NURSING PROCESS

ASSESSING
ASSESSMENT OF SKIN INTEGRITY

The nurse conducts an examination of the integument as part of a routine assessment

and during regular care. Removing barriers to assessment is very important to assess
the skin condition underneath.

ASSESSMENT OF WOUNDS

UNTREATED WOUNDS

•assess the location and extent of tissue damage

•inspect the wound for bleeding.

•inspect the wound for foreign bodies

•assess associated injuries

•if the wound is contaminated with foreign material, determine when the client last
had a tetanus toxoid injection

PRINCIPLES OF CARE INCLUDE:

[Link] severe bleeding by:

(a) applying direct pressure over the wound

(b) elevating the involved extremity.

2. Prevent infection by

(a) cleaning or flushing abrasions or lacerations with normal saline

(b) covering the wound with a clean dressing

3. Control swelling and pain by applying ice over the wound and surrounding tissues.

4. If bleeding is severe or if internal bleeding is suspected, and if emergency

equipment is available, assess the client for signs of shock.
TREATED WOUNDS

•are usually assessed to determine the progress of healing.

•it involves observation of its appearance, size, drainage, and the presence of swelling,
pain, and status of drains or tubes

ESTIMATING THE AMOUNT OF WOUND DRAINAGE:

 Minimal drainage only stains the dressing

 Moderate drainage saturates the dressing without leakage prior to scheduled

dressing changes

 Heavy drainage overflows the dressing prior to scheduled changes.

PRESSURE ULCERS.

THE NURSE NOTES THE FOLLOWING:

• LOCATION OF THE ULCER, RELATED TO A BONY PROMINENCE.

• SIZE OF ULCER IN CENTIMETERS

• PRESENCE OF UNDERMINING OR SINUS TRACTS

• STAGE OF THE ULCER

• COLOR OF THE WOUND BED AND LOCATION OF NECROSIS.

• CONDITION OF THE WOUND MARGINS.

• INTEGRITY OF SURROUNDING SKIN.

• CLINICAL SIGNS OF INFECTION, SUCH AS REDNESS, WARMTH,

SWELLING, PAIN, ODOR, AND EXUDATE

DESCRIPTION OF PRESSURE ULCERS & CLASSIFICATION OF ULCER:

•STAGE I: Characterized by erythema that does not resolve within minutes of
pressure relief. Skin remains intact.

•STAGE II: Partial thickness loss of skin involving the epidermis or dermis – may
involve both. The ulcer is superficial and may present as a blister, abrasion, or
shallow crater. Free of eschar.

•STAGE III: Full thickness loss which goes through the dermis to the subcutaneous
tissue but does not extend through the underlying fascia. Appears as a crater and
may include undermining.

• STAGE IV: Full thickness skin loss with extensive damage through the
subcutaneous tissue to the fascia and may involve muscle layers, joint, and/or
bone.

LABORATORY DATA

• a decreased leukocyte count can delay healing and increase the possibility of
infection.

• a hemoglobin level below the normal range indicates poor oxygen delivery to the
tissues.

•prolonged coagulation times can result in excessive blood loss and prolonged clot
absorption.

•hypercoagulability can lead to intravascular clotting, and result in a deficient blood

supply to the wound area.

•serum protein analysis provides an indication of the body’s nutritional reserves for
rebuilding cells.

•wound cultures can either confirm or rule out the presence of infection.

•sensitivity studies are helpful in the selection of appropriate antibiotic therapy. The
nurse obtains a wound culture whenever an infection is suspected.
 DIAGNOSING

THE NANDA INTERNATIONAL NURSING DIAGNOSES THAT RELATE TO

CLIENTS :

• RISK FOR PRESSURE ULCER

• RISK FOR IMPAIRED SKIN INTEGRITY

• IMPAIRED TISSUE INTEGRITY

ADDITIONAL NURSING DIAGNOSES MAY BE APPROPRIATE FOR

CLIENTS WITH EXISTING IMPAIRED SKIN OR TISSUE INTEGRITY:

• RISK FOR INFECTION

• ACUTE PAIN

PLANNING

MAJOR GOALS

•TO MAINTAIN SKIN INTEGRITY

•TO AVOID POTENTIAL ASSOCIATED RISKS.

IMPLEMENTING

Nursing interventions for maintaining skin integrity and wound care involve
supporting wound healing, preventing pressure ulcers, treating pressure ulcers,
dressing and cleaning wounds, supporting and immobilizing wounds, and applying
heat and cold.

