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Transcript of Tissue Integrity
Factors Affecting Wound Healing
Nursing Process for Wounds
RYB Wound Classification
Red - Protect
Yellow - Cleanse
Black - Debride
Caring for a Client with Drains
Vacuum Assisted Closure (VAC) or Negative Pressure Wound Therapy
Unit 5 Module D
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.
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
Vitamin D production
Factors Affecting Skin Integrity
Amount of underlying tissues
Illness (chronic illnesses)
Health of the individual
Age - Related Changes
Developmental Considerations - Amount of Underlying Tissue
Health of the Individual
Types of Wounds
Wounds with loss of tissue
Pressure Ulcer (decubitus)
Wounds without loss of tissue
Discuss phases of
Complications of Wound Healing
Impaired skin integrity related to unrelieved prolonged PRESSURE
Usually over bony prominence
PRESSURE IS MAJOR CAUSE
Friction and Shear
Etiology of Pressure Ulcers
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
Support wound healing
Moist wound healing
Nutrition and fluids
PREVENT pressure ulcers
Avoiding skin trauma
Providing supportive devices
Pharmacology for Wounds
ask about penicillin allergy
development of superinfections