Goals:

Promotion of healing
Prevention of infection and other complications
- Requires care and aseptic procedures during hospitalization.
- Teaching about ongoing wound care at home.
Client should know how to clean, dress, and promote healing.
Client should also know signs of complication.

Assessment for untreated wounds:

Location and extent of tissue damage; measurement of length, width, and depth of wound.
Inspection for bleeding.
Inspection for foreign bodies.
- Determining last tetanus shot (if wound is contaminated)
Assessing associated features (i.e.: fractures, internal bleeding)

Assessment for treated wounds:

Observing appearance, size, and draining.
Observing for swelling, pain, and status of drains and tubes.
Estimating amount of drainage:
- How much of the dressing is saturated?
When wounds are undermined, gently expose undermined area w/thin, flexible probe. Once end of tract is reached, gently raise probe so bulge created by end can be seen and its length can be measured.
- Do not use cotton tipped swab. It can leave fibers in wound.
Sinus tracts are often caused by infection and have significant damage. Treatment includes antibiotics, irrigation surgical incision to open and drain it, and vacuum therapy.

Diagnosis:

Be aware that if impairment is severe, the client is immunosuppressed, or the wound was caused by trauma, the risk for infection is greater.
Also be aware that Impaired skin integrity is generally r/t wounds that do not penetrate the dermis. Impaired tissue integrity applies to wounds that extend subcutaneously.

Planning:

Goal for impaired tissue integrity is to maintain skin integrity and avoid potential related risks.

Implementation: 4 major areas in which the nurse can help:

Maintaining moist wound healing
- Dressing and frequency of change should support moist wound bed conditions. Beds that are too dry or disturbed often fail to heal,
Providing sufficient nutrition and hydration.
- Have client take in at least 2,500 mL a day unless contraindicated.
- Ensure client recieves vitamins C, A, B, and B5, as well as the mineral zinc.
- A dietician consult may be helpful.
Preventing infection: 2 main aspects
1. Preventing microorganisms from entering wound.
2. Prevenitng spread of bloodborn pathogens between client and others.
Proper positioning.
- Position client to keep pressure off wound.
- Change positions without shear or friction damage.
- Assist the client in being as mobile as possible. Activity enhances circulation.
- If client is immobile, ROM exercises and a turning schedule should be implemented.

Evaluation

Regular evaluation is important when client is at risk for impaired tissue integrity.

	Created by Olivia McRitchie over 6 years ago

NCLEX Nursing (Medical-Surgical) Note on Wound Healing, created by Olivia McRitchie on 21/03/2018.