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Chapter 48 Skin Integrity and Wound Care

Chapter 48 Skin Integrity and Wound Care. Scientific Knowledge Base: Skin. Dermal-epidermal junction Separates dermis and epidermis Epidermis Top layer of skin Dermis Inner layer of the skin. Pressure Ulcers. Pressure ulcer Pressure sore, decubitus ulcer, or bed sore Pathogenesis

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Chapter 48 Skin Integrity and Wound Care

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  1. Chapter 48Skin Integrity and Wound Care

  2. Scientific Knowledge Base:Skin • Dermal-epidermal junction • Separates dermis and epidermis • Epidermis • Top layer of skin • Dermis • Inner layer of the skin

  3. Pressure Ulcers • Pressure ulcer • Pressure sore, decubitus ulcer, or bed sore • Pathogenesis • Pressure intensity • Blanching • Pressure duration • Tissue tolerance

  4. Risk Factors for Pressure Ulcer Development

  5. Classification of Pressure Ulcers

  6. Wounds • Classification • Wound healing • Repair • Complications

  7. Nursing Knowledge Base • Prediction and prevention of pressure ulcers • Norton Scale • Physical and mental condition, activity, mobility, and continence • Braden Scale • Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

  8. Factors Influencing Pressure Ulcer Formation and Wound Healing • Nutrition • Tissue perfusion • Infection • Age • Psychosocial impact of wounds

  9. Assessment • Skin • Presence of ulcers • Mobility • Nutrition and fluid status • Pain • Existing wounds, appearance, character • Wound culture

  10. Nursing Diagnosis and Planning • The assessment will reveal important information regarding the client’s status. • Use NANDA-I–approved diagnoses. • Write client goals and outcomes specific to the client’s needs.

  11. Implementation • Health promotion • Topical skin care • Protect bony prominences, skin barriers for incontinence. • Positioning • Turn every 1 to 2 hours as indicated. • Support surfaces • Decrease the amount of pressure exerted over bony prominences.

  12. Acute Care • Wound management • Debridement • Mechanical, autolytical, chemical, or surgical/sharp • Nutrition • Client education

  13. Dressings • Dry or moist • Gauze • Hydrocolloid • Protects the wound from surface contamination • Hydrogel • Maintains a moist surface to support healing • Wound V.A.C. • Uses negative pressure to support healing

  14. Dressings • Changing • Know type of dressing, placement of drains, and equipment needed. • Securing • Tape, ties, or binders • Comfort measures • Carefully remove tape. • Gently cleanse the wound. • Administer analgesics before dressing change.

  15. Wound Cleansing

  16. Bandages and Binders • Bandages • Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin • Binder application • Breast, abdominal, sling

  17. Heat and Cold Therapy • Assessment for temperature tolerance • Bodily responses to heat and cold • Factors influencing heat and cold tolerance • Education

  18. Evaluation • Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals.

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