Skin
Chapter 32: Skin Integrity and Wound Care — Nursing Study Notes
These notes follow your learning objectives and prioritize high-yield information for cramming, while keeping the important definitions, classifications, nursing interventions, and assessment details from your chapter. I’ve organized them so you can study each objective separately.
1. Factors that affect skin integrity
Skin integrity = the condition of having intact skin layers that protect the body. A wound is a disruption in normal skin integrity.
The skin's main functions are protection, thermoregulation, sensation, and metabolism.
Factor | Effect on skin integrity and wound healing |
|---|---|
Age | Infants have thin, permeable skin and increased risk of breakdown. Older adults have drier, thinner skin, less elasticity, and slower healing. |
Mobility | Immobility causes prolonged pressure over bony prominences, reducing blood flow and causing tissue injury. |
Nutrition | Protein and calories support tissue repair. Vitamin C, zinc, and copper support collagen formation. Low cholesterol and inadequate fats impair the skin's protective barrier. |
Hydration | Dehydration decreases skin turgor. Overhydration causes edema. Both increase the risk of skin damage. |
Sensation and cognition | Neuropathy, spinal cord injury, stroke, dementia, or altered consciousness can prevent a patient from recognizing pressure, pain, heat, or the need to reposition. |
Circulation | Poor arterial circulation reduces oxygen delivery; poor venous circulation causes pooling, edema, and tissue breakdown. Both delay healing. |
Medications | Steroids and NSAIDs may inhibit healing; anticoagulants increase hematoma risk; chemotherapy can delay healing. Some drugs cause photosensitivity or severe skin reactions. |
Moisture | Urine, stool, sweat, and excessive drainage cause maceration and skin breakdown. Feces are particularly damaging because of digestive enzymes and microorganisms. |
Fever | Increases sweating and oxygen requirements, raising the risk of maceration and tissue injury. |
Microorganisms | Contamination, colonization, and infection can interfere with healing. |
Lifestyle | Excessive sun exposure, tobacco use, poor cleansing habits, and unsterile tattoos or piercings can damage skin or delay healing. |
Skin structure: quick review
Epidermis: outer protective layer.
Stratum corneum: prevents water loss and entry of pathogens, chemicals, and fluids.
Stratum germinativum: produces new skin cells.
Melanocytes: produce melanin, which gives skin color and protects against UV radiation.
Langerhans cells: help trigger immune responses.
Dermis: contains blood vessels, nerves, sweat and oil glands, hair follicles, collagen, and elastin.
Subcutaneous tissue: provides insulation, stores energy, and protects underlying organs.
Nutrition memory aid: Protein + calories + fluids + vitamin C + zinc + copper = support for healthy skin and wound healing.
2. Identify wounds using accepted classification schemes
Wounds can be classified by skin integrity, healing time, contamination, depth, and wound type.
A. Skin integrity
Closed wound: skin remains intact; example: contusion (bruise).
Open wound: skin or mucous membranes are broken; examples: incision, abrasion, laceration, and puncture.
B. Duration and healing
Acute wound: expected to heal within a relatively short time without complications.
Chronic wound: healing is prolonged or stalled, often because of infection, trauma, ischemia, edema, or underlying disease. A wound that fails to heal within 2–4 weeks may be considered chronic.
C. Level of contamination
Classification | Description |
|---|---|
Clean | Uninfected, minimal inflammation, and no entry into the respiratory, gastrointestinal, or genitourinary tracts. |
Clean-contaminated | Surgical incision enters one of these tracts, without obvious infection. |
Contaminated | Open traumatic wound or major break in aseptic technique; high infection risk. |
Infected | Significant bacterial growth with evidence of infection. The chapter defines this as over 100,000 organisms/g of tissue; beta-hemolytic streptococci are considered infection at any quantity. |
Signs of infection include redness, warmth, swelling, fever, increasing pain, foul odor, and substantial or purulent drainage.
