1. Chapter 30
Wound Care
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2. Skin and Wound Care The skin is the body’s first line of defense.
A wound is a break in the skin or mucous membrane.
A wound is a portal of entry for microbes.
Infection is a major threat.
Wound care involves:
Preventing infection
Preventing further injury to the wound and nearby tissues
You must prevent skin injury and give good skin care to help prevent skin breakdown.
Wound care also prevents blood loss and pain.
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3. Wounds Common causes of wounds are:
Surgery
Trauma
Pressure ulcers from unrelieved pressure
Decreased blood flow through the arteries or veins
Nerve damage
Older and disabled persons are at great risk for skin breakdown.
The nurse uses the nursing process to keep the person’s skin healthy.
Some centers have a skin care team to manage all skin problems. The team includes an RN, a physical therapist, a dietitian, and often a wound ostomy continence nurse.
Review Focus on Rehabilitation: Wound Care on p. 496.
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4. Types of Wounds Wounds are described in the following ways:
Intentional wounds and unintentional wounds
Open and closed wounds
Clean wounds
Clean-contaminated wounds
Contaminated wounds
Infected wounds (dirty wound)
Chronic wounds
Partial- and full-thickness wounds
Clean-contaminated wounds occur from the surgical entry of the reproductive, urinary, respiratory, or GI (gastro-intestinal) system.
Review Box 30-1 on p. 496.
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5. Types of Wounds (Cont’d)
Wounds are also described by their causes:
Abrasion
Contusion
Incision
Laceration
Penetrating wound
Puncture wound
Ulcer
An abrasion is a partial-thickness wound caused by the scraping away or rubbing of the skin (Fig. 30-1, p. 496).
A contusion is a closed wound caused by a blow to the body (a bruise). Also called a deep tissue injury (Fig. 30-2, p. 497).
An incision is a cut produced surgically by a sharp instrument (Fig. 30-3, p. 497).
A laceration is an open wound with torn tissues and jagged edges (Fig. 30-4, p. 497).
A penetrating wound is an open wound that breaks the skin and enters a body area, organ, or cavity (Fig. 30-5, p. 497).
A puncture wound is an open wound made by a sharp object (knife, nail, metal, wood, glass). It may be intentional or unintentional (Fig. 30-6, p. 497).
An ulcer is a shallow or deep crater-like sore of the skin or a mucous membrane, p. 497.
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6. Skin Tears A skin tear is a break or rip in the skin.
The hands, arms, and lower legs are common sites for skin tears.
Causes
Friction and shearing
Pulling or pressure on the skin
Falls or bumping a hand, arm, or leg on any hard surface
Holding the person’s arm or leg too tight
Tell the nurse at once if you cause or find a skin tear.
In a skin tear, the epidermis (top skin layer) separates from the underlying tissues. The skin is “peeled back” (Fig. 30-7, p. 497).
Skin tears are also caused by:
Removing tape or adhesives.
Bathing, dressing, and other tasks.
Pulling buttons and zippers across fragile skin.
Jewelry—yours or the person’s.
Skin tears are painful.
They are portals of entry for microbes.
To prevent skin tears, follow the care plan.
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7. Risk Factors for Skin Tears
Persons at risk for skin tears:
Need moderate to total help in moving
Have poor nutrition
Have poor hydration
Have altered mental awareness
Are very thin
Careful and safe care helps prevent skin tears and further injury.
Follow the care plan and the nurse’s directions. They may include dressings and elastic bandages to protect the skin and promote healing and protective arm or leg sleeves (Fig. 30-8, p. 498).
Review Residents With Dementia: Persons at Risk (Skin Tears) on p. 498.
Review Box 30-2 on p. 498.
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8. Circulatory (Vascular) Ulcers
Open sores on the lower legs or feet
Caused by decreased blood flow
Types
Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Poor circulation can result in:
Pain
Open wounds
Edema
Infection and gangrene
Persons with diseases affecting the blood vessels are at risk. These wounds are painful and hard to heal.
Some diseases affect blood flow to and from the legs and feet.
Edema is swelling caused by fluid collecting in tissues.
Gangrene is a condition in which there is death of tissue.
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9. Venous (Stasis) Ulcers
Open sores on the lower legs or feet caused by poor blood flow through the veins
The heels and inner aspect of the ankles are common sites.
Risk factors include:
History of blood clots or varicose veins
Decreased mobility
Obesity
Hereditary
Leg or foot surgery
Advanced age
Surgery on the bones and joints
Phlebitis (inflammation of a vein)
Stasis means stopped or slowed fluid flow.
