Академический Документы
Профессиональный Документы
Культура Документы
CARE
JPP
SKIN INTEGRITY
Hypodermis
Temperature regulation via vasodilation,
Dermis
Protects against blood loss.
Synthesis of pigments and vitamin D
Temperature regulation via vasodilation,
Epidermis
Protects against: dehydration, mechanical
TYPES OF WOUNDS
INTENTIONAL
Occur during therapy
Ex. Operations or venipuncture.
UNINTENTIONAL
Accidental trauma
Ex. Fractured arm in an
automobile collision.
TYPES OF WOUNDS
CLOSED
If the tissues are traumatized without a
OPEN
When the skin or mucous membrane
surface is broken.
TYPE
CAUSE
DESCRIPTION&CHARACTERISTICS
INCISION
Sharp instrument
CONTUSION
ABRASION
PUNCTURE
Open wound
LACERATION
Tissues torn apart, often Open wound; edges are often jagged
from accidents (e.g.,
with machinery)
PENETRATIN
G WOUND
Open wound
TYPES OF WOUNDS
Incision
TYPES OF WOUNDS
TYPES OF WOUNDS
TYPES OF WOUNDS
-wounds
CLEAN WOUNDS
CLEAN-CONTAMINATED WOUNDS
CONTAMINATED WOUNDS
DIRTY OR INFECTED WOUNDS
TYPES OF WOUNDS
CLEAN WOUNDS
Uninfected wounds in which minimal
inflammation is encountered
The respiratory, alimentary, genital, and
urinary tracts are not entered.
Primarily closed wounds.
TYPES OF WOUNDS
CLEAN-CONTAMINATED WOUNDS
Surgical wounds in which the
respiratory, alimentary, genital or
urinary tract has been entered.
Such wounds show no evidence of
infection.
TYPES OF WOUNDS
CONTAMINATED WOUNDS
Include open, fresh, accidental
wounds and surgical wounds
involving a major break in sterile
technique or a large amount of
spillage from the GI tract .
Show evidence of inflammation.
TYPES OF WOUNDS
Degree of wound
contamination
Degree of wound
contamination
TYPES OF WOUNDS
Wounds are also classified by depth (tissue
layers involved)
PARTIAL THICKNESS
Confined to the skin, that is, the dermis
and epidermis.
Heal by regeneration.
FULL THICKNESS
Involving the dermis, epidermis,
WOUND HEALING
REGENERATION
(RENEWAL OF TISSUES)
TYPES OF WOUND
HEALING*
PHASES OF WOUND
HEALING
INFLAMMATORY PHASE
PROLIFERATIVE PHASE
MATURATION OR REMODELING PHASE
INFLAMMATORY PHASE
Initiated immediately after injury and lasts 3 to 6 days.
2 major processes occur during this phase: hemostasis and
phagocytosis.
Hemostasis
The cessation of bleeding
Results from vasoconstriction of the larger blood vessels in
the affected area, retraction (drawing back) of injured
blood vessels, the deposition of fibrin (connective tissue)
and the formation of blood clots in the area. *
A scab also forms on the surface of the wound.*
Below the scabs, epithelial cells migrate into the
wound from the edges.
The epithelial cells serve as a barrier between the
body and the environment, preventing the entry of
microorganisms.
INFLAMMATORY PHASE
Cellular response
During cell migration, leukocytes (specifically
,neutrophils) move into the interstitial space.
These are replaced about 24hours after injury by
macrophages, which arise from the blood monocytes.
The macrophages engulf microorganisms and cellular
debris by a process known as PHAGOCYTOSIS.
The macrophages also secrete an angiogenesis factor
(AGF), which stimulates the formation of epithelial
buds at the end of injured blood vessels.
The microcirculatory network that results sustains the
healing process and the wound during its life.
This inflammatory response is essential to healing,
and measures that impair inflammation, such as
steroid medications, can place the healing process at
risk.
PROLIFERATIVE PHASE
MATURATION PHASE
KINDS OF WOUND
DRAINAGE
Serous exudate
Consists chiefly of serum
derived from blood and the
serous membranes of the body,
such as the peritoneum.
Looks watery and has few cells.
E.g., the fluid in a blister from a
burn
KINDS OF WOUND
DRAINAGE
Purulent exudate
Thicker than serous exudate because of the
presence of pus.
Pus - consist of leukocytes, liquefied dead
tissue debris, and dead and living bacteria.
