Post on 03-Feb-2022
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1
Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
After completing this lecture the students will be able to:
1. Describe wounds and identify the common types of wounds.
2. Define pressure ulcer and identify clients at risk for developing pressure ulcers.
3. Describe the four stages of pressure ulcer development.
4. Discuss the processes involved in wound healing.
5. Differentiate primary, secondary, and tertiary wound healing.
6. Identify factors that affect wound healing.
7. Describe the principles of wound assessment and care.
8. Identify nursing diagnoses associated with impaired skin integrity.
9. Identify essential aspects of planning care to maintain skin integrity and promote
wound healing.
The skin is the body’s first line of defense, protecting the underlying structures from
invasion by organisms. Important nursing functions are maintaining skin integrity
and promoting wound healing. Impaired skin integrity, such as wound, may occur as
a result of trauma, surgery, and other invasive procedures. The potential for skin
breakdown and eventual pressure ulcer formation also exists whenever factor such
as prolonged pressure, constant irritation of the skin, and immobility are present.
Nurse plays a major role in maintaining the patient’s skin integrity, in identifying
risk factors that predispose a patient to a break in integrity, in intervening to prevent
or reduce a patient’s risk for impaired skin integrity, and in providing specific
wound care when breaks in integrity arise. A wound: is a break or disruption in the normal integrity of the skin, mucous
membrane, and body tissue.
1. Intentional wounds: occurs during treatment or therapy, under aseptic conditions
(e.g., surgical incision and venipuncture).
2. Unintentional wounds: result from unexpected trauma, or accident created in an
unsterile environment and therefore poses a greater risk of infection.
1. Open wound: occurs from intentional or unintentional trauma. The skin surface is
broken, providing a portal of entry for microorganisms. Examples include incisions
and abrasions.
2. Closed wound: damage of soft tissue and under lining structures while the skin
remains intact, may involve internal injury and hemorrhage. Result from a blow,
force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash.
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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
1. Incision: Open wound; deep or shallow; caused by sharp instrument (e.g., knife or
scalpel), once the edges have been sealed together as a part of treatment or healing,
the incision becomes a closed wound.
2. Contusion: Closed wound caused from a blunt instrument, skin appears ecchymotic
(bruised) because of damaged blood vessels.
3. Abrasion: Open wound involving the skin caused by surface scrape, either
unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to
remove pockmarks).
4. Puncture: Open wound, caused by penetration of the skin and often the underlying
tissues by a sharp instrument, either intentional or unintentional.
5. Laceration: Open wound, edges are often jagged, tissues torn apart, often from
accidents (e.g., with machinery).
6. Penetrating wound: Open wound caused by penetrating of the skin and the
underlying tissues, usually unintentional (e.g., from a bullet or metal fragments).
1. Clean wounds: are uninfected wounds in which there is minimal inflammation and
the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean
wounds are primarily closed wounds.
2. Clean-contaminated wounds: are intentional wounds e.g., surgical wounds in
which the respiratory, gastrointestinal, genital or urinary tract has been entered. Such
wounds show no evidence of infection.
3. Contaminated wounds: include open, fresh, accidental and surgical wounds
involving a major break in sterile technique or a large amount of spillage from the
gastrointestinal tract. Contaminated wounds show evidence of inflammation.
4. Dirty or infected wounds: include wounds containing dead tissue and wounds with
evidence of a clinical infection, such as purulent drainage.
1. Superficial wound: (e.g., first degree burn), involves loss of only the epidermis
layer (e.g., a superficial excoriation caused by friction); may take several days to a
week to heal.
2. Partial thickness: (e.g., second degree burn), involves loss of dermis and epidermis
layers; heal by regeneration, may take 2 to 3 weeks to heal.
3. Full thickness: (e.g., third degree burn), involving the dermis, epidermis,
subcutaneous tissue, and possibly muscle and bone; require connective tissue repair,
may take months or years to heal.
Is a wound with a localized area of tissue necrosis that tend to developing when soft
tissue is compressed between a bony prominence and an external surface for a
prolonged period of time.
