Prefinal - Skin Integrity Flashcards
is the body’s largest organ and is the primary defense against infection.
Skin
A disruption in the integrity of body tissue
Wound
Classification according to Wound Type:
Incised
Contusion
Punctured
Abrasions
Classification of Wounds Thickness
Superficial
Deep
Wounds that leave the deeper skin layers intact. These types of wounds are usually caused by friction rubbing against an abrasive surface.
Superficial (on the surface) wounds
Wounds that go through all the layers of the skin and into underlying tissue like muscle or bone.
Deep wounds
Factors Affecting Wound Healing
Age
Nutrition
Oxygenation
Smoking
Drug Therapy
Diabetes Miletus
this Factor Affecting Wound Healing means that Although the elderly can heal most wounds, they have a slower healing process, and all phases of wound healing are also affected.
Age
this Factor Affecting Wound Healing means that Optimal wound healing requires adequate nutrition. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength and increased infection rates.
Nutrition
this Factor Affecting Wound Healing means that Oxygen plays a very significant role in wound healing – it is needed for cellular function and can kill bacteria and cause resistance to infection. Oxygen stimulates the creation of new blood vessels and also aids growth factors to form new skin. Your red blood cells carry oxygen throughout the body.
Oxygenation
this Factor Affecting Wound Healing means that Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue.
Smoking
this Factor Affecting Wound Healing means that The medications most likely to impair wound healing and damage skin integrity include antibiotics, anticonvulsants, steroids, and nonsteroidal anti-inflammatory drugs.
Drug Therapy
this Factor Affecting Wound Healing means that Diabetes mellitus is one of the major contributors to chronic wound healing problems. When diabetic patients develop an ulcer, they become at high risk for major complications, including infection and amputation.
Diabetes Miletus
(persistent bleeding) is abnormal and may indicate a slipped surgical suture, dislodged clot, or erosion of a blood vessel.
Hemorrhage
Some bleeding from a wound is normal during and immediately after initial trauma and surgery.
wound contamination
Infection
Effects of Having a Wound
Dehiscence
Evisceration
is the partial or complete separation of the wound edges and the layers below the skin.
Dehiscence
occurs when the client’s viscera protrudes through the disrupted wound.
Evisceration
Nursing Process for Altered Skin Integrity
Assessment of Wounds
Health history
Allergies to tape, latex, medications, or other substances
Physical examination
Location of wound
Size of wound
General appearance and drainage
Pain
Laboratory data
ASSESSMENT TOOL:
A- anatomical location, Age of wound
S-size, Shape
S- sinus tract, Tunnelling, Undermining
E- exudate
S- sepsis (including odour)
S-surrounding skin
M-maceration
E-edge, Epithelialization
N-necrotic tissue
T-tissue bed, Tenderness (pain)
S-status- changes in condition, improvement
Nursing Diagnoses
Impaired Tissue Integrity
Risk for Infection
Disturbed Body Image
Acute or Chronic Pain
Deficient Knowledge
Outcome Identification and Planning
After my health teachings, the client will manifest positive receptivity/response to
health instructions
> wound begins to heal after a week
> gains weight at least 3 pounds a week
> bearable pain in the affected area
Principles for Wound Dressing:
Use Standard Precautions at All Times
When using a swab or gauze to cleanse a wound, work from the clean area out toward the dirtier area.
When irrigating a wound, warm the solution to room temperature, preferably to body temperature, to prevent lowering of the tissue temperature.
Be sure to allow the irrigant to flow from the cleanest area to the contaminated area to avoid spreading pathogens.
is the application of a hot agent, warmer than skin either in a moist or dry form on the surface of the body;
Hot application
Purpose of Hot Application:
To relieve pain and congestion
To provide warmth
To promote suppuration
To promote healing
To decrease muscle tone
To soften the exudates
is the application of a cold agent cooler than skin either in a moist or dry form, on the surface of the skin.
Cold application
Purpose of Cold Application:
To reduce pain and body temperature,
To anesthetize an area
To control hemorrhage
To control the growth of bacteria
To prevent gangrene
To prevent edema
To reduce inflammation
Local Dry Heat Examples:
Infrared Therapy
Shortwave diathermy
A heating pad
Heating lamps
Local Moist Heat Examples:
Hot bath
A poultice
Stupes
A sitz bath
Aquathermia pads
A paraffin or wax bath
to improve the healing of wounds, relieve pain, stiffness, and fatigue from rheumatoid arthritis
Infrared Therapy
uses high-frequency electromagnetic energy to generate heat to treat pain from kidney stones, and PID.
Shortwave diathermy
is used for the warming of parts of the body in order to manage pain
A heating pad
increase blood circulation and hasten wound healing.
Heating lamps
is for stress/ pain relief, muscle relaxation, improved sleep, and calorie burn.
Hot bath
also called a cataplasm, is a paste made of herbs, plants, and other substances with healing properties.
A poultice
is a hot, wet cloth or sponge with a medication for external application to lessen irritation/inflammation
Stupes
is a warm water bath that helps to relieve pain from episiotomy wound (a surgical cut made between the vaginal opening and anus to aid in the delivery of the baby), hemorrhoids (painful and swollen blood vessels in the rectum or anus)
A sitz bath
or blankets are useful in treating muscle sprains and for areas with mild inflammation or edema.
Aquathermia pads
can also aid in healing problems with the skin.
A paraffin or wax bath
General Dry Heat Examples:
Sunbathing
Electric cradle or incubator
protects a person against inflammation & improves memory.
Sunbathing
provides an environment that can be adjusted to provide the ideal temperature as well as the perfect amount of oxygen, humidity, and light.
Electric cradle or incubator
General Moist Heat Examples
Steam baths
A whirlpool bath
relieve tension, soothe nerve endings, relax muscles, and minimize joint pain, as well as minimize the pain of headaches due to the high-heat environment.
Steam baths
reduces the amount of pain in the joints or muscles and improves body blood flow.
A whirlpool bath
Local Dry Cold Examples
Ice bag
Ice collar
Ice pack (poultice)
Ice cradle
Chemical cold packs
Local Moist Cold Examples
Ice to suck
Cold compress
Evaporating lotion
General Dry Cold Example
Hypothermia
General Moist Cold Examples
Cold sponging
Cold bath
Cold packs
Other measures to relieve pain
> Contralateral stimulation
