline
Content
 Be sure your students understand
how pressure ulcers develop
from blanching of the skin
through the four stages of
pressure ulcer development.
 Review the process for cleaning
and dressing a pressure ulcer.
Page 9 of 22
Copyright © 2015 Wolters Kluwer
Text
page
968–
971
PPT
slide
30–35
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Boxes
Pre-Lecture Quizzes
Written Assignments
31-3 Comparison of
Stages of Pressure
Ulcers, pp. 970–971
True/False
 The first indication that a
pressure ulcer may be
developing is a blanching
of the skin over the area
under pressure.
Research in Nursing
Bridging the Gap to
Evidence-Based
Practice,
p. 969
Visit a health care
facility to assess and
document the condition
of a patient recovering
from a serious wound.
Write a brief report
discussing the process
of wound healing, the
Case Studies
You are a visiting nurse caring factors that affect this
process, and the
for a 32-year-old writer who
condition of the wound
became paraplegic as a result
of a motorcycle accident 1 year assessed.
ago. He is recovering from a
Make a list of the type
subsequent depression; your
of blended skills you
visits are to monitor not only
his emotional outlook but also will need to diagnose
to encourage his hygienic self- and treat patients with
care and offer strategies for his alterations in skin
integrity.
success. He wears a leg bag
and is incontinent of stool. You
Group Assignments
are monitoring a red spot on
Interview experienced
his left buttock, which has
nurses in various health
progressed to a pressure ulcer
care settings about their
in which subcutaneous fat is
experience with caring
visible.
for patients with
 Outline the mechanisms
pressure ulcers. Then,
that contributed to the
answer the following
development of the
related questions and
pressure ulcer.
 What specific assessments share your findings in a
class discussion:
should be performed to
 What types of
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care



prevent formation of
pressure ulcers?
How would you stage his
pressure ulcer?
Indicate the information
that would be included in
an assessment of his
wound.
Identify appropriate
outcomes for this patient’s
plan of care.



Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Spanish-English Audio
Glossary


patients may be
predisposed to the
condition?
What factors
contribute to the
development of
pressure ulcers?
What treatment do
you find most
effective?
How do you
attempt to prevent
pressure ulcers in
your patients?
Have you
incorporated any
new methods for
treating pressure
ulcers in your care
plan?
What is the
psychological effect
of pressure ulcers
on the patient?
Clinical Assignments
Work in pairs to identify
the pressure points on
the body most
susceptible to the
development of a
pressure ulcer. Devise
positions to alleviate
specific pressure ulcers
and eliminate the effect
of friction and shearing
forces.
Test Generator
Page 10 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
Questions
Use the test generator
software to identify
questions related
specifically to this
objective.
*Adaptive Learning
Powered by prepU
Individualized, adaptive
learning through
quizzing and
remediation is available
for this chapter.
*Study Guide
Legend: IR: Instructor’s Resource; SR: Student’s Resource; PPT: PowerPoint (IR); *Premium content: additional purchase required
Page 11 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.5 Accurately assess and document the condition of wounds.
Lecture Outline
Content
 Teach your students to use the
nursing process for wound
assessment. Discuss the
techniques (inspection and
palpation) used to assess wounds
and make other important
assessment observations (such as
the existence of sutures, drains or
tubes, manifestations of
complications).
 Review the NANDA nursing
diagnoses in the textbook and
brainstorm with the class to
develop a list of possible
diagnoses for patients with
wounds.
Text
page
973–
981,
995–
996
PPT
slide
32,
36–37
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Figures
Pre-Lectures Quizzes
Written Assignments
31-6 Incision with
sutures, p. 976
True/False
 Serosanguineous drainage,
which is clear and watery,
is composed primarily of
the clear, serous portion of
the blood and from serous
membranes.
 There is no standard
frequency for how often
dressings should be
changed.
Visit a health care
facility to assess and
document the condition
of a patient recovering
from a serious wound.
Write a brief report
discussing the process
of wound healing, the
factors that affect this
process, and the
condition of the wound
assessed.
31-7 Braden scale for
predicting pressure
sore risk, p. 977
31-8 Pressure Ulcer
Scale for Healing
(PUSH) PUSH Tool
3.0, p. 979, PPT slide
32
31-19 Wound and
skin assessment/
documentation tool,
p. 995
31-20 Electronic
wound and skin
assessment/
documentation tool,
p. 996
Tables
31-4 Common Types
of Drains, p. 975
Boxes
31-4 RYB Wound
Classification, p. 976
Page 12 of 22
Copyright © 2015 Wolters Kluwer
Fill-in-the-Blank
 Dead tissue that appears as
dry, black, and leathery is
known as ________,
which delays wound
healing.
Make a list of the type
of blended skills you
will need to diagnose
and treat patients with
alterations in skin
integrity.
Case Studies
You are a visiting nurse caring
for a 32-year-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 not only
his emotional outlook but also
to encourage his hygienic selfcare and offer strategies for his
success. He wears a leg bag
Test Generator
Questions
Use the test generator
software to identify
questions related
specifically to this
objective.
*Adaptive Learning
Powered by prepU
Individualized, adaptive
learning through
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
Focused
Assessment Guide
and is incontinent of stool. You
are monitoring a red spot on
Skin Integrity, p. 974 his left buttock, which has
progressed to a pressure ulcer
Guidelines for
in which subcutaneous fat is
Nursing
visible.
31-1 Measuring
 Outline the mechanisms
Wounds and Pressure
that contributed to the
Ulcers, p. 975
development of the
pressure ulcer.
Examples of

