Skin Integrity and Wound Care

Skin Integrity and Wound Care
Chapter 48 Skin Integrity and Wound Care The skin is the body’s largest organ, accounting for 15% of the total body weight. The skin provides: A protective barrier against disease-causing organisms. A sensory organ for pain, temperature, and touch. Vitamin D synthesis. Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing pattern will help students recognize alterations that require intervention. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Scientific Knowledge Base
Skin Epidermis Top layer of skin Dermis Inner layer of skin Collagen Dermal–epidermal junction Separates dermis and epidermis The skin has two layers: the epidermis and the dermis. The epidermis has several layers within it. The stratum corneum is the thin, outermost layer that is flattened with dead keratinized cells. Cells in the basal layer divide, proliferate, and migrate toward the epidermal surface. The dermis provides tensile strength, mechanical support, and protection to underlying muscles, bones, and organs. The dermis is made of collagen, blood vessels, and nerves. Collagen is a tough fibrous protein. Fibroblasts, which are responsible for collagen formation, are the only distinctive cell type within the dermis. The normal aging process alters skin characteristics and makes skin more vulnerable to damage. [Review Box 48-1, Focus on Older Adults: Skin-Associated Issues, with students.] [Shown is Figure 48-1: Layers of skin. (From Applegate E: The anatomy and physiology learning system, ed 3, St Louis, 2006, Saunders.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Scientific Knowledge Base (Cont.)
Pressure ulcers Pressure sore, decubitus ulcer, or bed sore Pathogenesis Pressure intensity Tissue ischemia Blanching Pressure duration Tissue tolerance A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results. Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in dark-skinned patients. [Review Box 48-2, Characteristics of Dark Skin with Impaired Integrity, with students.] [Review Box 48-3, Cultural Aspects of Care: Skin Color Impact, with students.] Pressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures. [Shown is Figure 48-2: Pressure ulcer with tissue necrosis.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study Mr. Omar Ahmed, a 76-year-old accountant, has come to the hospital again, this time for pneumonia. Before admission, he was unable to eat and lost more than 20 lbs over the last 2 months. Three years ago, he had coronary artery bypass surgery. As a precaution, he is placed on telemetry monitoring. He also has hypertension and type 2 diabetes mellitus. His mobility is limited because of weakness. [Ask students: What mobility concerns do you anticipate for Mr. Ahmed? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Mr. Ahmed is retired. He lives in a one-family home with his wife, Natalie. Their children and grandchildren live nearby and visit often. He complains that his “bottom hurts” from lying in bed. Lynda Abraham is the nursing student assigned to the medical nursing unit. This is her first hospital-based clinical practice. [Ask students: What risk factors does Mr. Ahmed have for pressure ulcer development? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Risk factors for pressure ulcer development Impaired sensory perception Impaired mobility Alteration in LOC Shear Friction Moisture These six factors contribute to pressure ulcer formation. Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations. Patients who are unable to independently change position are at risk because they cannot change or shift off of bony prominences. Patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves. Shear is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface. Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface. The presence and duration of moisture on the skin reduce the skin’s resistance to other physical factors. [Shown is Figure 48-3: Shear exerted in sacral area.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Classification of Pressure Ulcers
Stage I Intact skin with nonblanchable redness Stage II Partial-thickness skin loss involving epidermis, dermis, or both Stage III Full-thickness tissue loss with visible fat Stage IV Full-thickness tissue loss with exposed bone, muscle, or tendon Assess pressure ulcers at regular intervals using systematic parameters to evaluate wound healing, plan appropriate interventions, and evaluate progress. Assessment includes wound location, depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions (if present include sinus tracts and tunneling), exudate description (if present odor), and condition of surrounding skin. Pressure ulcer staging describes the pressure ulcer depth at the point of assessment. Pressure ulcers do not progress from a Stage III to a Stage I. A Stage III ulcer demonstrating signs of healing is described as a healing Stage III pressure ulcer. The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance (2014) have developed clinical practice guidelines for pressure ulcers and have advanced the following classification/staging system. The NPUAP uses the term “staging” and the European group uses the term “category”. Category/Stage I: Nonblanchable Redness. Intact skin presents with nonblanchable redness of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Category/Stage II: Partial-thickness. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury. Category/Stage III: Full-thickness Skin Loss. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full-thickness Tissue Loss. Full-thickness tissue loss with exposed bone, tendon, or muscle. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. Exposed bone/muscle is visible or directly palpable. Unstageable/Unclassified: Full-thickness Skin or Tissue Loss—Depth Unknown. Fu-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury—Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may be rapid even with optimal treatment. Assess the type of tissue in the wound base; this information is used to plan appropriate interventions. The assessment of tissue type includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must be removed by a skilled clinician or with the use of an appropriate wound dressing before the wound is able to heal. Black, brown, tan, or necrotic tissue is eschar, which needs to be removed before healing can proceed. Use a disposable wound-measuring devices to obtain the measurement of width and length. Measure depth by using a cotton-tipped applicator in the wound bed. Wound exudate should describe the amount, color, consistency, and odor of wound drainage, and is part of the wound assessment. Excessive exudate indicates the presence of infection. Examine the periwound area for redness, warmth, and signs of maceration and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. [Review Figure 48-4, Diagram of stages. A, Stage I pressure ulcer. B, Stage II pressure ulcer. C, Stage III pressure ulcer. D, Stage IV pressure ulcer. E, Unstageable wound. F, Suspected deep tissue injury, (Used with permission of the National Pressure Ulcer Advisory Panel. Copyright © NPUAP), with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Wound classifications Process of wound healing Partial-thickness wounds: shallow in depth, moist and painful, and the wound base generally appears red Full-thickness wounds: extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location A wound is a disruption of the integrity and function of tissues in the body. Understanding the etiology of a wound is important because the treatment for it varies, depending on the underlying disease process. There are many ways to classify wounds. Wound classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, and descriptive qualities of the wound tissue such as color. Wound classification enables a nurse to understand the risks associated with a wound and implications for healing. [Review Table 48-1, Wound Classification, with students.] Wound healing involves integrated physiological processes. Wounds can be classified by the extent of tissue loss: partial-thickness wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers) and full-thickness wounds that involve total loss of the skin layers (epidermis and dermis). A partial-thickness wound heals by regeneration. Partial-thickness wounds are shallow in depth, moist, and painful, and the wound base generally appears red. A full-thickness wound extends into the subcutaneous layer and the depth and tissue type will vary depending on body location. A full-thickness wound heals by forming new tissue, a process that can take longer than the healing of a partial-thickness wound. Copyright © 2017, Elsevier Inc. All Rights Reserved.

