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Chapter 32 Wound Care
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The skin is the body’s first line of defense.
You must prevent skin injury and give good skin care to help prevent skin breakdown.
Older and disabled persons are at great risk for skin breakdown.
A wound is a break in the skin or mucous membrane.
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Common causes of wounds are:
Surgery
Trauma
Pressure ulcers from unrelieved pressure
Decreased blood flow through the arteries or veins
Nerve damage
The nurse uses the nursing process to keep the person’s skin healthy.
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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
Chronic wounds
Partial- and full-thickness wounds
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Wounds also are described by their cause:
Abrasion
Contusion
Incision
Laceration
Penetrating wound
Puncture wound
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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
Tell the nurse at once if you cause or find a skin tear.
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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.
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PRESSURE ULCERS (DECUBITUS ULCERS, BED SORES, PRESSURE SORES)
A pressure ulcer is an injury usually from unrelieved pressure.
A pressure ulcer usually occurs over a bony prominence.
Pressure, shearing, and friction are common causes.
Risk factors include:
Breaks in the skin
Poor circulation to an area
Moisture
Dry skin
Irritation by urine and feces
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Persons at risk for pressure ulcers are those who:
Are bedfast or chairfast
Need some or total help in moving
Are agitated or have involuntary muscle movements
Have loss of bowel or bladder control
Are exposed to moisture
Have poor nutrition
Have poor fluid balance
Have lowered mental awareness
Have problems sensing pain or pressure
Have circulatory problems
Are older
Are obese or very thin
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Pressure ulcer stages
Stage 1: The skin is red in persons with light skin. The skin is red, blue, or purple in persons with dark skin.
Stage 2: Partial-thickness skin loss
Stage 3: Full-thickness skin loss
Stage 4: Muscle and bone are exposed and damaged.
Sites
Pressure ulcers usually occur over bony areas called pressure points.
The ears also are sites for pressure ulcers.
In obese people, pressure ulcers can occur in areas where skin has contact with skin.
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Prevention and treatment
Good nursing care, cleanliness, and skin care are essential.
The person at risk for pressure ulcers is placed on a surface that reduces or relieves pressure.
The doctor orders wound care products, drugs, treatments, and special equipment to promote healing.
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Protective devices are often used to prevent and treat pressure ulcers.
Bed cradles
Heel and elbow protectors
Heel and foot elevators
Gel- or fluid-filled pads and cushions
Eggcrate-type pads
Special beds
Pillows, trochanter rolls, foot boards, and other positioning devices
Report and record any signs of skin breakdown or pressure ulcers at once.
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VENOUS ULCERS (STASIS ULCERS)
Are 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.
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Risk factors include:
History of blood clots
History of varicose veins
Decreased mobility
Obesity
Leg or foot surgery
Advanced age
Surgery on the bones and joints
Phlebitis (inflammation of a vein)
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Prevention and treatment involve:
Follow the person’s care plan to prevent skin breakdown.
Prevent injury.
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
Elastic stockings or elastic bandages
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ARTERIAL ULCERS
Are open wounds on the lower legs or feet caused by poor arterial blood flow
Are 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
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DIABETIC FOOT ULCER
Is an open wound on the foot caused by complications from diabetes
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
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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)
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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
Evisceration
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Wound appearance
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.
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Drainage must leave the wound for healing.
When large amounts of drainage are expected, the doctor inserts a drain.
Drainage is measured in three 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
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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
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The following types of dressings are common:
Gauze
Non-adherent gauze
Transparent adhesive film
Dressings that contain special agents to promote wound healing
Dressings are wet or dry.
Dry dressing
Wet-to-dry dressing
Wet-to-wet dressing
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Securing dressings
Microbes can enter the wound and drainage can escape if the dressing is dislodged.
Tape and Montgomery ties are used to secure dressings.
Binders hold dressings in place.
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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.
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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.
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QUALITY OF LIFE
Residents have the right to care that promotes healthy skin and prevents skin breakdown.
Everyone must keep the person’s skin healthy.
Follow the person’s care plan.
Be very careful not to injure the skin during care.
Treat the person with dignity and respect.
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