0133427269 Module21 TissueIntegrity LectureOutline

The Concept of Tissue Integrity Integumentary systemincludes skin, hair, nails, and sebaceous, sweat, and mammary glands Nursing functions ( maintain skin integrity, promote wound healing Tissue integrity includes integumentary, mucous membrane, corneal, subcutaneous tissues Normal presentation of the skin Functions of skin Protects underlying tissues Nerves and skin enable perception of touch, pain, pressure, heat, cold Body temperature regulation Synthesize vitamin D Physiology review Three distinct layers (see Figure 211 THREE-DIMENSIONAL VIEW OF THE SKIN, p. 1446) Epidermis Outermost part of skin, composed of epithelial cells Stratum basaledeepest layer of epidermis Melaninprotective shield from effects of ultraviolet light Keratinfibrous, water-repellent protein ( gives epidermis protective quality Stratham spinosumnext layer Stratum granulosummiddle layer ( slows water loss across epidermis Keratinizationthickening of cells membranes ( begins in this layer Stratum lucidum present only in areas of thick skin ( made up of flattened, dead keratinocytes Stratum corneumoutermost layer of epidermis 75 total thickness of epidermis 2030 sheets of dead cells arranged in shingles ( flake off as dry skin Dermis Second, deeper layer of skin ( flexible connective tissue Supplied with blood cells, nerve fibers, lymphatic vessels Hair follicles sebaceous, sweat glands Two layers Papillary layer ( contains capillaries, receptors for pain and touch Reticular layer ( contains blood vessels, sweat, sebaceous glands, deep pressure receptors, dense bundles of collagen fibers Regions between bundles form lines of cleavage in skin ( surgical incisions parallel to lines heal more easily Subcutaneous tissue Loose connective tissue ( stores half bodys fat cells Cushions body Insulates body Genetic and lifespan considerations Changes occur throughout life ( visible ( contribute to self-perception, self-esteem See Table 211 AGE-RELATED SKIN CHANGES, p. 1447 Epidermis Epidermal cells contain less moisture upon aging Rough, dry appearance Longer healing time Dermis Decreases in thickness, functionality in third decade Elastin quality declines, quantity increases ( wrinkling, sagging Senile purpuradiscolored areas caused by thinner, easily damaged capillaries Subcutaneous tissue With age, subcutaneous tissue atrophies in some body areas, increases in others Thinner in face, neck, hands, lower legs Increased in abdomen in all, thighs in women Alterations to skin integrity See CONCEPTS RELATED TO TISSUE INTEGRITY, p. 1449 Alterations and manifestations Intact skin ( presence of normal skin and skin layers uninterrupted by wounds Affected by many factors Pruritus Erythema Skin disorders Infectious Inflammatory Neoplastic Skin lesions Primary lesions (see Table 212 PRIMARY SKIN LESIONS, p. 1450 Secondary lesions ( see Table 213 SECONDARY SKIN LESIONS, p. 1451 Wounds ( see Table 214 TYPES OF WOUNDS, p. 1451 Intentionaloccur during therapy (e.g., venipunctures, surgery) Unintentionalaccidental (e.g., fractured arm) Degree of contamination Clean wounds Clean-contaminated wounds Contaminated wounds Dirty, infected wounds See Box 211 CLASSIFYING WOUNDS BY DEPTH, p. 1452 Untreated wounds Control severe bleeding Prevent infection Control swelling, pain Assess for signs of shock Treated wounds Treated or sutured wounds should be observed to determine progress in healing See ALTERATIONS AND THERAPIES Tissue Integrity, p. 1453 Prevalence Common in U.S. population 1 in 3 individuals has a skin disorder Most common disorders ( dermatitis, inflammatory reactions to topical drugs, infectious diseases of the skin Genetic considerations and nonmodifiable risk factors Having one or both parents, siblings, or close relatives with a particular disorder increases an individuals likelihood of having the same disorder Heritable skin disorders include epidermolysis bullosa, ichthyosis, albinism Ethnicity is a risk factor for a number of disorders Gender ( men have more infectious skin disorders women have more pigmentary and autoimmune disorders Age ( changes in skin thickness, surface pH, and quality of wound healing made older adults more susceptible to