Chapter 58 Special Skin and Wound Care

1. Chapter 58Special Skin and Wound Care

2. Wounds • Any abnormal opening or break in the skin is a wound. • Accidental or unintentional • **Abrasion • **Puncture • **Laceration • Intentional • **Surgical incision • Has clean edges

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 • Evaluation of wounds • Angiograms or the laser Doppler, biopsy and wound culture

4. 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

5. 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.

6. Characteristics of Wounds • Tunneling • Channels within wound • Undermining • Tissue that has receded beneath the skin, creating a shelf or free edge with a space underneath • Wound edges • Periwound area • Wound base • Wound measurement • Linear measurement, planimetry • Stereophotogrammetry • Wound photography, wound tracing

7. Causes of Skin Breakdown • **Immobility, low level of activity, advancing age • **Inadequate nutrition, hydration levels • 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. Types of Skin Breakdown • Incontinence-associated dermatitis (IAD) • IAD can be prevented by using an incontinence cleanser and a moisture barrier paste before damage occurs. • Pressure ulcer or decubitus ulcer • Prevention of pressure ulcers and other skin breakdown is a primary nursing responsibility. • Shoulder blades, elbows, coccyx, hips, knees, sides of ankle and back of heel may be affected** • Venous stasis ulcer • Diabetic ulcers • Due to impaired circulation**

9. Pressure Ulcers • Pressure ulcers • Result of pressure on the skin, in excess of that of which a particular client’s skin and underlying tissue can safely tolerate • Bony prominences such as: shoulder blades, elbows, coccyx, hips, knees, sides of ankle and back of head** • Debridement** • Prediction of pressure ulcer risk • Braden scale • Sensory perception, moisture level, activity, mobility, nutrition and friction/shear** • Total points possible=23. The lower the score, the greater the risk***

10. Classification of Pressure Ulcers • 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

11. Causes of Wounds • Pressure • **Shear • Friction • Stripping • **Urine or stool incontinence • Perspiration • Maceration

12. Wound Healing-First intention**

13. Wound Healing-second intention**

14. Wound Healing-Third intention**

15. Prevention of Pressure Ulcers • Turn/reposition immobile clients frequently • Assist to obtain adequate hydration and nutrition • High calorie, high protein diet with vitamins A, C, E • Massaging skin can avoid skin breakdown • DO NOT rub or massage an already reddened or darkened area-could cause worsening of skin breakdown**

16. Dressings • Dressings serve to protect wounds from contamination, assist in debridement, protect against further damage during healing** • Dry, sterile dressing • Protects wound from contamination • Wet-to-dry dressing • Used for infected wounds healing by secondary intention** • Packing • Usually done in the case of a puncture wound or wound sinus tract

17. Dressings • Wet-to-wet dressing • Used on clean, open wounds or on wounds that are granulating in • Commercially prepared special dressings (next slide) • Penrose drain • Closed drainage systems • Hemovac used in wound in which bloody drainage is expected after surgery**

18. Wound Care Product Categories • Hydrocolloid • DUODERM • Foam • Absorption of exudate • Alginate and hydrofiber • Used for absorption and maintaining moist wound bed • Hydrogel—amorphous • used to promote debridement

19. Wound Care Products • Hydrogel—sheet • Used in lightly draining wounds • Antimicrobial products • Used in contaminated wounds • Gauze • Dries out unless used with another product • Impregnated gauze • Used to pack cavity or cover a dressing to maintain moisture

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

21. Equipment Used in Wound Care • Vacuum-assisted closure (VAC)—negative pressure wound therapy • Increases growth of granulation tissue and decreases healing time** • Wound irrigation systems • Manual wound irrigation • Performed with a hand-held syringe** • Sutures or staples • Generally done in 7-10 days after surgery**