SUPPORTING WOUND HEALING

[Link] wound healing -the dressing and frequency of change should support moist
wound bed conditions.

[Link] and fluids-clients should be assisted to take in at least 2,500 ml of fluids a

day unless conditions contraindicate this amount the nurse should ensure that
clients receive sufficient protein, vitamins c, a, b1, b5, and zinc.

[Link] infection –

•preventing microorganisms from entering the wound

• preventing the transmission of blood borne pathogens to or from the client to others

4. Positioning- to promote wound healing, clients must be positioned to keep pressure

off the wound.

PREVENTING PRESSURE ULCERS

THE INSTITUTE FOR HEALTHCARE IMPROVEMENT DELINEATES TWO

MAJOR STEPS:

1. Identifying clients at risk

[Link] implementing prevention strategies for all clients who are identified as
being at risk.

•PROVIDING NUTRITION

-because an inadequate intake of calories, protein, vitamins, and iron is believed to be

a risk factor for pressure ulcer development, nutritional supplements should be
considered for nutritionally compromised clients.

•MAINTAINING SKIN HYGIENE

-When bathing the client, the nurse should minimize the force and friction applied to
the skin, using mild cleansing agents that minimize irritation and dryness and that do
not disrupt the skin’s “natural barriers.”

-Avoid using hot water, which increases skin dryness and irritation
 •AVOIDING SKIN TRAUMA

-Providing the client with a smooth, firm, and wrinkle-free foundation on which to sit
or lie helps prevent skin trauma. clients must be positioned, transferred, and
turned correctly

-For bedridden clients, shearing force can be reduced by elevating the head of the bed
to no more than 30°, if this position is not contraindicated by the client’s condition

-Baby powder and cornstarch are never used as friction or moisture prevention.
instead, use moisturizing creams and protective films.

-frequent shifts in position, even if only slight, effectively change pressure points.

 Any at-risk client confined to bed—even when a special support mattress is

used—should be repositioned at least every 2 hours, depending on the client’s
need, to allow another body surface to bear the weight.

SIX BODY POSITIONS CAN USUALLY BE USED:

PRONE, SUPINE, RIGHT AND LEFT LATERAL (SIDE-LYING), AND RIGHT AND
LEFT SIMS’ POSITIONS

 massage over bony prominence should be avoided. Traditionally, nurses have

used massage to stimulate blood circulation.

•PROVIDING SUPPORTIVE DEVICES

-In order for circulation to remain uncompromised, pressure on the bony prominences
should remain below capillary pressure for as much time as possible through a
combination of turning, positioning, and use of pressure-relieving surfaces.

-For clients confined to bed, three types of support surfaces can be used to relieve
pressure: The overlay mattress ,replacement mattress ,specialty beds .

- To protect a client’s heels in bed, supports such as wedges or pillows can be used to
raise the heels completely off the bed.

TREATING PRESSURE ULCERS

•THE RYB COLOR CODE -THIS CONCEPT IS BASED ON THE COLOR OF AN

OPEN WOUND—RED, YELLOW, OR BLACK (RYB)—RATHER THAN THE
DEPTH OR SIZE OF A WOUND.

GOALS OF WOUND CARE

PROTECT RED, CLEANSE YELLOW, AND DEBRIDE BLACK.

RED WOUNDS- Are usually in the late regeneration phase of tissue repair .they need
to be protected to avoid disturbance to regenerating tissue.

THE NURSE PROTECTS RED WOUNDS BY :

(a)gentle cleansing

(b) protecting periwound skin with alcohol-free barrier film

(c)filling dead space with hydrogel or alginate

(d)covering with an appropriate dressing such as transparent film, hydrocolloid

dressing, or a clear absorbent acrylic dressing

(e) changing the dressing as infrequently as possible.

YELLOW WOUNDS- are characterized primarily by liquid to semiliquid “slough”

That is often accompanied by purulent drainage or previous infection. The nurse
cleanses yellow wounds to remove nonviable tissue.

BLACK WOUNDS -are covered with thick necrotic tissue, or eschar. Black wounds
require debridement

DEBRIDEMENT MAY BE ACHIEVED IN FOUR DIFFERENT WAYS:

•IN SHARP DEBRIDEMENT, A SCALPEL OR SCISSORS IS USED TO

SEPARATE AND REMOVE DEAD TISSUE.

•MECHANICAL DEBRIDEMENT IS ACCOMPLISHED THROUGH

SCRUBBING FORCE OR DAMP-TO DAMP DRESSINGS.