skin disorders Dark skin tone ( keloids, psudofolliculitis, dermatosis papulose nigra Light skin tone ( more susceptible to sun damage Case Study Part 1 ( Arthur Sullivan is a 52-year-old Caucasian male who was scheduled for neurosurgery to remove a pituitary tumor, p. 1452 Prevention Modifiable risk factors Proper skin care and maintenance ( skin should be kept clean, dry, and moisturized Avoid irritants or allergens known to inflame the skin Chronic illnesses and their treatments interfere with the appearance and function of skin Screenings Regular self-examination of the skin Professional examination of the skin Assessment Nursing assessment Skin diseases, previous bruising, general skin condition, skin lesions, usual healing Inspection and palpation ( skin color, turgor, edema, lesions See ASSESSMENT INTERVIEW Skin and Tissue Integrity, p. 1456 See INTEGUMENTARY ASSESSMENT, pp. 1457-1460 See FOCUS ON DIVERSITY AND CULTURE Skin Color, p. 1460 Diagnostic tests Skin biopsy Cultures Immunofluorescent studies, Wood lamp, potassium hydroxide, Tzanck test Patch tests Laboratory data Case Study Part 2 ( Because of Mr. Sullivans complications, his hospital stay extends to 8 weeks , p. 1460 Interventions and therapies Goals of treatment ( control severity, prevent infection, promote healing Independent Determine whether home remedies are hindering healing and provide information about home remedies that will help Educate clients about good hygiene Teach infection prevention methods Emphasize nutrition and exercise Collaborative Pharmacologic therapies Treatments vary depending on severity of condition See MEDICATIONS, Tissue Integrity, pp. 14611463 Review The Concept of Tissue Integrity Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Three years after his release from the hospital, Mr. Sullivans venous ulcer has improved but is still not healed completely, p. 1463 Exemplar 21.1 Burns Overview Injury resulting from exposure to heat, chemicals, radiation, electric current Pathophysiology and etiology Types of burns Thermal burns Exposure to dry or moist heat See Figure 213, THERMAL (SCALD) BURNS, p. 1464 Chemical burns Acids, alkaline agents, organic compounds Also classified by how they structurally alter proteins See Box 212, HOUSEHOLD CHEMICALS THAT MAY CAUSE BURNS, p. 1465 Electrical burns Severity depends on type, duration of current, amount of voltage Direct current ( lightning bolt ( very high voltage ( may have cardiac arrest Radiation burns Sunburn, radiation treatment for cancer ( superficial Nuclear power accidents, extensive exposure ( multisystem involvement Etiology In U.S., 450,000 individuals with burns treated in hospitals each year 3,500 die each year ( 3,000 from fire the rest from other causes Children ( 88,000 injured and 600 die each year Residential fires are most common cause Risk factors Age, careless smoking, intoxication, physical and mental disabilities Water scalding affects younger children and older adults See LIFESPAN CONSIDERATIONS Children and Burns, p. 1466 Older adults ( slower reaction times, impaired mobility, sensory impairment Other factors associated with burn risk Gender males more likely to suffer serious burns Socioeconomic status Poor individuals at higher risk Race/ethnicity African Americans and Native Americans at higher risk Rural location Located far from fire departments and emergency responders Physical and/or mental disability May not understand risks, have impaired mobility and decreased reaction time Occupation Those who work with chemicals, gasoline, electricity or extreme heat at greater risk Prevention Vary by setting and cause Take proper precautions in the home, especially if children are present See Box 21-3 BURN PREVENTION IN THE HOME, p. 1466 Use proper safety equipment in workplaces Smokers should take appropriate precautions Clinical manifestations Classification of burns Depth of the burn Superficial ( burns skin remains intact, heals in 36 days Partial-thickness burns ( involve entire dermis Superficial-partial thickness burn ( bright red, moist, glistening appearance with blisters Deep partial-thickness burn extends further into dermis pale, waxy, moist or dry, large or flat blisters, heals in