Nursing Chapter 36 Homework Discuss The Defining Characteristics Etiology Risk Factors

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Describe factors affecting skin integrity.

Concepts for Lecture

1. Genetics and heredity determine many aspects of a person’s skin,

including color, sensitivity to light, and allergies.

Age influences skin integrity. The skin of both the very young

and the very old is more fragile and susceptible to injury than that of

most adults. However, wounds tend to heal more rapidly in infants

and children.

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Identify clients at risk for pressure ulcers.

Concepts for Lecture

1. Risk factors for pressure ulcers include friction and shearing, immo-

bility, inactivity, inadequate nutrition, fecal and urinary inconti-

2. Several risk assessment tools are available that provide the nurse

with systematic means of identifying clients at high risk for pressure

ulcer development. The U.S. Public Health Service’s Panel for the

Prediction and Prevention of Pressure Ulcers in Adults (PPPPUA)

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SKIN INTEGRITY AND WOUND CARE

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Provide additional examples of disease condi-

tions and medications. Ask the students to

identify why these conditions or medications

may influence skin integrity.

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• Have the students identify factors that may

influence the skin integrity of their assigned

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Give the students outlines of the human body in

supine, prone, and side-lying positions. Have the

students mark a potential pressure site on the out-

lines.

• Divide the students into groups. Assign each

group a pressure ulcer risk factor. Have each

group develop specific interventions to

using the pressure ulcer risk tool used in the

agency.

prevent pressure ulcer formation for their

262 CHAPTER 36 / Skin Integrity and Wound Care

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Describe the four stages of pressure ulcer development.

Concepts for Lecture

2. Stage II: Partial-thickness skin loss (abrasion, blister, or shallow

crater) involves the epidermis and possibly the dermis.

3. Stage III: Full-thickness skin loss involves damage or necrosis of

subcutaneous tissue that may extend down to, but not through,

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4

Differentiate primary and secondary wound healing.

Concepts for Lecture

1. Primary intention healing occurs when the tissue surfaces have been

approximated (closed) and there is minimal to no tissue loss; it is

2. A wound that is extensive and involves considerable tissue loss, and

in which the edges cannot or should not be approximated, heals by

3.

Wounds that are left open for 3 to 5 days to allow edema or infection to

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5

Describe the three phases of wound healing.

Concepts for Lecture

1. The inflammatory phase of wound healing is initiated immediately

after injury and lasts 3 to 5 days. Two major processes occur during

2. The proliferative phase of wound healing extends from day 3 or 4 to

about day 21 postinjury. Fibroblasts (connective tissue cells) begin

to synthesize collagen, a protein that adds tensile strength to the

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Show slides or pictures of pressure ulcers in

various stages. Have the students identify the

ulcer stage and write nursing notes describing

each ulcer.

• Discuss the method used in the agency to

stage pressure ulcers.

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• Obtain pictures of wounds that demonstrate

primary, secondary, and tertiary healing.

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• If possible, locate pictures of wounds in

various stages of healing. Describe the associ-

ated findings.

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CHAPTER 36 / Skin Integrity and Wound Care 263

3.

The maturation phase (or remodeling) of wound healing begins about

day 21 and can extend 1 or 2 years after the injury. Fibroblasts continue

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Identify three major types of wound exudate.

Concepts for Lecture

1. Exudate is material such as fluid and cells that have escaped from

blood vessels during the inflammatory process. It is deposited in tis-

2. Serous exudate consists chiefly of serum (the clear portion of the

blood) derived from blood and the serous membranes of the body. It

looks watery and has few cells. An example of serous exudate is the

fluid in a blister.

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7

Identify the main complications of and factors that affect wound healing.

Concepts for Lecture

1. The main complications of wound healing include hemorrhage,

infection, and dehiscence and evisceration.

2. Characteristics of the individual such as age, nutritional status,

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• Obtain pictures of various types of wound

drainage and have the students identify them.

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present.

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• Discuss the signs and symptoms of dehiscence

and evisceration and the appropriate nursing

interventions.

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have wounds, in terms of recognizing and

reporting signs and symptoms of complica-

• Using the nursing diagnoses reference book

required by the curriculum, have the students

264 CHAPTER 36 / Skin Integrity and Wound Care

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Identify assessment data pertinent to skin integrity, pressure sites, and

wounds.

Concepts for Lecture

1. During the review of systems as part of the nursing history,

2. Inspection and palpation of the skin focuses on determination of skin

3. Nurses commonly assess both untreated and treated wounds.

Assessing untreated wounds includes assessing the location and

4. Assessing treated wounds, or sutured wounds, involves observation

5. When a pressure ulcer is present, the nurse notes location of the

ulcer related to a bony prominence; size of the ulcer in centimeters

6. When assessing common pressure sites, the nurse inspects pressure

areas for discoloration and capillary refill or blanch response when

7.