These photos show wounds by color assessment: A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-color wound. You need to assess the type of tissue in the wound base, and this information is used to plan appropriate interventions. Assessment of tissue type includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Recall that granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing; soft yellow or white tissue is characteristic of slough (stringy substance attached to the wound bed), and it must be removed by a skilled clinician before the wound is able to heal; black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed. [Shown is Figure 48-5: Wounds classified by color assessment. A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-color wound. (A and D, Courtesy Scott Health Care—A Molnlyche Company, Philadelphia, PA; B and C from Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 5, St Louis, 2016, Elsevier.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Process of wound healing (Cont.) Primary intention Edges are approximated Secondary intention A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals by primary intention. The skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly, with minimal scar formation, as long as infection and secondary breakdown are prevented. In contrast, a wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. If scarring from secondary intention is severe, loss of tissue function is often permanent. [Shown is Figure 48-6: A, Wound healing by primary intention such as a surgical incision. Wound healing edges are pulled together and approximated with sutures or staples, and healing occurs by connective tissue deposition. B, Wound healing by secondary intention. Wound edges are not approximated, and healing occurs by granulation tissue formation and contraction of the wound edges. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, St Louis, 2009, Mosby.).] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Process of wound healing (Cont.) Wound repair Partial-thickness wound repair: inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers Full-thickness wound repair: hemostasis, inflammatory, proliferative, and maturation Partial-thickness wounds are shallow involving loss of epidermis and possible loss of dermis. These wounds heal by regeneration because epidermis regenerates. An example of a partial-thickness wound is a scrap or an abrasion. Full-thickness wounds extending into the dermis and heal by scar formation because deeper structures do not regenerate. Pressure ulcers are an example of full-thickness wounds. Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers. Tissue trauma causes the inflammatory response, which in turn causes redness and swelling to the area with a moderate amount of serous exudate. This response is generally limited to the first 24 hours after wounding. The epithelial cells begin to regenerate, providing new cells to replace the lost cells. The epithelial proliferation and migration start at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells only migrate across a moist surface. In a dry wound, the cells migrate down into a moist level before resurfacing can occur. New epithelium is only a few cells thick and must undergo reestablishment of the epidermal layers. The cells slowly reestablish normal thickness and appear as dry, pink tissue. The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammation, proliferation, and maturation. During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair. In the inflammation stage, damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and white blood cells into the damaged tissues. The proliferative phase begins with the appearance of new blood vessels as reconstruction progresses and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. Fibroblasts are present in this phase and are the cells that synthesize collagen, providing the matrix for granulation. Collagen provides strength and structural integrity to a wound. During this period the wound contracts to reduce the area that requires healing. Finally, the epithelial cells migrate from the wound edges to resurface. In a clean wound, the proliferation phase accomplishes the following: the vascular bed is reestablished (granulation tissue), the area is filled with replacement tissue (collagen, contraction, and granulation tissue), and the surface is repaired (epithelialization). Impairment of healing during this stage usually results from systemic factors such as age, anemia, hypoproteinemia, and zinc deficiency. Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces. Collagen fibers undergo remodeling or reorganization before assuming their normal appearance. Usually, scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. In dark-skinned individuals, the scar tissue may be more highly pigmented than surrounding skin. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Complications of wound healing Hemorrhage Hematoma Infection Dehiscence Evisceration Hemorrhage, or bleeding from a wound site, is normal during and immediately after initial trauma. Hemorrhage occurs externally or internally. You detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock. A hematoma is a localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because pressure from the expanding hematoma obstructs blood flow. External hemorrhaging is obvious. Observe all wounds closely, particularly surgical wounds, in which the risk of hemorrhage is great during the first 24 to 48 hours after surgery or injury. Wound infection is the second most common health care–associated infection. Wound infection is present when the microorganisms invade the wound tissues. The local clinical signs of wound infection can include erythema, increased amount of wound drainage, and change in appearance of the wound drainage (thick, color change, presence of odor), periwound warmth, pain, or edema. The patient has a fever, tenderness, and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism. [Review Table 48-2, Types of Wound Drainage, with students.] When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing is at risk for dehiscence. With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency. Immediately place damp sterile gauze over site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Knowledge Base
Prediction and prevention of pressure ulcers Risk assessment Braden scale Prevention Economic consequences of pressure ulcers Medicare and Medicaid: no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization By identifying at-risk patients, you are able to put interventions into place for the at-risk patient and spare patients with little risk for pressure ulcer development the unnecessary and sometimes costly preventive treatment. Several risk-assessment scales developed by nurses enable systematic risk assessment of patients. The Braden Scale was developed based on risk factors in a nursing home population and is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. [Review Table 48-3, Braden Scale for Predicting Pressure Ulcer Risk, with students.] When a patient develops a pressure ulcer, the length of stay is extended and the overall cost of care increases. The Centers for Medicare and Medicaid Services (CMS) implemented a policy effective October 1, 2008, whereby hospitals no longer receive additional reimbursement for care related to eight conditions, including stage III and stage IV pressure ulcers that occur during the hospitalization. This policy was put in place to provide additional incentives for hospitals to improve quality of care. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Knowledge Base (Cont.)
Factors influencing pressure ulcer formation and wound healing Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds For maintenance of skin and wound healing, patients need 1500 kcal/day. At times, enteral or parenteral nutrition may need to be provided. Patients need vitamins A and C, calories, and proteins to heal. [Review Table 48-4, Role of Selected Nutrients in Wound Healing, with students.] Tissue perfusion occurs when tissue oxygenation fuels cellular function. Patients who are in shock or who are diagnosed with diabetes mellitus are at risk for poor tissue perfusion. Wound infection prolongs the inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction. Signs of wound infection include pus; change in odor, volume, or redness of tissue; fever; and pain. Increased age affects all phases of wound healing. A decrease in functioning of the macrophage leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization. Body image changes caused by a wound may lead to problems with self-concept. Factors that affect the patient’s perception of the wound include the presence of scars, drains (drains are often necessary for weeks or even months after certain procedures), odor from drainage, and temporary or permanent prosthetic devices. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Thinking Integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients to understand the risk to skin integrity and wound healing Use Wound, Ostomy and Continence Nurses Society (WOCN) guidelines when planning care Be disciplined, creative, and diligent Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require the nurse to anticipate the information necessary, analyze the data, and make decisions regarding patient care. Critical thinking is always changing. During assessment consider all elements that build toward making appropriate nursing diagnoses. [Review Figure 48-7, Critical thinking model for skin integrity and wound care assessment, with students.] When caring for patients who have impaired skin integrity and chronic wounds, integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients to understand the risk to skin integrity and wound healing. Knowledge of normal musculoskeletal physiology, the pathogenesis of pressure ulcers, normal wound healing, and the pathophysiology of underlying diseases enables you to have a scientific basis for care. The WOCN (2010) has guidelines for assessment of risk for impaired skin integrity, prevention measures, interventions to promote wound healing, and other standards of practice, which you should use in planning care. Past experience with patients at risk for impaired skin integrity or patients with wounds increases the experiential knowledge base, helping you to identify interventions. Finally, you need to be disciplined during assessment to obtain comprehensive and correct data. You also need to be creative. Because chronic wounds are difficult to heal, be diligent in evaluating nursing interventions and determining which interventions are effective and which need modification. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Process: Assessment