more than 21 days ( contractures, scarring, impairment possible Full thickness burns All layers of skin, may extend into subcutaneous fat, connective tissue, muscle, bone Caused by prolonged contact with source of burn Require skin grafting to heal Extent of the burn ( expressed as percentage of total body surface area (TBSA) See Figure 218 THE RULE OF NINES, p. 1469 See Figure 219 THE LUND AND BROWDER, p. 1469 See Table 215 AMERICAN BURN ASSOCIATION CLASSIFICATION OF BURN INJURY, p. 1469 Burn wound healing Inflammation( immediately following injury Platelets aggregate, fibrin deposited, thrombus forms causes hemostasis Vasodilation and increase in capillary permeability follow Neutrophils infiltrate, then monocytes are converted into macrophages, which secrete growth factors that stimulate provisional wound matrix Proliferation Fibroblasts ( major cell in wound within 23 days Granulation tissue forms, epithelial cells cover wound Remodeling May last for years Collagen fibers reorganize, scars contract and fade Hypertrophic scaran overgrowth of dermal tissue within boundaries of wound Keloida scar that extends beyond the boundaries of the wound Clients with dark skin at greater risk for both Systemic effects of burn injuries Pathophysiological changes from major burn involve all body systems Can result in massive infection, fluid and electrolyte imbalances, hypothermia Respiratory function compromised if source of burn inhaled Dysrhythmias, circulatory failure common Respiratory system Inflammation of airway from breathing in hot gases and smoke Interstitial pulmonary edema ( when fluid escapes from pulmonary vasculature into interstitial compartment of lung tissue Smoke poisoning ( toxic gases and particulate matter deposit directly on pulmonary mucosa Cardiovascular system Hypovolemic shock ( fluid shifts from intracellular and intravascular to interstitium due to loss of cell wall integrity ( compromises lymphatic system Cardiac rhythm alterations ( due to release of substances, oxygen free radicals, and ischemic myocardial cells Peripheral vascular compromise ( compartment syndrome may result in burns that encircle an extremity Integumentary system Common results Loss of water secondary to evaporation Infection secondary to loss of skin integrity Difficulty maintaining body temperature due to heat loss Zones of Injury ( see Figure 2111, THE ZONES OF INJURY, p. 1472 During acute stage of injury ( eschar forms Gastrointestinal system ( dysfunction depends on size of wound Burn trauma causes paralytic ileus, the absence of bowel sounds Stress ulcers (Curling ulcers) Urinary system ( urine output decreases Myoglobinuria or hemoglobinuria ( result of underlying muscle damage or release of dead erythrocytes Immune system ( risk of infection due to compromise in humoral and cell-mediated immune systems Metabolism Ebb phasefirst 3 days of injury Flow phaseincreases in cellular activity and protein catabolism Lifespan and cultural considerations Age has significant impact on response to burn injury Older adults at greatest risk for death Collaboration Minor burns ( outpatient for treatment, client teaching Sunburn is most common type Administer mild analgesics Blisters may be left intact or debrided Follow-up care includes twice daily wound cleansing with application of topical ointment, ROM exercises for affected joints, weekly clinic appointments Severe burns ( see Figure 2112 THE CLIENTS PROGRESSION, p. 1474 Emergent/resuscitative stage ( onset of injury through successful fluid resuscitation First aid, fluid resuscitation, assessment See Box 21-4 PREHOSPITAL CLIENT MANAGEMENT, p. 1475 Acute stage ( start of dieresis through closure of burn wound Wound care Nutrition therapy Infection prevention Pain management Rehabilitative stage ( begins with wound closure, ends with client return to highest level of health restoration Prevention of contractures, scars Clients successful resumption of work, family, social roles Range-of-motion (ROM) exercises to enhance mobility, support injured joints Emergency and acute care Airway and ventilator management Intubation indicated for all clients with burns to chest, face, or neck Primary treatment plan oriented to preventing