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

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

Inspection and Description of Wounds Inspection sites include Back of the head, ears, heels, coccyx, shoulder blades, elbows, as well as insertion sites for intravenous (IV), nasogastric (NG) tubes, or tracheostomy tubes Skin observation: darkly pigmented skin damage may be purplish, bluish or gray and shiny* Evaluation of wounds Angiograms or the laser Doppler, biopsy and wound culture evaluate vascular ulcers Laboratory testing, including biopsy and wound culture, determines wound treatment

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

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

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

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

Causes of Wounds-TAB:E 58-2 Pressure Shear* Friction* Stripping Urine or stool incontinence Perspiration Maceration

Types of Skin Breakdown Incontinence-associated dermatitis (IAD) IAD can be prevented by using an incontinence cleanser and a special moisture barrier creaqm wipe before damage occurs* *keep them clean and dry! Pressure wound or decubitus ulcer Prevention of pressure wounds and other skin breakdown is a primary nursing responsibility *TURN Q 2 hours Venous stasis ulcer Diabetic ulcers *diabetic neuropathic ulcers

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 Areas affected: bony prominences, heels, ears Classification of pressure wounds Stages Debridement* Prediction of pressure wound risk Braden scale and the Norton scale

Braden Scale Rates the following: Sensory perception, moisture level, activity, mobility, nutrition and friction/shear* Allows healthcare personnel to take steps to prevent the development of skin breakdown*

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

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

Wound Healing *first intention *second intention *fills with granulation tissue *third intention *deep scarring

Wound Healing

Wound Healing (cont.)

Wound Healing (cont.)

Dressings Dressings serve to protect wounds from contamination Dry, sterile dressing *Wet-to-dry dressing Uses Debridement occurs as the dried dressing is removed Do not loosen a wet to dry dressing with normal saline or any other solution before removing the dried dressing material Dry the surrounding skin before applying dressing

Dressings Packing *sinus tract Special sponge material or gel foam may be used Wet-to-wet dressing Commercially prepared special dressings *DuoDerm or hydrocolloid Penrose drain Closed drainage systems

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

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

Debridement Mechanical Application of wet to dry Chemical containing dressings Hydrotherapy Wound irrigation Sharp debridement Enyzmatic Debridement

Wound Drains Penrose Closed Drainage Systems JP Hemovac*

Vacuum Assisted Closure-Negative Pressure Applies negative pressure to a wound Speeds growth of granulation tissue and decreases healing time

Wound Irrigation Removed debris from an open wound after injury or from an infected surgical incision Simpulse Varicare system is handheld and provides irrigation under pressure Continuous Intermittent manual

Sutures and Staples Removal in 7-10 days Remove every other staple first

Types of Tape Used in Securing Dressings Micropore Sticks to anything: While it’s specifically designed for medical purposes, it will stick to anything. It needs to be applied dry, but it sticks through sweat, hair, and blood no problem. Made with pores: It is covered in a grid-like pattern of tiny holes. Sweat and body fluid will pass right through it. Air can reach the skin underneath it Transpore breathable and perforated plastic medical tape that offers strong adhesion. Cloth Gentle on skin: It doesn’t adhere so strongly that it will rip out hair or leave sticky residue. It’s designed to be easily replaced on a daily basis with little to no irritation.