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

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

3. 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

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

5. 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

6. 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

7. 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

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

9. 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

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

11. 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.

12. 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

13. 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

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

15. 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.

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

17. Wound Healing

18. Wound Healing (cont.)

19. Wound Healing (cont.)

20. 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

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

22. 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

23. 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.

24. 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.

25. End of Presentation