D. Wound depth
Superficial: involves only the epidermis.
Partial-thickness: extends through the epidermis but not the dermis, as described in this chapter.
Full-thickness: extends into subcutaneous tissue or deeper structures.
Penetrating: may be used to indicate involvement of internal organs.
E. Common wound types
Wound | Definition |
|---|---|
Abrasion | Scrape of superficial skin layers. |
Abscess | Localized collection of pus. |
Contusion | Bruise caused by blunt trauma; skin is usually intact. |
Crushing injury | Tissue compression or disruption, often associated with fractures. |
Excoriation | Superficial damage from scratching or mechanical force. |
Incision | Clean-edged wound caused intentionally by a sharp instrument. |
Laceration | Torn skin with jagged edges. |
Penetrating wound | An object enters and lodges in body tissue. |
Puncture wound | Small entry wound caused by a sharp object; infection risk is high. |
Tunnel | Wound tract with an entrance and exit site, as defined in the chapter. |
3. Describe the three phases of wound healing
1–5
DAYS
1. Inflammatory phase — cleansing
Hemostasis: vessels constrict, platelets aggregate, and a clot forms to stop bleeding.
Inflammation: increased blood flow and white blood cells help remove bacteria and debris.
Expected findings can include redness, edema, pain, and warmth.
A scab helps seal and protect the wound.
5–21
DAYS
2. Proliferative phase — granulation
Fibroblasts produce collagen.
New blood and lymph vessels develop.
Granulation tissue fills the wound.
Epithelial cells migrate across the wound to cover it.
Granulation tissue is pink-red, delicate, and bleeds easily.
Weeks–
MONTHS
3. Maturation phase — remodeling
Begins around the second or third week.
Collagen is reorganized to increase tensile strength.
Continues for months, including 3–6 months of substantial remodeling.
Scar tissue may form and does not regain the full strength of original tissue.
Exam tip: Inflammation = clean; proliferation = fill; maturation = strengthen.
4. Distinguish primary, secondary, and tertiary intention healing
Type | What happens? | Healing characteristics |
|---|---|---|
Primary intention | Wound edges are brought together, usually with sutures, staples, or adhesive. | Minimal tissue loss, faster healing, little scarring. Example: clean surgical incision. |
Secondary intention | Wound remains open and fills from the bottom upward with granulation tissue. | Extensive tissue loss or wound should not be closed; slower healing, greater infection risk, more scarring. |
Tertiary intention | Wound is initially left open, then closed after the wound is clean and infection, edema, and foreign material are absent. | Also called delayed primary closure; scarring is greater than primary but less than secondary healing. |
Regenerative healing: Partial-thickness wounds may heal by regeneration, replacing damaged cells with new tissue and generally leaving little or no scar.
Memory aid: Primary = together; secondary = stays open; tertiary = open first, closed later.
5. Describe the three types of wound drainage
Drainage is called exudate.
Type | Appearance | What it suggests |
|---|---|---|
Serous | Clear, watery, straw-colored | Fluid with little cellular material; common in clean wounds. |
Sanguineous | Bloody; bright red if fresh, darker red-brown if older | Bleeding or capillary damage. |
Serosanguineous | Thin, watery, pink or blood-tinged | Mixture of serum and blood; common in new wounds. |
Other terms you should recognize:
Purulent: thick pus, often yellow and foul-smelling; suggests infection. May appear blue-green with Pseudomonas.
Purosanguineous: pus mixed with blood; suggests small vessels have ruptured.
When documenting drainage, record amount, color, consistency, and odor.