SUPPURATION- the process of pus
formation
PYOGENIC BACTERIA- bacteria that
produce pus. *
Vary in color, some acquiring tinges of blue,
green, or yellow.*
KINDS OF WOUND
DRAINAGE
COMPLICATIONS OF
WOUND HEALING
BLEEDING
(HEMORRHAGE)
INFECTION
DEHISCENCE (WITH
POSSIBLE EVISCERATION)
COMPLICATIONS OF
WOUND HEALING
Hemorrhage
Massive bleeding
May be caused by a dislodged clot, a
COMPLICATIONS OF
WOUND HEALING
Hemorrhage
The risk is greatest during the
first 48hours after surgery.*
Is an emergency case.
Nursing responsibility: the
nurse should apply pressure
dressings to the area and
monitor the clients vital
COMPLICATIONS OF
WOUND HEALING
INFECTION*
Occurs when the microorganisms colonizing the wound
COMPLICATIONS OF
WOUND HEALING
COMPLICATIONS OF
WOUND HEALING
DEHISCENCE
COMPLICATIONS OF
WOUND HEALING
DEHISCENCE
Nursing responsibility
AGE
NUTRITIONAL STATUS
LIFESTYLE
MEDICATIONS
NURSING MANAGEMENT
Assessment
Skin integrity
Wounds
Nursing Interventions
NURSING MANAGEMENT
TREATED WOUNDS
Sutured wounds
Usually assessed to determine the progress of
healing.
These wounds may be inspected during changing
of a dressing.
If the wound itself cannot be directly inspected,
the dressing is inspected and other data regarding
the wound (e.g., the presence of pain)*
Nursing Responsibility-Observe its appearance, size,
drainage, and the appearance of swelling, pain, and
status of drains or tubes.
NURSING MANAGEMENT
Undermining
-occurs when the wound reaches under the skin surface.
-The edges of the wound around an open center may be raw or
appear healed but the undermining can result in a sinus tract or
tunnel that extends the wound many centimeters beyond the
main wound surface.
-to fully assess the size of the wound explore the undermined
area with a thin, flexible probe. Once the end of the tract is
reached, gently raise the probe so that the bulge created by the
end can be seen and its length measured on the skin surface.*
-sinus tracts are often caused by infection and have significant
drainage.
-treatment: antibiotics, irrigation, surgical incision to open and
drain the tract, or vacuum therapy for large tracts.
NURSING MANAGEMENT
DIAGNOSING
Risk for Impaired Skin
Integrity
Impaired Skin Integrity
Impaired Tissue Integrity
Risk for Infection
Pain
NURSING MANAGEMENT
PLANNING
The major goals for clients at risk for
impaired skin integrity are to maintain
skin integrity and to avoid potential
associated risks.
Clients with impaired skin integrity need
to demonstrate progressive wound
healing and regain intact skin.
Include planning for home care.
NURSING MANAGEMENT
IMPLEMENTING
Nursing interventions for maintaining
Supporting
Wound
Healing
Preventing microorganisms
from entering the wound
Preventing the transmission of
blood borne pathogens to or
from the client to others.
Standard Precautions
Wear gloves when touching blood
and body fluids, mucous membranes,
or non intact skin of all clients, and
when handling items or surfaces
soiled with blood or body fluids.
Wash hands thoroughly after
removing gloves, and if contaminated
with blood or body fluids.
Wound care
Wash hands before and after caring for
wounds
Wear gloves, surgical masks, and protective
eyewear as appropriate if procedures
commonly cause droplets or splashing of blood
or body fluids (e.g., wound irrigation)
Touch an open or fresh surgical wound only
when wearing sterile gloves or using a sterile
instrument.
Remove or change dressings over closed
wounds when they become wet.
>Preventing
pressure ulcer
>Treating
pressure ulcers
DRESSING WOUNDS
wound
To provide thermal insulation
To absorb drainage or debride a wound or both
To prevent hemorrhage
To splint or immobilize the wound site and
thereby facilitate healing and prevent injury.
TYPES OF DRESSING
or is infected
Frequency of dressing change, ease or
difficulty of dressing application and cost.
TYPES OF WOUND
DRESSINGS
DRESSING
DESCRIPTION
PURPOSE
EXAMPLES
Transparent
adhesive tapes/
wound barriers
Adhesive plastic,
semipermeable,
nonabsorbent
dressings allow
exchange of
oxygen between
the atmosphere
and wound bed.
They are
impermeable to
bacteria and water.
