NURS 202 Chapter Notes - Chapter 46: Wound Healing, Exudate, Pressure Ulcer
Document Summary
Prevention of skin breakdown is a major nursing focus for all patients, irrespective of their age or the health care setting. Patients should be assessed for risk of skin breakdown with the use of a validated risk assessment tool, such as the braden risk assessment tool, on admission to care and subsequently at least once per week. Alterations in mobility, sensory perception, level of consciousness, and nutrition, as well as the presence of moisture, increase the risk of pressure ulcer development. Preventive skin care is aimed at controlling external pressure on bony prominences and keeping the skin clean, well lubricated, hydrated, and free of excess moisture. Proper positioning (the 30-degree rule) reduces the effects of pressure and guards against shearing force. Wound assessment requires a description of the appearance of the wound base, size (length width depth), presence of exudate, and the periwound skin condition. Moist wound-healing approaches are based on evidence and support the healing cycle of wounds.
