1. Skin Integrity and Wound Care
Chapter 48
Skin Integrity and Wound Care
The skin is the body’s largest organ, accounting for 15% of the total body weight. The skin provides:
A protective barrier against disease-causing organisms
A sensory organ for pain, temperature, and touch
Vitamin D synthesis
Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing pattern will help students recognize alterations that require intervention.

2. Scientific Knowledge Base: Skin
Dermal-epidermal junction
Separates dermis and epidermis
Epidermis
Top layer of skin
Dermis
Inner layer of skin
Collagen
The skin has two layers: the epidermis and the dermis.
The epidermis has several layers within it. The stratum corneum is the thin, outermost layer that is flattened with dead keratinized cells. The basal layer divides, proliferates, and migrates toward the epidermal surface.
The dermis provides tensile strength, mechanical support, and protection to underlying muscles, bones, and organs. The dermis is made of collagen, blood vessels, and nerves.
Collagen is a tough fibrous protein. Fibroblasts, which are responsible for collagen formation, are the only distinctive cell type within the dermis.
[Box 48-1 on p covers skin-related issues in older adults.]

3. Layers of the Skin
The thin stratum corneum protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents.
The stratum corneum allows evaporation of water from the skin and permits absorption of certain topical medications.
[Figure 48-1 shown here from page 1177 shows the layers of skin in detail.]

4. Pressure Ulcers Pressure ulcer Pathogenesis
Pressure sore, decubitus ulcer, or bed sore
Pathogenesis
Pressure intensity
Tissue ischemia
Blanching
Pressure duration
Tissue tolerance
A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction.
Pressure is the major contributor to pressure ulcers.
If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results.
Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in dark-skinned patients.
[See Box 48-2 on p Characteristics of Dark Skin with Impaired Integrity; see also Box 48-3 on text p Cultural Aspects of Care: Skin Color Impact.]
Pressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.
The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.

5. Pressure Ulcer with Necrosis
This photo shows a pressure ulcer with tissue necrosis.
[Shown is Figure 48-2 on p ]

6. Case Study
Mr. Omar Ahmed, a 76-year-old accountant, has come to the hospital again, this time for pneumonia. Before admission, he was unable to eat and lost more than 20 lbs over the last 2 months. Three years ago, he had coronary artery bypass surgery. As a precaution, he is placed on telemetry monitoring. He also has hypertension and type 2 diabetes mellitus. His mobility is limited because of weakness.
[Ask the class: What mobility concerns do you anticipate for Mr. Ahmed?]

7. Case Study (cont’d)
Mr. Ahmed is retired. He lives in a one-family home with his wife, Natalie. Their children and grandchildren live nearby and visit often. He complains that his “bottom hurts” from lying in bed.
Lynda Abraham is the nursing student assigned to the medical nursing unit. This is her first hospital-based clinical practice.
[Consider what risk factors Mr. Ahmed has for pressure ulcer development.]

8. Risk Factors for Pressure Ulcer Development
Impaired sensory perception
Alterations in level of consciousness
Impaired mobility
Shear
Friction
Moisture
These six factors contribute to pressure ulcer formation.
Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development.
Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations.
Patients who are unable to independently change position are at risk because they cannot change or shift off of bony prominences.
Patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves.
Shear is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface.
Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface.
The presence and duration of moisture on the skin reduce the skin’s resistance to other physical factors.
[Box 48-2 on p discusses characteristics of dark skin with impaired integrity.]

9. Shear Force in Sacral Area
Shear force is a factor in ulcer development.
[Shown is Figure 48-3 from text p ]

10. Classification of Pressure Ulcers
Stage I
Intact skin with nonblanchable redness
Stage II
Partial-thickness skin loss involving epidermis, dermis, or both
Stage III
Full-thickness tissue loss with visible fat
Stage IV
Full-thickness tissue loss with exposed bone, muscle, or tendon
The National Pressure Ulcer Advisory Panel (NPUAP) has defined pressure ulcers.
The European Pressure Ulcer Advisory Panel (EPUAP) and the NPUAP have developed a definition for an ulcer in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of injury is unknown. An unstageable ulcer is a full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Suspected deep-tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear.
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Slough is a stringy substance attached to the wound bed; it must be removed by a skilled clinician before the wound is able to heal.
Black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed.
[Figure 48-4 on p, 1180 provides a diagram of the stages.]

11. Wounds Classification Wound healing Repair
Partial-thickness wound repair
Full-thickness wound repair
Hemostasis (fibrin)
Inflammatory phase
Proliferative phase (epithelialization)
Remodeling
Two methods are currently used to classify skin wounds:
Describe the status of skin integrity, the cause of the wound, the severity or extent of injury or damage, and the cleanliness of the wound (see Table 48-1 on p. 1181).
Describe qualities of the wound tissue such as color (see Table 48-2 on p. 1183).
Wound exudate should describe the amount, color, consistency, and odor of wound drainage and is part of the wound assessment.
Wound healing occurs by primary or secondary intention. Primary intention occurs when the edges are approximated.
Secondary intention occurs when the wound heals with scar tissue (shown on subsequent slide).
The surgical incision heals by primary intention (Fig. 48-6, A, p. 1182). The skin edges are approximated, or closed, and the risk of infection is low.
In contrast, a wound involving loss of tissue such as a burn, pressure ulcer, or severe laceration heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention.
The form that wound repair takes depends on the wound’s thickness. Partial thickness will heal via the inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers. Full-thickness wounds heal via inflammatory response, proliferation, and remodeling.
Hemostasis is a series of events designed to control blood loss, establish bacterial control, and seal the defect that results when an injury occurs. Clots form a fibrin matrix that later provides a framework for cellular repair.
In the inflammatory stage, damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues.
With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. Main activities during this phase include filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization.
Remodeling, or maturation, the final stage of healing, sometimes takes place for longer than a year, depending on the depth and extent of the wound.
Complications include hemorrhage, infection, dehiscence, evisceration, and fistulas.

