Module 7.docx - Module 7 Providing Wound Skin Care to Patients Skin assessment Understanding skin structure helps you maintain skin integrity and

Module 7.docx - Module 7 Providing Wound Skin Care to...

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Module 7: Providing Wound & Skin Care to Patients Skin assessment Understanding skin structure helps you maintain skin integrity and promote wound healing. Intact skin protects the patient from chemical and mechanical injury. Age-related changes such as reduced skin elasticity, decreased collagen, and thinning of underlying muscle and tissues can cause the older adult's skin to be easily torn in response to mechanical trauma, especially shearing forces hypodermis decreases in size with age. Older patients have little subcutaneous padding over bony prominences; thus, they are more prone to skin breakdown o Integrity of skin Open wound Closed wound Depth of wound Superficial wound Partial-thickness wound Full-thickness wound Closed wound o Presence of Infection Clean wound Clean contaminated wound Contaminated wound Infected wound Colonized wound Some recommendations regarding the management of wound-related pain include: o Appropriate selection of dressings
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o Protection of surrounding tissue from irritating wound drainage or dressing materials o Aggressive treatment of infection, which is known to increase the presence of inflammation and pain o Positioning of the patient in a way that avoids pressure over the wound o Use of binders or other devices to splint the wound edges o Premedication before turning, dressing changes, and debridement. Braden Risk Assessment Braden Scale for Predicting Pressure Ulcer Risk The Braden Scale ( Table 48-3 ) was developed on the basis of risk factors in a nursing home population ( Braden and Bergstrom, 1994 ) and is widely used on general patient care units in hospitals. However, the Braden Scale has shown insufficient predictive validity and poor accuracy in discriminating intensive care patients at risk for developing pressure ulcers ( Hyun et al., 2013 ). Research involving critical care patients continues. The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development Skin breakdown Three pressure-related factors 1186contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. Preventing skin breakdown How to prevent ulcers on patient’s feet Evaluating the amount of pressure (checking skin for nonbranching hyperemia) and determining the amount of time that a patient tolerates pressure (checking to be sure after relieving pressure that the affected area blanches). The second factor related to tissue tolerance is the ability of the underlying skin structures (blood vessels, collagen) to help redistribute pressure. Systemic factors such
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as poor nutrition, increased aging, hydration status, and low blood pressure affect the tolerance of the tissue to externally applied pressure Impaired skin integrity occurs from prolonged pressure (e.g., from lying in one position,
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  • Fall '16
  • Exam 3, Fundamentals Of Nursing, Exam3

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