3
Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
A. Friction and shearing: Friction is a force acting parallel to the skin surface. e.g.,
sheets rubbing against skin create friction. Shearing force is a combination of
friction and pressure. It occurs commonly when a client assumes a sitting position in
bed.
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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
B. Immobility and inactivity: Normally people move when they experience
discomfort due to pressure on an area of the body. Immobility e.g., paralysis, can
hinder a person’s ability to change positions independently and relieve the pressure,
even if the person can perceive the pressure.
C. Inadequate nutrition: Prolonged inadequate nutrition causes weight loss, muscle
atrophy, and the loss of subcutaneous tissue. These three conditions reduce the
amount of padding between the skin and the bones, thus increasing the risk of
pressure ulcer development. More specifically, inadequate intake of protein,
carbohydrates, fluids, zinc, and vitamin C contributes to pressure ulcer formation.
5
Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
D. Fecal and urinary incontinence: Moisture from incontinence promotes skin
maceration (tissue softened by prolonged wetting or soaking) and makes the
epidermis more easily eroded and susceptible to injury. Digestive enzymes in feces,
and urea in urine, also contribute to skin excoriation (loss of the superficial layers of
the skin). Any accumulation of secretions or excretions is irritating to the skin,
harbors microorganisms, and makes an individual prone to skin breakdown and
infection.
E. Decreased mental status: Individuals with a reduced level of awareness, e.g.,
unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers
because they are less able to recognize and respond to pain associated with
prolonged pressure.
F. Diminished sensation: reduces a person’s ability to respond to trauma, to injurious
heat and cold, and to the tingling (“pins and needles”). And also impairs the body’s
ability to recognize and provide healing mechanisms for a wound.
G. Excessive body heat: An elevated body temperature increases the metabolic rate,
thus increasing the cells’ need for oxygen. Also severe infections with
accompanying elevated body temperatures may affect the body’s ability to deal with
the effects of tissue compression.
H. Advanced age: older person more prone to impaired skin integrity.
I. Chronic medical conditions: e.g., diabetes (D.M) and cardiovascular disease
(CVD) are risk factors for skin breakdown and delayed healing. These conditions
compromise oxygen delivery to tissues by poor perfusion and thus cause poor and
delayed healing and increase risk of pressure ulcer.
1) Stage I: erythema of intact skin.
2) Stage II: partial-thickness skin loss (abrasion, blister, or shallow crater) involving
the epidermis and possibly the dermis.
3) Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to, but not through, underlying fascia. The ulcer
presents clinically as a deep crater with or without undermining of adjacent tissue.
4) Stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or
supporting structures, such as a tendon or joint capsule.
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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
Stage 1 stage 2
Stage 3 stage 4
1) Primary intention healing: occurs where the tissue surfaces have been
approximated (closed) and there is minimal or no tissue loss; it is characterized by
the formation of minimal granulation tissue and scarring. Example: closed surgical
incision.
2) Secondary intention healing: seen in wound that is extensive and involves
considerable tissue loss, and in which the edges cannot or should not be
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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
approximated. The wound is left open, and granulation tissue gradually fills in the
deficit. Example pressure ulcer and burns.
3) Tertiary intention healing (delayed or secondary closure): seen in wounds with
poor circulation or infection. Wound suturing is delayed until the problems resolves
(edema, infection, or exudate to drain) example diabetic foot.
1. Defensive (inflammatory) phase: begins immediately after injury and lasts 3 to 6
days. Two major processes occur during this phase: hemostasis and phagocytosis.
A. Hemostasis (the cessation of bleeding): results from vasoconstriction of the larger
blood vessels in the affected area, retraction (drawing back) of injured blood vessels,
the deposition of fibrin (connective tissue), and the formation of blood clots in the
area.