atelectasis and maintaining alveolar oxygen exchange Maintain head of bed at 30 Immediate intubation if there is airway obstruction Humidification of either room air or oxygen Medications to dilate constricted bronchial passages For those with major burn, arterial line is placed for continuous assessment of ABGs If CO poisoning is present, carboxyhemoglobin levels must be checked Circulatory support and fluid resuscitation ( IV fluids to restore blood volume Crystalloid fluids administered through two large-bore catheters 50 fluid infused during first 8 hours, remainder during next 16 hours Hourly urine output ( indicator of effective fluid resuscitation Invasive hemodynamic monitoring may be needed Diagnostic tests Urinalysis Complete blood count Serum electrolytes Renal function tests Total protein, albumin, transferrin, prealbumin, retinol binding protein, alpha-1-acid glycoprotein, C-reactive protein Creatine phosphokinase Blood glucose Serial ABGs Pulse oximetry Carboxyhemoglobin measurement Serial chest x-ray studies Serial 12-lead ECGs Surgery Escharotomy ( removing eschar with scalpel or by electrocautery Surgical debridement ( for clients with extensive or full-thickness burns Autografting ( healthy skin from client is applied to burn wound Cultured epithelial autografting ( 3- to 4-week process of skin growth Pharmacologic therapy Analgesia IV narcotics ( morphine Opioids Antianxiety agents Antimicrobials Systemic infection leading cause of death in clients with major burns Diagnose infection through burn wound biopsy Broad-spectrum antibiotics Topical antibiotics Prophylactic antibiotics Tetanus prophylaxis ( intramuscular Antacids ( to prevent Curling ulcer Gastric aspirant through nasogastric tube Nonpharmacologic therapy Wound management Goals Control microbial colonization, prevent wound infection Prevent wound progression Achieve wound coverage as early as possible Promote function of healing skin Debridement Mechanical debridement Hydrotherapy Enzymatic debridement Dressing the wound Open method Closed methods Contractures a common problem ROM exercises prescribed to be done every 2 hours Uniform pressure prevents or reduces hypertrophic scarring Biological and biosynthetic dressings Homograft (allograft) Heterograft (xenograft) TransCyte and Apligraf Vacuum-assisted closure (VAC) Nutritional support Hypermetabolic, catabolic state ( from heat loss from burn wound, beta-adrenergic activity, pain, infection Caloric needs ( 4,0006,000 kcal/day Enteral feedings with nasointestinal feeding tube Central venous catheter if enteral feeding contraindicated Nursing Process Assessment Time of injury Cause of the injury First-aid treatment Past medical history Age Medications Body weight Diagnosis Ineffective Airway Clearance Impaired Gas Exchange Risk for Aspiration Risk for Decreased Cardiac Tissue Perfusion Risk for Ineffective Renal Perfusion Deficient Fluid Volume Acute Pain Risk for Infection Impaired Physical Mobility Imbalanced Nutrition Less Than Body Requirements Powerlessness Planning Major burn affects every body system, social, cultural, economic, ecologic, spiritual well-being Goals include the following Client will maintain clear, unobstructed airway Client will maintain ABG values and pulse oximetry within normal limits Client will demonstrate no cardiac dysrhythmias Client will maintain adequate fluid volume Client will receive adequate nutrition Clients blood pressure and heart rate will range within acceptable limits Client will maintain adequate pain control, reporting pain as a 3 or less Client will not develop a healthcare-associated infection Client will maintain full ROM following recovery Implementation ( see Table 216, INTERVENTIONS IN VARIOUS STAGES OF BURN INJURY, p. 1485 Promote fluid volume balance Assess blood pressure, heart rate frequently Monitor hemodynamic status Follow prescribed protocols for IV fluid resuscitation Monitor intake and output hourly Weigh daily Test stools, emesis for presence of blood Maintain warm environment Monitor fluid volume overload Provide effective pain management Measure clients level of pain using consistent measurement tool Medicate before painful procedures, patient-controlled