Through the patient’s eyes Skin Continually assess skin for signs of breakdown and/or ulcer development During the assessment processes, thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. Baseline and continual assessment data provides critical information about a patient’s skin integrity and the increased risk for pressure ulcer development. Focusing on specific elements, such as a patient’s level of sensation, movement, and continence status, helps guide the skin assessment. [Review Box 48-4, Nursing Assessment Questions: Skin Integrity, with students.] A patient who has realistic goals and is informed about the length of time for wound healing is more likely to adhere to the specific therapies designed to promote healing and prevent further skin breakdown. Therefore it is important to assess the patient’s perception of what is occurring with the wound-healing interventions. [Review Box 48-5, Procedural Guidelines: Skin Assessment, with students. Continually assesses the skin for signs of skin breakdown and/or ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. Pay particular attention to areas located over bony prominences; next to medical devices; under casts, traction, splints, braces, collars, or other orthopedic devices. The frequency of pressure checks depends on the schedule of appliance application and the response of the skin to the external pressure. [Shown is Figure 48-8: Formation of pressure ulcer on heel resulting from external pressure from bed mattress. (Courtesy Janice Colwell, RN, MS, CWOCN, FAAN, Clinical Nurse Specialist, University of Chicago Medicine.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment (Cont.) When you note hyperemia, gently palpate the reddened tissue; differentiate whether the skin redness is blanchable or nonblanchable. Blanchable erythema is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved. It may result from normal reactive hyperemia that should disappear within several hours, or it may result from inflammatory erythema with an intact capillary bed. Nonblanchable erythema is visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary bed/microcirculation. This is an indication for a Category/Stage I pressure ulcer. Use visual and tactile inspection over the body areas most frequently at risk for pressure ulcer development. Body surfaces subjected to the greatest weight or pressure are at greatest risk for pressure ulcer formation. [Shown is Figure 48-9: A, Bony prominences most frequently underlying pressure ulcer. B, Pressure ulcer sites. (Modified from Trelease CC: Developing standards for wound care, Ostomy Wound Manage 20:46, 1988.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment (Cont.) Pressure ulcers Predictive measures Mobility
Nutritional status Body fluids Pain Pressure ulcers have multiple etiological factors. Assessment for pressure ulcer risk includes using an appropriate predictive measure and assessing a patient’s mobility, nutrition, presence of body fluids, and comfort level. [Review Skill 48-1, Assessment for Risk for Pressure Ulcer Development and Skin Assessment, with students.] On admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities, individuals need to be assessed for risk of pressure ulcer development. Once you identify patients at risk for pressure ulcer development, institute appropriate interventions to maintain skin integrity and implement prevention strategies. Perform reassessment for pressure ulcer risk on a scheduled basis. You must assess mobility as part of baseline data. If a patient has some degree of mobility independence, reinforce the frequency of position changes and measures to relieve pressure. The frequency of position changes is based on ongoing skin assessment; and is revised it as data changes. Malnutrition is a risk factor for pressure ulcer development. A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 pounds in a brief period are all signs of actual or potential nutritional problems. Continual exposure of the skin to body fluids increases a patient’s risk for skin breakdown and pressure ulcer formation. It is important to prevent and reduce the patient’s exposure to body fluids, and when exposure occurs, you need to provide meticulous hygiene and skin care. [Review Box 48-6, Risk for Skin Breakdown from Body Fluids, with students.] Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risk. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment (Cont.) Wounds Emergency setting Stable setting
Wound appearance Character of wound drainage Drains Wounds should be assessed on an ongoing basis: at the time of injury, during wound care, when the patient’s overall condition changes, and on a regularly scheduled basis. It is important that you initially obtain information regarding the cause and history of the wound, treatment of the wound, wound description, and response to therapy. You see wounds in any setting, including clinics, emergency departments, youth camps, or your own backyard. The type of wound determines the criteria for inspection. Assess the wound once the patient is stable. The type of wound determines the criteria for inspection. When the injury is a result of trauma from a dirty penetrating object, determine when the patient last received a tetanus toxoid injection. When a patient’s condition is stabilized (e.g., after surgery or treatment), assess the wound to determine progress toward healing. If the wound is covered by a dressing and the health care provider has not ordered it changed, do not directly inspect it unless you suspect serious complications, such as a large volume of bright red bleeding, excessive odor, or severe pain under the dressing. When removing dressings, take care to avoid accidental removal or displacement of underlying drains. Because removal of dressings can be painful, consider giving an analgesic at least 30 minutes before exposing a wound. The outer edges of a wound normally appear inflamed for the first 2 to 3 days, but this slowly disappears. Within 7 to 10 days a normally healing wound resurfaces with epithelial cells, and edges close. If infection develops, the area directly surrounding the wound becomes brightly inflamed and swollen. [Review Table 48-5, Assessment of Abnormal Healing in Primary and Secondary Intention Wounds, with students.] Note the amount, color, odor, and consistency of drainage. The amount of drainage depends on the type of wound. Types of drainage include serous, sanguineous, serosanguineous, and purulent. If the drainage has a pungent or strong odor, you should suspect an infection. The health care provider inserts a drain into or near a surgical wound if there is a large amount of drainage. Some drains are sutured in place. Exercise caution when changing the dressing around drains that are not sutured in place to prevent accidental removal. Assess the number and type of drains, drain placement, character of drainage, and condition of collecting equipment. If there is a collecting device, measure the drainage volume. When a drain is connected to suction, assess the system to be sure that the pressure ordered is being exerted. Evacuator units such as a Hemovac or Jackson-Pratt exert a constant low pressure as long as the suction device is fully compressed. These types of drainage devices are often referred to as self-suction. [Shown at top is Figure 48-10: Penrose drain with dressing.] [Shown at bottom is Figure 48-11: Jackson-Pratt drainage device. A, Drainage tube and reservoir. B, Emptying drainage reservoir.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment (Cont.) Wounds (Cont.) Wound closures Palpation of wound
