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UNIT 4 Supporting Physiological Function
Knowledge Check 32-6 ■ What stage of pressure injury does Mr. Harmon (Meet Your Patient) have? ■ What factors have contributed to its development?
A
Think Like a Nurse 32-3: Clinical Judgment in Action
Based on your knowledge of the factors that have contributed to Mr. Harmon’s (Meet Your Patient) pressure injury development, what actions may lead to healing of the pressure injury? Note: To answer this question, you do not need to know about wound care (e.g., irrigation) for a pressure injury. Focused Nursing History To assess wound-healing ability and the risk for skin breakdown, you will need to gather data on factors that affect skin integrity (discussed previously): age, mobil- ity, nutrition, hydration, sensation, circulation, medica- tions, moisture, lifestyle, underlying health and disease status, and the presence of microorganisms (Fig. 32-10). Also consider the psychosocial issues related to coping with chronic wounds. Bolstering coping strategies and increasing resilience can help with increasing feelings of well-being; likewise, improving well-being can improve wound healing (Dudfield et al., 2019). You will need to assess with care and com- passion how the patient: ■ Copes with the pain of a chronic wound ■ Handles the loss of control and independence ■ Is adapting to changes in body image ■ Deals with the financial burden of caring for com- plex wounds ■ Adjusts to the social isolation that comes with impaired mobility and chronic illness For history questions to help you assess these factors,
Vertebrae (spinal processes)
Sacrum
Pelvis (ischial tuberosity)
Heels (calcanei)
B
Side of head (parietal and temporal bones) Ear
Shoulder (acromial process)
Ilium
Greater trochanter
Knee (medial
Malleolus (medial and lateral)
and lateral condyles)
C
Back of head (occipital bone)
Scapulae Elbows
Sacrum Heels
(olecranon process)
(calcaneus)
D
Cheek and ear (zygomatic bone)
Shoulder (acromial process)
Breasts (women)
Genitalia (men)
Knees (patellae)
Toes (phalanges)
See Chapter 32, Focused Assessment, History Questions for Skin and Wound Assessment, in Volume 2.
FIGURE 32-11 Pressure injuries most commonly develop over the bony prominences. A, Sitting. B, Lateral. C, Supine. D, Prone. ( Source: Adapted from Agency for Healthcare Research and Quality [AHRQ] Clinical Practice Guidelines.)
Focused Physical Examination Physical assessment of skin integrity focuses on skin inspection, mobility, and activity assessment. Assessing the Skin Assess all areas of the body routinely for skin color, integrity, temperature, texture, turgor, mobility, moisture, lesions, and hair distribu- tion. Check pressure points for erythema, tenderness, or edema. Assess all bony prominences of individuals at risk for skin breakdown routinely (Fig 32-11). Examine skin under special garments such as shoes, heel eleva- tors, and antiembolism stockings. Also assess vulnera- ble pressure points for bed- or chair-bound patients. See Chapter 19 for more details on skin assessment.
maintain skin integrity, prevent pressure injury, and treat wounds. ASSESSMENT/RECOGNIZING CUES The National Pressure Injury Advisory Panel (NPIAP) recommends that nurses perform a comprehensive wound assessment while identifying other health prob- lems and their impact on wound healing. A thorough skin evaluation includes a nursing history, physical examination, and diagnostic testing.
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