analgesia (PCA) Administer IV narcotic analgesics as prescribed Explain all procedures, expected levels of discomfort Use methods of nonnarcotic pain control in combination with medications Allow client to verbalize pain experience Protect skin integrity Estimate extent, depth of burn wound Provide daily wound care Elevate burned, newly skin-grafted extremities Immobilize skin graft sites Provide special skin care to sensitive body areas Prevent infection Monitor daily for manifestations of wound infection Monitor for positive blood cultures Monitor for hyperemia, cough, chest pain, wheezing, rhonchi, decreased oxygen saturation, purulent sputum Monitor for presence of bacteria in urine, fever, urgency, frequency, dysuria, suprapubic pain Obtain daily WBC counts Determine tetanus immunization status Maintain high-kilocalorie intake Maintain a septic environment using standard precautions Culture all wounds, body secretions per protocol Administer prescribed antimicrobial medications Maintain physical mobility Perform active, passive ROM exercises to all joints every 2 hours Applied splints as prescribed Maintain limbs and functional alignment Anticipate needs for analgesia Promote balanced nutrition Maintain nasogastric/nasal intestinal tube placement Maintain enteral/parenteral nutritional support as prescribed Weigh client daily Obtain daily laboratory values for protein, iron, CBC, glucose, albumin Facilitate empowerment Allow client as much control over surroundings, routine as possible Keep needed items within reach Encourage client to express feelings Set short-term, realistic goals for client Evaluation Client maintains stable vital signs Client receives adequate pain management Clients nutritional needs are met Client infection free See CLIENT TEACHING Burn Care, p. 1486 Review Burns Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 21.2 Contact Dermatitis Overview Contact dermatitis ( inflammation of skin that occurs in response to direct contact with an allergen, irritant Latex allergies ( increasing problem in healthcare workders Pathophysiology and etiology Etiology Allergic contact dermatitis ( cell-mediated or delayed hypersensitivity to allergens Irritant contact dermatitis ( inflammation of skin from irritants See Box 215 COMMON CAUSES OF CONTACT DERMATITIS, p. 1488 Risk factors ( allergies, eczema, moist environment, burns, plants, chemicals, metals, frequent hand washing Clinical manifestations Allergic contact dermatitis Erythema, edema, pruritus, vesicles, bullae b) Develop several hours to 3 days after exposure Irritant contact dermatitis Discrete area of redness, corresponds to exposure location Develops within a few hours of contact, peaks within 24 hours, resolves quickly with removal of the irritant See Table 217 DISTRIBUTION OF LESIONS BY TYPE OF ALLERGEN, p. 1489 Lifespan and cultural considerations Individuals with impaired skin barrier function and slower healing processes at risk for developing contact dermatitis Older adults ( more likely to develop allergic contact dermatitis less likely to develop irritant contact dermatitis Younger clients ( more likely to develop irritant contact dermatitis Collaboration Treatment begins with identifying the causative agent and ending client Education involves information about products containing the allergen or irritant, how to avoid it, substitutes for it, methods for limiting exposure See CLINICAL MANIFESTATIONS AND THERAPIES Contact Dermatitis, p. 1489 Diagnostic tests Patch testing Skin prick testing Skin injection testing Pharmacologic therapy Calamine lotion Cool compresses with aluminum acetate promote drying Wet dressings or colloidal oatmeal soaks relieve itching Acute allergic reactions ( medium potency topical corticosteroids Reactions greater than 10 of body ( oral corticosteroids Antibiotics if area becomes infected Nonpharmacologic therapy Collaborative care Work with employers and OSHA or workplace issues Work with school nurse for school-age children Refer to allergist for further testing Complementary and alternative therapy Used to complement pharmacologic therapy, not replace it Topical treatments ( aloe vera, chamomile Diet therapies ( probiotics Nursing process