NSG-300 Topic 4 Learning Guide:
Skin Integrity and Wound Care Objectives:
1. Examine the factors that place clients at risk for impaired skin integrity.
Poor nutrition, fluid imbalance, improper healing, immobility, moisture, friction, impaired sensory
perception, shear, inability to perceive pressure, decreased activity level, inability to reposition
2. Apply the elements of a comprehensive wound assessment.
- Wound location
- Depth of tissue involvement (staging)
- Type and approximate percentage of tissue in wound bed
- Wound dimensions (if present include sinus tracts and tunneling)
- Exudate description (if present odor)
- Condition of surrounding skin
3. Utilize the planning component of the nursing process to demonstrate nurse’s role and
responsibilities for skin and wound care.
- Assessment:
- Diagnosis:
- Planning:
- Implementation:
- Evaluate:
4. Determine nursing interventions that promote healing and the prevention of wound
infections in clients with impaired skin integrity.
-position change q 2 hours
-bed sheet change every shift or more based on needs
-reduce moisture (creams)
-
Critical Concepts:
Ch. 48 1. Skin a. Layers (dermis, epidermis, dermal-epidermal junction)
2. Pressure injuries
a. Pathogenesis:
- pressure intensity
- Tissue ischemia
- Blanching
- Pressure duration
- Tissue tolerance
b. Risk factors:
- Impaired sensory perception
- Impaired mobility
- Alteration in LOC
, - Shear
- Friction
- Moisture
- Decreased activity level
- Poor nutrition intake
- Inability to reposition
3 Classification of pressure injuries
- STAGE 1:
- Non-blanchable erythema of intact skin
- STAGE 2:
- Partial thickness skin loss with exposed dermis (ruptured blister)
- STAGE 3:
- full thickness skin loss
- Fat tissue & exposed skin
- Slough and or eschar may be visible
- STAGE 4:
- Full thickness skin and tissue
- Exposed muscle, tendon, ligament, fascia, cartilage, or bone
4. Wounds - a disruption of the integrity and function of tissues in the body
- Result from trauma causing laceration or puncture or from surgical intervention
- Two types: closed and open wounds
- Closed wounds examples: contusions, hematomas, or stage 1 pressure injuries
- Open: split, incised or cracked and underlying tissues are exposed to environment
a. Classification
- Partial thickness wound repair:
- Involve only partial loss of skin layers
- Full thickness wound repair:
- Involve total loss of skin layers
b. Process of wound healing
- Primary Intention: surgical incision
- Edges approximated, or closed and risk of infection decreases
- Quick healing with minimal scar
- Secondary Intention: bum, Stage 2 pressure injury, or severe laceration
- Wound left open until it becomes filled by scar tissue
- Longer healing, increase risk of infection
- If severe: loss of tissue function permanent
c. Complications of wound healing
- Hemorrhage: bleeding from a wound site, normal during, and immediately after
- Infection: MC HAI
- Surgical sites infection, microorganisms invade wound tissue
- Erythema, increase wound drainage, increase thickness, color change, presence
of odor, warmth, and pain
, - Dehiscence:
- Separation or splitting open layers of surgical wound
- 3-11 days after injury
- At risk: infection, diabetes, decrease nutrition
- Evisceration:
- Extrusion of viscera or intestines through surgical wound
- Emergency: surgical repair
5. Prediction and prevention of pressure injuries
- Risk assessment: Braden Scale
- Economic consequences of pressure injuries:
- Acute and restorative care
- Age
6. Critical thinking and the nursing process related to skin/wounds/ pressure injuries
- ASSESSMENT:
- Through clients eyes:
- Clients level of sensation
- Presence of medical devices, medical adhesives, independent or assisted
movement
- Expectations:
- Home care?
- Quick return to work?
