Skin Integrity & Wound Healing 32 C H A P T E R nated with environmental bacteria. ■ Have the patient stay in bed with the knees bent to minimize strain on the incision. ■ Do not put a binder on the patient. ■ Notify the surgeon and ready the patient for surgery (see Chapter 36 for care of the surgical patient). Fistulas Learning Outcomes After completing this chapter, you should be able to: A large dressing covers the incision on Mr. Harmon’s left hip. During your assessment, you loosen the dressing and see that the staples are intact at the incision site, and there is a min- A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Fistulas often result from infection or debris left in the wound. Fistulas can occur after bowel surgery, especially in compromised patients. It can also occur spontaneously and is associ- ated with certain diseases, such as inflammatory bowel disease (IBD) and cancer (McNichol et al., 2021). An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway. Chronic drain- age from the fistula may lead to skin breakdown and delayed wound healing. The most common sites of fis- tula formation are the gastrointestinal and genitouri- nary tracts. Figure 32-9 illustrates a fistula between the rectum and vagina. ➤ Discuss the factors that affect skin integrity. ➤ Identify wounds based on accepted classification schemes. ➤ Describe the three phases of wound healing. ➤ Distinguish primary intention healing, secondary intention healing, and tertiary intention healing. ➤ Describe the three types of wound drainage. ➤ Review the major complications of wound healing. ➤ Explain the factors involved in the development of pressure injury. ➤ Use the Braden scale to assess risk for pressure injury. ➤ Assess and categorize pressure injuries based on the staging system. ➤ Provide nursing care that limits the risk of pressure injury development. ➤ Differentiate the kinds of chronic wounds. ➤ Accurately chart an assessment of a wound. ➤ Demonstrate appropriate techniques for irrigating a wound. ➤ Describe care of a wound with a drain. ➤ Differentiate the five forms of wound débridement. ➤ Discuss the different kinds of tissue found in wounds. ➤ Discuss when and how to use absorbent dressings, alginate dressings, collagen dressings, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings. ➤ Describe guidelines to follow when applying heat or cold therapy. ➤ Demonstrate bandage and binder application. Meet Your Patient To explore learning resources for this chapter, Go to www.DavisAdvantage.com and find: Answers and Suggested Responses for all questions in this chapter Concept Map Knowledge Map References and Bibliography
FIGURE 32-9 A fistula is an abnormal passa two body cavities or a cavity and the skin. common in the gastrointestinal and genito
Key Concepts Skin integrity Wound Wound healing Related Concepts See the Concept Map on DavisAdvantage. Example Client TEXT STEP #1 Build a solid foundation. Skin Integrity & Wound Healing
2 to 4 weeks may be considered chr injury is a type of chronic wound. To sure injuries, see the Example Client sure Injury and Figures 32-10 and 32-11 Practical Knowledge knowing how As a nurse, you will care for man have wounds or who are at risk down. The remainder of the chapter
Condition Pressure Injury STUDENT RESOURCES The questions and exercises in this book allow you to practice the kind of thinking you will use as a full-spectrum nurse. Critical-thinking questions usually have more than one right answer, so we do not provide “correct” answers for these features. Try to answer these questions yourself. It is more important to develop your nursing judgment than to just cover content. You will learn more by discussing the questions with your peers. If you are still unsure, see the Davis Advantage chapter resources for suggested responses.
Key Concepts Skin integrity Wound Wound healing Related Concepts See the Concept Map on Davis Advantage. Example Client
Two types of case studies bring concepts to life, connecting what you read to what you will see and do in practice.
William Harmon is a 78-year-old man who fell and frac- tured his left hip 3 days ago.After being admitted to the hospital, he underwent an open reduction and internal fixation (ORIF) of the left hip.Today is his second postop- erative day. He is unable to roll or pull himself up in the bed. Mr. Harmon’s weight on admission was 140 lb (63.64 kg). His height is 73 in (185.42 cm). His family reports that he has been steadily losing weight. He expresses little interest in eating and says he has suffered depression since his wife died last year.