•CHEMICAL DEBRIDEMENT- COLLAGENASE ENZYME AGENTS SUCH AS

PAPAINUREA ARE CURRENTLY MOST RECOMMENDED FOR THIS USE.

• IN AUTOLYTIC DEBRIDEMENT, DRESSINGS TRAP THE WOUND

DRAINAGE AGAINST THE ESCHARWHEN THE ESCHAR IS REMOVED

DRESSING WOUNDS

PURPOSES:

• TO PROTECT THE WOUND FROM MECHANICAL INJURY

• TO PROTECT THE WOUND FROM MICROBIAL CONTAMINATION

• TO PROVIDE OR MAINTAIN MOIST WOUND HEALING

• TO PROVIDE THERMAL INSULATION

• TO ABSORB DRAINAGE OR DEBRIDE A WOUND OR BOTH

• TO PREVENT HEMORRHAGE

• TO SPLINT OR IMMOBILIZE THE WOUND SITE AND THEREBY

FACILITATE HEALING AND PREVENT INJURY.

TYPES OF DRESSINGS

•THE
THE TYPE OF DRESSING USED DEPENDS ON

(a) the location, size, and type of the wound;

(b) the amount of exudate;

(c) whether the wound requires debridement or is infected;

(d) such considerations as frequency of dressing change, ease or difficulty of dressing

application, and cost

TRANSPARENT DRESSINGS

-Are often applied to wounds including ulcerated or burned skin areas.

ADVANTAGES:

• act as temporary skin.

• are nonporous, nonabsorbent, self-adhesive dressings that do not require changing

as other dressings do.

• because they are transparent, the wound can be assessed through them.

• because they are semiocclusive, the wound remains moist and can retain a small
amount of serous exudate, which promotes epithelial growth, hastens healing, and
reduces the risk of infection.

• because they are elastic, they can be placed over a joint without disrupting the
client’s mobility.

• they adhere only to the skin area around the wound and not to the wound itself
because they keep the wound moist.

• they allow the client to shower or bathe without removing the dressing.

HYDROCOLLOID DRESSINGS

-are frequently used over pressure ulcers.

ADVANTAGES:

• they last 3 to 7 days.

• they do not need a “cover”
cover” dressing and are water resistant, so the client can shower or
bathe.

• they can be molded to uneven body surfaces.

• they act as temporary skin and provide an effective bacterial barrier.

• they decrease pain and thus reduce the need for analgesics.

•they absorb moderate drainage and therefore can be used on slowly draining wounds.
wounds.

DISADVANTAGES

• They are occlusive, are opaque, and obscure wound visibility.

• They have a limited absorption capacity.

• They can facilitate anaerobic bacterial growth.

• They can soften and wrinkle at the edges with wear and movement.

• They can be difficult to

to remove and may leave a residue on the skin.

SECURING DRESSINGS

1. Place the tape so that the dressing cannot be folded back to expose the wound.

2. Ensure that the tape is long enough and wide enough to adhere to several inches of
skin on each side of the dressing, but not so long or wide that the tape loosens with
activity

3. Place the tape in the opposite direction from the body action

CLEANING WOUNDS

•wound cleaning involves the removal of debris, such as foreign materials, excess
slough, necrotic tissue, bacteria, and other microorganisms

A. Wound Irrigation
An irrigation is the washing or flushing out of an area. Sterile technique is required
for a wound irrigation because there is a break in the skin integrity. Irrigation
pressures should range from 4 to 15 pounds per square inch.

B. Gauze packing
In this technique, moist 4×4 non–cotton-filled gauzes are packed in the wound to
absorb exudate but they are not allowed to dry before removal.

SUPPORTING AND IMMOBILIZING WOUNDS

 BANDAGES AND BINDERS

PURPOSES:

• SUPPORTING A WOUND

• IMMOBILIZING A WOUND
WOUND

• APPLYING PRESSURE

• SECURING A DRESSING
DRESSING

• RETAINING WARMTH

BANDAGES

1. A bandage is a strip of cloth used to wrap some part of the body. Gauze is one of
the most commonly used, because it is light and porous and readily molds to
the body. Gauze is used to retain dressings on wounds and to bandage the
fingers, hands, toes, and feet. It supports dressings and at the same time
permits air to circulate.

2. Elasticized bandages are applied to provide pressure to an area. They are commonly
used as tensor bandages or as partial stockings to provide support and
improve the venous circulation in the legs

BASIC TURNS FOR ROLLER BANDAGES

• Circular Turns

Circular turns are used to anchor bandages and to terminate them.