6. Review the major complications of wound healing
Complication | Definition and key findings | Nursing priority |
|---|---|---|
Hemorrhage | Profuse or rapid blood loss. Risk is greatest during the first 24–48 hours after surgery or injury. | Assess bleeding, dressings, drains, vital signs, pain, swelling, and signs of shock; report significant bleeding immediately. |
Infection | Microorganisms invade tissue and cause harm. Findings include warmth, redness, swelling, increasing pain, fever above 38°C (100.4°F), foul odor, and purulent drainage. | Assess promptly and notify the provider as indicated. |
Dehiscence | Separation of one or more layers of a wound. May cause a sudden “pop” or tear and increased serosanguineous drainage. | Reduce strain, position with head elevated about 20° and knees flexed, apply a binder if indicated, and notify the provider immediately. |
Evisceration | Complete wound separation with internal organs protruding. Surgical emergency. | Cover organs with sterile saline-moistened dressings, keep the patient in bed with knees bent, do not apply a binder, notify the surgeon immediately, and prepare for surgery. |
Fistula | Abnormal passage between two body cavities or between a cavity and the skin. | Assess persistent or unusual drainage and notify the provider. Fistulas can cause skin breakdown and delayed healing. |
Infection clues
NERDS — superficial wound infection clues: Nonhealing wound, Exudate, Red/friable granulation tissue, Debris (necrotic tissue), Smell.
STONES — deep infection clues: Size increases, Temperature increases, bone involvement (probe to or exposed bone), New breakdown, Exudate/erythema/edema, Smell.
These are assessment mnemonics from the chapter, not substitutes for clinical evaluation.
7. Factors involved in pressure injury development
A pressure injury is localized damage to the skin and underlying tissue, usually over a bony prominence or beneath a medical device.
Four major contributing forces
Pressure: compresses small blood vessels, reducing oxygen and nutrient delivery and causing ischemia.
Friction: skin rubs against another surface, damaging superficial layers.
Shear: tissue layers slide over one another, compressing deeper tissue and reducing blood flow. Example: a patient sliding down in bed.
Moisture: urine, stool, and sweat soften skin and increase its vulnerability to damage.
Other risks include immobility, impaired sensation, poor circulation, malnutrition, dehydration, edema, fever, infection, tobacco use, and reduced oxygen supply.
Early sign: Skin may initially become pale and cool from ischemia. After pressure is relieved, it may become red from reactive hyperemia. Persistent redness suggests tissue damage.
8. Use the Braden scale to assess pressure injury risk
The Braden scale assesses six areas that influence pressure injury risk.
Assessment category | What the nurse evaluates |
|---|---|
Sensory perception | Ability to feel and respond to discomfort or pressure. |
Moisture | How often skin is exposed to moisture. |
Activity | Degree of physical activity, such as walking or remaining in bed. |
Mobility | Ability to change and control body position. |
Nutrition | Usual nutritional intake. |
Friction and shear | Degree of sliding, rubbing, and assistance needed for movement. |
Score each category according to the scale's criteria.
Add the six scores to obtain the total.
Lower score = greater risk of developing a pressure injury.
The Braden Q is a pediatric version.
The Norton scale is another risk tool; it assesses physical condition, mental state, activity, mobility, and incontinence.
The full scoring descriptors and cutoffs for each risk category are not included in the supplied chapter excerpt, so use your course's Braden scale form for exact scoring.
9. Assess and categorize pressure injuries
High-yield staging guide — classify according to the deepest tissue involvement visible or palpable, not simply the wound's size.
Stage 1 — Intact skin
Localized, nonblanchable redness, usually over a bony prominence.
Skin may be painful, firm, soft, warmer, or cooler than surrounding skin.
Discoloration persists after pressure is relieved.
May be difficult to identify in darker skin tones.
Stage 2 — Partial-thickness loss
Dermis is exposed; wound is shallow and reddish-pink.
May appear as an intact or ruptured serum-filled blister.
No slough or bruising.
Do not classify moisture-associated skin damage, skin tears, tape burns, or excoriations as stage 2.
Stage 3 — Full-thickness skin loss
Subcutaneous tissue/adipose is visible.
May have a deep crater, undermining, or necrosis.
May extend to but not through underlying fascia.
Bone and tendon are not exposed or directly palpable.
