SAFETY PROTECTION SKIN INTEGRITY WOUND CLASSIFICATION An intentional

*SAFETY PROTECTION/ SKIN INTEGRITY

WOUND CLASSIFICATION • An intentional wound • An unintentional wound • An open wound • A closed wound

PHASES OF WOUND HEALING Ø Inflammatory phase Ø Fibroplasia (proliferation) phase Ø Maturation (remolding) phase

WOUND HEALING PROCESSES l Primary healing l Secondary healing l Tertiary healing

FACTORS AFFECTING WOUND HEALING l l l AGE CIRCULATION OXYGENATION WOUND CONDITION PATIENTS HEALTH/OVERALL CONDITION

WOUND COMPLICATIONS l HEMORRHAGE l DEHISCENCE l EVISCERATION l INFECTION

PSYCHOLOGICAL EFFECTS OF WOUNDS l Pain l Anxiety &Fear l Alterations in body image

ASSESSING THE WOUND l l l INSPECTION PALPATION DRAINAGE PAIN SUTURES, STAPLES, DRAINS, TUBES, AND MANIFESTATIONS OF COMPLICATIONS

DIAGNOSING IN WOUND CARE l l SKIN INTEGRITY IMPAIRMENT RISK FOR SKIN INTEGRITY RISK FOR INFECTION BODY IMAGE DISTURBANCE

PLANNING: Expected outcomes for pressure ulcers l l l Patient will: participate in the prescribed treatment to promote healing Patient will demonstrate progressive healing of the pressure ulcer Develop no new areas of skin breakdown

IMPLEMENTING WOUND CARE l l l Teaching for home care of a wound to patient and/or care giver Implementing every two hour position change schedule Use of positioning devices for protection and comfort

PRESSURE ULCERS: l PATHOLOGY OF ULCER DEVELOPMENT: • ISCHEMIA • FRICTION • SHEARING FORCE

FACTORS EFFECTING PRESSURE ULCER DEVELOPING l l l MOBILITY & IMMOBILITY NUTRITION & HYDRATION MOISTURE ON THE SKIN MEMTAL STATUS AGE

PRESSURE ULCER STAGING l STAGE ONE – non-blanchable erythema of intact skin; the heralding lesion of skin ulceration l STAGE TWO – partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater

PRESSURE ULCER STAGING CON’T. l Stage Three; full thickness skin loss involving epidermis and. The ulcer is superficial and presents clinically as a deep crater with or without undermining of adjacent tissue. l Stage Four; full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure (a. g. , tendon, joint capsule)

ASSESSING THE RISK FOR OR ACTUAL PRESSURE ULCER Hx of skin problems trauma, chronic debilitating disease, immobility, age integumentary status, musculoskeletal status nutritional status, HMG/HMT, serum albumin, psychosocial status

DIAGNOSING PRESSURE ULCERS l l l l Risk for impaired skin integrity Risk for impaired tissue integrity Risk for infection Impaired bed mobility Altered tissue perfusion Pain Altered nutrition; less than body requirements

EVALUATING PRESSURE ULCER CARE l l l Demonstrate progressive healing Improved overall physical condition Remains free of infection at any pressure ulcer site Responds effectively to the teaching strategies and plans Communicates need for additional support