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29 Cards in this Set
- Front
- Back
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Chapter 36
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Skin integrity and wound care
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Factors affecting Integumentary function
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Circulation
Nutrition Epidermis integrity Allergies Infection Abnormal growth rate Trauma |
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Adequate nutrition for the skin requires
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Vitamins
Minerals Water Protein |
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Mechanical forces of skin damage include
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Friction
Shear Pressure |
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Risk factors for pressure ulsers
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Friction and shearing
Immobility Inadequate nutrition Fecal and urinary incontinence Decreased mental status Diminished sensation excess body heat Advanced age Chronic mental conditions Poor lifting and transferring Incorrect posturing hard support surfaces Incorret application of pressure relief devices |
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The Braden Scale is used to
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***** risk for skin breakdown
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Four stages of pressure ulser formation
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Stage 1-4
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Stage I
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Skin intact and pink with no blanching
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Stage II
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Some skin loss with open areas
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Stage III
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Loss of sub cutaneous and open wound
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Stage IV
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Full thickness skin loss and exposure of muscle or bone
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Primary intention healing
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Tissue surfaces closed as in the closure of a surgical would
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Secondary intention healing
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Extensive tissue loss with open edges as in a pressure usler.
More complications with healing and infection |
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Tertiary intentional healing
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Wound that is initially left open to clear edema, infection, and exudate. Then closed
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3 phases of wound healing
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Inflammatory
Proliferative Maturation |
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Exudate
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Wound drainage
Exudate Tunneling Tubes/drains Pain |
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Dehiscense
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Wound opening up
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Evisceration
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Guts coming out
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Fistula
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Connections forming between 2 organs
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Systemic factors affecting wound healing
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Nutrition
Decreased O2 Decreased circulation Immunosuppressive drugs |
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Individual factors affecting wound healing
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Age
Obesity Smoking Medication Stress |
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Local factors affecting wound healing
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Mechanism/nature of injury
Presence of infection Local wound environment |
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Eschar
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Dried plasma proteins and dead cells
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Necrosis
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Dead tissue that must be removed
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Nursing diagnosis
Risk for impaired skin integrity |
At risk for skin being adverseily affected
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Nursing diagnosis
Impaired skin integrity |
Altered epidermis and or dermis
Wound may extend through the epidermis, but not the dermis |
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Nursing diangosis
Impaired tissue integrity |
Damage to and tissue type
Wound extends into the subcutaneous, muscle, or bone |
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Nursing diangosis
Risk for infection |
If the skin impairment is severe, pt is immunocompromised, or wound is caused by trauma
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Nursing diangosis
Pain |
Related to nerve involvement or consequence of procedures to treat the wound
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