CHAPTER 10 Integumentary System^411
NURSING DIAGNOSES
- Impaired skin integrity
- Impaired physical mobility
- Nutrition altered: less than what body requires
NURSING INTERVENTION
- Prevention is the key to pressure ulcers.
- Mobility or repositioning of patients unable to move themselves; every 1 to
2 hours. - Proper nutrition to encourage healing.
- Adequate fluid intake.
- Remove pressure from stage I areas.
- Use pillows to reduce pressure.
- Use specialized wheelchair cushions to reduce pressure.
- Daily skin inspection.
- Stop smoking in order to increase oxygen to tissues.
- Daily measurement of wounds to assess status including length, width, and
depth.
Wounds and Healing
A wound is any break in the skin. It may be intentional, as with surgery, or unin-
tentional, as a result of trauma. Types of wounds include surgical, penetrating (such
as a knife), crushing, burn, lacerations, bites, (human, animal), ulcers, and pressure
ulcers. Immediately after a wound occurs, inflammation begins with platelet aggre-
gation. Next, leukocytes travel to the area for infection surveillance. A prolifera-
tive phase starts when the epidermal cells move toward the wound, and cover the
approximated wound edges, usually by the third day. The fibroblastic phase occurs
with collagen and fibroblasts forming a scar.
Wound healing occurs in various ways. Primary intention happens when edges
are closely approximated and new tissue, or granulation, knits the close edges
together. Wound healing by secondary intention occurs in a larger wound where
the edges are further apart. This is often intentional when the wound is infected,
dirty, or from a bite. The granulation tissue builds across the surface of the wound
forming a large clot and sequentially, a larger scar.
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