C H A P T E R 32
Skin Integrity & Wound Healing
Learning Outcomes After completing this chapter, you should be able to:
Key Concepts Skin integrity Wound Wound healing Related Concepts See the Concept Map on DavisAdvantage. Example Client
➤ 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.
Condition Pressure Injury
Meet Your Patient
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- imal amount of sero- sanguineous drainage on the bandage. As you
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.
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