Wound cultures Gram stains Biopsy Surgical wounds are closed with staples, sutures, or wound adhesives. Look for irritation around staple or suture sites and note whether closures are intact. Normally for the first 2 to 3 days after surgery the skin around sutures or staples is edematous due to the normal inflammatory response. When inspecting a wound, observe for swelling or separation of wound edges. While wearing gloves, lightly press the wound edges, detecting localized areas of tenderness or drainage collection. If pressure causes fluid to be expressed, note the character of the drainage. Extreme tenderness indicates infection. If you detect purulent or suspicious looking drainage, obtaining a specimen of the drainage for culture may be necessary. Never collect a wound culture sample from old drainage. Resident colonies of bacteria from the skin grow within exudate and are not always the true causative organisms of a wound infection. Clean a wound first with normal saline to remove skin flora. Aerobic organisms grow in superficial wounds exposed to the air, and anaerobic organisms tend to grow within body cavities. Use a different method of specimen collection for each type of organism per agency policy. Gram stains of drainage are often performed as well. This test allows the health care provider to order appropriate treatment earlier than when only cultures are done. No additional specimens are usually required. The microbiology laboratory needs only to be notified to perform the additional test. The gold standard of wound culture is tissue biopsy. A health care provider or wound care specialist with special training obtains the biopsy. [Review Box 48-7, Recommendations for Standardized Techniques for Wound Cultures, with students.] [Shown is Figure 48-12: Wound culturette tube.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Lynda reviews the nursing assessment and finds that Mr. Ahmed was admitted with a pressure ulcer. The ulcer is a stage II, 1 × 2-inch and 1/8-inch deep partial-thickness wound over his sacral area. No necrotic tissue is present, and the wound bed has red moist tissue. When Lynda prepares to conduct skin assessment, she recalls information about the pathogenesis of pressure ulcers and guidelines for skin assessment for patients with darkly pigmented skin. [Ask students: Can you recall the descriptions of the ulcer stages, so that you know why Mr. Ahmed’s ulcer is a stage II? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Lynda observed care of a stage IV pressure ulcer during an experience in an extended care facility. From that experience, she increased her knowledge about the debilitating effects of pressure ulcers. In addition, she was able to practice skin assessment techniques during her clinical experience in the extended care facility. Review of previous clinical experiences is often helpful in preparing to care for a patient. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Identify the support surface that would be appropriate to decrease pressure on Mr. Ahmed’s skin. Mr. Ahmed cannot tolerate positions that might relieve or reduce pressure to his skin. Inspect and palpate the wound. The wound is a 1 × 2-inch, full-thickness ulcer over the sacral area with a red moist base. Reddened periwound skin. Conduct a calorie count Mr. Ahmed is eating fewer than 1600 calories daily. [Ask students: What nursing diagnosis do you think is appropriate? Discuss: Nursing diagnosis: Impaired skin integrity related to pressure over bony prominence in sacral region.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Diagnosis Nursing diagnoses associated with impaired skin integrity and wounds: Risk for infection Imbalanced nutrition: less than body requirements Acute or chronic pain Impaired physical mobility Impaired skin integrity Risk for impaired skin integrity Ineffective peripheral tissue perfusion Impaired tissue integrity Assessment reveals clusters of data to indicate whether an actual or a risk for impaired skin integrity exists. In addition, the assessment data will provide information on the related factor. For example, a postoperative patient has purulent drainage from a surgical wound and reports tenderness around the area of the wound. These data support a nursing diagnosis of impaired skin integrity related to infection. After completing an assessment of a patient’s wound, the nurse identifies nursing diagnoses that direct supportive and preventive care. [Review Box 48-8, Nursing Diagnostic Process: Impaired Skin Integrity Related to Infection, with students.] Some patients are at risk for poor wound healing because of previously defined factors that impair healing. Thus, even though the patient’s wound appears normal, the nurse identifies nursing diagnoses such as impaired nutrition or ineffective peripheral tissue perfusion that direct nursing care toward support of wound repair. The nature of a wound can cause problems unrelated to wound healing. Alteration in comfort and impaired mobility are problems that have implications for the patient’s eventual recovery. For example, a large abdominal incision causes enough pain to interfere with the patient’s ability to turn in bed effectively. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Planning Goals and outcomes Setting priorities
Plan interventions according to Risk for pressure ulcers Type and severity of the wound Presence of complications Setting priorities Preventing pressure ulcers Promoting wound healing Teamwork and collaboration After identifying nursing diagnoses, develop a plan of care for a patient who has actual or is at risk for impaired skin integrity. During planning synthesize information from multiple resources, think critically, and consider professional standards. [Review Figure 48-13, Critical thinking model for skin integrity and wound care planning, with students.] Patients who have large, chronic wounds or infected wounds have multiple nursing care needs. A concept map helps to individualize care for a patient who has multiple health problems and related nursing diagnoses. [Review Figure 48-14, Concept map for Mrs. Stein, with students.] Plan interventions according to the risk for pressure ulcers or the type and severity of the wound and the presence of any complications such as infection, poor nutrition, peripheral vascular diseases, or immunosuppression that can affect wound healing (see the Nursing Care Plan). A goal frequently identified when working with a patient with a wound is to see the wound moving toward healing within a 2-week period. Establish nursing care priorities in wound care based on the comprehensive patient assessment and goals and established outcomes. These priorities also depend on whether the patient’s condition is stable or emergent. An acute wound needs immediate intervention, whereas in the presence of a chronic, stable wound, the patient’s hygiene is more important. When there is a risk for pressure ulcer development, preventive interventions, such as skin care practices, elimination of shear, and positioning, are high priorities. Promotion of wound healing is a major nursing priority, and the type of wound care administered depends on the type, size, and location of the wound and overall treatment goals. Other patient factors to consider when establishing priorities include patient preferences, daily activities, and family factors. These factors are important regardless of the setting for health care. The priorities of care may not vary from outpatient, home, acute care, or restorative care settings. Anticipating the patient’s discharge wound care needs and related equipment and resources, such as referral to a home care agency or outpatient wound care clinic, help to improve not only wound healing but also the patient’s level of independence. Patients and their families often need to continue the objectives of wound management after discharge. Consider the ability of the caregiver and the amount of time needed to change a particular dressing when selecting a dressing for the patient to use after discharge. [Review Box 48-9, Home Care Recommendations, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Goal: Pressure will be reduced to the sacral area, and the wound will show movement toward healing in 1 week. Expected outcomes Wound will decrease in diameter in 7 days. No evidence of further wound formation will be noted in 3 days. It is important to set achievable goals and expected outcomes for the patient. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 1. The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. are approximated. B. migrate across the incision. C. appear slightly pink. D. slightly overlap each other. Answer: A Rationale: A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals by primary intention. The skin edges are approximated, or closed, and the risk of infection is low. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation Health promotion Prevention of pressure ulcers
Topical skin care and incontinence management Positioning Support surfaces Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3) education. [Review Table 48-6, A Quick Guide to Pressure Ulcer Prevention, with students.] Perform skin assessment at least daily; assess high-risk more often, such as every shift. Use cleaners with nonionic surfactants that are gentle to the skin. Make an effort to control, contain, or correct incontinence, perspiration, or wound drainage. Use the expertise of an advanced practice nurse with a focus on wound care or management of incontinence while caring for at-risk patients. Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces. Consider repositioning the patient at least every 2 hours if allowed by their overall condition. When repositioning, use positioning devices to protect bony prominences. The WOCN guidelines (2010) recommend a 30-degree lateral position, which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions. After repositioning the patient, reassess the skin. Never massage reddened areas. Massaging reddened areas increases the breakdown of the capillaries in the underlying tissues and leads to the risk of tissue injury and pressure ulcer formation. Support surfaces reduce the hazards of immobility to the skin and musculoskeletal system. [Ask students: What are some examples of support surfaces? Discuss: any mattress, integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay.] [Review Table 48-7, Support Surfaces, with students.] [Review Box 48-10, Patient Teaching: Pressure-Redistribution Surfaces, with students.] In selecting a support surface, know the patient’s risks and the purpose for the support surface. Teach patients and families the reason for and proper use of the devices. [Shown is Figure 48-15: Thirty-degree lateral position at which pressure points are avoided. (Adapted from Bryant RA, Nix DP, editors: Acute and chronic wounds: current management concepts, ed 5, St Louis, 2016, Mosby.)] [Review Figure 48-16, Considerations for choosing the appropriate support surface, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation (Cont.)
