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Weekly Powerpoints - Skin Integrity and Wound Healing...

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Skin Integrity and Wound Healing Kimberly Glenn MN, RN, CPN Clinical Associate Professor N312 Foundations
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S AFETY – Risk of Injury R/T Different Factors Factor How it affect wound healing Safety concerns Increased age Skin frail, loss of skin turgor, peripheral circulation & oxygenation, collagen, altered immune system •Skin more prone to friction/shearing damage, slower to regenerate Nutrition (Vit c, copper, zinc) Need protein for collagen and tissue formation •Won’t have the protein needed for repair Chronic diseases & or medications Additional stress on body already trying to mend. Meds can interfer w/ ability to mend or fight off infection •Body overloaded & not able to mend in timely manner 2
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S AFETY – Risk of Injury R/T Different Factors Factor How it affect wound healing Safety concerns Moisture Can lead to maceration •Skin breaks down when moist, good medium for bacteria Fever metabolism: less nutrients avail for tissue repair. Sweating can add to moisture level 3 Tissue perfusion Provides circulation (blood & oxygen) needed for repair More prone to infection
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S AFETY - System Specific Physiology: Wound Healing Process Inflammatory : inflamed- red , ?swollen, tender (platelets come to stop bleeding & WBC’s come to fight infection) Proliferation: contracting of the wound (edges approximate more, less likely to separate during this stage) Maturation: remodel-can take up to a year. Wound appears white (capillaries that formed during inflammatory stage are no longer needed)
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S AFETY - System Specific Physiology Wound Healing Process (p 1284) Primary intention Little to no tissue loss/edges approximated Low risk infection or scarring. Ex Secondary intention Tissue loss/wound edges widely separated Heals from inner layer to surface-longer healing time. Ex: Increased risk for &
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S AFETY - System Specific Physiology Wound Healing Process (p 1284) Tertiary intention Deep with widely separated edges Delayed closure of wound edges. NO suturing for a period of time-will leave open then suture at later date after risk of infection is past. Ex:
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S A FETY - System Specific Assessment: Wound Classification Open/closed (tissue integrity) Acute/chronic (length of time for healing) Acute: short; chronic: long term Clean/contaminated/infected Superficial/partial or full-thickness (depth-seen with burns) superficial-surface only; partial: into dermis Penetrating (if involves internal organs)
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S A FETY - System Specific Assessment: Charting info Location : be specific, anatomical, forms often include drawings to help identify site
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This note was uploaded on 02/16/2011 for the course NURS 312 taught by Professor Glenn during the Fall '10 term at South Carolina.

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Weekly Powerpoints - Skin Integrity and Wound Healing...

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