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Potter: Fundamentals of Nursing, 8th Edition

Chapter 48: Skin Integrity and Wound Care Key Points - Printable Pressure ulcers contribute to patient discomfort and decreased functional status, increased length of stay in acute and extended care settings, and increased cost of care. Wound assessment scales help measure improvement of a healing pressure ulcer; do not use the staging system for this purpose. Evaluate all patients on an ongoing basis for risk factors that contribute to development of impaired skin integrity. Alterations in mobility, sensory perception, level of consciousness, and nutrition and the presence of moisture increase the risk for pressure ulcer development. The risk of impaired skin integrity related to immobilization depends on the extent and duration of immobilization. Pressure, shearing force, and friction are contributing factors to the development of pressure ulcers. When the external pressure against the skin is greater than the pressure needed to keep the capillary open, blood flow decreases to the adjacent tissues. Meticulous ongoing assessment of the skin and identification of risk factors are important in decreasing the opportunity for pressure ulcer development. Preventive skin care is aimed at controlling external pressure on bony prominences and keeping the skin clean, well lubricated and hydrated, and free of excess moisture. Proper positioning reduces the effects of pressure and guards against the shearing force. Therapeutic beds and mattresses redistribute the effects of pressure; however, base selection on assessment data to identify the best bed for individual needs. Cleaning and topical agents used to treat pressure ulcers vary according to the stage of the pressure ulcer and condition of the wound bed. Assessment of the ulcer enables the nurse to select proper skin care agents. Direct nutritional interventions at improving wound healing through increasing protein and calorie levels. Wound assessment requires a description of the appearance of the wound base, size, presence of exudate, and the periwound skin condition. When tissue loss is extensive, a wound heals by secondary intention. The chances of wound infection are greater when the wound contains dead or necrotic tissue, when foreign bodies lie on or near the wound, and when the blood supply and tissue defenses are reduced. The principles of wound first aid include control of bleeding, cleaning, and protection. The layers of a dry dressing absorb drainage and prevent entrance of bacteria. A moist environment supports wound healing. The wet-to-dry dressing mechanically removes dead tissue and wound exudate to debride the wound. When cleaning wounds or drain sites, clean from the least to most contaminated area, away from wound edges.
Copyright 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

Key Points - Printable


Apply a bandage or binder in a manner that does not impair circulation or irritate the skin. An acute sprain, closed fracture, or bruise responds best to cold applications.

Copyright 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.