Acute Care Management of pressure ulcers Wound management Debridement Education Nutritional status Protein status Hemoglobin Treatment of patients with pressure ulcers requires a holistic approach that uses the expertise of several multidisciplinary health care professionals. In addition to the nurse, the health care provider, the wound care nurse specialist, physical therapist, occupational therapist, nutritionist, and pharmacist are involved. [Review Skill 48-2, Treating Pressure Ulcers, with students.] An individualized plan of care must be developed for each patient, taking into account age, nutrition, present medical conditions, and other contributing factors. A wound does not move through the phases of healing if it is infected. Preventing wound infection includes cleaning and removing nonviable tissue. Irrigation is a common method of delivering a wound-cleansing solution to the wound. Wound irrigation provides debridement of necrotic tissue with pressure that can remove debris from the wound bed without damaging healthy issues. Debridement is the removal of nonviable, necrotic tissue. Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing. Methods of debridement include mechanical, autolytic, chemical, and sharp/surgical. Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. Chemical debridement may use topical enzymes to induce changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the type of enzyme used, the preparation digests or dissolves the tissue. These preparations require a health care provider’s order. Dakin’s solution breaks down and loosens dead tissue in a wound. Surgical debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument. A moist environment supports the movement of epithelial cells and facilitates wound closure. A variety of educational tools, including videotapes and written materials, are available for you to use when teaching patients and caregivers/family to prevent and treat pressure ulcers and care for wounds. The Joint Commission (2008) recommends nutritional assessment within 24 hours of admission. [Review Box 48-11, Recommendations for Nutritional Assessment and Management of Pressure Ulcers, with students.] Patients with pressure ulcers who are underweight or are losing weight need enhanced caloric and protein supplementation. A patient can lose as much as 50 g of protein per day from an open, weeping pressure ulcer. A low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia. When possible, maintain hemoglobin at 12 g/100 mL. [Shown is Figure 48-17: Wound irrigation.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Repositioning redistributes pressure.
Post and implement a turning schedule. Redistributes the amount of pressure on the bony prominences Obtain and place over the patient’s mattress a low-air-loss overlay. Remove debris and old drainage from wound site, preventing further wound progression/skin breakdown. Clean wound and periwound skin; dry periwound skin. The use of hydrocolloid dressing will support moist wound healing and will protect the wound. Apply a hydrocolloid dressing to the wound. Adequate nutrition such as protein intake, increased calorie count, and vitamins aid in wound healing. Determine in collaboration with dietitian an appropriate diet. Interventions and their rationales are shown for Mr. Ahmed. Note that the first two actions address pressure management, the next two address wound care, and the final intervention addresses nutrition management. Copyright © 2017, Elsevier Inc. All Rights Reserved.

First Aid for Wounds Hemostasis Control bleeding. Allow puncture wounds to bleed. Do not remove a penetrating object. Bandage Cleaning Gentle Normal saline Protection In an emergency setting, use first aid measures for wound care. Under stable conditions, a variety of interventions ensure wound healing. When a patient suffers a traumatic wound, first aid interventions include stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury. After assessing the type and extent of the wound, control bleeding by applying direct pressure on it with a sterile or clean dressing such as a washcloth. After bleeding subsides, an adhesive bandage or gauze dressing taped over the laceration allows skin edges to close and a blood clot to form. Normally allow a puncture wound to bleed to remove dirt and other contaminants such as saliva from a dog bite. When a penetrating object such as a knife blade is present, do not remove the object. The presence of the object provides pressure and controls some bleeding. The process of cleaning a wound involves selecting an appropriate cleaning solution and using a mechanical means of delivering that solution without causing injury to the healing wound tissue. Gently cleaning a wound removes contaminants that serve as sources of infection. However, vigorous cleaning using a method with too much mechanical force causes bleeding or further injury. According to WOCN guidelines, normal saline is the preferred cleaning agent. Regardless of whether bleeding has stopped, protect a wound from further injury by applying sterile or clean dressings and immobilizing the body part. A light dressing applied over minor wounds prevents entrance of microorganisms. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Dressings Purposes of dressings Protects from microorganisms Aids in hemostasis Promotes healing by absorbing drainage or debriding a wound Supports wound site Promotes thermal insulation Provides a moist environment The more extensive the wound, the larger the dressing required. The use of dressings requires an understanding of wound healing. A variety of dressing materials are commercially available. The correct dressing selection facilitates wound healing. For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops. In contrast, when dressing a wound healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or assisting in debridement. When the skin is broken, a dressing helps reduce exposure to microorganisms. Pressure dressings promote hemostasis. Applied with elastic bandages, a pressure dressing exerts localized downward pressure over an actual or potential bleeding site. A pressure dressing eliminates dead space in underlying tissues so wound healing progresses normally. The primary function of a dressing on a healing wound is to absorb drainage. When wounds such as a necrotic wound require debriding, a wet-to-dry dressing technique can be considered. Place the moist dressing into the wound. The contact dressing is allowed to dry so it sticks to underlying tissue, and debridement occurs during removal. This type of debridement is non selective and can remove viable tissue. Dressings applied to a draining wound require frequent changing to prevent microorganism growth and skin breakdown. A dressing needs to support a moist wound environment if the wound is healing by secondary intention. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Dressings (Cont.) Types of dressings Gauze Transparent film Hydrocolloid Hydrogel Foam Composite Dressings vary by type of material and mode of application (wet or dry). The WOCN guidelines (2010) are helpful when selecting dressings based on the goal of wound treatment. [Review Skill 48-3, Applying Dry and Moist Dressings, with students.] [Review Box 48-12, Dressing Considerations, with students.] To avoid causing damage to the periwound skin, it is important that the dressing technique that you use to treat pressure ulcers and other wounds is not excessively moist. [Review Box 48-13, Evidence-Based Practice: Moisture-Associated Skin Damage, with students.] Most pressure ulcers require dressings. The type of dressing is usually based on the stage of the pressure ulcer, the type of tissue in the wound, and the function of the dressing. [Review Table 48-8, Dressings by Pressure Ulcer Stage, with students.] Gauze sponges are the oldest and most common dressing. They are absorbent and are especially useful in wounds to wick away wound exudate. Another type of dressing is a self-adhesive, transparent film. This type of dressing traps moisture over a wound, providing a moist environment. Hydrocolloid dressings are dressings with complex formulations of colloids and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds. Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. This type of dressing hydrates wounds and absorbs small amounts of exudate. Hydrogel dressings are for partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin. Foam and alginate dressings are for wounds with large amounts of exudate and those that need packing. Foam dressings are also used around drainage tubes to absorb drainage. Calcium alginate dressings are manufactured from seaweed and come in sheet and rope forms. The alginate forms a soft gel when in contact with wound fluid. These highly absorbent dressings are for wounds with an excessive amount of drainage and do not cause trauma when removed from the wound. Several manufacturers produce composite dressings, which combine two different dressing types into one dressing. Research is ongoing regarding which type of dressing is best for which type of wound. [Shown is Figure 48-18: Transparent film dressing.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Dressings (Cont.) Changing dressings Know type of dressing, placement of drains, and equipment needed. Prepare the patient for a dressing change. Review previous wound assessment. Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change. Describe procedure steps to lessen patient anxiety. Gather all supplies. Recognize normal signs of healing. Answer questions about the procedure or wound. A complete patient and wound history is essential in determining when a clean dressing technique is appropriate. For example, chronic pressure ulcer wounds use a clean technique. On the other hand, a fresh surgical wound requires sterile technique so as not to introduce microorganisms into a healing wound. The health care provider’s order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. The medical or operating room record usually indicates whether drains are present and from what body cavity they drain. After the first dressing change, describe the location of drains and the type of dressing materials and solutions to use in the patient’s care plan. Often it is necessary to teach patients how to change dressings in preparation for home care. In this situation, demonstrate dressing changes to the patient and family and then provide an opportunity for them to practice. The patient needs to be able to change a dressing independently or with assistance from a family member before discharge. Contaminated dressings in the home should be disposed of in a manner consistent with local regulations. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Dressings (Cont.) Packing a wound Negative-pressure wound therapy The first step in packing a wound is to assess its size, depth, and shape. These characteristics are important in determining the size and type of dressing used to pack a wound. The dressing needs to be flexible and in contact with the entire wound surface. Overpacking causes pressure on the tissue in the wound bed. Pack the wound only until the packing material reaches the surface of the wound; there should never be so much packing material that it extends higher than the wound surface. A treatment modality for wounds is negative-pressure wound therapy (NPWT) or vacuum-assisted closure (one brand name is V.A.C.). NPWT is the application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid. The vacuum-assisted closure (V.A.C.) is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. NPWT supports wound healing by edema reduction and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion. Secondary effects include angiogenesis, granulation tissue formation, and reduction in bacterial bioburden. There have been modifications to the V.A.C. The V.A.C. Instill allows intermittent instillation of fluids into the wound, especially those wounds not responding to traditional NPWT. NPWT is used for treating acute and chronic wounds. Wear time for the dressing is between 24 hours and 5 days. As the wound heals, granulation tissue lines the surface of the wound. The wound has a stippled or granulated appearance. The surface area sometimes increases or decreases, depending on wound location and the amount of drainage removed by the NPWT system. NPWT is also used to enhance the adherence of split-thickness skin grafts. It is placed over the graft intraoperatively, decreasing the ability of the graft to shift and evacuating fluids that build up under it. An airtight seal must be maintained. [Review Box 48-14, NPWT: Maintaining an Airtight Seal, with students.] [Review Skill 48-4, Implementation of Negative-Pressure Wound Therapy, with students.] [Shown at top is Figure 48-19: A, Dehisced wound before wound V.A.C. therapy. B, Dehisced wound after wound V.A.C. therapy. V.A.C., Vacuum-assisted closure. (Courtesy Kinetic Concepts, [KCI], San Antonio, Tex.)] [Shown at bottom is Figure 48-20: V.A.C. system using negative pressure to remove fluid from area surrounding wound, reducing edema and improving circulation to area. V.A.C., Vacuum-assisted closure. (Courtesy Kinetic Concepts [KCI], San Antonio, Tex.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Dressings (Cont.) Securing Tape Ties Binders Use tape, ties, or a secondary dressing to secure a dressing over a wound site. The choice of anchoring depends on the wound size and location, the presence of drainage, the frequency of dressing changes, and the patient’s level of activity. Most often strips of tape are used to secure dressings. Nonallergenic paper and silicone tapes minimize skin reactions. Choose the tape size that sufficiently secures the dressing. When applying tape, ensure that it adheres to several inches of skin on both sides of the dressing and that it is placed across the middle of the dressing. When securing the dressing, press the tape gently, making sure to exert pressure away from the wound. This way, tension occurs in both directions away from the wound, minimizing skin distortion and irritation. Never apply tape over irritated or broken skin. To remove tape safely, loosen the ends and gently pull the outer end parallel with the skin surface toward the wound. Apply light traction to the skin away from the wound as the tape is loosened and removed. The traction minimizes pulling of the skin. To avoid repeated removal of tape from sensitive skin, secure dressings with pairs of reusable Montgomery ties. Each section consists of a long strip; half contains an adhesive backing to apply to the skin, and the other half folds back and contains a cloth tie or a safety pin/rubber band combination that you fasten across a dressing and untie at dressing changes. To provide even support to a wound and immobilize a body part, apply elastic gauze, elastic stretch net or binders over a dressing. [Shown is Figure 48-21: Montgomery ties. A, Each tie is placed at side of dressing. B, Securing ties encloses dressing.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Dressings (Cont.) Comfort measures Administer analgesic medications 30 to 60 minutes before dressing changes Carefully remove tape Gently clean wound edges Carefully manipulate dressings and drains to minimize stress on sensitive tissues Turn and position patient carefully A wound is often painful, depending on the extent of tissue injury and wound care often requires the use of well time analgesia prior to any wound procedure. Administer analgesic medications 30 to 60 minutes before dressing changes (depending on the time of peak action of a drug). In addition, there are several techniques useful in minimizing discomfort during wound care. Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cleaning skin and drain sites Basic Skin Cleaning Clean from least contaminated to the surrounding skin Use gentle friction When irrigating, allow the solution to flow from the least to most contaminated area Some health care providers order cleaning a wound or drain site if a dressing does not absorb drainage properly or if an open drain deposits drainage onto the skin. Wound cleaning requires good hand hygiene and aseptic techniques. Clean surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze or by irrigation. The following three principles are important when cleaning an incision or the area surrounding a drain: 1. Clean in a direction from the least contaminated area, such as from the wound or incision, to the surrounding skin or from an isolated drain site to the surrounding skin. 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to most contaminated area. [Review Skill 48-5, Performing Wound Irrigation, with students.] After applying a solution to sterile gauze, clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice. Drain sites are a source of contamination because moist drainage harbors microorganisms. If a wound has a dry incisional area and a moist drain site, cleaning moves from the incisional area toward the drain. Use two separate swabs or gauze pads, one to clean from the top of the incision toward the drain and one to clean from the bottom of the incision toward the drain. To clean the area of an isolated drain site, clean around the drain, moving in circular rotations outward from a point closest to the drain. In this situation, the skin near the site is more contaminated than the site itself. To clean circular wounds, use the same technique as in cleaning around a drain. [Shown is Figure 48-22: Methods for cleaning a wound site.] [Shown is Figure 48-23: Cleaning a drain site.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cleaning skin and drain sites (Cont.) Irrigation Wound irrigations Suture care Staple removal Irrigation is a way of cleaning wounds. Use an irrigating syringe to flush the area with a constant low-pressure flow of solution. The gentle washing action of the irrigation will cleanse a wound of exudate and debris. Irrigation is particularly useful for open, deep wounds; wounds involving an inaccessible body part such as the ear canal; or when cleaning sensitive body parts such as the conjunctival lining of the eye. Irrigation of an open wound requires sterile technique. Use a 35-mL syringe with a 19-gauge soft angiocatheter to deliver the solution. Never occlude a wound opening with a syringe because this results in the introduction of irrigating fluid into a closed space. Make sure that fluid flows directly into the wound and not over a contaminated area before entering the wound. Sutures are threads or metal used to sew body tissues together. The patient’s history of wound healing, the site of surgery, the tissues involved, and the purpose of the sutures determine the suture material used. Sutures are available in a variety of materials, including silk, steel, cotton, linen, wire, nylon, and Dacron. They come with or without sharp surgical needles attached. Steel staples are a common type of outer skin closure that causes less trauma to tissue than sutures while providing extra strength. Sutures are placed within tissue layers in deep wounds and superficially as the final means for wound closure. Policies vary within institutions as to who is able to remove sutures. If it is appropriate that the nurse remove them, a health care provider’s order is required. Special scissors with curved cutting tips or special staple removers slide under the skin closures for suture removal. To remove staples, insert the tips of the staple remover under each wire staple. While slowly closing the ends of the staple remover together, squeeze the center of the staple with the tips, freeing it from the skin. [Shown at top is Figure 48-24: Incision closed with metal staples.] [Shown at bottom is Figure 48-25: Staple remover.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Suture care (Cont.) Suture removal To remove sutures, first check the type of suturing used. With intermittent suturing, the surgeon ties each individual suture made in the skin. Continuous suturing, as the name implies, is a series of sutures with only two knots, one at the beginning and one at the end of the suture line. Retention sutures are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal. Never pull the visible portion of a suture through underlying tissue. Sutures on the surface of the skin harbor microorganisms and debris. The portion of the suture beneath the skin is sterile. Pulling the contaminated portion of the suture through tissues can lead to infection. Prior to taking out the sutures, cleanse the suture line with normal saline. Clip suture materials as close to the skin edge on one side as possible and pull the suture through from the other side. [Shown at top is Figure 48-26: Examples of suturing methods. A, Intermittent. B, Continuous. C, Blanket continuous. D, Retention.] [Shown at bottom is Figure 48-27: Removal of intermittent suture. A, Cut suture as close to skin as possible, away from knot. B, Remove suture and never pull contaminated stitch through tissues.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Drainage Evacuation Constant, low-pressure vacuum to remove and collect drainage When drainage interferes with healing, evacuation is achieved by using either a drain alone or a drainage tube with continuous suction. You may apply special skin barriers, including hydrocolloid dressings similar to those used with ostomies, around drain sites with significant drainage. The skin barriers are soft material applied to the skin with adhesive. Drainage flows on the barrier but not directly on the skin. Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder and immediately reset the evacuator to apply suction. [Shown is Figure 48-28: Setting suction on drainage evacuator. 1, With drainage port open, raise level on diaphragm. 2, Push straight down on lever to lower diaphragm. 3, Closure of port prevents escape of air and creates vacuum pressure.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 2. A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A. it has no odor. B. a culture is negative. C. the edges reveal the presence of fluid. D. it shows purulent drainage coming from the incision site. Answer: D Copyright © 2017, Elsevier Inc. All Rights Reserved.