12. Wound Colors These photos show wounds by color assessment:
A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-color wound.
You need to assess the type of tissue in the wound base, and this information is used to plan appropriate interventions. Assessment of tissue type includes the amount (percentage) and appearance (color) of viable and nonviable tissue.
Recall that granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing; soft yellow or white tissue is characteristic of slough (stringy substance attached to the wound bed), and it must be removed by a skilled clinician before the wound is able to heal; black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed.
[Shown is Figure 48-5, A, B, C, D, from text p ]

13. Primary and Secondary Intention
A, Wound healing by primary intention such as a surgical incision. Wound healing edges are pulled together and approximated with sutures or staples; healing occurs by connective tissue deposition.
B, Wound healing by secondary intention. Wound edges are not approximated, and healing occurs by formation of granulation tissue and contraction of wound edges.
[Shown is Figure 48-6 from text p ]

14. Complications of Wound Healing
Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration
Hemorrhage, or bleeding from a wound site, is normal during and immediately after initial trauma.
A hematoma is a localized collection of blood underneath the tissues.
Wound infection is the second most common health care–associated infection. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent and causes a yellow, green, or brown color, depending on the causative organism.
[See Table 48-2 Types of Wound Drainage on p ]
Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing is at risk for dehiscence.
With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency that requires surgical repair.

15. Nursing Knowledge Base
Prediction and prevention of pressure ulcers
Risk assessment
Braden scale
Sensory perception, moisture, activity, mobility, nutrition, and friction and shear
Prevention
Economic consequences
When a patient develops a pressure ulcer, the length of stay is extended and the overall cost of care increases.
Prevention includes special beds and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.
The Centers for Medicare and Medicaid Services (CMS) implemented a policy effective October 1, 2008, whereby hospitals no longer receive additional reimbursement for care related to eight conditions, including stage III and IV pressure ulcers that occur during the hospitalization.
[Table 48-3 on p covers the Braden scale.]

16. Factors Influencing Pressure Ulcer Formation and Wound Healing
Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds
For maintenance of skin and wound healing, patients need 1500 kcal/day. At times, enteral or parenteral nutrition may need to be provided. Patients need vitamins A and C, calories, and proteins to heal.
[See Table 48-4 on p Role of Selected Nutrients in Wound Healing.]
Tissue perfusion occurs when tissue oxygenation fuels cellular function. Patients who are in shock or who are diagnosed with diabetes mellitus are at risk for poor tissue perfusion.
Wound infection prolongs the inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction. Signs of wound infection include pus; change in odor, volume, or redness of tissue; fever; and pain.
Increased age affects all phases of wound healing. A decrease in functioning of the macrophage leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization.
Body image changes caused by a wound may lead to problems with self-concept. Factors that affect the patient’s perception of the wound include the presence of scars, drains (drains are often necessary for weeks or even months after certain procedures), odor from drainage, and temporary or permanent prosthetic devices.

17. Assessment Skin Pressure ulcers Predictive measures Mobility
Nutritional status
Body fluids
Pain
Baseline assessments and continual assessments provide valuable data that indicate skin integrity, as well as any risks for pressure ulcer development.
When you suspect abnormal reactive hyperemia, outline the affected area with a marker to make reassessment easier. These signs are early indicators of impaired skin integrity, but damage to the underlying tissue is sometimes more progressive. Tactile assessment enables you to use palpation to acquire further data about induration and damage to the skin and underlying tissues.
[Review Figure 48-9 on p. 1189, which diagrams common pressure ulcer locations.]
A benefit of predictive instruments is improved early detection by nurses of patients at greatest risk for ulcer development.
Assessment includes documenting the level of mobility and the potential effects of impaired mobility on skin integrity.
Continual exposure of the skin to body fluids increases a patient’s risk for skin breakdown and pressure ulcer formation.
[Box 48-6 on p covers risk for skin breakdown from body fluids.]
Malnutrition is a risk factor for pressure ulcer development.
Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.
[Box 48-4 on p presents skin integrity assessment questions.]
[Figure 48-7 on p considers critical thinking aspects of assessment.]
[Box 48-5 on p covers procedural guidelines for skin assessment.]