Stage 4 — Extensive tissue destruction
Full-thickness skin and tissue loss.
Exposed or directly palpable bone, tendon, muscle, or other support structures.
Slough, eschar, undermining, and sinus tracts may occur.
Healing may take a year or longer.
Deep tissue pressure injury (DTI)
Persistent deep-red, maroon, or purple discoloration.
Skin may be intact or blistered; area may be painful or boggy.
Underlying damage can be severe before visible breakdown occurs.
Unstageable
Full-thickness tissue loss is present, but slough or eschar obscures the wound base.
True depth and stage cannot be determined until the base is visible.
Do not remove stable, dry, adherent heel eschar without an appropriate clinical indication; it may serve as a natural cover.
Essential staging rules
Pressure injuries heal by filling with granulation tissue; the dermis is not replaced.
Never reverse-stage a healing pressure injury. Document “stage 4 pressure injury, healing,” not “stage 3.”
Stage 3 versus stage 4 depends on exposed or palpable deeper structures, not merely depth in centimeters.
Do not stage a wound when its base is obscured by slough or eschar.
10. Nursing care to prevent pressure injuries
Prevention is the priority intervention.
1. Assess and monitor
Assess skin daily and more frequently for high-risk patients.
Inspect bony prominences, heels, and skin beneath devices, shoes, and compression garments.
Look for redness, tenderness, edema, temperature changes, and breakdown.
Reassess when the patient's condition changes.
2. Relieve pressure
Reposition regularly according to the patient's needs and care plan.
Use appropriate support surfaces and pressure-relieving devices.
Offload heels and other vulnerable areas.
Encourage activity and mobility as tolerated.
3. Reduce friction and shear
Use proper transfer and repositioning techniques.
Avoid dragging the patient across sheets.
Reduce sliding down in bed and maintain appropriate positioning.
4. Manage moisture
Gently cleanse skin promptly after incontinence.
Apply moisture-barrier creams.
Use absorbent products that wick moisture away.
Keep skin folds clean and dry.
5. Support nutrition and hydration
Provide adequate calories, protein, fluids, and necessary nutrients.
Refer to a dietitian when nutritional problems are present.
Monitor for dehydration and edema.
6. Address other risk factors
Optimize circulation and oxygenation.
Manage underlying disease, fever, and infection.
Protect areas with reduced sensation.
Educate the patient and caregivers about skin checks and repositioning.
7. Evaluate progress
Use a pressure injury risk tool such as the Braden scale.
The PUSH tool tracks healing using wound area, exudate, and wound-bed tissue; its score decreases as the injury heals.
Nursing diagnosis to remember: Risk for Impaired Skin Integrity is appropriate for patients who have risk factors but have not yet developed the relevant skin damage.
11. Differentiate the kinds of chronic wounds
Type | Cause and typical appearance | Key nursing consideration |
|---|---|---|
Pressure injury | Pressure, friction, and shear; commonly over bony prominences or beneath devices. | Relieve pressure and prevent further tissue damage. |
Arterial ulcer | Poor arterial oxygen supply. Usually small, round, “punched-out,” with smooth edges; pale wound base, cool shiny skin, hair loss, and delayed capillary refill. Often very painful, especially at night or with activity. | Assess arterial circulation; impaired perfusion delays healing. |
Venous stasis ulcer | Venous valve dysfunction, obstruction, or poor calf-muscle function causes pooling and edema. Common around the inner ankle or lower calf; shallow with irregular edges and a red, granular base. | Manage venous return as prescribed. Compression requires assessment for arterial disease first. |
Diabetic foot ulcer | Reduced circulation and often reduced sensation; commonly on the sole, ball of the foot, or underside of toes. May be painless despite tissue damage. | Offload pressure, protect the foot, and monitor carefully for infection. |
Remember: arterial = poor blood reaching the tissue; venous = blood pooling in the tissue; diabetic = circulation plus sensation and immune-protection problems.
