Chapter 58: Special Skin and Wound Care

1. 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