18. Pressure Ulcer on Heel
This photo shows formation of a pressure ulcer on the heel resulting from external pressure from mattress of bed.
[Shown is Figure 48-8 from text p ]

19. Assessment Wounds Emergency setting Stable setting Wound appearance
Character of wound drainage
Drains
Wound closures
Palpation of wound
Wound cultures
You see wounds in any setting, including clinics, emergency departments, youth camps, and your own backyard. The type of wound determines the criteria for inspection. For example, you do not need to inspect for signs of internal bleeding after an abrasion, but you should inspect in the event of a puncture wound.
An abrasion is superficial with little bleeding and is considered a partial-thickness wound.
A laceration sometimes bleeds more profusely, depending on the depth and location of the wound.
Puncture wounds bleed in relation to the depth and size of the wound.
When a patient’s condition is stabilized, assess the wound to determine progress toward healing.
Observe whether wound edges are closed. A surgical incision healing by primary intention should have clean, well-approximated edges.
Note the amount, color, odor, and consistency of drainage. Types of drainage include the following: serous, sanguineous, serosanguineous, and purulent.
Table 48-5 on p gives assessment examples of abnormally healing primary and secondary intention wounds.
The health care provider inserts a drain into or near a surgical wound if a large amount of drainage is noted.
Surgical wounds are closed with staples, sutures, or wound closures.
When inspecting a wound, observe swelling or separation of wound edges. While wearing gloves, lightly press the wound edges, detecting localized areas of tenderness or drainage collection. If pressure causes fluid to be expressed, note the character of the drainage.
If you detect purulent or suspicious-looking drainage, obtaining a specimen of the drainage for culture may be necessary.
[Box 48-7 on p has recommendations for standardized techniques for wound cultures.]

20. Penrose Drain
A Penrose drain lies under a dressing; at the time of placement, a pin or clip is placed through the drain to prevent it from slipping farther into the wound.
[Figure on p shows a Penrose drain.]

21. Case Study (cont’d)
Lynda reviews the nursing assessment and finds that Mr. Ahmed was admitted with a pressure ulcer. The ulcer is a stage II, 1 × 2-inch and 1/8-inch deep partial-thickness wound over his sacral area. No necrotic tissue is present, and the wound bed has red moist tissue. When Lynda prepares to conduct skin assessment, she recalls information about the pathogenesis of pressure ulcers and guidelines for skin assessment for patients with darkly pigmented skin.
[Ask the class: Can you recall the descriptions of the ulcer stages, so that you know why Mr. Ahmed’s ulcer is a stage II?]

22. Case Study (cont’d)
Lynda observed care of a stage IV pressure ulcer during an experience in an extended care facility. From that experience, she increased her knowledge about the debilitating effects of pressure ulcers. In addition, she was able to practice skin assessment techniques during her clinical experience in the extended care facility.
Review of previous clinical experiences is often helpful in preparing to care for a patient.

23. Jackson-Pratt Drainage Device
Evacuator units such as a Hemovac or Jackson-Pratt (shown here) exert constant low pressure as long as the suction device (bladder or container) is fully compressed.
[This is Figure on p ]

24. Wound Culturette Tube This photo is of a wound culturette tube.
[Shown is Figure on p ]

25. Case Study (cont’d)
Identify the support surface that would be appropriate to decrease pressure on Mr. Ahmed’s skin.
Mr. Ahmed cannot tolerate positions that might relieve or reduce pressure to his skin.
Inspect and palpate the wound.
The wound is a 1 × 2-inch, full-thickness ulcer over the sacral area with a red moist base. Reddened periwound skin.
Conduct a calorie count
Mr. Ahmed is eating fewer than 1600 calories daily.
[Ask the class: What nursing diagnosis do you think is appropriate? Discuss.
Nursing diagnosis: Impaired skin integrity related to pressure over bony prominence in sacral region.]

26. Nursing Diagnosis and Planning
Risk for infection
Impaired tissue integrity
Acute or chronic pain
Imbalanced nutrition: less than body requirements
Impaired skin integrity
Impaired physical mobility
Ineffective peripheral tissue perfusion
Risk for impaired skin integrity
Multiple nursing diagnoses associated with impaired skin integrity and wounds are shown on the slide.
Consider that the nature of a wound can cause problems unrelated to wound healing. Alteration in comfort and impaired mobility are problems that have implications for the patient’s eventual recovery.
Write patient goals and outcomes specific to the patient’s needs.
[Box 48-8 on p covers Impaired Skin Integrity Related to Infection Diagnosis.]
[Figure on p covers planning in detail.]
The nursing care plan on pp and 1194 reviews a plan for resolving Impaired skin integrity.
Figure on p provides a concept map for the process.

27. Case Study (cont’d)
Goal: Pressure will be reduced to the sacral area, and the wound will show movement toward healing in 1 week.
Expected outcomes
Wound will decrease in diameter in 7 days.
No evidence of further wound formation will be noted in 3 days.
It is important to set achievable goals and expected outcomes for the patient.

28. Quick Quiz!
1. The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges A. Are approximated. B. Migrate across the incision. C. Appear slightly pink. D. Slightly overlap each other.
Answer: A

29. Implementation Health promotion
Topical skin care and incontinence management
Protect bony prominences, skin barriers for incontinence.
Positioning
Turn every 1 to 2 hours as indicated.
Support surfaces
Decrease the amount of pressure exerted over bony prominences.
Support surfaces include mattresses, integrated bed systems, mattress replacement, and an overlay or set cushion.
Shearing force is a force that acts perpendicular to the plane of interaction.
When positioning a patient with light skin, observe for normal reactive hyperemia and blanching.
[Box 48-9 on p gives recommendations for home care.]
[Table 48-6 on p serves as a quick guide to pressure ulcer prevention.]