Assessment Chief complaint ( onset, characteristics, course, severity, precipitating and relieving factors Examination Diagnosis Impaired Skin Integrity related to contact dermatitis as evidenced by pruritis and rash Deficient Knowledge Planning Clients skin integrity will be restored and protected Clients triggers will be identified and eliminated Client will remain free of infection Implementation Medications, treatments relieve symptoms, do not cure disease Dry skin increases pruritis May be necessary to change diet, environment Remove clothing worn after outside activities Wash clothes before first wearing, extra rinse Place barrier between allergen and skin Apply topical corticosteroids, keep using for 23 weeks Apply wet dressings Antihistamines cause drowsiness, use caution See CLIENT TEACHING How to Reduce Dry Skin and Relieve Pruritus, p. 1491 Evaluation Control of dermatitis is maintained, no infection occurs Triggers identified and eliminated Clients sleep minimally disturbed by itching Review Contact Dermatitis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 21.3 Pressure Ulcers Overview Ischemic lesions of the skin and underlying tissue caused by external pressure that impairs the flow of blood flow ( causes tissue necrosis, eventual ulceration Develop over bony prominence, any part of body subjected to external pressure, friction, shearing forces Pathophysiology and etiology Etiology Develop from external pressure that compresses blood vessels, forces that tear and injure vessels Shearing forces ( one tissue layer slides over another Pressure ( distorts capillaries, interferes with normal blood flow Risk factors Immobility Inadequate nutrition Fecal and urinary incontinence Maceration Excoriation Decreased mental status Diminished sensation Excessive body heat Advanced age Loss of lean body mass Generalized thinning of epidermis Decreased strength, elasticity of skin Increased dryness Diminished pain perception Diminished being this, arterial flow Chronic medical conditions Other factors Poor lifting and transfer techniques Incorrect positioning Hard support surfaces Incorrect application of pressure-relieving devices Prevention Providing nutrition Maintaining skin hygiene Avoiding skin trauma Provding supportive devices ( see Table 21-8 MECHANICAL DEVICES FOR REDUCING PRESSURE ON BODY PARTS, p. 1495 Clinical manifestations Staging ( see Table 219 PRESSURE ULCER STAGING, pp. 1496-1497 Stages IIV Unstageable ( eschar present See CLINICAL MANIFESTATIONS AND THERAPIES Pressure Ulcers, p. 1498 Collaboration Diagnostic tests Determine presence of secondary infection and differentiate cause of ulcer Surgery Debridement Larval therapy Pharmacologic therapy See Table 2110 PRODUCTS USED TO TREAT PRESSURE ULCERS, p. 1498 Topical and systemic antibiotics Topical products that promote healing Dressings that maintain moisture and protect wounds from friction and bacterial colonization Nonpharmacologic therapy Collaborating with physical therapists, primary caregiver Referrals to home health agencies ( Nursing process Assessment ( See Figure 216 BODY PRESSURE AREAS, p. 1499 See PRESSURE ULCER ASSESSMENT, p. 1500 Document Location Size Presence of undermining Stage Color of wound bed, location of necrosis, eschar Integrity of surrounding skin Clinical signs of infection Client complaints of pain, discomfort Signs of infection Risk assessment tools ( see Figure 2117 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK, p. 1501 Diagnosis Risk for Impaired Skin Integrity Impaired Skin Integrity Risk for Infection Imbalanced Nutrition Less Than Body Requirements Risk for Compromised Human Dignity Situational Low Self-Esteem Planning Client who is immobile, bed rest ( will be repositioned every 2 hours Client who is mobile ( maintain, improve activity levels Client will report any alterations Client will articulate importance of maintaining adequate nutrition and hydration Client will describe measures to protect, heal tissue Implementation Maintain skin integrity Conduct systematic skin inspection daily Clean skin when soiled, routine intervals Minimize environmental factors Avoid massage over bony prominences Minimize skin exposure to moisture Minimize skin