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UNIT 4 Supporting Physiological Functioning
3. For the following patients, write a nursing diagnosis related to skin integrity. Include problem, etiology, and defining characteristics. If you do not have enough data for one of those components, state what additional data you need. a. Mrs. Whitefeather is 95 years old. She has cancer, and she has stopped eating and has become emaciated. Recently she has become too weak to move about in bed without help. However, her skin is intact with no redness, even over her bony prominences. She has a low score on the Braden Scale for Predicting Pressure Sore Risk.
b. Mason Allen is 4 years old. He has a severe case of poison ivy and has blisters on his skin. He has been scratching and has bleeding, excoriated areas over his limbs, face, and trunk.
c. Sabreen Hassen has a stage 2 pressure injury on her left heel.
4. For each of the following concepts, use critical thinking to describe how or why it is important to nursing, patient care, or skin integrity and wound healing. Note that these are not to be merely definitions. Shearing Preventing pressure injury
Friction
Wound assessment
Pressure
Dressing changes
Wound healing process
What Are the Main Points in This Chapter?
➤ The layers of the skin are the epidermis (outermost), the dermis, and the subcutaneous layer (innermost). ➤ The major functions of the skin are protection of the internal organs, unique identification of an individ- ual, thermoregulation, metabolism of nutrients and metabolic waste products, and sensation. ➤ Age, mobility, nutrition, hydration, moisture underly- ing conditions, medications, contamination or infec- tion, diminished sensation, cognitive impairment, hygiene, and lifestyle are factors that influence the ability to maintain intact skin and heal wounds. ➤ If there are no breaks in the skin, a wound is described as closed . A wound is considered open if there is a break in the skin or mucous membranes. ➤ Acute wounds may be intentional (e.g., surgical inci- sions) or unintentional (e.g., trauma) and are expected to heal without complications. ➤ Wounds that exceed the anticipated length of recov- ery are classified as chronic wounds. Chronic wounds include pressure, arterial, and venous wounds and diabetic ulcers. A chronic wound may linger for months or years. ➤ Clean wounds are uninfected wounds with minimal inflammation. Clean-contaminated wounds are sur- gical incisions that enter the gastrointestinal, respira- tory, or genitourinary tracts. Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. Infected wounds are wounds with evidence of infection, such as presence of microorganisms.
➤ A wound that involves minimal or no tissue loss and has wound edges that are approximated are said to heal by primary intention. ➤ A wound that involves extensive tissue loss and has margins that cannot be approximated, or is infected, heals by secondary intention. ➤ Tertiary intention healing, or delayed primary clo- sure, occurs when two surfaces of granulation tissue are brought together. Initially the wound is allowed to heal by secondary intention. ➤ Healing occurs in three stages. The inflammatory phase lasts from 1 to 5 days and consists of two major processes: hemostasis and inflammation. The prolif- erative phase occurs from days 5 to 21. It is character- ized by cell development aimed at filling the wound defect and resurfacing the skin. The maturation phase begins in the second or third week and contin- ues until the wound is completely healed. ➤ Wound closure methods include adhesive strips (Steri-Strips), absorbent sutures, surgical staples, and surgical glue. ➤ Drainage is the flow of fluids from a wound or cavity. It is often referred to as exudate (fluid that oozes as a result of inflammation). ➤ Complications of wound healing include hemor- rhage, infection, dehiscence, evisceration, and fistula formation. ➤ Pressure injury is caused by unrelieved pressure over time that compromises blood flow to tissue, resulting in ischemia in the underlying tissue.
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