WOUNDS, HEAT OR COLD, AND HYGIENE

• Personal Hygiene


  Measures for personal cleanliness and grooming
• Room environment, Equipment, Hygiene care schedule

  Factors influencing Hygiene
• Early AM, After breakfast, Afternoon, PM care, Provide as needed


  Hygiene care schedule
• For a person in coma, Incontinent person, Diaphoretic person


  Provide as needed (Hygiene care schedule)
• Maintain skin integrity, Prevent skin impairment, Promote adequate circulation, Promote hydration, Promote communication


  Purpose of Hygiene
• Defense against infection, Defense of awareness, Controls body temperature


  Definitions of Intact Skin
• Color, texture, thickness, turgor, temperature, Hydration


  Assessment of Intact Skin
• Daily skin inspection and documentation


  is an important part of skin care and prevention of decubitus ulcers
• prevent complications or skin impairment


  Nursing goal of Intact Skin
• Skin


  is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury.
• Intact skin


  refers to the presence of normal skin and skin layers uninterrupted by wounds.
• Wound


  is a breakdown in the protective function of the skin; the loss of continuity of epithelium, with or without loss of underlying connective tissue (i.e. muscle, bone, nerves) following injury to the skin or underlying tissues/ organs caused by surgery, a blow, a cut, chemicals, heat/ cold, friction/ shear force, pressure or as a result of disease, such as leg ulcers or carcinomas
• Intentional trauma


  occurs during therapy. Examples are operations or venipuncture. Although removing a tumor, for example, is therapeutic, the surgeon must cut into body tissues, thus traumatizing them.
• Unintentional wounds


  are accidental; for example, a person may fracture an arm in an automobile collision. 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.
• Open wound


  when the skin or mucous membrane surface is broken.
• Closed wound


  the tissues are traumatized without a break in the skin
• Dressing


  is a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm.
• dressing


  is designed to be in direct contact with the wound,
• bandage,


  which is most often used to hold a dressing in place.
• atelectasis


  collapse of the alveoli
• Heat and cold


  are applied to the body for local and systemic effects
• Heat


  has been a long-standing remedy for aches and pains, and people often equate ___ with comfort and relief.
• Heat


  causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients, antibodies, and leukocytes.
• Heat


  is often used for clients with musculoskeletal problems such as joint stiffness from arthritis, contractures, and low back pain.
• Cold


  lowers the temperature of the skin and underlying tissues and causes vasoconstriction.
• Vasoconstriction


  reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness.
• Cold


  is most often used for sports injuries (e.g., sprains, strains, fractures) to limit post injury swelling and bleeding.
• Heat


  Sedative effect
• Cold


  Local anesthetic effect
• The application of heat promotes soft tissue healing and increases suppuration.
• Heat

  vasodilation
• Heat

  Increases capillary permeability
• Heat

  Increases cellular metabolism
• Heat


  Increases inflammation and Slows bacterial growth
• Cold


  Vasoconstriction
• Cold

  Decreases capillary permeability
• Cold


  Decreases cellular metabolism
• Cold

  decreases inflammation
• Heat


  in Muscle spasm, it Relaxes muscles and increases their contractility.
• Cold


  in Muscle spasms, Relaxes muscles, and decreases muscle contractility.