Venous ulcers can develop when valves in the leg veins do not close well. The veins do not pump blood back to the heart in a normal way. Blood and fluid collect in the legs and feet. Small veins in the skin can rupture.
When veins rupture, hemoglobin enters the tissues, causing the skin to turn brown. The skin is dry, leathery, and hard. Itching is common.
Venous ulcers can occur from skin injury, such as scratching, or they can occur without trauma.
Venous ulcers are painful, and walking is difficult. Fluid may seep from the wound. Infection is a risk. Healing is slow.
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10. Prevention and Treatment
Prevention and treatment involve:
Follow the person’s care plan to prevent skin breakdown.
Prevent injury. Do not bump the legs and feet.
Elevate the extremities. Do not put pressure on heels or calves
Handle, move, and transfer the person carefully and gently.
Persons at risk need professional foot care.
Drugs for infection and to decrease swelling
Medicated bandages and other wound care products
Devices used for pressure ulcers
Compression stockings or elastic bandages
Review Box 30-3 on p. 499.
You do not cut the toenails of persons with diseases affecting the circulation.
Compression stockings or elastic bandages promote comfort, healing, and circulation by providing support and pressure to the veins, and they prevent injury.
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11. Treatment Compression stockings (anti-embolism stockings) Thrombus
Exert pressure on the veins
Promote venous blood return to the heart
Help prevent venous ulcers and blood clots (thrombi) in leg veins
Thrombus
Can form in deep leg veins
Can break loose and travel in the bloodstream (embolus)
An embolus can lodge in a vein in the lungs (pulmonary embolus)
Elastic bandages
Have the same purpose as compression stockings
Support and reduce swelling from injuries
Can be used to hold dressing in place
A pulmonary embolus can cause severe respiratory problems and death. Report chest pain or shortness of breath at once.
Review the list on p. 498 in the textbook that describes persons at risk for thrombi.
Review Delegation Guidelines: Compression Stockings on p. 500.
Review Promoting Safety and Comfort: Compression Stockings on p. 500.
Review the Applying Compression Stockings procedure on p. 501.
Review Focus on Communication: Elastic Bandages on p. 502.
Review Delegation Guidelines: Elastic Bandages on p. 502.
Review Promoting Safety and Comfort: Elastic Bandages on p. 502.
Review the Applying Elastic Bandages procedure on p (see Fig , p. 503).
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12. Arterial Ulcers
Open wounds on the lower legs or feet caused by poor arterial blood flow
Found between the toes, on top of the toes, and on the outer side of the ankle
Smoking is a risk factor.
Treatment involves:
Treating the disease causing the ulcer
Drugs and wound care
A walking and exercise program
Professional foot care
These ulcers (Fig , p. 504) are caused by diseases or injuries that decrease arterial blood flow to the legs and feet. High blood pressure, diabetes, and narrowed arteries from aging are common causes.
The leg and foot may feel cold and look blue or shiny. The ulcer is very painful.
Follow the care plan (see Box 30-3, p. 499) and prevent further injury.
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13. Diabetic Foot Ulcers
Open wounds on the foot caused by complications from diabetes
Diabetes can affect the nerves and blood vessels.
You need to:
Check the person’s feet every day.
Report any sign of a foot problem to the nurse at once.
Follow the care plan.
When nerves are affected, the person can lose sensation in a foot or leg. Loss of sensation can be complete or partial. The person may not feel pain, heat, or cold. Infection and a large sore can develop.
When blood vessels are affected, blood flow decreases. Tissues and cells do not get needed oxygen and nutrients. Wounds heal poorly.
Tissue death (gangrene) can occur. Sometimes the affected part is amputated to prevent the spread of gangrene.
Some persons have both nerve and blood vessel damage.
Review Box 30-4 on p. 504.
Review Figure 30-15, A-H on p. 505.
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14. Wound Healing The healing process has three phases:
Inflammatory phase (3 days)
Proliferative phase (day 3 to day 21)
Maturation phase (day 21 to 2 years)
Healing occurs in three ways:
First intention (primary intention, primary closure)
Second intention (secondary intention)
Third intention (delayed intention, tertiary intention)
During the inflammatory phase, bleeding stops. A scab forms over the wound. The scab protects against microbes entering the wound. Blood supply to the wound increases, bringing nutrients and healing substances as well as signs and symptoms of inflammation.
Proliferate means to multiply rapidly. Tissue cells multiply to repair the wound.
In the maturation phase, the scar gains strength. The red, raised scar becomes thin and pale.
In first intention, wound edges are brought together to close the wound. The wound edges are held together (Fig A, p. 506).