12. Accurately chart a wound assessment
Document objective findings using consistent terminology and measurements.
Assessment element | What to document |
|---|---|
Location | Exact anatomical site and side of body. |
Type | Acute or chronic; open or closed; pressure injury stage if applicable. |
Size | Length, width, and depth in centimeters. Use a consistent method and patient position. |
Edges | Approximated, separated, rolled (epibole), or irregular. |
Tunneling/undermining | Location using a clock-face reference and depth in centimeters. |
Wound bed | Tissue types present and estimated percentage of each. |
Drainage | Amount (none, light, moderate, heavy), color, consistency, and odor. |
Surrounding skin | Color, warmth, swelling, maceration, tenderness, or crepitus. |
Pain | Patient's reported pain, including changes and pain during treatment. |
Treatment | Cleansing, irrigation, débridement if performed, dressing applied, and drain output when present. |
Progress | Compare measurements, drainage, tissue, and surrounding skin with previous assessments. |
Important wound-bed terminology
Granulation tissue: pink to red, moist, granular tissue with new blood vessels; indicates healing.
Epithelial tissue: pink or pearly-white new skin cells growing across the wound.
Slough: moist, soft, stringy, yellow, tan, gray, or white dead tissue.
Eschar: dry, thick, leathery, black, brown, or gray dead tissue.
Clean, nongranulating tissue: pink, shiny, smooth tissue without granulation.
Necrotic tissue generally delays healing. However, stable heel eschar should not automatically be removed.
Example of objective charting
SAMPLE DOCUMENTATION — FICTIONAL FINDINGS
Right heel wound measures 2.0 cm × 1.5 cm × 0.3 cm. Wound bed contains 80% red granulation tissue and 20% yellow slough. Moderate serosanguineous drainage noted without odor after cleansing. Periwound skin intact, with mild erythema. Patient reports pain of 3/10 during dressing change. Wound cleansed and prescribed dressing applied. Findings compared with previous assessment.
Copy example
Charting tip: Record what you observe and measure, not vague descriptions such as “wound looks good.” Document actual percentages when multiple tissue types are present.
13. Demonstrate appropriate techniques for irrigating a wound
Purpose: Remove loose debris, exudate, and contaminants without damaging viable tissue.
General nursing principles:
Verify the order, wound-care plan, and prescribed solution.
Explain the procedure, provide privacy, assess pain, and administer prescribed analgesia if needed.
Perform hand hygiene and use the appropriate PPE and aseptic technique.
Position the patient so irrigation fluid can drain into a receptacle without contaminating clean areas.
Protect clothing and surrounding skin.
Use the prescribed solution and irrigation equipment.
Direct the flow over the wound to remove debris without forcing contaminants deeper into tissue.
Control pressure: excessive force can damage tissue or push bacteria into deeper structures. Use the device and pressure specified by the clinical protocol.
Continue until the wound is adequately cleansed according to the order or protocol.
Dry and protect the surrounding skin, reassess the wound, apply the prescribed dressing, and document the procedure and findings.
Remember: Use sterile technique where required by the procedure and clinical setting. Do not invent an irrigation pressure or solution volume; follow the prescribed protocol.
14. Describe care of a wound with a drain
A wound drain removes fluid that might otherwise collect in the wound and interfere with healing.
Nursing responsibilities include:
Assess the insertion site, surrounding skin, drainage, and signs of infection.
Measure and record drainage amount, color, consistency, and odor.
Maintain the drain and its collection system according to the prescribed device-specific procedure.
Keep the system secured and patent; prevent accidental pulling, kinking, or dislodgment.
Change dressings and provide site care using the prescribed aseptic technique.
Report unexpected increases or decreases in drainage, fresh bleeding, purulent drainage, fever, increasing pain, or other signs of complications.
Exam focus: Measure the fluid in the collection container and document it accurately. Do not remove or manipulate a drain unless authorized by the order and your scope of practice.