What specific assessments
NANDA-I Nursing
should be performed to
Diagnoses
prevent formation of
Patient With a Wound
pressure ulcers?
or Pressure Ulcer, p.

How would you stage his
980
pressure ulcer?
Examples of Nursing  Indicate the information
Interventions and
that would be included in
Nursing Outcomes
an assessment of his
Classifications
wound.
(NIC/NOC)
 Identify appropriate
Risk for Impaired
outcomes for this patient’s
Skin Integrity, p. 981
plan of care.
Promoting Health
Literacy
In Patients With
Breast Cancer, p. 981
quizzing and
remediation is available
for this chapter.
*Lippincott DocuCare:
Fundamentals: Wound
Care: Irwina
Russellinski
*Study Guide
Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Spanish-English Audio
Glossary
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Page 13 of 22
Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.6 Provide nursing interventions to prevent pressure ulcers.
Lecture Outline
Content
 Teach your students to use the
nursing process to develop a plan
of care to prevent or minimize
pressure ulcers. Explain to your
students how to use risk
assessment forms such as the
Norton scale and the Braden
scale.
 Discuss the type of information
that should be collected in a
nursing history designed to
assess for skin integrity.
 Discuss nursing interventions to
prevent injury to the skin and to
promote optimal health.
Page 14 of 22
Copyright © 2015 Wolters Kluwer
Text
page
981–
982,
994
PPT
slide
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Guidelines for
Nursing Care
Discussion Topics
Written Assignments
Outline strategies to prevent
pressure ulcer development in
patients.
Make a list of the type
of blended skills you
will need to diagnose
and treat patients with
alterations in skin
integrity.
31-2 Preventing
Pressure Ulcers,
p. 982
Case Studies
You are a visiting nurse caring
for a 32-year-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 not only
his emotional outlook but also
to encourage his hygienic selfcare and offer strategies for his
success. He wears a leg bag
and is incontinent of stool. You
are monitoring a red spot on
his left buttock, which has
progressed to a pressure ulcer
in which subcutaneous fat is
visible.
 Outline the mechanisms
that contributed to the
development of the
pressure ulcer.
 What specific assessments
should be performed to
prevent formation of
pressure ulcers?
 How would you stage his
pressure ulcer?
Group Assignments
Interview experienced
nurses in various health
care settings about their
experience with caring
for patients with
pressure ulcers. Then,
answer the following
related questions and
share your findings in a
class discussion:
 What types of
patients may be
predisposed to the
condition?
 What factors
contribute to the
development of
pressure ulcers?
 What treatment do
you find most
effective?
 How do you
attempt to prevent
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care