Circular turns usually are not applied directly over a wound because of the discomfort
the bandage would cause.
•Spiral
Spiral Turns

Are used to bandage parts of the body that are

fairly uniform in circumference

 Spiral reverse turns

are used to bandage parts of the body that are

fairly uniform in circumference

 •Recurrent Turns
are used to cover distal parts of the body,
•Figure-Eight Turns
are used to bandage an elbow, knee, or ankle, because they permit some movement
after application.

BINDERS

•Abinder is a type of bandage designed for a specific body part

•Binders are used to support large areas of the body

 ARM SLING

 STRAIGHT ABDOMINAL BINDER

HEAT AND COLD APPLICATIONS

 causes vasodilation and increases blood flow to the affected area
 Application of heat promotes soft tissue healing and increases suppuration.
 increases capillary permeability
 Heat is often used for clients with musculoskeletal problems such as joint
stiffness from arthritis, contractures, and low back pain.

LOCAL EFFECTS OF COLD

 Lowers the temperature of the skin and underlying tissues

 Causes vasoconstriction.
 Cold is most often used for sports injuries to limit postinjury swelling and
bleeding.

SYSTEMIC EFFECTS OF HEAT AND COLD

 HEAT:MAY CAUSE EXCESSIVE PERIPHERAL VASODILATION

 COLD: BLOOD PRESSURE CAN INCREASE BECAUSE BLOOD IS

SHUNTED FROM THE CUTANEOUS CIRCULATION TO THE INTERNAL
BLOOD VESSELS.

THERMAL TOLERANCE

Specific conditions necessitate precautions in the use of hot or cold applications:

• NEUROSENSORY IMPAIRMENT:
IMPAIRMENT:

• IMPAIRED MENTAL STATUS

STATUS

• IMPAIRED CIRCULATION
CIRCULATION

• IMMEDIATELY AFTER INJURY OR SURGERY

• OPEN WOUNDS

ADAPTATION OF THERMAL RECEPTORS

Temperature (thermal) receptors adapt to temperature changes.

 REBOUND PHENOMENON

The rebound phenomenon occurs at the time the maximum therapeutic effect of the
hot or cold application is achieved and the opposite effect begins.

FOR ALL LOCAL APPLICATIONS OF

OF HEAT OR COLD, THE NURSE NEEDS TO
FOLLOW THESE GUIDELINES:
GUIDELINES:

• determine the client’s ability to tolerate the therapy.

• identify conditions that might contraindicate treatment
• explain the application to the client.
• assess the skin area to which the heat or cold will be applied.
• ask the client to report any discomfort.
• return to the client 15 minutes after starting the heat or cold therapy, and observe the
local skin area for any untoward signs.
• remove the equipment at the designated time, and dispose of it appropriately.
• examine the area to which the heat or cold was applied, and record the client’s
response.
DRY HEAT
•hot water bottle,
•aquathermia pad,
•disposable heat pack
•electric pad.
MOIST HEAT
•Hot compress,
•hot pack,
•soak, or
•sitz bath
DRY COLD
•hot water bottle,
•aquathermia pad,
•disposable heat pack
•electric pad.
MOIST HEAT
•Hot compress,
•hot pack,
•soak, or
•sitz bath
DRY COLD
•cold pack,
•ice bag,
• ice glove,
•ice collar
MOIST COLD
•Cold compress
•cooling sponge bath

HOT WATER BAG

A common source of dry heat used in the home

The following temperatures of the water used to fill the bag are considered safe in most
situations and provide the desired effect:

•NORMAL ADULT AND CHILD OVER 2 YEARS------- 46°C TO 52°C

• DEBILITATED OR UNCONSCIOUS ADULT, OR CHILD UNDER 2 YEARS----

40.5°C TO 46°C

STEPS TO APPLY A HOT WATER BAG:

• measure the temperature

• fill the bag about two-thirds full.

• expel the remaining air and secure the top.

• dry the bag and hold it upside down to test for leakage.

• wrap the bag in a towel or cover and place it on the body site remove after 30
minutes or in accordance with agency protocol.

AQUATHERMIA PAD

is constructed with tubes containing water. the pad is attached by tubing to an

electrically powered control unit that has an opening for water and a temperature
gauge .

TO APPLY AN AQUATHERMIA
AQUATHERMIA PAD, THE NURSE CARRIES
CARRIES OUT THE
FOLLOWING STEPS:

• fill the reservoir of the unit two-thirds full of water

• set the desired temperature.