15. Differentiate the five forms of wound débridement
Débridement = removal of dead (devitalized) tissue and foreign material to support wound healing.
Type | How it works | Main point |
|---|---|---|
1. Sharp/surgical | A trained clinician uses a sterile scalpel or scissors to remove devitalized tissue. | Rapid and precise. |
2. Mechanical | Physical removal through irrigation/lavage, selected dressings, or hydrotherapy. | May remove both dead and healthy tissue; can be painful. |
3. Enzymatic | Proteolytic agents break down necrotic tissue. | More selective than mechanical methods; protect viable tissue and follow product directions. |
4. Autolytic | Moisture-retaining dressings allow the body's enzymes to break down dead tissue. | Generally better tolerated but slower. Avoid in infected wounds or immunosuppressed patients according to the chapter. |
5. Biotherapy | Medical-grade larvae digest dead and infected tissue. | Selectively removes necrotic tissue; requires appropriate containment and patient preparation. |
Critical débridement cautions
Do not automatically remove a stable heel eschar.
Avoid removing eschar when circulation to the ulcer site is poor.
Wet-to-dry dressings are a form of mechanical débridement but can be painful and remove healthy granulation tissue.
Débridement selection depends on the wound, tissue viability, circulation, infection status, and the patient's overall condition.
16. Discuss the different types of tissue found in wounds
Tissue | Appearance | Nursing goal |
|---|---|---|
Slough | Soft, moist, yellow/white/tan, stringy or adherent dead tissue. | Remove when indicated by the wound-care plan. |
Eschar | Dry, thick, leathery, dark necrotic tissue. | Débride when indicated; preserve stable heel eschar when appropriate. |
Granulation | Pink-red, moist, pebbled tissue with new vessels and fibroblasts. | Protect it and promote healing; it bleeds easily. |
Clean, nongranulating | Pink, shiny, smooth bed without granulation. | Protect and promote healthy tissue growth. |
Epithelial | Pink or pearly-white regenerating skin spreading over the wound. | Protect the fragile new cells. |
Remember: Granulation fills the wound; epithelialization covers it.
17. When and how to use wound dressings
The purpose of a dressing is to maintain appropriate moisture, absorb drainage, protect against contamination, support healing, and protect surrounding skin.
A primary dressing touches the wound bed. A secondary dressing covers or secures the primary dressing.
Dressing type | Best use | Important cautions |
|---|---|---|
Absorbent | Absorbs wound drainage and protects the wound. Useful when drainage needs to be collected. | Change according to saturation and the prescribed plan; protect surrounding skin from moisture. |
Alginate | Highly absorbent dressing generally used for moderate to heavy drainage. | Not intended for dry wounds; usually requires a secondary dressing. |
Collagen | Supports the wound-healing process and collagen formation in selected wounds. | Choose according to wound characteristics and the prescribed plan. |
Gauze | Cleansing, protection, packing cavities or tracts, and managing deep, dirty, or heavily draining wounds. | May adhere to tissue and damage new cells. Pack loosely; do not overpack. |
Transparent film | Superficial wounds with minimal drainage and IV sites; allows visual inspection without removing the dressing. | Not suitable for heavily draining wounds or fragile skin; trapped moisture can cause maceration. |
Hydrocolloid | Shallow wounds with minimal drainage, including selected stage 2 pressure injuries. Maintains moisture and supports autolysis. | Avoid infected wounds and wounds requiring drainage or packing, such as tunnels. Opaque, so the wound cannot be directly inspected through it. |
Hydrogel | Dry wounds, wounds needing moisture, and selected wounds with slough or eschar. Helps rehydrate tissue and supports autolysis. | Has limited absorption; generally needs a secondary dressing. Excess moisture can macerate surrounding skin. |
Foam | Moderate to heavy drainage; absorbs exudate, insulates, and maintains a moist environment. | Avoid dry, desiccated wounds and wounds with tunnels or tracts according to the chapter's guidance. Saturated foam can macerate surrounding skin. |
Antimicrobial | Selected wounds where reducing microbial burden is a treatment goal. | Use the appropriate product for the wound and prescribed plan; antimicrobial dressings do not replace infection assessment or treatment. |
Dressing selection: quick rules
Heavy drainage: choose an appropriate absorbent dressing.