30. Avoiding Pressure Points
Here is a 30-degree lateral position at which pressure points are avoided.
[Shown is Figure from text p ]
[Box on p covers teaching pressure-redistribution surfaces.]
[Table 48-7 on p goes over support surfaces.]
[Figure on p provides a flow chart for choosing an appropriate support surface.]

31. Acute Care Management of pressure ulcers Wound management
Debridement (removal of nonviable, necrotic tissue)
Mechanical, autolytic, chemical, or sharp/surgical
Education
Nutritional status
Protein status
Hemoglobin
You will want to take a holistic approach to wound management. You will want to work with the dietitian, the wound care nurse, and the pharmacist to ensure that all patient needs are met.
An individualized plan of care must be developed for each patient, taking into account age, nutrition, present medical conditions, and other contributing factors.
A wound does not move through the phases of healing if it is infected. Preventing wound infection includes cleaning and removing nonviable tissue.
Mechanical debridement includes wound irrigation (high-pressure irrigation and pulsatile high-pressure lavage) and whirlpool treatments.
Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids.
Chemical debridement may use topical enzymes to induce changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the type of enzyme used, the preparation digests or dissolves the tissue. These preparations require a health care provider’s order. Dakin’s solution breaks down and loosens dead tissue in a wound.
Surgical debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.
A moist environment supports the movement of epithelial cells and facilitates wound closure.
You need to impress on the patient and the patient’s family the importance of nutrition, fluids, and body positioning.
The Joint Commission (2008) recommends nutritional assessment within 24 hours of admission.
Patients with pressure ulcers who are underweight or are losing weight need enhanced caloric and protein supplementation. A patient can lose as much as 50 g of protein per day from an open, weeping pressure ulcer.
A low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia. When possible, maintain hemoglobin at 12 g/100 mL.
[Box on p gives recommendations for nutritional assessment and management of pressure ulcers.]

32. Case Study (cont’d)
Post and implement a turning schedule.
Repositioning redistributes pressure.
Obtain and place over the patient’s mattress a low-air-loss overlay.
Redistributes the amount of pressure on the bony prominences
Clean wound and periwound skin; dry periwound skin.
Remove debris and old drainage from wound site, preventing further wound progression/skin breakdown.
Apply a hydrocolloid dressing to the wound.
The use of hydrocolloid dressing will support moist wound healing and will protect the wound.
Determine in collaboration with dietitian an appropriate diet.
Adequate nutrition such as protein intake, increased calorie count, and vitamins aid in wound healing.
[Interventions and their rationales are shown for the Case Study patient.
Note that the first two actions address pressure management, the next two address wound care, and the final intervention addresses nutrition management.]

33. Wound Irrigation
Irrigation is a common method of delivering a wound cleaning solution to the wound.
[Shown is Figure from text p ]

34. First Aid for Wounds Hemostasis Cleaning Protection Control bleeding.
Allow puncture wounds to bleed.
Do not remove a penetrating object.
Bandage
Cleaning
Gentle
Normal saline
Protection
In an emergency setting, use first aid measures for wound care. Under stable conditions, a variety of interventions ensure wound healing. When a patient suffers a traumatic wound, first aid interventions include stabilizing cardiopulmonary function (see Chapter 40), promoting hemostasis, cleaning the wound, and protecting it from further injury.
After assessing the type and extent of the wound, control bleeding by applying direct pressure on it with a sterile or clean dressing such as a washcloth. After bleeding subsides, an adhesive bandage or gauze dressing taped over the laceration allows skin edges to close and a blood clot to form.
Normally allow a puncture wound to bleed to remove dirt and other contaminants such as saliva from a dog bite. When a penetrating object such as a knife blade is present, do not remove the object. The presence of the object provides pressure and controls some bleeding.
The process of cleaning a wound involves selecting an appropriate cleaning solution and using a mechanical means of delivering that solution without causing injury to the healing wound tissue.
Gently cleaning a wound removes contaminants that serve as sources of infection. However, vigorous cleaning using a method with too much mechanical force causes bleeding or further injury.
According to Wound, Ostomy and Continence Nurses Society (WOCN) guidelines, normal saline is the preferred cleaning agent.
Regardless of whether bleeding has stopped, protect a wound from further injury by applying sterile or clean dressings and immobilizing the body part. A light dressing applied over minor wounds prevents entrance of microorganisms. (Dressings are discussed on subsequent slides.)

35. Purposes of Dressings Protect a wound from microorganism contamination
Aid in hemostasis
Promote healing by absorbing drainage and debriding a wound
Support or splint the wound site
Protect patients from seeing the wound (if perceived as unpleasant)
Promote thermal insulation of the wound surface
For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops. In contrast, when dressing a wound that is healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or assisting in debridement.
The dressing technique varies, depending on the goal of the treatment plan for the wound.
If the goal is to maintain a moist environment for a clean granulating wound, it is important to not let the saline-moistened gauze dressing dry and stick to it.
This is in direct contrast to the dressing technique that you use if the goal of care is to mechanically debride the wound using a saline wet-to-dry dressing. When wounds such as a necrotic wound require debriding, use a wet-to-dry dressing technique. Place the moist dressing (contact dressing) into the wound, and allow it to dry. The contact dressing debrides necrotic tissue and debris. In this case, the contact dressing is allowed to dry so it sticks to underlying tissue, and debridement occurs during removal.

