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CHAPTER 32 Skin Integrity & Wound Healing
Caring for the Williams Family (continued)
A. What should be your first course of action?
her other wounds, you notice that her left knee is erythematous, warm, and painful to touch and that there is a moderate amount of purulent drainage. What assessment questions should you ask? E. Nadine tells you that Kayla would not allow her to clean or dress the abraded knees.You cleanse Kayla’s knee and remove several small pieces of gravel from the wound bed.The wound is yellow and malodorous. What kind of care will Nadine need to provide to Kayla to heal the left knee?
B. What kind of care will Kayla need at the clinic?
C. You determine that the scalp laceration will need to be sutured.What actions should you take to prepare Kayla for the suturing? D. One week later, Kayla arrives at the clinic with her grandmother to have the sutures removed.The scalp laceration is dried and healed.When you inspect
Practical Knowledge
clinical application As a nurse, you will care for many patients who have wounds or who are at risk for impaired skin integrity. To apply your theoretical knowledge of wound assessment and wound care, you will need practical knowledge found in the Procedures and Clinical Insights. PROCEDURES Specific nursing interventions directed at maintaining skin integrity or healing wounds make use of procedures for obtaining wound cultures, cleansing wounds, and dressing wounds; for placing and removing wound closures, caring for wound drains, and applying binders and bandages; and Clinical Insights for applying local heat and cold therapy. Procedure 32-1 ■ Obtaining a Wound Culture by Swab ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover. ➤ Note: This procedure uses modified sterile technique because wound care is now usually performed using a clean approach rather than strict sterile technique.
Equipment ■ Three pairs of clean nonsterile gloves ■ Aerobic culturette tube with sterile calcium alginate or rayon swab ■ Sterile 4 in. × 4 in. gauze in an impermeable tray or separate 4 × 4 packs and an impermeable barrier ■ Sterile 0.9% (normal) saline solution for irrigation, warmed to body temperature when possible (cold solution lowers the temperature of the wound bed and slows the healing process) ■ 35-mL syringe
Delegation This procedure requires knowledge of wound healing. It needs to be performed by a registered nurse (RN). Do not delegate this skill to unlicensed assistive personnel (UAP). Preprocedure Assessments NOTE: If the wound is covered when you begin, you will make these assessments once you remove the soiled dressing and after
cleansing the wound. ■ Assess for pain.
Wounds may be painful, and wound irrigation may increase pain. Provide prescribed pain medication 30 minutes before performing the procedure, if indicated.
■ 19-gauge angiocatheter ■ Gown and face shield ■ Emesis basin ■ Water-resistant disposable drapes
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