B. Phagocytosis: The blood supply to the wound increases, bringing with it oxygen and
nutrients needed in the healing process. The area appears reddened and edematous as
a result. The increased blood supply transports leukocytes (specifically, neutrophils)
to the interstitial space. These are replaced about 24 hours after injury by
macrophages. These macrophages engulf microorganisms and cellular debris by a
process known as phagocytosis. The macrophages also secrete an angiogenesis
factor, which stimulates the formation of epithelial buds at the end of injured blood
vessels. The increased blood supply also removes the "debris of the battle" which
includes dead cells, bacteria, and exudate or material and cells discharged from
blood vessels.
2. Reconstructive (proliferative) phase: the second stage begins on the 3th
or 4th
day
after injury and lasts for (2-3) weeks. This phase contain the process of collagen
deposition, angiogenesis (the formation of new blood vessels), granulation tissue
development, and wound contraction.
3. Maturation phase: final stage of healing begins on about day 21 and can extend to 2
years or more, depending on the depth and extent of the wound. During this phase
the scar tissue remodeled. Although the scar tissue continues to gain strength, it
remains weaker than the original tissue it replaces. Capillaries eventually disappear,
leaving a vascular scar (a scar that is white because it lacks a blood supply).
Characteristics of the individual such as age, nutritional status, lifestyle, and
medications influence the speed of wound healing.
Healthy children and adults often
heal more quickly than older adults, because the blood circulation and O2 delivery to
the wound, clotting, inflammatory response, and phagocytosis may be impaired in
the elderly; thus, the risk of infection is greater.
A. A balance diet with adequate amounts of protein, carbohydrates, lipids, vitamins
(e.g., A and C), and minerals (such as iron, zinc, and copper) is needed to increase
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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
the body's resistance to pathogens and decrease the susceptibility of skin and
mucous membranes to infection and trauma.
B. Malnutrition reduces humoral and cell mediated factors, leading to
immunocompromise, thus impairing wound healing and increasing infection risk.
C. Obese clients are at increased risk of wound infection and slower healing because
adipose tissue usually has a minimal blood supply that impairs delivery of nutrients
and other elements needed for healing; also, suturing of fatty tissue is more difficult.
D. Drying up of wound tissue (ells dehydrate and die in a dry environment).
E. Over hydration related to urinary and fecal incontinence can lead to impairing
wound healing and increasing the risk of infection (moisture increase in the pH of
the skin, thus results overgrowth of infectious agents).
A. People who exercise regularly tend to have good circulation and because blood
brings oxygen and nourishment to the wound, they are more likely to heal quickly.
B. Smoking reduces the amount of functional hemoglobin in the blood, thus reduces the
amount of oxygen in the tissue. (Decreased arterial oxygen alters the synthesis of
collagen and the formation of epithelial cells, causing wounds to heal more slowly).
result in
delayed healing.
A. Cardiovascular disease (CVD): increase the risk of delayed healing due to impaired
O2 delivery to tissues.
B. Anemia: decreased O2 delivery to the tissues and interfere with tissue repair.
C. diabetes mellitus (DM):
DM can impair tissue perfusion and oxygen delivery.
Elevated blood glucose impairs leukocyte function and phagocytosis.
The high glucose environment is an excellent medium for growth of bacteria, fungal,
and yeast infections.
D. Anti-inflammatory drugs (e.g., steroids and aspirin) and antineoplastic agents reduce
inflammatory response and slow collagen synthesis. Anti-inflammatory drugs
suppress protein synthesis, wound contraction, epithelialization, and inflammation.
E. Prolonged use of antibiotics, with development of resistant strain of bacteria, may
increase the risk of wound infection.
Assessing Untreated Wounds: 1. Assess the location (anatomical location of wound), and extent of tissue damage
(e.g., partial thickness or full thickness).
2. Size: measure the wound length, width, and depth (e.g., 5 inches suture line on
the right lower quadrant of the abdomen.
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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
3. Inspect the wound for bleeding. The amount of bleeding varies according to the
type of wound and location. Penetrating wounds may cause internal bleeding.
4. Inspect the wound for foreign bodies (soil, broken glass, shreds of cloth).
5. Assess associated injuries such as fractures, internal bleeding, spinal cord
injuries, or head trauma.