548
UNIT 3 Essential Nursing Interventions
Condition Pressure injury
Mobility and activity
4797_Ch32_001-036.indd 1 Poisoning Poisoning death rates have more than quadrupled in the past 20 years. Although young children are frequent victims, the increase has been mainly among adults. In many cases, the person does not die but becomes ill or suffers other effects. Poisoning exposure accounts for more than 2 million emergency department visits per year in the United States (CDC, 2022). ■ Young children are poisoned most often by improper storage of household chemicals, medicines and vita- mins, and cosmetics (see Box 21-1). of home safety hazards in this section should help you answer this question. Except for motor vehicle accidents, most fatal acci- dents occur in the home. The leading causes of death in the home are poisonings, falls, fires and burns, and choking. For children, maternal mental health problems and having older siblings are associated with less safe homes (Zonfrillo et al., 2018). The use of lead in paint has been banned since 1978, but lead-based paint can still be found in older homes and toys produced in some foreign countries. Some soil (which young children often put in their mouths) contains high levels of lead. In the United States, poor, urban, and immigrant populations are at higher risk for lead exposure than other groups. ■ Older children and adolescents may attempt suicide by overdosing with medicines or be poisoned acci- dentally when experimenting with recreational or prescription drugs. ■ Adults experience poisoning as a result of illegal drug use or misuse or abuse of prescription drugs, especially narcotic medications, tranquilizers, and antidepressants. ■ Household cleansers, including oven cleaner, drain cleaner, toilet bowl cleaner, and furniture polish ■ Medicines, including cough and cold preparations, vitamins, pain medications, antidepressants, anticonvulsants, and iron tablets, which may look like candies to children ■ Indoor houseplants, including poinsettia, Dieffenbachia, Philodendron, and many others ■ Cosmetics, hair relaxer, nail products, mouthwash ■ Kerosene, gasoline, lighter fluid, paint thinner, lamp oil, antifreeze, windshield washer fluid, lighter fluid, and other chemicals ■ Alcoholic beverages BOX 21-1 ■ Poisonous Agents Commonly Ingested by Children
imal amount of sero- sanguineous drainage on the bandage. As you ■ Death from prescription analgesics and prescrip- tion opioids has reached epidemic levels in the past decade, greater than deaths from heroin and cocaine combined. A big part of the problem is nonmedical use—using pain medications without a prescription or using them just for the high they cause. In 2018, an estimated 10.3 million people aged 12 years or older misused opioids in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022).
Time and pressure
1 Caring for the Williams Family Kayla Robinson, Stanley and Nadine Williams’ 3-year-old grandchild, fell at the neighborhood playground. She has abrasions on her knees, a deep puncture wound on her left hand, and a laceration on her scalp. Mr. and Mrs.Williams bring her to the clinic for assessment. She is crying loudly and moving all extremities. No treatment has been given. (Continued)
Sensation
Knowledge Check 32-5 ■ Describe four types of wound closures. ■ Identify five types of wound complications. ■ Describe three signs of internal hemorrhage. ■ Compare dehiscence and evisceration. ■ Treatment choice depends on the poison ingested. For most poisonings, the most effective intervention is professional administration of activated charcoal orally or via gastric tube. However, charcoal is not effective for ethanol, alkali, iron, boric acid, lithium, methanol, or cyanide. Depending on the situation, other options for medical treatment include gastric lavage, dialysis, administration of antidotes (i.e., Narcan), and forced diuresis.