Indicate the information
that would be included in
an assessment of his
wound.
Identify appropriate
outcomes for this patient’s
plan of care.
Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Spanish-English Audio
Glossary


pressure ulcers in
your patients?
Have you
incorporated any
new methods for
treating pressure
ulcers in your care
plan?
What is the
psychological effect
of pressure ulcers
on the patient?
Interview someone with
a skin alteration
regarding the
psychological effects
that person is
experiencing as well as
the effect of the wound
on the person’s
activities of daily living.
After preparing a list of
possible effects, identify
nursing interventions to
minimize these
complications. In a class
discussion, express
whether you feel
comfortable taking care
of a patient with a skin
alteration and what you
could do to improve
your skills in this area.
Clinical Assignments
Work in pairs to identify
the pressure points on
the body most
Page 15 of 22
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Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
susceptible to the
development of a
pressure ulcer. Devise
positions to alleviate
specific pressure ulcers
and eliminate the effect
of friction and shearing
forces.
Web Assignments
Search the Internet for
nursing articles
discussing new methods
of treating pressure
ulcers. Identify
information patients
may need to care for
their wounds at home.
Report your findings to
the class.
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software to identify
questions related
specifically to this
objective.
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Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
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Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.7 Implement appropriate dressing changes for different kinds of wounds.
Lecture Outline
Content
Text
page
 Describe the two methods of
982–
caring for wounds (closed
993
method and open method) and
review when and why each
method is used.
 Discuss the types and purposes of
dressings available for wound
healing. Make sure the students
understand that the number and
types of dressings used depend
on the location and size of the
wound and the amount and type
of drainage.
 Review the procedure for
cleaning a wound and changing a
dressing. Demonstrate the
procedure and have the students
practice it with a partner.
 Discuss the use of wound drains,
tubes, and catheters and how to
care for them.
 Review the procedure for
obtaining a wound culture.
 Discuss the care of open wounds,
infected wounds, and chronic
wounds. Review the color
classification system for care of
an open wound (R, Y, B).
PPT
slide
35–46
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Figures
Pre-Lecture Quizzes
Group Assignments
31-9 Surgical pad
applied as last layer
of wound dressing,
p. 983
Fill-in-the-Blank
 Ties attached to an
adhesive backing to hold
dressings in place are
known as _____________
straps.
Interview someone with
a skin alteration
regarding the
psychological effects
that person is
experiencing as well as
the effect of the wound
on the person’s
activities of daily living.
After preparing a list of
possible effects, identify
nursing interventions to
minimize these
complications. In a class
discussion, express
whether you feel
comfortable taking care
of a patient with a skin
alteration and what you
could do to improve
your skills in this area.
3-10 Precut dressing
placed around
surgical drain, p. 983
31-11 Transparent
film dressing placed
on intravenous access
site, p. 984
31-12 Hydrocolloid
dressing in place on
wound, p. 984
31-13 Techniques for
applying various
bandages, p. 989
31-14 Montgomery
straps make it
possible to care for a
wound without
removing adhesive
strips with each
dressing change, p.
990
31-15 Penrose drain,
Page 18 of 22
Copyright © 2015 Wolters Kluwer
Apply the Concepts
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Watch & Learn Videos

Skin Integrity and Wound
Care: Irrigating a Wound
Using Sterile Technique
Practice & Learn Interactive
Case Studies

Cleaning a Wound and
Applying Sterile Dressing
Spanish-English Audio
Glossary
Clinical Assignments
Your teacher will
provide a variety of
bandages, binders,
and/or other wound care
products. Take turns
demonstrating their use
by applying them to a
partner while ensuring
asepsis.
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
p. 990, PPT slide 44
31-16 Jackson-Pratt
drain, p. 991, PPT
slide 45
31-17 Hemovac drain,
p. 991
31-18 Applying SteriStrips on an incision,
p. 992
Tables
31-5 Examples of
Wound
Dressings/Products,
pp. 985–986
31-6 Types of Tape,
p. 988
Guidelines for
Nursing Care
31-3 Cleaning
Wounds, p. 987
31-4 Applying
Bandages and
Binders, p. 988
31-5 Removing
Staples and Sutures,
p. 993
Skills