6. If the wound is contaminated with foreign material, determine when the client
last had a tetanus toxoid injection. A tetanus immunization or booster may be
necessary.
Assessing treated wounds or sutured wounds: 1. Usually assessed to determine the progress of healing. These wounds may be
inspected during changing of a dressing.
2. Assess general appearance, size and status of drain or tubes: color of the wound
and surrounding area helps to determine the wound's present phase of healing.
Document amount, color, location, odor, and consistency of any drainage.
3. Assess pain: any pain or tenderness at the wound site should be notified and
documented.
4. Laboratory data:
Cultures of the wound drainage are used to determine the presence of infection
and to identify the causative organism. The sensitivity results list the antibiotics
that will effectively treat the infection.
An elevated WBCs count is indicative of an infectious process.
A decreased leukocyte count may indicate that the client is at increased risk for
developing an infection related to decreased defense mechanisms.
Hemoglobin (Hb) level below normal range indicates poor O2 delivery to the
tissues.
A decreased albumin, there are decreased resources of protein for wound healing.
for example 1. Impaired tissue integrity related to surgical incision as manifested by…..
2. Risk for infection related to malnutrition, decreased defense mechanisms.
3. Pain related to inflammation, infection as evidence by……
The goal focusing on promoting wound healing, preventing infections, and
educating the client.
1. Initiate emergency measures:
Slandered precautions are always implemented.
If hemorrhage is detected, sterile dressing and pressure should be applied to
stop the bleeding and elevated the effected extremity.
When dehiscence or evisceration occurs, the client should be instructed to
remain quiet and to avoid coughing or straining. Sterile dressing, soaked with
sterile normal saline should be used to cover the wound and abdominal
11
Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah
جمــــهوريــة العــــراق
والبحث العلمي اليـليم العـعــوزارة الت
ياءــــنبأة وارث الــــامعـج
لتمريضية اـلـك
Republic of Iraq بسم الله الرحمن الرحيم
Ministry of Higher Education and Scientific Research
University of Warith Al-anbiya'a
College of Nursing
contents. This will reduce the risk of bacterial contamination and drying of the
viscera. Notify the surgeon immediately and the client prepared for surgical
repair of the area.
Vital signs should be monitored frequently.
2. Cleanse the wound: the goal of cleansing the wound is to remove debris and
bacteria from the wound bed with as little trauma to the healthy granulation
tissue as possible. It is recommended that isotonic solutions such as normal
saline or lactated ringers be used to preserve healthy tissue. Commonly used
antiseptic agents such as povidone-iodine 10% hydrogen peroxide 3%, sodium
hypochlorite, and acetic acid are effective in destroying bacteria but at the
same time destroy fibroblasts and healthy granulation tissue.
The major principles to keep in mind when cleansing a wound are:
a. Use standard precautions at all times.
b. When using a swab or gauze to cleanse a wound, work from the clean area out
toward the dirtier area.
c. 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 irrigate to flow from the cleanest area to the contaminated area to
avoid spreading pathogens.
3. Provide suture care.
4. Dressing the wound: covering the wound with a sterile dressing, when the
first layer of dressing becomes saturated with blood, applies a second layer. Do
so without removing the first layer of dressing, because blood clots might be
disturbed, resulting in more bleeding.
The purposes of wound dressing are:
a. Provide moist environment and therefore enhance epithelialization.
b. Supporting healing by absorbing drainage.
c. Protect the wound from microbial invasion.
d. Promote homeostasis.
e. Provide thermal isolation of the wound.
f. Protect the wound from physical trauma and supporting the wound site.
5. Monitor drainage of wounds: when excessive drainage accumulates in the
wound, tissue healing is delayed. To facilitate drainage of any excess fluid, a
tube or drain should be inserted.
6. Control swelling and pain: by applying ice over the wound and surrounding
tissues.
7. Checking bandages, binders, and slings: bandages and binders are applied
over wound dressing sites to secure, immobilize, or support a body part; to
hold a dressing in place; or to prevent or minimize swelling of a body part.
evaluate the clients achievement of the goals establishes during
the planning phase.