Second intention is for contaminated and infected wounds. Wounds are cleaned and dead tissue removed. Wound edges are not brought together. Healing takes longer and leaves a larger scar. Infection is a great risk (Fig B, p. 506).
In third intention, the wound is left open and closed later. It combines first and second intention. Infection and poor circulation are common reasons for third intention (Fig C, p. 506).
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15. Wound Healing & Complications
Many factors affect healing and increase the risk of complications.
The type of wound
The person’s age, general health, nutrition, and lifestyle
Circulation
Drugs
Nutrition
Immune system changes
Complications include:
Infection
Dehiscence: separation of wound layers
Evisceration: dehiscence plus protrusion of abdominal organs
Good circulation is needed.
Protein is needed for tissue growth and repair.
Infection is a risk for persons with immune system changes and for those taking antibiotics. Specific antibiotics kill specific pathogens. In doing so, other pathogens may be allowed to grow and multiply.
In dehiscence (Fig , p. 507), the person often describes the sensation of the wound “popping open.”
Dehiscence and evisceration (Fig , p. 507) are surgical emergencies.
Review Focus on Rehabilitation: Complications of Wound Healing on p. 507.
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16. Wound Appearance & Drainage
Doctors and nurses observe the wound and its drainage.
You need to make certain observations when assisting with wound care.
Wound drainage is observed and measured.
Serous drainage is a clear, watery fluid.
Sanguineous drainage is bloody drainage.
Serosanguineous drainage is thin, watery drainage that is blood-tinged.
Purulent drainage is thick green, yellow, or brown drainage.
Review Box 30-5 on p. 508.
Report and record your observations according to center policy.
During injury and the inflammatory phase of wound healing, fluid and cells escape from the tissues. Drainage amounts depend on wound size and site. Bleeding and infection also affect the amount and kind of drainage.
The amount and color of sanguineous drainage are important (Fig B, p. 508). Hemorrhage is suspected when large amounts are present. Bright drainage means fresh bleeding.
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17. Drainage Drainage must leave the wound for healing.
When large amounts of drainage are expected, the doctor inserts a drain.
Drainage is measured in two ways:
Noting the number and size of dressings with drainage
Weighing dressings before applying them to the wound
Dressings are then weighed after removal.
Measuring the amount of drainage in the collection container if closed drainage is used
If drainage is trapped inside the wound, underlying tissues swell. The wound may heal at the skin level, but underlying tissues do not close. Infection and complications can occur.
When the dressing is weighed, the dry dressing weight is subtracted from the wet dressing weight.
A Penrose drain is a rubber tube that drains onto a dressing (Fig , p. 508), so it is an open drain. Microbes can enter the drain and wound.
Closed drainage systems prevent microbes from entering the wound. A drain is attached to suction. The Hemovac (Fig , p. 508) and Jackson Pratt (Fig , p. 509) systems are examples. So is negative-pressure wound therapy, which uses suction applied over a foam dressing secured with a transparent film (Fig , p. 509). The nurse or wound specialist is responsible for the care, but it may be the nursing assistant’s responsibility to change the drainage canister and record the output.
Other drainage systems are used depending on the wound type, size, and location.
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18. Dressings Wound dressings have many functions.
Protect wounds from injury and microbes.
Absorb drainage.
Remove dead tissue.
Promote comfort.
Cover unsightly wounds.
Provide a moist environment for wound healing.
Apply pressure (pressure dressings) to help control bleeding.
Dressing type and size depend on many factors: the type of wound, its size and site, amount of drainage, infection, the dressing’s function, and frequency of dressing changes.
The doctor and nurse choose the dressing for each wound.
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19. Types of Dressings The following types of dressings are common:
Gauze
Nonadherent gauze
Transparent adhesive film
Dressings that contain special agents to promote wound healing
Hydrocolloids
Hydrogels
Negative-pressure dressings
Dressings are wet or dry.
Dry dressing
Wet-to-dry dressing
Wet-to-wet dressing
Dressings are described by the material used and how it is applied. There are many dressing products (Fig , p. 509).
Gauze dressings absorb drainage and moisture.
Nonadherent gauze has a nonstick surface. It does not absorb drainage.
Transparent adhesive film allows air to reach the wound (but not fluids and microbes) and allows wound observation.
Hydrocolloids such as DuoDERM and Coloplast are adhesive dressings that interact with the wound drainage to form a gel.
Hydrogels are glycerin- or water-based dressings used to hydrate a wound.
Negative-pressure dressings are a type of therapy that speeds up healing by using a controlled negative-pressure device (Fig , p. 509).