Dry wound: consider a moisture-donating dressing such as hydrogel.
Shallow wound with little drainage: a hydrocolloid or transparent film may be appropriate, depending on the wound.
Deep cavity or tract: appropriate packing material may be needed to prevent dead space; never pack tightly.
Fragile surrounding skin: protect it and minimize adhesive-related trauma.
Infection or necrotic tissue: reassess the wound and follow the prescribed infection-management and débridement plan.
No single dressing is best for every wound. Choose based on wound depth, drainage, tissue, infection status, surrounding skin, and treatment goals.
18. Guidelines for applying heat or cold therapy
Heat therapy
Effects: Vasodilation, increased blood flow, increased delivery of oxygen and nutrients, improved removal of waste products, and muscle relaxation.
Uses: Selected wounds and musculoskeletal problems involving stiffness or discomfort.
Forms include moist compresses, soaks, sitz baths, heating pads, hot packs, and circulating-water pads.
Cold therapy
Effects: Vasoconstriction, decreased capillary permeability, reduced local metabolism, local anesthesia, and reduced muscle tension.
Uses: Reduce swelling, inflammation, and pain; help control bleeding and fever; treat selected sprains, strains, fractures, and contusions.
Safety guideline | Why it matters |
|---|---|
Assess skin condition, sensation, circulation, and patient tolerance before treatment. | Impaired sensation or circulation increases injury risk. |
Use extra caution with infants, older adults, and patients with sensory impairment. | They are more vulnerable to burns and cold injury. |
Use extra caution on highly vascular areas and injured skin. | These areas may be particularly sensitive. |
Apply to a small area when possible and follow the prescribed duration and temperature. | Large-area treatment and prolonged exposure increase risk. |
Cover dry-heat devices with the appropriate cover or towel; never allow the patient to lie on a heating pad. | Prevents burns and excessive pressure. |
Do not microwave wet towels for heat application. | Uneven heating can cause burns. |
Monitor skin and the patient's response during treatment. | Detects early tissue damage. |
Do not increase the temperature simply because the sensation becomes less intense after about 15 minutes. | Thermal receptors adapt, but tissue may still be injured. |
Potential complications:
Heat applied to a large area may cause vasodilation, hypotension, and faintness.
Cold may increase blood pressure, cause shivering, or damage tissue if prolonged.
19. Demonstrate bandage and binder application
Bandages
A bandage is a cloth, gauze, or elastic covering wrapped around a body part.
Cloth bandages: commonly used for slings and securing large dressings.
Gauze bandages: conform to body contours and secure dressings.
Elastic bandages: provide pressure and support, such as for venous circulation.
Rolled bandages: continuous strips unrolled around a body part.
Binders
A binder supports or immobilizes a body part and may help protect a wound from separation.
Type | Purpose |
|---|---|
Arm sling/triangular binder | Supports an upper extremity. |
T-binder | Secures dressings or pads in the perineal area. |
Abdominal binder | Supports the abdomen and may reduce tension on an abdominal incision. |
General application principles
Explain the procedure and determine the purpose of the bandage or binder.
Assess the affected area before application.
Select the appropriate size and type; narrow bandages suit small body parts, while wider bandages suit arms and legs.
Apply smoothly and securely, without excessive pressure or wrinkles.
Ensure dressings remain secured and the device does not interfere with circulation.
Reassess the patient's comfort, skin, circulation, sensation, and movement after application.
Report new pain, numbness, color changes, coolness, swelling, or other signs of impaired circulation.
Important: A binder is not appropriate for every wound complication. In particular, do not apply a binder when evisceration occurs.