To provide
protection
against
contamination
and friction; to
maintain a clean
moist surface
that facilitates
cellular
migration; to
provide
insulation by
preventing fluid
evaporation;
and to facilitate
wound
assessment.
Op-Site,
Tegaderm,
Bioclusive
DESCRIPTION
PURPOSE
EXAMPLES
Impregnated non
adherent dressing
Woven or
nonwoven cotton
or synthetic
materials are
impregnated with
petrolatum,
saline, zinc-saline,
antimicrobials, or
other agents.
Require
secondary
dressings to
secure them in
place, retain
moisture, and
provide wound
protection.
To cover, soothe,
and protect
partial-and fullthickness wounds
without exudate
Adaptic, Carrasyn,
Xeroform
DESCRIPTION
PURPOSE
EXAMPLES
Hydrocolloids
Waterproof
adhesive wafers,
pastes, or
powders.
Wafers,designed
to be worn for up
to 7 days, consist
of two layers. The
inner adhesive
layer has particles
that absorb
exudate and form
a hydrated gel
over the wound;
the outer film
provides a seal.
To absorb
exudate; to
produce a moist
environment that
facilitates healing
but does not
cause maceration
of surrounding
skin; to protect
the wound from
bacterial
contamination,
foreign debris,
and urine or
feces; and to
prevent shearing.
DuoDerm,
Comfeel,
Tegasorb, restore,
Replicare
DESCRIPTIO
N
PURPOSE
EXAMPLES
Hydrogels
Glycerin or
water-based
non-adhesive
jellylike
sheets,
granules, or
gels are
oxygen
permeable,
unless
covered by a
plastic film.
May require
secondary
To liquefy
Aquasorb,
necrotic tissue elasto-gel,
or slough,
vigilon
rehydrate the
wound bed,
and fill in
dead space.
DESCRIPTION
PURPOSE
EXAMPLES
Polyurethane
foams
Nonadherent
hydrocolloid
dressings; these
need to have
their edges
taped down or
sealed. Require
secondary
dressings to
obtain an
occlusive
environment.
Surrounding
skin must be
protected to
prevent
maceration
To absorb light
to moderate
amounts of
exudate; to
debride wounds
Lyofoam,
allevyn,
vigifoam,
flexzan
DESCRIPTION
PURPOSE
EXAMPLES
Exudate
absorbers
(alginates)
Nonadherent
dressings of
powder, beads
or granules,
ropes, sheets,
or paste
conform to the
wound surface
and absorb up
to 20 times
their weight in
exudate;
require a
secondary
dressing
To provide a
moist wound
surface by
interacting with
exudate to form
a gelatinous
mass; to absorb
exudate; to
eliminate dead
space or pack
wounds; and to
support
debridement.
Debrisan,
Sorbsan,
Kaltostat,
Algiderm
APPLYING WOUND
DRESSINGS
APPLYING WOUND
DRESSINGS
APPLYING WOUND
DRESSINGS
-clean the wound if indicated.
Put on clean/ sterile gloves in accordance with
agency practice.
Clean the wound with the prescribed solution.
Dry the surrounding skin with dry gauze.
-assess the wound
-apply the wound barrier.
Follow the manufacturers instruction.*
Remove and dispose of gloves.
-assess and change the dressing as indicated
-document the dressing change and the clients
response.
SECURING
DRESSINGS
SECURING DRESSINGS
SECURING DRESSINGS
STEPS TO FOLLOW:
Place the tape so that the dressing cannot be
CLEANING WOUNDS
CLEANING WOUNDS
CLEANING WOUNDS
CLEANING WOUNDS
CLEANING WOUNDS
IRRIGATION(LAVAGE)
Is the washing or flushing out of an area.
Sterile technique is required for a wound
irrigation because there is a break in the skin
integrity.
Irrigation pressures should range from 4 to 15
pound per square inch (psi).
Below 4 psi, the irrigation may not be
effective, and above 15 psi, it may damage
tissues.
A 35ml syringe with a 19 gauge needle or
catheter provides approx. 8psi.
Gauze Packing
Using the wet to damp technique
has been used to pack wounds for
debridement.
IRRIGATING A WOUND
IRRIGATING A WOUND
IRRIGATING A WOUND
IRRIGATING A WOUND
Use of heat
The first 24h after traumatic injury.
Use of cold
Open wounds- increase tissue damage
by decreasing blood flow to an open
wound
Impaired circulation- further impair
nourishment of the tissues and cause
tissue damage.
supporting and
immobilizing
wounds
Wound care
Perform appropriate client teaching for
Thank you!