injury due to friction, shearing Client positioning Maintain head of bed at lowest elevation consistent with condition Use assistive devices Place at-risk client on pressure-reducing device Chair bound clients ( use pressure-reducing device Prevent infection of pressure ulcers Maintain skin hygiene Maintain appropriate nutrition and hydration Recognize early stages Maintain, improve current activity levels Prevent nutritional imbalance Process factors involved Offer nutritional supplements Consult with dietitian Prevent compromised human dignity and situational low self-esteem Conduct physical exam, indicators of abuse, neglect Develop caring, trusting relationship Teach family members, caregivers importance of repositioning, skin hygiene Assist family members, caregivers with obtaining supported devices Evaluation Treatment plan may need to be evaluated and modified daily Review Pressure Ulcers Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 21.4 Wound Healing Overview Healing is a quality of living tissue ( also called regeneration Rate of healing depends on factors such as the type of healing, the location and size of the wound, and the clients health Physiology Types of wound healing Primary intention healing ( tissue surfaces have been approximated with minimal or no tissue loss Closed surgical incision Tissue adhesive Secondary intention healing ( extensive wound with tissue loss and edges that cannot/should not be approximated Pressure ulcer Tertiary intention healing ( wounds left open for 35 days, then closed ( allows edema, infection to resolve, wound to drain Phases of wound healing ( see Figure 2118 WOUND HEALING OCCURS, p. 1507 Inflammatory phase ( immediate, lasts 36 days Proliferative phase ( from 34 days to about day 21 Maturation phase ( about day 21 to 12 years postinjury Risk factors for complications Hemorrhage Infection Dehiscence with possible evisceration Prevention Nutrition Lifestyle Medications Clinical manifestations Exudate ( material that has escaped from blood vessels during inflammatory process Deposited in or on tissue Three types of exudates Serous exudatesaccompanies mild inflammation, clear or straw colored Purulent exudatesthicker than serous, opaque or milky Sanguineous exudatesindicates damage to capillaries, seen in open wounds Lifespan and cultural considerations Healthy children and adults heal more quickly than older adults Presence of chronic conditions impairs healing Older adults ( slow healing as a result of normal cellular and molecular changes Collaboration Many kinds of healthcare providers involved with wound care Clients should be taught to recognize symptoms of infection and other complications Diagnostic tests If infection is suspected ( culture and sensitivity tests Surgery Repair damaged tissues or vessels and reclose wound Surgical debridement Escharotomy Pharmacologic therapy Depends on whether healing is normal or impaired Antibiotics for infected wounds Growth factors to stimulate wound healing Opioids and NSAIDs for pain management Nonpharmacologic therapy For wounds with normal healing ( Infection prevention measures, compression bandages or hosiery, diets high in protein, carbohydrates, and vitmins For wounds with impaired healing ( vacuum-assisted closure, cellular therapies, biosurgery Nursing Process Assessment Assess location, extent of tissue damage, undermining Inspect wound for bleeding Inspect wound for foreign bodies Assess associated injuries Determine last tetanus toxoid injection Diagnosis Risk for Impaired Skin Integrity Impaired Skin Integrity Impaired Tissue Integrity Risk for Infection Acute Pain Planning Client will maintain skin integrity, avoid potential associated risks Client will demonstrate progressive wound healing, regained intact skin Implementation Facilitate wound healing Promote optimal nutrition and hydration Prevent infection Position to minimize pressure on the wound Evaluation Expected outcomes include Skin and tissue integrity maintained Wound decreases in size Client demonstrates understanding of preventive care measures Review Wound Healing Relay Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect 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