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Tissue Integrity

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by

Stephanie Greer

on 8 March 2017

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Transcript of Tissue Integrity

Types of Wounds
Intentional

Unintentional

Open

Closed

Acute

Chronic
Factors Affecting Wound Healing
Nursing Process for Wounds
Assessment
Diagnosing
Planning
Implementing
Evaluating
RYB Wound Classification
Red - Protect
Yellow - Cleanse
Black - Debride
Caring for a Client with Drains
Penrose Drain
Jackson-Pratt Drain
Hemovac
Vacuum Assisted Closure (VAC) or Negative Pressure Wound Therapy
Tissue Integrity
Unit 5 Module D
Objectives
1. Identify considerations in the assessment of adult clients with alterations in skin integrity.

2. Describe conditions and activities that place a client at risk for altered skin integrity.

3. Identify priority actions for older adults who have an alteration in skin integrity.

4. Examine the nurse’s role in pharmacological therapy for a client who has an alteration in skin integrity.
Antimicrobial

5. Evaluate the nursing process in planning and providing care to a client who has an alteration in skin integrity and nursing interventions.

6. Discuss the correct use and functioning of therapeutic devices that support skin integrity.

7. Identify health care education and safgety needs for clients who have a potential for or alteration in skin integrity.

8. Examine the nursing process as it relates to the client at risk for or with alteration in skin integrity.
SKIN...The body's first line of defense...
Integumentary system includes: subcutaneous tissue, glands, hair, nails, blood vessels, nerves, and sensory organs of the skin.

Functions of the Skin & Mucous Membranes
Protection
Temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunological
Absorption
Elimination

Factors Affecting Skin Integrity
Genetics
Age
Amount of underlying tissues
Illness (chronic illnesses)
Health of the individual
Adequate circulation

Genetics
Age - Related Changes
Developmental Considerations - Amount of Underlying Tissue
Chronic Illness
Health of the Individual
Adequate Circulation
Intentional
Unintentional
Open
Closed
Acute
Chronic
Types of Wounds
Wounds with loss of tissue
Burns
Pressure Ulcer (decubitus)
Severe Laceration
Wounds without loss of tissue
Surgical Incision
Minor Laceration
Wound Healing
Primary
Secondary
Tertiary


Discuss phases of
wound healing

Complications of Wound Healing
Infection
Hemorrhage
Dehiscence
Evisceration
Fistula
Impaired skin integrity related to unrelieved prolonged PRESSURE
Usually over bony prominence
PRESSURE IS MAJOR CAUSE
Contributing factors
External Pressure
Friction and Shear
Immobility
Nutrition/hydration
Moisture
Mental Status
Age

Etiology of Pressure Ulcers
Blanching
Reactive hyperemia – when pressure is relieved (not a pressure ulcer)
Suspected deep tissue injury
Stage I: nonblanchable erythema signaling potential ulceration
Stage II: partial-thickness skin loss involving epidermis and possibly dermis
Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Stage IV: full thickness tissue loss with exposed bone, tendon, or muscle.
Unstageable: base of ulcer is covered by slough and/or eschar

Stages of Pressure Ulcer Development
Risk Assessment
PREVENT
Implementation
Support wound healing
Moist wound healing
Nutrition and fluids
Prevent infection
Positioning
PREVENT pressure ulcers
Nutrition
Skin hygiene
Avoiding skin trauma
Providing supportive devices

Wound Cleansing
Pharmacology for Wounds
Aminoglycosides
ototoxicity
nephrotoxicity
Cephalosporins
ask about penicillin allergy
development of superinfections
Tetracycline
photo-sensitivity
Full transcript