Laboratory data, such as leukocyte count, hemoglobin level, blood

coagulation studies, serum protein analysis (albumin level), and results

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Identify nursing diagnoses associated with impaired skin integrity.

Concepts for Lecture

1. The NANDA nursing diagnoses (2007) that relate to clients who

have skin wounds or who are at risk for skin breakdown are Risk for

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• Set up manikins with wounds and dressings.

Simulate exudate. Divide the students into

groups and have them describe the wound

characteristics.

integrity. Discuss findings at postconference.

look up the defining characteristics, etiology,

or risk factors for the nursing diagnoses

related to skin integrity.

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• Have the students develop nursing diagnoses

for an assigned client who has risk factors for

or actual impaired skin integrity. Discuss the

defining characteristics, etiology, or risk

CHAPTER 36 / Skin Integrity and Wound Care 265

Impaired Tissue Integrity (damage to mucous membranes or corneal,

integumentary, or subcutaneous tissue).

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10

Identify essential aspects of planning care to maintain skin integrity and pro-

mote wound healing.

1. The major goals for clients at Risk for Impaired Skin Integrity (pres-

2. Increasingly, wound care is provided in the home, and the client and

family assume much of the responsibility for assessing and treating

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11

Describe nursing strategies to treat pressure ulcers, promote wound healing,

and prevent complications of wound healing.

Concepts for Lecture

1. To treat pressure ulcers, the nurse should follow agency protocols

and the primary care provider’s orders, if any. In addition, minimize

direct pressure on the ulcer by repositioning the client at least every

2. The goals of the Red, Yellow, Black (RYB) color guide to wound

care are to protect (cover) red, cleanse yellow, and debride black.

Red wounds need to be protected to avoid disturbance to regenerat-

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• Divide the students into groups. Provide each

group with a case study of a client who has

impaired skin integrity. Ask the students to

identify the nursing diagnoses related to skin

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• Invite a wound/ostomy/continence nurse to

discuss current trends in pressure ulcer treat-

ment.

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• Review the agency’s policies and procedures

3. To promote wound healing, the client should be assisted to have an

oral intake of at least 2,500 mL of fluids a day unless contraindicat-

ed. Ensure that the client receives sufficient protein; vitamins C, A,

4.

Two major aspects to controlling wound infection are preventing micro-

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Identify purposes of commonly used wound dressing materials and binders.

Concepts for Lecture

1. Table 36–5 lists selected types of wound dressings, purposes, indica-

tions, and examples.

Transparent film is used to provide protection against contami-

nation and friction, to maintain a clean moist surface that facilitates

cellular migration, to provide insulation by preventing fluid evapora-

tion, and to facilitate wound assessment.

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• Prepare a display of different types of wound

dressings and a description of when each

should be used.

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• Review wound dressings used in the agency as

well as the agency’s policies and procedures

related to these.

2. Bandages and binders serve various purposes, such as supporting a

wound, immobilizing a wound, applying pressure, and retaining

warmth. When applied correctly, they promote healing, provide

comfort, and can prevent injury.

Many bandages are made of gauze, which is light and porous

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Identify essential steps of:

Concepts for Lecture

1. The steps in obtaining wound specimens are listed in Skill 36–1.

Essential steps include determining whether the wound is to be

cleansed prior to obtaining the specimen, whether the site from

2. The essential steps in applying dressings include following the man-

ufacturer’s instruction for applying the dressings described in Learn-

ing Outcome 13 (see Table 36–5). Dressings are placed so that the

3.

The steps in irrigating a wound are listed in Skill 36–2. Essential steps

include checking for the type of irrigating solution to be used, the

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Prepare manikins with various types of wounds

and dressings. Have the students practice chang-

• Have the students practice bandaging on man-

ikins.

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268 CHAPTER 36 / Skin Integrity and Wound Care

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14

Identify physiological responses to and purposes of heat and cold.

Concepts for Lecture

1. The physiological effects of heat include causing vasodilation,

2. Indications for heat include (a) muscle spasms (heat relaxes muscles

and increases their contraction); (b) inflammation (heat increases

3. The physiological effects of cold include causing vasoconstriction,

4.

Indications for cold include (a) muscle spasms (cold relaxes muscles and

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15

Recognize when it is appropriate to delegate aspects of skin and wound care

to unlicensed assistive personnel.

1. Obtaining a wound culture is an invasive procedure that requires the

application of sterile technique, knowledge of wound healing, and

3. While changing a wound dressing also involves assessment of the

wound, the UAP may assist the RN in this procedure. However, this

task may not be delegated completely to the UAP as this involves

assessment, a role the RN can only perform.

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Demonstrate appropriate documentation and reporting of skin integrity and

wound care.

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Documentation of the wound should include the following: type and

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Discuss contraindications for use of heat or cold.

observed clinically or have used with assigned

clients. Ask the students to provide rationales

2. Use of photo wound–measuring guides provide documentation of

scale and alignment with the body.