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CHAPTER 32 Skin Integrity & Wound Healing
CLINICAL REASONING
Applying the Full-Spectrum Nursing Model
PATIENT SITUATION Tio Santos is a 66-year-old man with obesity, diabetes, and hypertension. He is being seen for a wound on his right foot that doesn’t seem to be healing. He injured his foot when repairing drywall at home. He is otherwise relatively sedentary at home. The wound is oozing, swollen, tender, and warm to the touch. Mr. Santos is now running a low-grade fever of 100.4°F (38°C) at home. He tells you his foot is very painful, especially with any weight bearing, and throbs when he is sitting or lying still. You measure the wound bed to be 6 cm x 4 cm and note purulent exudate at the distal edge. He is referred to an outpatient wound care center for treatment.
THINKING 1. Theoretical Knowledge: a. What is the Braden scale and why might it be used for Mr. Santos?
b. What risk factors for delayed wound healing does Mr. Santos have?
2. Critical Thinking (Considering Alternatives, Deciding What to Do): a. To care for Mr. Santos’ wound, should you use sterile gloves, clean nonsterile gloves, or no gloves? Explain your thinking.
DOING 3. Practical Knowledge (Assessment): a. What symptoms of infection does Mr. Santos have?
b. To be certain the wound is infected, what would you need to know or do?
CARING 4. Self-Knowledge: Imagine you are Mr. Santos and have had a wound on your foot for 6 weeks. What would be the most troublesome symptom in your daily life? What would concern you the most? Critical Thinking and Clinical Judgment 1. You are caring for a 22-year-old man with paralysis from the waist down secondary to a motor vehicle accident. He has been admitted to the hospital with a urinary tract infection manifested by a fever of 102°F (39°C) and lethargy. His family reports he has been withdrawn and sits in his wheelchair looking at his phone all day. a. What risk factors does this patient have for skin breakdown?
b. What locations of his body should you be most concerned for the formation of pressure injury?
c. What actions should you take to decrease the risk of pressure injury for your patient? What further information do you need?
2. A 63-year-old male patient is admitted to your unit after an emergency appendectomy. His appendix was ruptured, and the surgeon has left the wound open to heal by secondary intention. A Jackson–Pratt drain is in place in the wound bed. A moderate amount of purosanguineous drainage is visible in the drain. The surgeon has ordered saline-moistened gauze packing every 4 hours. a. What actions should you take as you prepare to do the first dressing change?
b. How will you secure the dressing?
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