Intrinsic factors
6/22/23 4:52 PM
• Nutrition • Age
Tissue tolerance
658 Carbon Monoxide Exposure Carbon monoxide (CO) is a colorless, tasteless, odor- less toxic gas. Exposure can cause headaches, weakness, nausea, and vomiting; prolonged exposure leads to sei- zures, dysrhythmias, unconsciousness, brain damage, and death. Each year in the United States, CO poisoning causes approximately 350 unintentional deaths (CDC, 2017a). ■ Most CO exposures occur at home. ■ Most CO exposures involve females, children under the age of 17 years, and adults aged 18 to 44 years. ■ CO poisoning accounts for a majority of deaths at the scene of fires and is also a relatively common cause of death by suicide. ■ Many CO deaths occur during cold weather among older adults and the poor who seek nonconventional heat sources (e.g., gas ranges and ovens) to stay warm. Scalds and Burns The following are common causes of scalds and burns: ■ Scald injuries (e.g., from hot water, steam, or grease) are the most common cause of burns in children younger than age 3. Scalding burns (especially on both feet or both hands) and cigarette burns in children and vulnerable older adults should always prompt you to assess for abuse (see Procedure 6-1). ■ Warming food or formula in the microwave may cause the food to become hotter than intended, lead- ing to burns in infants and young children. ■ Sunburn can cause a first- or second-degree burn. ■ Contact burns may occur from contact with metal surfaces and vinyl seats when cars are parked in the sun. The risk of contact burns in all age-groups is greater in the presence of such heating devices as kerosene heaters, wood-burning stoves, and home sauna heating elements. People may use these as heat
Think Like a Nurse 32-2: Clinical Judgment in Action
• Circulation • Underlying
health status
iCare highlights the role of caring in nursing by modeling behaviors and conversations that demonstrate how to provide compassionate care. Extrinsic factors
Recall the case of Mr. Harmon (Meet Your Patient).What form of wound healing (primary, secondary, or tertiary) is he undergoing? How long would you expect it to take before his wounds heal?
• Friction • Shearing •Moisture
26
UNIT 4 Supporting Physiological Function
4798_Ch32_658-704.indd 658 Think Like a Nurse: Clinical Judgment in Action questions put you in the nurse’s role to develop your clinical judgment skills from day one. CHRONIC WOUNDS A chronic wound is one that has not healed within the expected time frame. Wounds that do not heal within UNIT 11 Factors Affecting Health 212
pain. Key P tion is nor occur as so Sterile wat larly when Ideally,
20/06/23 5:37 PM
32-1
FIGURE 32-10 Several factors contribute to of a pressure injury.
contamination from biofilm in the hospital setting Age and Developmental Stage Age and devel- opmental stage influence the likelihood of becoming ill. Certain health problems can be correlated to develop- mental stage. For example, more than 75% of new breast cancer cases are diagnosed in female patients older than age 50. As another example, adolescent boys have much higher rates of head injury and spinal cord injury than paraplegic who has developed a stage 4 sacral pressure ulcer with a foul odor. He is expecting sFome of his friends from school for a visit. Ken, his nurse, while nonchalantly cleaning up the room, makes sure to remove the garbage liner with the old dressings in it. He also brings in some fresh-cut flowers and a cup of wet coffee grounds. Both the flowers and the coffee grounds are natural odor eliminators. Mr. Brown has a great visit with his friends from school. breast cancer. A genetic marker for this type of breast cancer has been discovered, indicating that some people inherit a tendency to develop breast cancer. Sex Many diseases occur more commonly in one sex than in another. For example, rheumatoid arthritis, oste- oporosis, and breast cancer are more common in female individuals, whereas ulcers, color blindness, and bladder cancer are more common in male individuals. Skin Integrity and Wound Healing ■ Scenario 1— Mary is caring for Mrs. Skylar, a 62-year-old patient with diabetes and venous stasis ulcers on her legs. Since developing these venous stasis ulcers, Mrs. Skylar has become very self-conscious and embarrassed about her legs.When taking Mrs. Skylar to x-ray, Mary covers Mrs. Skylar’s legs with a bath blanket for comfort and privacy. Mary was not only providing comfort and protecting privacy. She was also aware of Mrs. Skylar’s feelings and cared enough to respond to them. ■ Scenario 2— Mr. Robert Brown is an 18-year-old
Social Determinants of Health boxes and icons help you to think about the many conditions that affect health. Social Determinants of Health 8-1 Economic Stability ■ Employment ■ Food insecurity ■ Housing instability ■ Poverty Education Access and Quality ■ Early childhood education and development ■ Enrollment in higher education ■ High school graduation ■ Language and literacy Social and Community Context ■ Civic participation ■ Discrimination ■ Incarceration
Isotonic Nonhem Nontoxi impa Transpa bed. Inexpen volum Warmed Selectin
4797_Ch32_001-036.indd 13 ■ Wild plants and mushrooms ■ Pesticides, rodent poisons
following a ■ Piston sy posable mize han elongate gation flu
h21_544-574.indd 548
11/05/23 4:58 PM
3
Powered by FlippingBook