36. Dressings Dry or moist Film dressing
Gauze
Film dressing
Hydrocolloid—protects the wound from surface contamination
Hydrogel—maintains a moist surface to support healing
Wound vacuum assisted closure (V.A.C.)—uses negative pressure to support healing
The use of dressings requires an understanding of wound healing and factors that influence healing. A variety of dressing materials are available. You will learn various dressing techniques in the nursing skills lab.
The choice of dressings and the method of dressing a wound influence healing.
Before placing a dressing on a pressure ulcer, it is important to know the stage of the pressure ulcer; to have done a thorough assessment of it; and to understand the goal of the treatment, the mechanism of action of the dressing, and principles of wound care.
[See also Table 48-8 Dressings by Pressure Ulcer Stage.]
Gauze sponges are absorbent and are especially useful in wounds to wick away the wound exudate. Gauze is available in different textures and in various lengths and sizes; 4 × 4 is the most common size. Gauze can be saturated with solutions and used to clean and pack a wound.
When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out, unfolded, and lightly packed into the wound.
Use a film dressing as a secondary dressing and for autolytic debridement of small wounds. It has the following advantages:
Adheres to undamaged skin
Serves as a barrier to external fluids and bacteria but still allows the wound surface to “breathe” because oxygen passes through the transparent dressing
Promotes a moist environment that speeds epithelial cell growth
Can be removed without damaging underlying tissues
Permits viewing a wound
Does not require a secondary dressing
Hydrocolloid dressings are dressings with complex formulations of colloid, elastomeric, and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds; they are available in a variety of sizes and shapes. This type of dressing has the following functions:
Absorbs drainage through the use of exudate absorbers in the dressing
Maintains wound moisture
Slowly liquefies necrotic debris
Is impermeable to bacteria and other contaminants
Is self-adhesive and molds well
Acts as a preventive dressing for high-risk friction areas
May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing
Hydrogel dressings are gauze or sheet dressings impregnated with water- or glycerin-based amorphous gel. Hydrogel has the following advantages:
Is soothing and can reduce wound pain
Provides a moist environment
Debrides necrotic tissue (by softening necrotic tissue)
Does not adhere to the wound base and is easy to remove
[See also Box on text p Dressing Considerations; and Box on text p Evidence-Based Practice: Moisture-Associated Skin Damage.]

37. Transparent film dressing
Transparent film dressing is ideal for small superficial wounds such as partial-thickness wounds and to protect high-risk skin.
[Box on p discusses considerations for dressing wounds.]
[Box on p discusses moisture-associated skin damage.]
[Shown is Figure from text p ]

38. Dressings (cont’d) Changing Prepare the patient for a dressing change
Know type of dressing, placement of drains, and equipment needed.
Prepare the patient for a dressing change
Evaluate pain.
Describe procedure steps.
Gather supplies.
Recognize normal signs of healing.
Answer questions about the procedure or wound.
A complete patient and wound history is essential in determining when a clean dressing technique is appropriate. For example, chronic pressure ulcer wounds use a clean technique. On the other hand, a fresh surgical wound requires sterile technique so as not to introduce microorganisms into a healing wound.
Follow health care facility for policies and procedures.
Document findings, and report to other staff members.
For very complex dressing care, consult with the wound care/enterostomal nurse, or carefully develop a step-by-step procedure to provide consistent wound care.
Make sure to offer pain medications before beginning wound care/dressing changes.

39. During a Dressing Change
Assess the skin beneath the tape.
Perform thorough hand hygiene before and after wound care.
Wear sterile gloves before directly touching an open or fresh wound.
Remove or change dressings over closed wounds when they become wet or if the patient has signs or symptoms of infection, and as ordered.
The health care provider’s order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. An order to “reinforce dressing prn” (add dressings without removing the original one) is common right after surgery, when the health care provider does not want accidental disruption of the suture line or bleeding.
The medical or operating room record usually indicates whether drains are present and from what body cavity they drain.
After the first dressing change, describe the locations of drains and the types of dressing materials and solutions to be used in the patient’s care plan. Follow the guidelines on the slide during a dressing change procedure.
Often it is necessary to teach patients how to change dressings in preparation for home care. In this situation, demonstrate dressing changes to the patient and family, and then provide an opportunity for them to practice.

