SKIN INTEGRITY AND
WOUND CARE
SKIN AND SKIN
BREAKDOWN
WOUND CLASSIFICATION:
AN INTENTIONAL WOUND
UNINTENTIONAL WOUNDS
AN OPEN WOUND
AN CLOSED WOUND
PHASES OF WOUND HEALING
INFLAMATORY PHASE
FIBROPLASIA (Proliferation )phase
Maturation (remolding) phase
WOUND HEALING PROCESSES
PRIMARY HEALING
SECONDARY HEALING
TERTIARY HEALING
FACTORS AFFECTING WOUND
HEALING
AGE
CIRCULATION & OXYGENATION
WOUND CONDITION
OVERALL PATIENT HEALTH
WOUND COMPLICATIONS
INFECTION:
 Purulent
Drainage
 Increased Drainage
 Pain
 Redness
 Swelling
 Increased Body Temperature
 Increased White Blood Cell Count
(WBC)
DEHISCENCE OR
EVISCERATION DEFINE EACH:
Patients at greatest risk for these
complications Include:
Obese or malnourished
Have infected wounds
Excessive coughing
Vomiting or straining
HEMMORHAGE
Occurrences may be due to:
Slipped sutures
A dislodged clot from stress at the suture
line or operative site
Infection
Erosion of a blood vessel by a foreign
body such as a drain
PSYCHOLOGICAL EFFECTS OF
WOUNDS
PAIN
ANXIETY AND FEAR
ALTERATION IN BODY IMAGE
ASSESSING THE WOUND
Inspection
Sight
Smell
Palpation
Appearance
Drainage
Pain
DIAGNOSING IN WOUND CARE
Altered skin integrity
Risk for infection
Pain
Delayed surgical recovery
Body image disturbance
PLANNING EXPECTED
OUTCOMES FOR WOUND CARE
Facilitating the patients return to health
Providing interventions that facilitate wound
healing
Reduce the risk for complications
Promote psychosocial adaptation
IMPLEMENTING WOUND CARE
Promote wound healing
Prevent further injury
Prevent alterations in skin integrity
Prevent infections
Promote physical and emotional comfort
Facilitate coping
TEACHING FOR HOME CARE OF
A WOUND
Explain the terminology
Identify risk factors
Explain where and how pressure
ulcers develop
Describe various prevention
strategies and options
EVALUATING WOUND CARE
Evaluating is based on the expected
outcome (EO)
No complications
Wound is progressing through the
healing stages
PRESSURE ULCERS:
PATHOLOGY OF ULCER
DEVELOPMENT:
External Pressure
Friction
Shearing Forces
FACTORS AFFECTING
PRESSURE ULCER DEVELOPING
Mobility
Immobility
Nutrition
Hydration
Moisture on the skin
Mental status
Age
PRESSURE ULCER STAGING
Stage I
Stage II
Stage III
Stage IV
ASSESSING THE RISK
FOR:PRESSURE ULCERS
Nursing history
Physical assessment pg.933
Mobility
Nutrition
Incontinence
Use of Braden scale pg.936
ASSESSING: “ACTUAL”
PRESSURE ULCER
1st sign of pressure =“blanching”
(local anemia, is called “ischemia”)
Ischemia is rapid followed by
hyperemia when pressure is relieved.
DIAGNOSING PRESSURE
ULCERS
Impaired Skin Integrity*
The stage of the ulcer is a factor in determining
the nursing diagnosis
Stage I and II pressure = superficial skin damage.
Stage III and IV pressure ulcer = full thickness
skin loss and damage to underlying tissue
Impaired Tissue Integrity is more appropriate*
PLANNING EXPECTED
OUTCOMES FOR PRESSURE
ULCERS
Patient participation
Demonstrate progression in healing of the
ulcer
Demonstrate increase in body wt. and
muscle size
Remain free of infection at the wound site
Develop no new areas of skin breakdown
Demonstrate self-care measures
necessary to prevent development of a
pressure ulcer
IMPLEMENTING
INTERVENTIONS TO PREVENT
PRESSURE ULCERS:
Protecting the skin from external mechanical
forces
Teach patient and caregivers about
prevention
Pressure ulcer care
Cleaning the pressure ulcer
Dressing the pressure ulcer
Controlling infection
Providing care when surgical intervention is
necessary
Evaluate Pressure Ulcer Care
Had the patient and caregiver
participated effectively in prevention
and treatment
Prevention of additional skin
breakdown
Demonstrated progressive healing of
pressure ulcer
Remained free of infection
Improved overall physical condition