1. Skin Integrity & Wound Care

2. Functions of the Skin
The body’s first line of defense protecting it from microbial and foreign substance invasion.
An intact skin surface provides a barrier to harmful microorganisms.
A wound is a disruption in the normal integrity of the skin.
Creates a potentially dangerous and possibly life-threatening situation

3. Wound Complications
Infection
Hemorrhage
Dehiscence
Evisceration

4. Pressure Ulcers and Preventive Measures
Definition
A wound caused by unrelieved pressure that results in damage to underlying tissue
Pressure-relieving measures:
Frequent turning
Pressure-relieving devices
Positioning

5. Pressure Ulcer Stages Stage I
Observable pressure-related alteration of intact skin
Stage II
Partial-thickness skin loss involving epidermis/dermis
Stage III
Full-thickness skin loss involving damage of subcutaneous tissue, extending to, but not through, underlying fascia
Stage IV
Full-thickness skin loss with extensive destruction or damage to muscle, bone, or supporting structures

6. Cleaning a Wound and Applying a Dry, Sterile Dressing
The goal of wound care is to promote tissue repair and regeneration to restore skin integrity.
Wound care involves cleaning of the wound and the use of a dressing as a protective covering over the wound.
Wound cleansing is performed to remove debris, contaminants, and excess exudate.
Sterile normal saline is the preferred cleansing solution.

7. Assessments Made When Applying a Saline Moistened Dressing
Assess the situation to determine the need for a dressing change; confirm any physician orders relevant to wound care.
Assess the current dressing if there is one.
Assess the patient’s level of comfort and the need for analgesics before wound care.
Assess the location, stage, drainage, and types of tissue present in the wound; measure the wound.
Assess the surrounding skin for color, temperature, edema, ecchymosis, or maceration.

8. Hydrocolloid Dressings
Definition
Wafer-shaped dressings with an adhesive backing to provide adherence to the wound and skin
Functions
Absorb drainage, maintain a moist wound surface, cover the wound surface, decrease risk for infection
Indication
Shallow to moderate-depth wounds with minimal drainage; stay in place for 3 to 7 days

9. Expected Outcomes When Irrigating a Wound
The wound is cleaned without contamination or trauma and without causing pain or discomfort.
The wound continues to show signs of progression of healing.
The patient demonstrates understanding about the need for wound irrigation.

10. Collecting a Wound Culture
Ordered if assessment of a patient and the patient’s wound suggests infection
Identifies the causative organism to provide useful information to select the most appropriate therapy.
Can be performed by a nurse or physician
Maintaining strict asepsis is crucial so that only the pathogen present in the wound is isolated
Using the correct culturette kit for collection of an aerobic or anaerobic organism is essential

11. Securing Montgomery Straps to a Dressing
Definition
Prepared strips of nonallergenic tape with ties inserted through holes at one end
A skin barrier is often applied before the straps to protect the skin
Indications
Wounds that require frequent dressing changes, such as wounds with increased drainage
The straps allow for wound care without removing adhesive strips, decreasing skin irritation and injury

12. Penrose Drain Use and Care
Hollow, open-ended rubber tube used after surgical procedures or for drainage of an abscess
Allows fluid to drain via capillary action into absorbent dressings
Can be advanced or shortened to drain different areas
The patency and placement of the drain are included in the wound assessment

13. Biliary Drains or T Tubes
Uses
Placed in the common bile duct after removal of the gallbladder (cholecystectomy) or a portion of the bile duct (choledochostomy)
The tube drains bile while the surgical site is healing
Care
The drainage amount is measured every shift, recorded, and included in output totals

14. A Biliary Drain or T-Tube Drain

15. Caring for a Jackson-Pratt Drain
Uses
Collects wound drainage in a bulblike device that is compressed to create gentle suction
Consists of perforated tubing connected to a portable vacuum unit
Typically used with breast and abdominal surgery
Care
Usually drains are emptied every 4 to 8 hours, and when they are half full of drainage or air
Patency, placement, and the amount and characteristics of the drainage are assessed

16. A Jackson-Pratt Drain

17. Use and Care of a Hemovac Drain
Perforated tubing connected to a portable vacuum unit
Placed into a vascular cavity where blood drainage is expected after surgery
Suction is maintained by compressing a springlike device in the collection unit
Typically the drain is emptied every 4 or 8 hours and when it is half full of drainage or air
Patency, placement of the drain, and the amount and characteristics of the drainage are assessed

18. A Hemovac Drain

19. Applying Negative Pressure Wound Therapy
Promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed
Results in reduction in bacteria in the wound and the removal of excess wound fluid, while providing a moist wound healing environment.
The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessel

20. Assessments Made Prior to Removing Sutures
Assess the appearance of the wound.
Approximation of wound edges, signs of dehiscence
Color of the wound and surrounding area
Presence of wound drainage noting color, volume, and odor
Assess stage of the healing process.
Assess the surrounding skin.
Color, temperature, edema, maceration, or ecchymosis

21. Expected Outcomes When Removing Surgical Staples
The staples are removed
without contaminating the incision area.
without causing trauma to the wound.
without causing the patient pain or discomfort.
The patient remains free from exposure to infectious microorganism.
The patient remains free of complications that would delay recovery.
The patient verbalizes positive aspects about self.

22. Therapeutic Effects of Sterile, Warm, Moist Compresses
Promote circulation to the wound.
Encourage wound healing.
Decrease edema.
Promote consolidation of wound exudate.
Decrease pain and discomfort at the wound site.

23. Assessments Made Prior to Assisting Patient With a Sitz Bath
Review any orders related to the Sitz bath.
Determine patient’s ability to ambulate to the bathroom and maintain sitting position for 15 to 20 minutes.
Inspect perineal/rectal area for swelling, drainage, redness, warmth, and tenderness.
Assess bladder fullness and encourage patient to void prior to sitz bath.

24. Using a Cooling Blanket/Hypothermia Pad
Definition
A blanket-sized Aquathermia pad that conducts a cooled solution, usually distilled water, through coils in a rubber or plastic blanket or pad
Uses
Helps to lower body temperature
May be preset to maintain a specific body temperature