40. Dressings Packing a wound Securing Comfort measures
Assess size, depth, and shape
Securing
Tape, ties, or binders
Comfort measures
Carefully remove tape.
Gently clean the wound.
Administer analgesics before dressing change.
Wound size, depth, and shape are important in determining the size and type of dressing used to pack a wound.
The dressing needs to be flexible and in contact with the entire wound surface. Make sure that the type of material used to pack the wound is appropriate. Many new dressing materials such as alginates are also used for packing. If gauze is the appropriate dressing material, saturate it with the ordered solution, wring out, unfold, and lightly pack into the wound. The entire wound surface needs to be in contact with part of the moist gauze dressing.
It is important to remember not to pack the wound too tightly.
A treatment modality for wounds is negative-pressure wound therapy (NPWT) or vacuum-assisted closure (one brand name is V.A.C.). (It is discussed on the next slide.) NPWT is the application of subatmospheric (negative) pressure of a wound through suction to facilitate healing and collect wound fluid.
Use tape, ties, or a secondary dressing and cloth binders to secure a dressing over a wound site. The choice of anchoring depends on the wound size and location, the presence of drainage, the frequency of dressing changes, and the patient’s level of activity.
To remove tape safely, loosen the ends and gently pull the outer end parallel with the skin surface toward the wound. Apply light traction to the skin away from the wound as the tape is loosened and removed. Traction minimizes pulling of the skin. Adhesive remover also loosens the tape from the skin. If tape covers an area of hair growth, the patient experiences less discomfort if you pull it in the direction of the hair growth.
(Montgomery ties are discussed on a later slide.)
Another method to protect the surrounding skin on wounds that need frequent dressing changes is to place strips of hydrocolloid dressings on either side of the wound edges, cover the wound with a dressing, and apply the tape to the dressing. To provide even support to a wound and immobilize a body part, apply elastic gauze or cloth bandages and binders over a dressing.
Use several techniques to minimize discomfort during wound care. Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound. Administering analgesic medications 30 to 60 minutes before dressing changes (depending on the time of peak action of a drug) also reduces discomfort.

41. V.A.C. (Vacuum-Assisted Closure)
The vacuum-assisted closure (V.A.C.) is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together.
Modifications have been made to the V.A.C. The V.A.C. Instill allows intermittent instillation of fluids into the wound, especially those wounds not responding to traditional (negative-pressure wound therapy (NPWT). NPWT is used in treating acute and chronic wounds. The schedule for changing NPWT dressings varies, depending on the type of wound and the amount of drainage. Wear time for the dressing is anywhere from 24 hours to 5 days. As the wound heals, granulation tissue lines its surface. The wound has a stippled or granulated appearance. The surface area sometimes increases or decreases, depending on wound location and the amount of drainage removed by the NPWT system. NPWT is also used to enhance the take of split-thickness skin grafts. It is placed over the graft intraoperatively, decreasing the ability of the graft to shift and evacuating fluids that build up under it. An airtight seal must be maintained.
[See also Box Maintaining an Airtight Seal.]
[Shown is Figure from text p ]

42. V.A.C. (cont’d)
Shown is a V.A.C. system that uses negative pressure to remove fluid from areas surrounding the wound, reducing edema and improving circulation to the area.
[Box on p reviews maintaining an airtight seal.]
[Shown is Figure from text p ]

43. Before and After V.A.C. Therapy
These are photos of a dehisced wound before (A) wound V.A.C. therapy and after (B) wound V.A.C. therapy.
[Shown is Figure from text p ]

44. Montgomery Ties
Montgomery ties are shown in these photos. A, Each tie is placed at side of dressing. B, Securing ties encloses dressing.
To avoid repeated removal of tape from sensitive skin, secure dressings with pairs of reusable Montgomery ties. Each section consists of a long strip; half contains an adhesive backing to apply to the skin, and the other half folds back and contains a cloth tie or a safety pin–and–rubber band combination that you fasten across a dressing and untie at dressing changes. A large, bulky dressing often requires two or more sets of Montgomery ties.
[These are Figures 48-22, A and B, from text p ]

45. Cleaning Skin
1. Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin.
2. Use gentle friction when applying solutions locally to the skin.
3. When irrigating, allow the solution to flow from the least to the most contaminated area.
These three principles are important when cleaning an incision or the area surrounding a drain. [Discuss.]

46. Cleaning Skin and Drain Sites
Apply noncytotoxic solution.
Irrigation
To remove exudates, use sterile technique with 35-mL syringe and 19-gauge needle.
Suture Care
Consult health care facility policy.
Drainage Evacuators
Portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage.
Wound cleaning removes surface debris.
Wound cleaning requires good hand hygiene and aseptic techniques.
Clean surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze or by irrigation.
After applying a solution to sterile gauze, clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice.
You sometimes use irrigation to remove debris from a wound. Irrigation is a special way of cleaning wounds. Use an irrigating syringe to flush the area with a constant low-pressure flow of solution. The gentle washing action of the irrigation cleans a wound of exudate and debris.
Always refer to health care facility policy and procedures for wound care and wound irrigation. The patient’s history of wound healing, the site of surgery, the tissues involved, and the purpose of the sutures determine the suture material used.
Policies vary within institutions as to who is able to remove sutures. If it is appropriate that the nurse remove them, a health care provider’s order is required. An order for suture removal is not written until the health care provider believes that the wound has closed (usually in 7 days).
When drainage interferes with healing, evacuation is achieved by using a drain alone or a drainage tube with continuous suction. You may apply special skin barriers, including hydrocolloid dressings similar to those used with ostomies around drain sites. The skin barriers are soft material applied to the skin with adhesive. Drainage flows onto the barrier but not directly onto the skin.
If available, consult the enterostomal/wound care nurse.