Page 19 of 22
Copyright © 2015 Wolters Kluwer
31-1 Cleaning a
Wound and
Applying a Dry,
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*Study Guide
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care






Sterile Dressing,
pp. 1004–1009
31-2 Applying a
Saline-Moistened
Dressing, pp.
1009–1012
31-3 Performing
Irrigation of a
Wound, pp.
1013–1016
31-4 Caring for a
Jackson-Pratt
Drain, pp. 1017–
1019
31-5 Caring for a
Hemovac Drain,
pp. 1019–1022
31-6 Collecting a
Wound Culture,
pp. 1022–1026
31-7 Applying
NegativePressure Wound
Therapy, pp.
1026–1029
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Copyright © 2015 Wolters Kluwer
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.8 Provide information to patients and caregivers for self-care of wounds at home.
Lecture Outline
Content
 Review the methods for
obtaining dressing supplies and
reimbursement for these supplies.
Discuss infection prevention in
the home, and interventions to
promote wound healing.
 Discuss the following sentence:
“Education is a vital component
in the treatment of pressure
ulcers.” What is the nurse's role
in educating the patient and
family regarding management
and treatment strategies?
Text
page
972–
973,
993–
994
PPT
slide
47–48
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Focused Critical
Thinking Guide
Apply the Concepts
Web Assignments
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Search the Internet for
nursing articles
discussing new methods
of treating pressure
ulcers. Identify
information patients
may need to care for
their wounds at home.
Report your findings to
the class.
31-1 Wound Care:
Promoting
Acceptance of
Changes in Body
Image, p. 972
Teaching Tips
31-1 Wound Care and
Healing, p. 994
Spanish-English Audio
Glossary
Test Generator
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Use the test generator
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questions related
specifically to this
objective.
*Adaptive Learning
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*Study Guide
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Page 21 of 22
Copyright © 2015 Wolters Kluwer
Instructor’s Notes
Taylor, Lillis, Lynn, & LeMone: Fundamentals of Nursing: The Art and Science of Person-Centered Nursing Care, 8th Edition
Chapter 31, Skin Integrity and Wound Care
31.9 Apply hot and cold therapy effectively and safely.
Lecture Outline
Content
Text
page
 Teach your students how to apply 996–
heat and cold to a specific part or 1003
all of a patient's body to bring
about local or systemic change in
body temperature. Discuss the
various devices for applying heat
or cold.
 Explain the physiologic effects of
the application of heat and cold
and the nursing care necessary
for patients receiving heat and
cold therapy.
PPT
slide
49–53
Figures, Tables, and
Features
Resources and In-Class
Activities
Outside Assignments/
Evaluation
Figures
Apply the Concepts
Web Assignments
31-21 Cloth-wrapped
ice bag, p. 1000
NCLEX-Style Review
Questions: Students can use
the NCLEX-Style Review
Questions to review and
practice for the NCLEX.
Use the Internet to
research the use of hot
and cold therapy for
bringing about a change
in body temperature.
Note any new therapies
regarding this practice,
and report your findings
to the class.
Guidelines for
Nursing Care
31-6 Assisting With a
Sitz Bath, p. 999
Nursing Plan of Care
31-1 For Mary
Biesicker, pp. 1002–
1003
Features
Concept map
displaying the nursing
process for Lucius
Everly, p. 1001
Skills

31-8 Applying an
External Heating
Pad, pp. 1030–
1032
Spanish-English Audio
Glossary
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software to identify
questions related
specifically to this
objective.
*Adaptive Learning
Powered by prepU
Individualized, adaptive
learning through
quizzing and
remediation is available
for this chapter.
*Study Guide
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Page 22 of 22
Copyright © 2015 Wolters Kluwer
Instructor’s Notes