Ensuring Skin Integrity (Wound Care)

Classification according to Wound Type

Classification of Wounds Thickness

Superficial (on the surface) wounds leave the deeper skin layers
intact. These types of wounds are usually caused by friction rubbing
against an abrasive surface.
Deep wounds go through all the layers
of the skin and into underlying tissue
like muscle or bone.

Stages of Wound Healing

https://www.youtube.com/watch?v=f9kQ4MQNMy0&t=3s
Although the elderly can heal most wounds, they have a slower healing
process and all phases of wound healing are also affected.

Optimal wound healing requires adequate nutrition. Nutrition deficiencies

impede the normal processes that allow progression through stages
of wound healing. Malnutrition has also been related to decrease wound
tensile strength and increase infection rates.

Oxygen plays a very significant role in wound healing – it is needed

for cellular function and can kill bacteria and cause resistance to
infection. Oxygen stimulates the creation of new blood vessels and
also aids growth factors to form new skin. Your red blood cells
carry oxygen throughout the body.
Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin,
resulting in tissue ischemia and impaired healing of injured tissue.

The medications most likely to impair wound healing and damage

skin integrity include antibiotics, anticonvulsants, steroids, and
nonsteroidal anti-inflammatory drugs.

Diabetes mellitus is one of the major contributors to chronic

wound healing problems. When diabetic patients develop an
ulcer, they become at high risk for major complications,
including infection and amputation.
Effects of Having a Wound
Nursing Process in for Altered Skin Integrity
After my health teachings, client will
manifest positive receptive / response to
health instructions
> wound begins to heal after a week
> gains weight at least 3 pounds a week
> bearable pain on the affected area
 Video on Wound Dressing
https://www.youtube.com/watch?v=WKGAs9uRlsI&t=179s
Other measures to relieve pain
> Contralateral stimulation
> Contralateral stimulation