Psychomotor wound notes - NUR222.01 underlyingtissues...

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NUR 222.01 Psychomotor Skills for Nursing Chapter 8 Skin Integrity and Wound Care A wound is a disruption in the normal integrity and function of the skin and  underlying tissues.  The patient experiencing a wound is at risk for wound complications: 1. Hemorrhage (externally, internally=hematoma) 2. Infection 3. Dehiscence (wound opens involuntarily) and Evisceration (organs come  out through wound-EMERGENCY) 4. Fistulas (increase risk of infection and loss of fluid and electrolytes,  abnormal passage between organs) Pressure ulcer, a wound caused by unrelieved pressure that results in damage to underlying tissue, are one of the most common skin and tissue disruptions and are costly in terms of healthcare expenditures.  What are nursing responsibilities related to skin?   Assess, diagnose-develop plan of care, implement plan-nursing  interventions, interventions lead to outcomes, Evaluate  What are causes of nosocomial infections? Health care acquired infection   bad hand hygiene, bad asepsis procedures in wound care 1
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Why might a patient experience pain during a dressing change? What is the  nurse’s responsibility to the patient during a dressing change? Full tissue loss may cause pain Wound heal by primary, secondary, or tertiary intention. Primary intention: primary union of the edges of a wound that progresses to  complete scar formation, usually heals rapidly (if this gets infected then  turns to secondary healing) Secondary intention:  wound closure in which the edges are separated,  granulation tissue develops to fill the gap, larger scar, than results from  primary intention, greater chance of infection and large scars Tertiary intention: left open for a few days to allow swelling or edema or  infection to subside, then sutured  What nursing diagnoses can you think of for a patient experiencing trauma  to the integumentary system.  1.  Risk for infection  2. Imbalanced nutrition: less than body requirements 3. Acute or chronic pain 4.  Impaired physical mobility  5.  Ineffective tissue profusion  6. Impaired tissue integrity  What causes a pressure ulcer? Pressure intensity: Occlusion of capillary which causes tissue ischemia  (damage)-diabetic pt’s because loss of sensation Pressure duration: Low pressure over a long time, or high pressure over a  short amount of time Tissue tolerance: Ability of tissue to endure pressure dependent on skin  integrity   Impaired sensory perception, Impaired mobility, Alteration in  LOC, Shearing forces, Friction, Moisture, nutrition, and age 2
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Wounds are assessed for: 1. appearance, (inspect and palpate). Look for approximation of the edges,  color of the wound and surrounding area. Observe for signs of infection.
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