1. Skin Integrity and Wound Care.pdf

Tishk International University Nursing Faculty Nursing Department Fundamental of Nursing Skin Integrity and Wound Care First Grade – Spring Semester 2019-2020 Instructor: Halmat Authman Rasheed LEARNING OUTCOMES Describe factors affecting skin integrity. General and specific types of wound. INTRODUC...

Tishk International University Nursing Faculty Nursing Department Fundamental of Nursing Skin Integrity and Wound Care First Grade – Spring Semester 2019-2020 Instructor: Halmat Authman Rasheed LEARNING OUTCOMES Describe factors affecting skin integrity. General and specific types of wound. INTRODUCTION The skin is the largest organ in the body and serves a 1 variety of important functions in maintaining health 2 and protecting the individual from injury. 1 Important nursing functions are maintaining skin 2 integrity and promoting wound healing. SKIN INTEGRITY Intact skin refers to the presence of 1 normal skin and skin 2 layers uninterrupted by wounds. The appearance of the skin and skin integrity are influenced by 1 § Internal factors genetic, age and underlying health 2 External factor activity TYPES OF WOUNDS Body wounds are either intentional or unintentional If the tissues are traumatized without a break in the skin, the wound is closed. The wound is open when the skin or mucous membrane surface is broken. Describing a wound according to the degree of wound contamination 1 Clean wounds are uninfected wounds in which there is minimal inflammation and the r e s p i r a t o r y, gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds 2 Clean-contaminated wounds are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection. ama bama la xale 3 jya dakretawa: 1. inflammation \ 2. infection X 3 Contaminated wounds include open, fresh, accidental wounds and surgical wounds. Contaminated wounds show evidence of inflammation. ama bama la xale 2 jya dakretawa: 1. inflammation \ 2. infection \ 4 Dirty or infected wounds include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage. Specific Types of Wounds 1 Incision: Sharp instrument (e.g., knife or scalpel). 2 Contusion: Blow from a blunt instrument. 3 Abrasion: Surface scrape, either unintentional (e.g., scraped knee from a fall)or intentional (e.g., dermal abrasion to remove pockmarks). 4 Puncture: Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional 5 Laceration: Tissues torn apart, often from accidents (e.g., with machinery. 6 Penetrating wound Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)