47. Methods for Cleaning a Wound Site
Methods for cleaning a wound site are diagrammed in this slide.
Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin.
[Shown is Figure from text p ]

48. Cleaning a Drain Site
Clean in a direction from an isolated drain site to the surrounding skin
[Shown is Figure from text p ]

49. Staples and Remover
The left photo shows an incision closed with staples. The right shows a staple remover.
To remove staples, insert the tips of the staple remover under each wire staple. While slowly closing the ends of the staple remover together, squeeze the center of the staple with the tips, freeing it from the skin
[Shown are Figures and from text p ]

50. Types of Sutures
Examples of suturing methods. A, Intermittent. B, Continuous. C, Blanket continuous. D, Retention.
[Shown is Figure from text p ]

51. Removal of Intermittent Suture
Removal of intermittent suture. A, Cut suture as close to skin as possible, away from the knot. B, Remove suture and never pull contaminated stitch through tissues.
To remove sutures, first check the type of suturing used. With intermittent suturing, the surgeon ties each individual suture made in the skin. Continuous suturing, as the name implies, is a series of sutures with only two knots: one at the beginning and one at the end of the suture line. Retention sutures are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal.
Never pull the visible portion of a suture through underlying tissue.
Sutures on the surface of the skin harbor microorganisms and debris. The portion of the suture beneath the skin is sterile. Pulling the contaminated portion of the suture through tissues can lead to infection. Clip suture materials as close to the skin edge on one side as possible, and pull the suture through from the other side.
[Shown is Figure from text p ]

52. Drainage Evacuators
This photo shows setting of suction on the drainage evacuator.
1. With drainage port open, raise level on diaphragm.
2. Push straight down on lever to lower diaphragm.
3. Closure of port prevents escape of air and creates vacuum pressure.
Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and the tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder, and immediately reset the evacuator to apply suction.
[Shown is Figure from text p ]

53. Quick Quiz!
2. A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be A. It has no odor. B. A culture is negative. C. The edges reveal the presence of fluid. D. It shows purulent drainage coming from the incision site.
Answer: D

54. Bandages and Binders
Functions: create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings
Bandages
Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin
Binder application
Breast, abdominal, sling
At times, simple gauze dressings do not supply adequate immobilization or support to a wound. Bandages and binders are applied over or around dressings to provide extra protection and/or therapeutic benefits by creating pressure over a body part, immobilizing a body part supporting a wound, reducing or preventing edema, or securing a splint or dressing.
When binder or bandages are applied, an assessment must be made.
[Ask students what responsibilities nurses have before applying a bandage or binder.
Answers may include:
Inspect skin for abrasions, edema, discoloration, exposed wound edges
Cover exposed wounds or open abrasions with a sterile dressing
Assess the condition of underlying dressings and change if soiled
Assess the skin of underlying areas that will be distal to the bandage for signs of circulatory impairment (coolness, pallor or cyanosis, diminished or absent pulses, swelling, numbness, and tingling) to provide a means for comparing changes in circulation after bandage application.]
After applying a bandage, the nurse assesses, documents, and immediately reports changes in circulation, skin integrity, comfort level, and body function.
Binders are especially designed for the body part to be supported. The most common type of binder is the abdominal binder. Well-fitting bras are now replacing breast binders. Both provide support after breast surgery or exert pressure to reduce lactation in a woman after childbirth.

55. Securing Binders
The left drawing shows securing an abdominal binder with Velcro.
On the right is a diagram of a sling.
An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs. Secure an abdominal binder with safety pins, Velcro strips, or metal stays.
Slings support arms with muscular sprains or fractures. A commercially manufactured sling consists of a long sleeve that extends above the elbow with a strap that fits around the neck. In the home, patients can use a large triangular piece of cloth.
The patient sits or lies supine during sling application. Instruct him or her to bend the affected arm, bringing the forearm straight across the chest. The open sling fits under the patient’s arm and over the chest, with the base of the triangle under the wrist and the point of the triangle at his or her elbow. One end of the sling fits around the back of the patient’s neck. Bring the other end up and over the affected arm while supporting the extremity. Tie the two ends at the side of the neck so the knot does not press against the cervical spine. Fold the loose material at the elbow evenly around the elbow and pin. Always support the lower arm and hand at a level above the elbow to prevent the formation of dependent edema.

56. Case Study (cont’d)
In preparation for her husband’s discharge, Mrs. Ahmed is interested in learning how to change Mr. Ahmed’s pressure ulcer dressing. Lynda develops a teaching plan to include Mrs. Ahmed, with the outcome goal that “At the end of the teaching session, Mrs. Ahmed will perform an acceptable return demonstration of dressing application.”
What teaching and evaluation strategies would be appropriate?
[Discuss with the class possible teaching and evaluation strategies; possible answers are below.]
Possible teaching strategies:
Plan time that Mrs. Ahmed is present and be prepared to spend 30 minutes in two separate teaching sessions.
Avoid using words that Mrs. Ahmed will not understand.
Provide a brief description of what will be taught to both patient and spouse. Include the patient in all of the teaching even though he is unable to see the wound.
Bring an extra dressing to the bedside to show Mrs. Ahmed what the dressing looks like and how to apply it.
Use a pictorial guide of a pressure ulcer to help Mrs. Ahmed understand what the wound looks like and how it will progress if it shows signs of healing.
Plan one session in which Mrs. Ahmed will watch a demonstration of the wound being cleaned and the dressing applied. Plan a second session where she will do a return demonstration.
At the end of each session, ask Mrs. Ahmed how she felt doing the dressing, and include Mr. Ahmed in this evaluation.
Evaluation Strategies
Ask Mrs. Ahmed questions as she does the procedure to evaluate her understanding of each step.
Ask Mrs. Ahmed what she will evaluate at each dressing change.
Observe Mrs. Ahmed changing the dressing and cleaning the wound. Observe any body language that indicates how she is feeling while doing the procedure.