- Environment:
- Turning
- Assistance with position change
- Skin:
- Tissue and wound base
- Color of viable and non-viable tissue
- Amount color, consistency, and odor of wound drainage
- Pain, redness, warmth
- Analysis & Nursing Diagnosis:
- EX:
- Risk of infection
- Acute or chronic pain
- Impaired mobility
- Impaired peripheral tissue perfusion
- Planning outcomes and Identification
- Outcomes: identify expected outcomes for each diagnosis and plan individualized
interventions
- Setting priorities: important things first
- Teamwork and Collaboration: work together
7. Acute wound care
- First aid for wounds
- Wound management
- Dressings
Skin Integrity and Wound Care Objectives:
1. Examine the factors that place clients at risk for impaired skin integrity.
Poor nutrition, fluid imbalance, improper healing, immobility, moisture, friction, impaired sensory
perception, shear, inability to perceive pressure, decreased activity level, inability to reposition
2. Apply the elements of a comprehensive wound assessment.
- Wound location
- Depth of tissue involvement (staging)
- Type and approximate percentage of tissue in wound bed
- Wound dimensions (if present include sinus tracts and tunneling)
- Exudate description (if present odor)
- Condition of surrounding skin
3. Utilize the planning component of the nursing process to demonstrate nurse’s role and
responsibilities for skin and wound care.
- Assessment:
- Diagnosis:
- Planning:
- Implementation:
- Evaluate:
4. Determine nursing interventions that promote healing and the prevention of wound
infections in clients with impaired skin integrity.
-position change q 2 hours
-bed sheet change every shift or more based on needs
-reduce moisture (creams)
-
Critical Concepts:
Ch. 48 1. Skin a. Layers (dermis, epidermis, dermal-epidermal junction)
2. Pressure injuries
a. Pathogenesis:
- pressure intensity
- Tissue ischemia
- Blanching
- Pressure duration
- Tissue tolerance
b. Risk factors:
- Impaired sensory perception
- Impaired mobility
- Alteration in LOC
, - Shear
- Friction
- Moisture
- Decreased activity level
- Poor nutrition intake
- Inability to reposition
3 Classification of pressure injuries
- STAGE 1:
- Non-blanchable erythema of intact skin
- STAGE 2:
- Partial thickness skin loss with exposed dermis (ruptured blister)
- STAGE 3:
- full thickness skin loss
- Fat tissue & exposed skin
- Slough and or eschar may be visible
- STAGE 4:
- Full thickness skin and tissue
- Exposed muscle, tendon, ligament, fascia, cartilage, or bone
4. Wounds - a disruption of the integrity and function of tissues in the body
- Result from trauma causing laceration or puncture or from surgical intervention
- Two types: closed and open wounds
- Closed wounds examples: contusions, hematomas, or stage 1 pressure injuries
- Open: split, incised or cracked and underlying tissues are exposed to environment
a. Classification
- Partial thickness wound repair:
- Involve only partial loss of skin layers
- Full thickness wound repair:
- Involve total loss of skin layers
b. Process of wound healing
- Primary Intention: surgical incision
- Edges approximated, or closed and risk of infection decreases
- Quick healing with minimal scar
- Secondary Intention: bum, Stage 2 pressure injury, or severe laceration
- Wound left open until it becomes filled by scar tissue
- Longer healing, increase risk of infection
- If severe: loss of tissue function permanent
c. Complications of wound healing
- Hemorrhage: bleeding from a wound site, normal during, and immediately after
- Infection: MC HAI
- Surgical sites infection, microorganisms invade wound tissue
- Erythema, increase wound drainage, increase thickness, color change, presence
of odor, warmth, and pain
, - Dehiscence:
- Separation or splitting open layers of surgical wound
- 3-11 days after injury
- At risk: infection, diabetes, decrease nutrition
- Evisceration:
- Extrusion of viscera or intestines through surgical wound
- Emergency: surgical repair
5. Prediction and prevention of pressure injuries
- Risk assessment: Braden Scale
- Economic consequences of pressure injuries:
- Acute and restorative care
- Age
6. Critical thinking and the nursing process related to skin/wounds/ pressure injuries
- ASSESSMENT:
- Through clients eyes:
- Clients level of sensation
- Presence of medical devices, medical adhesives, independent or assisted
movement
- Expectations:
- Home care?
- Quick return to work?
- Environment:
- Turning
- Assistance with position change
- Skin:
- Tissue and wound base
- Color of viable and non-viable tissue
- Amount color, consistency, and odor of wound drainage
- Pain, redness, warmth
- Analysis & Nursing Diagnosis:
- EX:
- Risk of infection
- Acute or chronic pain
- Impaired mobility
- Impaired peripheral tissue perfusion
- Planning outcomes and Identification
- Outcomes: identify expected outcomes for each diagnosis and plan individualized
interventions
- Setting priorities: important things first
- Teamwork and Collaboration: work together
7. Acute wound care
- First aid for wounds
- Wound management
- Dressings