Bandages and binders Principles for applying bandages and binders Binder application Slings Bandage application Uses for bandages and binders include: creating pressure over a body part, immobilizing a body part, supporting a wound, reducing or preventing edema, securing a splint, and securing dressings. Bandages are available in rolls of various widths and materials, including gauze, elasticized knit, elastic webbing, flannel, and muslin. Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation to prevent skin maceration. Elastic bandages conform well to body parts but are also for exerting pressure. Binders are bandages that are made of large pieces of material to fit a specific body part. Most binders are made of elastic or cotton. An abdominal binder and a breast binder are examples. Before applying a bandage or binder, inspect the skin for abrasions, edema, discoloration, or exposed wound edges, cover exposed wounds or open abrasions with a dressing, assess the condition of underlying dressings, and assess the skin of underlying areas that will be distal to the bandage for signs of circulatory impairment. After applying a bandage, the nurse assesses, documents, and immediately reports changes in circulation, skin integrity, comfort level, and body function. Carefully assess a bandage to be sure that it is applied properly and providing therapeutic benefit and replace any soiled bandages. Binders are especially designed for the body part to be supported. The most common type of binder is the abdominal binder. [Review Box 48-15, Procedural Guidelines: Applying a Binder, with students.] An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs. Secure an abdominal binder with safety pins or Velcro strips. Slings support arms with muscular sprains or fractures. A commercially manufactured sling consists of a long sleeve that extends above the elbow with a strap that fits around the neck. In the home, patients can use a large triangular piece of cloth. Always support the lower arm and hand at a level above the elbow to prevent the formation of dependent edema. Rolls of bandage secure or support dressings over irregularly shaped body parts. Each roll has a free outer end and a terminal end at the center of the roll. The rolled portion of the bandage is its body, and its outer surface is placed against the patient’s skin or dressing. Use a variety of bandage turns, depending on the body part to be bandaged. [Review Skill 48-6, Applying an Elastic Bandage, with students.] [Shown at right is Figure 48-29: Securing an abdominal binder with Velcro.] [Shown at left is Figure 48-30: Application of sling.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) In preparation for her husband’s discharge, Mrs. Ahmed is interested in learning how to change Mr. Ahmed’s pressure ulcer dressing. Lynda develops a teaching plan to include Mrs. Ahmed, with the outcome goal that “At the end of the teaching session, Mrs. Ahmed will perform an acceptable return demonstration of dressing application.” [Ask students: What teaching strategies would be appropriate? Discuss: Plan time that Mrs. Ahmed is present and be prepared to spend 30 minutes in two separate teaching sessions. Avoid using words that Mrs. Ahmed will not understand. Provide a brief description of what will be taught to both patient and spouse. Include the patient in all of the teaching even though he is unable to see the wound. Bring an extra dressing to the bedside to show Mrs. Ahmed what the dressing looks like and how to apply it. Use a pictorial guide of a pressure ulcer to help Mrs. Ahmed understand what the wound looks like and how it will progress if it shows signs of healing. Plan one session in which Mrs. Ahmed will watch a demonstration of the wound being cleaned and the dressing applied. Plan a second session where she will do a return demonstration. At the end of each session, ask Mrs. Ahmed how she felt doing the dressing, and include Mr. Ahmed in this evaluation.] [Ask students: What evaluation strategies would be appropriate? Discuss: Ask Mrs. Ahmed questions as she does the procedure to evaluate her understanding of each step. Ask Mrs. Ahmed what she will evaluate at each dressing change. Observe Mrs. Ahmed changing the dressing and cleaning the wound. Observe any body language that indicates how she is feeling while doing the procedure.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Heat and Cold Therapy Assessment for temperature tolerance Bodily responses to heat and cold Local effects of heat and cold Effects of heat application Effects of cold application Factors influencing heat and cold tolerance Exposure time Exposed skin Temperature Age Perception of sensory stimuli Before applying heat or cold therapies, assess the patient’s physical condition for signs of potential intolerance to heat and cold. Assess the skin, looking for any open areas, such as alterations in skin integrity, that increase the patient’s risk of injury. Include in your assessment the neurological system for sensation (to understand if the patient senses extremes of cold or heat) and the patient’s mental status to be sure that the patient can correctly communicate any issues with the hot or cold therapy. Assessment includes identification of conditions that contraindicate heat or cold therapy. Also assess the condition of equipment being used. Exposure to heat and cold causes systemic and local responses. Systemic responses occur through heat-loss mechanisms (sweating and vasodilation) or mechanisms promoting heat conservation (vasoconstriction and piloerection) and heat production (shivering). Local responses to heat and cold occur through stimulation of temperature-sensitive nerve endings within the skin. Recognize patients most at risk for injuries from heat and cold applications. [Review Table 48-9, Conditions That Increase Risk of Injury from Heat and Cold Application, with students.] Heat and cold stimuli create different physiological responses. The choice of heat or cold therapy depends on local responses desired for wound healing. [Review Table 48-10, Therapeutic Effects of Heat and Cold Applications, with students.] Heat generally is quite therapeutic, improving blood flow to an injured part. However, if heat is applied for 1 hour or more, the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area. Periodic removal and reapplication of local heat restores vasodilation. Continuous exposure to heat damages epithelial cells, causing redness, localized tenderness, and even blistering. The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia. The skin initially takes on a reddened appearance, followed by a bluish-purple mottling, with numbness and a burning type of pain. Skin tissues freeze from exposure to extreme cold. The response of the body to heat and cold therapies depends on the following factors: A person is better able to tolerate short exposure to temperature extremes than prolonged exposure. Exposed skin layers and certain areas of the skin (e.g., the neck, inner aspect of the wrist and forearm, and perineal region) are more sensitive to temperature variations. The foot and palm of the hand are less sensitive. The body responds best to minor temperature adjustments. If a body part is cool and a hot stimulus touches the skin, the response is greater than if the skin were already warm. A person has less tolerance to temperature changes to which a large area of the body is exposed. Tolerance to temperature variations changes with age. Patients who are very young or old are most sensitive to heat and cold. If a patient’s physical condition reduces the reception or perception of sensory stimuli, tolerance to temperature extremes is high, but the risk of injury is also high. Uneven temperature distribution suggests that the equipment is functioning improperly. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Heat and Cold Therapy (Cont.) Application of heat and cold therapies Choice of moist or dry Warm, moist compresses Warm soaks Sitz baths Commercial hot and cold packs Cold, moist, and dry compresses Cold soaks Ice bags or collars A prerequisite to using any heat or cold application is a health care provider’s order, which includes the body site to be treated and the type, frequency, and duration of application. Consult agency procedure manual for correct temperatures to use. [Review Box 48-16, Safety Suggestions for Applying Heat or Cold Therapy, with students.] You can administer heat and cold applications in dry or moist forms. The type of wound or injury, the location of the body part, and the presence of drainage or inflammation are factors to consider in selecting dry or moist applications. [Review Box 4-17, Choice of Dry or Moist Applications, with students.] Warm, moist compresses improve circulation, relieve edema, and promote consolidation of purulent drainage. Immersion of a body part in a warmed solution promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution. Position the patient comfortably, place waterproof pads under the area to be treated, and heat the solution to about 40.5° to 43° C (105° to 110° F). After immersing the body part, cover the container and extremity with a towel to reduce heat loss. It is usually necessary to remove the cooled solution and add heated solution after about 10 minutes. The patient who has had rectal surgery, an episiotomy during childbirth, painful hemorrhoids, or vaginal inflammation benefits from a sitz bath, a bath in which only the pelvic area is immersed in warm or, in some situations, cool fluid. The patient sits in a special tub or chair or a basin that fits on the toilet seat so the legs and feet remain out of the water. Commercially prepared disposable hot packs apply warm, dry heat to an injured area. The chemicals mix and release heat when you strike, knead, or squeeze the pack. Commercially prepared cold packs that are similar to the disposable hot packs for dry applications are available. When using cold compresses, observe for adverse reactions such as burning or numbness, mottling of the skin, redness, extreme paleness, and a bluish skin discoloration. Apply cold compresses for 20 minutes at a temperature of 15° C (59° F) to relieve inflammation and swelling. The procedure for preparing cold soaks and immersing a body part is the same as for warm soaks. The desired temperature for a 20-minute cold soak is 15° C (59° F). For a patient who has a muscle sprain, localized hemorrhage, or hematoma, or who has undergone dental surgery, an ice bag is ideal to prevent edema formation, control bleeding, and anesthetize the body part. Proper use of the bag requires the following steps: 1. Fill the bag with water, secure the cap, invert to check for leaks, and pour out the water. 2. Fill the bag two-thirds full with crushed ice so you are able to easily mold it over a body part. 3. Release any air from the bag by squeezing its sides before securing the cap because excess air interferes with conduction of cold. 4. Wipe off excess moisture. 5. Cover the bag with a flannel cover, towel, or pillowcase. 6. Apply the bag to the injury site for 30 minutes; you can reapply the bag in an hour. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Lynda observes Mr. Ahmed’s wound and measures it to be 1 × 1 inch with serous drainage and red color. Achievement of outcome by improved tissue type and reduced wound size Lynda palpates underlying skin around wound; the skin remains intact. Achievement of outcome by no evidence of advancing ulcer or tissue damage She asks Mr. Ahmed about discomfort; he denies any new sensations at the wound site. Achievement of outcome by no evidence of new tissue damage [Ask students: What other means of evaluation Lynda could be using? Discuss: Nutritional status. Lynda also asks Mr. Ahmed about his food intake and reviews Mr. Ahmed’s calorie count over the past week. He reports that his appetite is increasing, and that he is eating most of his meals. Calorie count shows a steady increase in daily consumption. The outcome has been achieved as noted by improved nutritional intake.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 3. A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: A. an absorbent surface to collect wound drainage. B. decreased incidence of skin maceration. C. potection from the external environment. D. moisture needed for wound healing. Answer: D Copyright © 2017, Elsevier Inc. All Rights Reserved.

Evaluation Through the patient’s eyes Patient outcomes
Include the patient and caregiver in the evaluation process Patient outcomes Individualize nursing interventions Patients with impaired skin integrity Ongoing evaluations Validated risk-assessment tool It is important to include the patient and caregiver in the evaluation process. Determine what they know about the formation of impaired skin integrity, determine how the patient and caregiver feel about the presence of the wound and the need for wound care, and develop a plan of care to provide education and support. Chronic wounds, such as pressure ulcers, take time to heal, and it is likely that the patient will be in the home setting with the pressure ulcer. Because each patient has different risk factors for impaired skin integrity, you need to individualize nursing interventions. Patients with minimal mobility impairments or relatively stable health status need only a few measures. You evaluate nursing interventions for reducing and treating pressure ulcers by determining the patient’s response to nursing therapies and whether the patient achieved each goal. Patients with impaired skin integrity need evaluation on an ongoing basis for factors that contribute to skin breakdown. This includes a comprehensive skin assessment and a wound assessment using a validated risk-assessment tool. Assessment provides the foundation for the plan of care, and evaluation is critical for monitoring the effectiveness of the plan. If the identified outcomes are not met for a patient with impaired skin integrity, questions to ask include the following: Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified? Did the plan of care decrease the contribution of each of these components? Was wound healing supported by providing the wound base with a moist protected environment? Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing? Finally, evaluate the need for additional referrals to other experts in wound care and pressure ulcers, such as nurses certified in wound care. Care of patients with a pressure ulcer or wound requires a multidisciplinary team approach. [Review Figure 48-31, Critical thinking model for skin integrity and wound care evaluation, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Lynda Abraham has completed her clinical experience with Mr. Ahmed. His pressure ulcer is still present, but it is reduced in size and demonstrates progress toward healing. No other sites of nonblanchable erythema were noted, and the rest of his skin remains intact. Lynda taught Mrs. Ahmed how to assess her husband’s skin for signs of increased risk for or further breakdown. Lynda, with the help of her instructor, devised a plan of care for the home, and they are meeting with the home care nurse today when she visits Mr. Ahmed at the hospital. [Ask students: Why is teaching family members key in continued health for patients at discharge? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Safety Guidelines for Nursing Skills
Position patient to prevent the patient from rolling over the side of the bed. Keep a plastic bag within reach to discard dressings and prevent cross-contamination. Keep extra gloves within reach to allow a change of gloves if the gloves become soiled. If irrigating a wound, use appropriate PPE. When applying an elastic bandage, check the extremity for temperature or sensation changes. Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with all members of the health care team, assess and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about care. When performing the skills in this chapter, remember the following points to ensure safe, individualized patient-centered care: Position patient in a manner that the side rails on the bed are in an upright position to prevent the patient from rolling over the side of the bed. When changing wound dressings, keep a plastic bag within reach to discard dressings and prevent cross-contamination. Keep extra gloves within reach to allow a change of gloves if the gloves become soiled. If irrigating a wound, use goggles and other personal protective equipment when the risk for splash exists. When applying an elastic bandage, check the extremity where the bandage is applied for temperature or sensation changes. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Skin Integrity and Wound Care

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