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Chapter 29
CHAPTER 37
Skin Integrity and Wound Healing
Skin Loss:
Stage I- Superficial- epidermis, 1st degree, red skin
Stage II- Partial thickness- epidermis to dermis, 2ed degree ex. blister
Stage III- Full thickness- extends through epidermis, dermis, subq; 3ed degree
Stage IV-involves epidermis, dermis, subq, muscle and bone
The RYB wound classification: Assists nurse in assessing the wound color surface
Red wounds: color of normal wound, recent without infection need to be protected and kept moist and
clean
Yellow wounds- have fibrinous slough or purulent exudate from bacteria; needs to be cleaned to remove
pus and slough; irrigate and cover with wet to dry
Black wounds- gray or brown contain necrotic tissue (eschar- scab or dry crust results from skin death);
wounds need debridement
*Always treat the worst color first
Assessment
Health history
Allergies and Family History
Aggravating factors- touch move cough make it hurt
Alleviating factors- medication, holing stomach
Personal social history- chronic issues to require narcotics
Functional ability- to provide self care
Physical exam- any concurrent conditions assessed
Wound assessment- location, size, general appearance/ drainage, pain
Laboratory data- elevate WBC indicate infection; decreased leukocytes increased risk infection, albumin
decreased increased wound healing and culture of wound drainage presence of infection
Sinus tract and undermining- wound healing from outside in, common w/ puncture wounds
Planning outcomes: wound healing primary intention
Implementation:
Emergency measures- surgical repair and vitals, pressure stop bleeding
Cleanse wound- clean to dirty
Dress the wound- keep wound moist, keep it clean, protect from physical trauma or bacteria
Monitor drainage- penrose drains- function by gravity & closed suction drains reservoir creates negative
pressure
Suture care- check numbers to be removed
Bandages, binders, slings- secure, immobilize or support body part
Heat cold therapy- vasodialation and vasoconstriction- precautions: neurosensory impaired, impaired
mental status, impaired circulation; moist open wounds vs. dry for sprains and closed wounds
NANDA Statements
Impaired skin integrity
Risk for infection
Acute pain
Chronic pain
Disturbed body image
Deficient knowledge
Pressure ulcers- bed sores- decubitus ulcers
Caused by ischemia, common on boney prominences- sacrum, heels
Blanching- white color of skin, when pressure relieved skin remains red
Shearing- friction
Risk factors: immobility, inactivity, incontinence, malnutrition, decreased mental status,
diminished sensation, age related changes
Braden’s scale for pressure ulcer risk
Sensory perception, moisture, degree of physical activity, mobility, nutrition, friction
Vascular ulcers
Arterial ulcers- weak or absent pulses, thin skin, lack of hair
Neuropathic ulcers- diabetic ulcers
Gram positive- have cell wall with thicker constituent known as peptidoglycan- purple gram stain
Gram negative organisms harder to treat due to complex cell wall- red gram stain
Morphology- coccus, bacillus, coccobacillus, fusiform bacillus, spirillum, vibrio, spirochete
Signs and symptoms of infection: fever, chills, sweats, redness, pain, swelling, fatigue, weight loss, increase
WBC, formation of pus
Empiric therapy- when life threatening complications is high and micro-organism can not be identified yet after
cultures antibiotic is given immediately
Prophylactic antibiotic therapy- used to prevent infection when a procedure increases likelihood of dangerous
microbial contamination
Superinfection-caused when antibiotics reduce or completely eliminate the normal bacterial flora; bacteria or
fungi needed to maintain normal function of organs are eliminated. Ex yeast infection from antibiotics
Signs- fever, perineal itching, oral leasions, vaginal irritation, cough, lethargy
Green or yellow sputum is indicative of bacterial infection during a viral respiratory illness
Inappropriate antibiotic prescribing, patients not complete antibiotic regiment, cause antibiotic resistant
medication
Drug –drug interactions and drug- food interactions
Host factors- patient age, allergy history, kidney liver function, pregnancy, genetic characteristicts, defenses
Infants children- can not take tetracyclines b/c affect bone teeth growth
Penicillin and sulfonamides common allergies
Teratogens- drugs that cause development abnormalities and birth defects in the fetus b/c several
antibiotics can pass through the placenta
Genetic host factor- adverse effects b/c- Glucose-6-phosphate dehydrogenase deficiency and slow
acetylation , sulfonamides and nirtofunantoin to person w/ G6PD def may result in hemolysis
Bacteriostatic- inhibit growth of bacteria but not kill them
Bactericidal- directly kill bacteria
B-lactamases is one way bacteria can fend off the effects of antibiotics
Antibiotics interfere with
Bacteria cell wall synthesis, interference with protein synthesis, inference with replication of nucleic
acids DNA and RNA, antimetabolite action that disrupts critical metabolic reactions of cell
Category of antibiotics:
Sulfonamides- bacteriostatic- also antimetabolites, only organisms that syntise their own folic acid are
inhibited by sulfonamides.
B-Lactam- some bacterias enzymes can break the chem bond between carbon and nitrogen in b lactam
ring causing an ineffective antibiotic- b lactamase inhibitors increase effectiveness of antibiotics
4 classes of b lactam antibiotics, if patient is allergic to penicillin have 4fold risk of alergy to other b-
lactam antibiotics- cross sensitivity
Penicillins- bactericidal, inhibit cell wall synthesis
b-lactamases destroy penicillins- clavulanic acid, tazobactam, sulbactam
natural penicillin V&G- treat syphilis
penicillinase-resistant pen.- nafcillin- resist breakdown by penicillinase
broad spectrum- aminopenicillins- effective against gram negative
amoxicillin
ampicillin
extended spectrum penicillins- antipseudomonal- able to treat pseudomonas,
Cephalosporins- bacteriacidal, most widely used antibiotic,cross sensitivity with penicillin and
bind to penicillin binding proteins, not active against fungi or viruses, produced by a fungus,
gram -/+ variable on generation 1-4
Carbapenems- broadest antibacterial of any antibiotic to date
MonoBactams-aztreonam only 1, g- bact, e coli, klebsiella,psudomonas
Macrolides— erythromycin - bacteriostatic w/ high concentration bacteriocidal, affects
Gi motility, can benefit in pt. with decrease GI mobility, treat AIDS
To be used if pt. is allergic to penicillin
Ketolides--
Tetracyclines- bacteriostatic, binds to ca2+ mg2+ and al3+, can not be used 8yrs b/c tooth discoloration,
not to be used preg women and nursing mothers, differ from one another by: oral absorption, body tissue
penetration, half-life
Broad spectrum; inhibit protein synthesis
Treat syndrome of ineffective antidiruretic hormone, cause formation of necessary scar tissue in lungs
OTHER NOTES:
Antifungal agents
Systemic mycotic infections
Superficial mycotic infections
Cutaneous infections
Retrovirus- replicate using reverse transcriptase RNA
Cytopathic Effect- refers to cellular degeneration due to viral entry and replication and usually results in cell
lysis
Viral Transformation- involves mutation of host genetic material that results in cancerous cells (oncogenic
viruses)
RESOURCES:
Fundamentals of Nursing 3rd edition, DeLaune
Pharmacology and the Nursing Process, 5th edition, Lilley, Harrington, Snyder