A dry gauze dressing absorbs drainage. The drainage is removed with the dressing. A dry dressing can stick to the wound. The dressing is removed carefully to prevent tissue injury and discomfort.
Wet-to-dry dressing is used to remove dead tissue from the wound. Gauze dressings are saturated with a solution. These “wet” dressings are applied to the wound. The solution softens dead tissue. The dressing absorbs the dead tissue, which is removed when the dressings are dry.
Wet-to-wet dressings are gauze dressings saturated with solution and placed in the wound. The dressing is kept moist.
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20. Dressings (Cont’d) Securing dressings
Microbes can enter the wound and drainage can escape if the dressing is dislodged.
Tape and adherent wraps are used to secure dressings.
Binders hold dressings in place.
The nurse may ask you to assist with dressing changes.
Some centers let you apply simple, dry, non-sterile dressings to simple wounds.
Adhesive tape remaining on the skin is hard to remove. It can irritate the skin.
An abrasion occurs if skin is removed with tape.
Do not apply tape to encircle the entire body part. If swelling occurs, circulation to the part is impaired.
Review Focus on Communication: Tape on p. 510.
Review Box 30-6 on p. 510.
Review Focus on Communication: Applying Dressings p. 510.
Review Teamwork and Time Management: Applying Dressings p. 510.
Review Delegation Guidelines: Applying Dressings p. 511.
Review Promoting Safety and Comfort: Applying Dressings on p. 511.
Review the Applying a Dry, Non-Sterile Dressing procedure on pp
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21. Binders Binders promote healing by:
Supporting wounds
Holding dressings in place
Preventing or reducing swelling
Promoting comfort
Preventing injury
An abdominal binder provides abdominal support and holds dressings in place.
A breast binder supports the breasts after surgery.
T-binders secure dressings in place after rectal and perineal surgeries.
Binders are wide bands of elastic fabric. They are applied to the abdomen, chest, or perineal areas.
Review Box 30-7 on p. .
Review Focus on Communication: Binders on p. 513.
Review Promoting Safety and Comfort: Binders on p. 513.
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22. Warm and Cold Applications
Promote healing and comfort
Reduce tissue swelling
Warm and cold have opposite effects on body function.
Doctors order heat and cold applications.
Severe injuries and changes in body function can occur from warm and cold applications.
In some agencies, only nurses apply heat and cold.
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23. Heat Applications Heat: When heat is applied to the skin:
Relieves pain
Relaxes muscles
Promotes healing
Reduces tissue swelling
Decreases joint stiffness
When heat is applied to the skin:
Blood vessels in the area dilate.
Blood flow increases.
Tissues have more oxygen and nutrients for healing.
Excess fluid is removed from the area faster.
The skin is red and warm.
Heat applications are often used for musculoskeletal injuries or problems (arthritis) and can be applied to almost any body part.
Dilate means to expand or open wider (Fig , p. 513).
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24. Complications Complications Persons at risk for complications include:
High temperature can cause burns.
Report pain, excessive redness, and blisters at once.
When heat is applied too long, blood vessels constrict.
Persons at risk for complications include:
Older and fair-skinned persons
Persons with problems sensing heat and pain (nervous system damage, loss of consciousness, circulatory disorders, confusion, some medications)
Persons with dementia
Persons with metal implants
When heat is applied too long, blood vessels constrict (narrow) (Fig , p. 513). Blood flow decreases. Tissues receive less blood. Tissue damage occurs, and the skin is pale.
Do not apply heat to an implant area. Metal implants pose risks because they conduct heat. Deep tissues can be burned. Pacemakers (cardiac devices) and joint replacements are made of metal.
Review Residents With Dementia: Complications on p. 513.
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25. Moist and Dry Warm Applications
With a moist heat application, water is in contact with the skin.
Moist heat has greater and faster effects than dry heat because water conducts heat.
Moist heat applications include a warm compress, a warm soak, a sitz bath, and warm packs.
Some warm packs and the aquathermia pad (Aqua-K, K-Pad) are dry heat applications.
With a dry heat application, water is not in contact with the skin.
A dry application stays at the desired temperature longer.
Dry heat does not penetrate as deeply as moist.
To prevent injury, moist heat applications have lower (cooler) temperatures than dry heat applications.
A compress (Fig A, p. 514) is a soft pad applied over a body area. It is usually made of cloth.
Sitz baths (Fig C, p. 514) are used to clean perineal and anal wounds, promote healing, relieve pain and soreness, increase circulation, and stimulate voiding.
A pack involves wrapping a body part with a wet or dry application.
Dry heat needs higher (hotter) temperatures to achieve the desired effect because water is not used; therefore burns are still a risk.
