Special Skin and Wound Care Chapter 58: Special Skin and Wound Care

Wounds Any abnormal opening or break in the skin May be accidental Abrasion Puncture Laceration May be intentional Surgical incision

Inspection and Description of Wounds Inspection sites include Back of the head, ears, heels, coccyx, shoulder blades, elbows, as well as insertion sites for intravenous (IV), nasogastric (NG) tubes, or tracheostomy tubes Evaluation of wounds Angiograms or the laser Doppler, biopsy and wound culture evaluate vascular ulcers Laboratory testing, including biopsy and wound culture, determines wound treatment

Characteristics of Wounds Tunneling Undermining Wound edges Periwound area Wound base Wound measurement Linear measurement, planimetry Stereophotogrammetry Wound photography, wound tracing

Drainage Drainage: Discharge from a wound Exudate: Drainage containing a great deal of protein and cellular debris Types of drainage: Serous Serosanguineous Sanguineous Purulent: Color, odor

Amounts of Drainage None: Dressing dry Scant: Wound tissue moist, no exudates Small: Wound moist throughout, drainage on 25% of dressings Moderate: Drainage on about 30% to 60% of dressings Large/copious: Wound tissues saturated; drainage on more than 60% to 75% of dressings In some cases, dressings are weighed to determine the exact amount of drainage

Causes of Skin Breakdown Immobility, low level of activity, advancing age Inadequate nutrition, hydration levels Presence of external moisture; incontinence Impaired mental status, alertness, or cooperation; heavy sedation and/or anesthesia, sensory loss Fever, low blood pressure, friable skin or infancy Impaired immune system, circulatory disorders; anemia Presence of cancer or other neoplasms

Causes of Wounds Pressure Shear Friction Stripping Urine or stool incontinence Perspiration Maceration

Types of Skin Breakdown Incontinence-associated dermatitis (IAD) IAD can be prevented by using an incontinence cleanser and a moisture barrier paste before damage occurs. Pressure wound or decubitus ulcer Prevention of pressure wounds and other skin breakdown is a primary nursing responsibility. Venous stasis ulcer Diabetic ulcers

Question Is the following statement true or false? The nurse should not massage any reddened pressure points or inspect wounds under fluorescent lights.

Answer True A nurse must not massage any discolored or reddened pressure points, as this can add to the irritation and accelerate skin breakdown. Wounds should not be inspected under fluorescent lights as fluorescent lights may result in an incorrectly diagnosed abnormal skin color or may mask variations in the client’s skin tone.

Pressure Wounds Pressure wounds Result of pressure on the skin, in excess of that of which a particular client’s skin and underlying tissue can safely tolerate Prediction of pressure wound risk Braden scale and the Norton scale

Classification of Pressure Wounds Stage 1 (I): Pressure-related alteration of intact skin, as compared with adjacent/opposite body area Stage 2 (II): Loss of epidermis with damage into dermis; appears as shallow crater/blister with red/pink wound bed with no sloughing Stage 3 (III): Subcutaneous tissues involved; subcutaneous fat may be visible Stage 4 (IV): Extensive damage to underlying structures; full-thickness tissue loss, with exposed bones, tendons, or muscles

Question Is the following statement true or false? A client with pressure wounds should avoid drinking too much fluids.

Answer False It is important to maintain skin hydration and elasticity. Dry, scaly skin is more subject to breakdown than is well-hydrated skin. The nurse is often ordered to encourage fluids of varying types for these clients.

Equipment Used in Wound Care Vacuum-assisted closure (VAC)—negative pressure wound therapy Wound irrigation systems Manual wound irrigation Sutures or staples

Wound Healing

Wound Healing (cont.)

Wound Healing (cont.)

Dressings Dressings serve to protect wounds from contamination Dry, sterile dressing Wet-to-dry dressing Packing Wet-to-wet dressing Commercially prepared special dressings Penrose drain Closed drainage systems

Wound Care Product Categories Hydrocolloid Foam Alginate and hydrofiber Hydrogel—amorphous Hydrogel—sheet Antimicrobial products Gauze Impregnated gauze

Objectives of Wound Care Wound cleansing Removal of dead tissue Prevention/management of infection Elimination of empty spaces Maintaining ordered moisture level Reducing pain Protecting wound and periwound skin

Question Is the following statement true or false? For suture removal, the nurse should place sterile scissors and forceps, cut the suture with sterile forceps, and then remove the suture by pulling straight up on the knot.

Answer True In this way, only the portion of the suture that was buried in the dermis and subcutaneous layer will be pulled through the suture track, greatly reducing the chances of introducing microorganisms into the wound. In addition, if the side opposite the knot is pulled, the knot will be pulled through the tissue, possibly causing it to tear the incision and increasing the client’s discomfort.

End of Presentation