• cover the pad and plug in the unit.

• apply the pad to the body part.

• use tape or gauze ties to hold the pad in place.

• if unusual redness or pain occurs, discontinue the treatment, and report the client’s
reaction.

HOT AND COLD PACKS

Provide heat or cold for a designated time. Directions on the package tell how to
initiate the heating or cooling process, for example, by striking, squeezing, or
kneading the pack.

ELECTRIC HEATING PADS

Electric pads provide a constant, even heat, are lightweight, and can be molded to a
body part. Electric pads, however, can burn if the setting is too high.

IN APPLYING ELECTRIC PADS, THE NURSE FOLLOWS

FOLLOWS THESE GUIDELINES:
GUIDELINES:

• do not insert sharp objects into the pad.

• ensure that the body area is dry

• use pads with a preset heating switch

• do not place the pad under the client

 ICE BAGS, ICE GLOVES, AND ICE COLLARS

Are filled either with ice chips or with an alcohol-based solution. They are applied to
the body to provide cold to a localized area always wrap the container in a towel or
cover.

COMPRESSES
Compresses can be either warm or cold. A compress is a moist gauze dressing
applied to a wound or injury.

SOAKS

A soak refers to immersing a body part or to wrapping a part in gauze dressings and
then saturating the dressing with a [Link] soaks are frequently done to soften and
remove encrusted secretions and dead tissue.

SITZ BATH
A sitz bath, or hip bath, is used to soak a client’s perineal or rectal area. The client sits
in a special tub or chair.
temperature:40°C to 43°C
duration : 20 minutes

FOLLOW THESE STEPS TO PROVIDE A SITZ BATH:

• assist the client into the bath.

• provide a bath blanket for the client’s shoulders, and eliminate drafts to prevent
chilling.

• observe the client closely during the bath for signs of faintness, dizziness, weakness,
accelerated pulse rate, and pallor.

• maintain the water temperature.

• assist the client out of the bath. Help the client to dry.

COOLING SPONGE BATHS

PURPOSE

Reduce a client’s fever by promoting heat loss through conduction and vaporization.
The bath is accompanied by antipyretic medication that acts to reset the hypothalamus
set point.

TEMPERATURES :27°C TO 37°C

THE NURSE SHOULD:

• Sponge the face, arms, legs, back, and buttocks.

• Leave each area wet and cover with a damp towel.

• Place ice bags and cold packs, if used, or a cool cloth on the forehead for comfort
and in each axilla and at the groin.

• Sponge one body part and then another.

• Discontinue the bath if the client becomes pale or cyanotic or shivers, or if the pulse
becomes rapid or irregular.

• Reassess the vital signs at 15 minutes and after completing the sponge bath.

EVALUATING

• to judge whether client outcomes have been achieved, the nurse uses data collected
during care.

If outcomes are not achieved, the nurse should explore the reasons why:

• HAS THE CLIENT’S PHYSICAL CONDITION CHANGED?

• WERE RISK FACTORS CORRECTLY IDENTIFIED?

• WERE APPROPRIATE DEVICES AND TECHNIQUES USED?

• WAS THE CLIENT UNABLE TO COMPLY WITH INSTRUCTIONS ABOUT

MOVING AND TURNING? WHY?

• WERE APPROPRIATE PRESSURE-RELIEVING DEVICES USED, AND

WERE THEY APPLIED CORRECTLY?

• WAS THE REPOSITIONING SCHEDULE ADHERED TO?

• ARE THE CLIENT’S NUTRITIONAL AND FLUID INTAKE ADEQUATE?

• WERE APPROPRIATE MEASURES USED TO CONTROL INCONTINENCE

AND PROTECT THE CLIENT’S SKIN?

• WAS THE WOUND SUPPORTED AND IMMOBILIZED EFFECTIVELY?

• WERE STRINGENT ASEPTIC PRACTICES IMPLEMENTED WHEN

CLEANING AND CHANGING DRESSINGS TO PREVENT INFECTION?

• WAS THE CLIENT RECEIVING ANTINEOPLASTIC OR

ANTI-INFLAMMATORY MEDICATIONS THAT INTERFERE WITH HEALING?

• WAS NONVIABLE TISSUE REMOVED BY AUTOLYTIC, CHEMICAL,

MECHANICAL, OR SURGICAL DEBRIDEMENT?
• WAS THE APPROPRIATE DRESSING APPLIED TO MAINTAIN MOIST
WOUND HEALING?

REPORTED BY:

Ching Sai, Coney