The aquathermia pad is an electrical device (Fig , p. 514) in which tubes inside the pad are filled with distilled water. Heated water flows to the pad through a hose. Keep the heating unit level with the pad and connecting hoses. Hoses must not have kinks or bubbles. Sometimes an aquathermia pad is applied over the compress to maintain the temperature.
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26. Cold Applications Are often used to treat sprains and fractures
Reduce pain, prevent swelling, and decrease circulation and bleeding
Cool the body when fever is present
Have the opposite effect of heat
Are useful right after an injury
Have a numbing effect on the skin
This helps reduce or relieve pain in the part.
Complications include pain, burns, blisters, and poor circulation.
When cold is applied for a long time, blood vessels dilate.
When cold is applied to the skin, blood vessels constrict (Fig , p. 513). Blood flow decreases. Tissues receive less oxygen and nutrients.
After an injury, cold applications decrease blood flow, which reduces the amount of bleeding. Less fluid collects in the tissues.
Burns and blisters occur from intense cold and when dry cold is in direct contact with the skin.
The prolonged application of cold has the same effect as heat applications.
Review Box 30-8 on p. 515 in the textbook.
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27. Moist & Dry Cold Applications
Persons at risk for complications include:
Older and fair-skinned persons
Persons with sensory impairments
Persons with dementia
Moist cold applications:
Penetrate deeper than dry ones
Are not as cold as dry applications
Include cold compresses and cold packs
Dry cold applications include:
Ice bags, ice collars, and ice gloves
Cold packs can be moist or dry applications.
Protect the person from injury during heat and cold applications.
Review Residents With Dementia: Complications on p. 515.
Review Focus on Communication: Applying Warm and Cold on p. 515.
Review Teamwork and Time Management: Applying Warm and Cold on p. 515.
Review Delegation Guidelines: Applying Warm and Cold on p. 516.
Review Promoting Safety and Comfort: Applying Warm and Cold on p. 516.
Review the Applying Warm and Cold Applications procedure on pp
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28. Cooling and Warming Blanket
Hyperthermia is a body temperature that is much higher than the person’s normal range.
Lowering the person’s body temperature is necessary.
Vital signs are checked often to prevent rapid or excess cooling.
Hypothermia is a very low body temperature.
A warming blanket is like a cooling blanket except warm settings are used.
Vital signs are checked often to prevent rapid or excess warming.
In hyperthermia, body temperature is usually greater than 103 F (Fahrenheit) (39.4 C [Centigrade]). Causes include hot weather, illness, dehydration, and not being able to perspire.
To treat hyperthermia, the doctor orders ice packs applied to the head, neck, underarms, and groin. Sometimes cooling blankets are used alone or with ice packs.
In hypothermia, body temperature is less than 95 F (35 C). Cold weather is a common cause. The person is warmed to prevent death. Treatment may include a warming blanket.
When used for cooling, the device is called a hypothermia blanket. When used for warming, it is called a hyperthermia blanket. The device has warm and cool settings. Rapid and excess cooling or warming are prevented.
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29. Meeting Basic Needs The wound can affect the person’s basic needs.
The wound causes pain and discomfort.
Good nutrition is needed for healing.
Infection is always a threat.
Delayed healing and infection are risks for persons who:
Are older or obese
Have poor nutrition
Have poor circulation and diabetes
Many factors affect safety and security needs.
Whatever the wound site or size, it affects function and body image.
Allow pain drugs to take effect before giving care.
Pain and discomfort can affect appetite. Tell the nurse if the person wants certain foods or drinks.
Infection is always a threat. Follow Standard Precautions and the Bloodborne Pathogen Standard. Wear PPE (personal protective equipment) as necessary. Carefully observe the wound for signs and symptoms of infection.
The person may have many fears because of the wound. Be gentle and kind, give thoughtful care, and practice good communication.
Love, belonging, and self-esteem needs are affected by wounds. Adjustment may be hard and rehabilitation necessary. Other health team members—therapists, social workers, psychiatrists, and the clergy—may be involved in the person’s care.
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30. Quality of Life To promote quality of life:
Follow the person’s care plan.
Be very careful not to injure the skin during care.
Treat the person with dignity and respect.
Try to understand the person’s concern.
Refer questions to the nurse.
Remember the right to personal choice.
Remember to explain procedures to residents.
Protect the right to privacy.
Provide a safe, comfortable setting.
Warm and cold are usually applied for 15 to 20 minutes. The person cannot move about during this time.
Review the ways comfort and safety can be promoted during this time. They are listed on p. 519.
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