57. Heat and Cold Therapy Assessment for temperature tolerance
Assess the skin and skin integrity.
Assess the patient’s response to stimuli.
Assess the equipment being used.
Identify any contraindications.
Bodily responses to heat and cold
Local effects of heat and cold
Factors influencing heat and cold tolerance
Application of heat and cold therapies
You will need to identify and understand normal body responses to localized temperature variations.
Heat and cold applied to an injured body part provide therapeutic benefit. However, level of consciousness influences the ability to perceive heat, cold, and pain. If a patient is confused or unresponsive, the nurse needs to make frequent observations of skin integrity after therapy begins. (Contraindications are reviewed on the next slide.)
Bodily responses: A person initially feels an extreme change in temperature but within a short time hardly notices it. This is dangerous because a person insensitive to heat and cold extremes can suffer serious tissue injury. You need to recognize patients most at risk for injury from heat and cold applications.
Local effects of heat: Heat generally is quite therapeutic, improving blood flow to an injured part. However, if heat is applied for 1 hour or longer, the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area. Periodic removal and reapplication of local heat restore vasodilation. Continuous exposure to heat damages epithelial cells, causing redness, localized tenderness, and even blistering.
Local effects of cold: The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia. The skin initially takes on a reddened appearance, followed by a bluish-purple mottling, with numbness and a burning type of pain. Skin tissues freeze from exposure to extreme cold.
Short exposures are more easily tolerated. The very young and the very old are most sensitive to temperature changes.
The body responds best to minor temperature changes over smaller body areas.
Uneven temperature distribution suggests equipment malfunction.
A prerequisite to using any heat or cold application is a health care provider’s order, which includes the body site to be treated and the type, frequency, and duration of application. Consult agency procedure manual for correct temperatures to use.
[Table 48-9 on p discusses Conditions That Increase Risk of Injury from Heat and Cold Application.]
[Box on p discusses Safety Suggestions for Applying Heat or Cold Therapy.]
[Box on p discusses Choice of Dry or Moist Applications.]
[Table on p discusses Therapeutic Effects of Heat and Cold Applications.]

58. Contraindications to Cold and Heat
Cold is contraindicated:
If the site of injury is edematous
In the presence of neuropathy
If the patient is shivering
If the patient has impaired circulation
Heat is contraindicated:
For areas of active bleeding
For an acute localized inflammation
Over a large area if a patient has cardiovascular problems
Cold further retards circulation to the area and prevents absorption of the interstitial fluid.
If the patient has impaired circulation (e.g., arteriosclerosis), this further reduces blood supply to the affected area.
Do not cover an active area of bleeding with a warm application because bleeding will continue.
Warm applications are contraindicated when the patient has an acute, localized inflammation such as appendicitis because heat causes the appendix to rupture.
If a patient has cardiovascular problems, it is unwise to apply heat to large portions of the body because the resulting massive vasodilation disrupts the blood supply to vital organs.

59. Case Study (cont’d)
Lynda observes Mr. Ahmed’s wound and measures it to be 1 × 1 inch with serous drainage and red color.
Achievement of outcome by improved tissue type and reduced wound size
Lynda palpates underlying skin around wound; the skin remains intact.
Achievement of outcome by no evidence of advancing ulcer or tissue damage
She asks Mr. Ahmed about discomfort; he denies any new sensations at the wound site.
Achievement of outcome by no evidence of new tissue damage
[Ask the class what other means of evaluation Lynda could be using? Nutritional status:
Lynda also asks Mr. Ahmed about his food intake and reviews Mr. Ahmed’s calorie count over the past week. He reports that his appetite is increasing, and that he is eating most of his meals. Calorie count shows a steady increase in daily consumption. The outcome has been achieved as noted by improved nutritional intake.]

60. Quick Quiz!
3. A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides A. An absorbent surface to collect wound drainage. B. Decreased incidence of skin maceration. C. Protection from the external environment. D. Moisture needed for wound healing.
Answer: D

61. Evaluation
Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified; and did the plan of care decrease the contribution of each of these components?
Was wound healing supported by providing the wound base with a moist protected environment?
Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing?
Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine whether the patient has met the identified outcomes or goals.
If the identified outcomes are not met for a patient with impaired skin integrity, possible questions to ask are shown on the slide.
Care of patients with a pressure ulcer or wound requires a multidisciplinary team approach.
[Figure on p diagrams the evaluation process.]

62. Case Study (cont’d)
Lynda Abraham has completed her clinical experience with Mr. Ahmed. His pressure ulcer is still present, but it is reduced in size and demonstrates progress toward healing. No other sites of nonblanchable erythema were noted, and the rest of his skin remains intact. Lynda taught Mrs. Ahmed how to assess her husband’s skin for signs of increased risk for or further breakdown. Lynda, with the help of her instructor, devised a plan of care for the home, and they are meeting with the home care nurse today when she visits Mr. Ahmed at the hospital.
[Discuss how teaching family members is key in continued health for patients at discharge.]