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
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

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 (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

8. Causes of Wounds-TAB:E 58-2
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 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

10. 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

11. 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*

12. 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

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

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

15. Wound Healing

16. Wound Healing (cont.)

17. Wound Healing (cont.)

18. 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

19. 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

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

21. 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

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

23. Wound Drains
Penrose
Closed Drainage Systems JP
Hemovac*

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

25. 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

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

27. 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.