Chapter 58: Special Skin and Wound Care
Open
The wound edge looks healthy, with evidence of tissue growth at the rim
Slough
To shed; to cast off; a mass of dead tissue (tan or yellow)
NCLEX alert
it will be important for you to understand causes of skin breakdown and types of wounds / ulcers as they relate to client teaching and nursing actions to prevent skin and tissue damage. For example, you may be asked to select the appropriate nursing actions to prevent the development of pressure wounds during your NCLEX examination
Surgical incision
A wound with clean edges
Linear measurement
A ruler is used to measure the width and length of a wound; doesn't measure wound depth and is not well suited to an irregular wound
Stereophotogrammetry
A special video camera downloads to a computer; this method allows color images and is noninvasive; it also gives some indication of wound depth
Eschar
A thick, leathery black crust of necrotic (dead tissue)
Serosanguineous
Bloody, containing a great deal of blood and some serum
Wet-to-dry dressing
Saturated dressing that is wrapped around a wound and left to dry; upon removal, the dressing pulls away tissue debris and drainage, making it a useful tool in debridement
Rolled under
The top layer of epidermis is rolled down over the lower edge of the wound (closed)
Wound tracing
Transparent paper may be laid over the wound and the edges lightly traced; this is effective for flat, irregular wounds
Drain
Tube or strip of material inserted into a wound, to aid in elimination of exudate
Pressure wound
Ulcerated sore often caused by prolonged pressure on a bony prominence or other area, especially if the client is allowed to lie in one position for an extended period
Stripping
Unintentional removal of epidermis by mechanical means, such as with tape removal
VAC
Vacuum-assisted closure
Calloused
Very hard, yellow to white
Denuded
Skin stripped away
Granulation
Soft and pinkish
Macerated
Softened by moisture
Small
Wound moist throughout, drainage on less than 25% of dressings
Venous stasis ulcer
Wound or ulceration caused by venous insufficiency or pooling of blood in dependent veins (usually in the legs)
Scant
Wound tissue moist, no visible exudate
Large/copious
Wound tissues saturated; drainage on more than 60% to 75% of dressings
Laceration
Wound with torn, ragged edges (e.g., an accidental or self-inflicted cut)
key points
a common cause of skin breakdown is pressure against tissues, causing ischemia and tissue death
key points
a dressing is often applied to a wound to protect it from contamination, collect exudate, debride the wound, and or protect against further damage
key points
a wound is a disruption in the Skins integrity
Friction
Superficial abrasion, resulting from the skin rubbing another surface (results in scrape, abrasion, or blister)
Wound photography
Photos of the wound illustrate the color of the wound bed and its edges, as well as giving an indication of the condition of surrounding skin
Erythema
Redness
Debridement
Removal of dead or infected tissues allows healthy tissue to grow, progressing from internal tissue outward
Purulent
Containing pus
Darkly pigmented skin
Damage may show as purplish, bluish, or gray and shiny
Lightly pigmented skin
Defined area of persistent redness or purple appearance
Diabetic ulcer/wound
Diabetic neuropathic ulcer
Drainage
Discharge from a wound
Pressure
External force sufficient to occlude blood in capillaries, resulting in tissue anoxia (lack of oxygen) and tissue death (necrosis)
Planimetry
Graph paper is used to duplicate the shape of a wound; this can allow a large, irregular wound to be drawn to scale and is best used for a flat wound
Shear
Interaction of gravity and friction against the skin's surface (appears as a cut or tear)
Serous
Made up of serum; clear, thin, and watery
Packing
Material placed (packed) into a wound to assist healing from the inside-out and to prevent pockets of infection (abscesses) from forming
NCLEX alert
be alert to the classification of pressure wounds, as well as the objectives and methods of wound care. You may be asked to demonstrate your knowledge in the NCLEX examination.
identify and describe the following types of wounds: abrasion, puncture, laceration, and surgical incision.
abrasion rubbing off of the Skin's surface example a skinned knee puncture a stab wound laceration wound with torn, ragged edges example is an accidental or self-inflicted cut surgical incision wound with clean edges, made under sterile conditions and are kept as free from microorganisms as possible
describe the evaluation of risk factors for skin breakdown and how these data are used
all clients must be elevated for the risk of developing pressure wounds / ulcers or skin breakdown on admission and regularly thereafter, according to facility protocol. Protocol usually requires more frequent skin examination of clients in the ICU, pediatric ICU. several methods are used to predict the risk of pressure wounds development. Two of these are the Braden scale in the Norton scale. If a client is found to be at a high risk, special measures must be taken to prevent the development of pressure wounds before they occur.
nursing alert
all use dressings are disposed of in red biohazard bags. This is particularly important if there is any drainage or blood on the dressing, or if it has been used as a packing.
nursing alert
avoid inspecting wounds under fluorescent lights when observing wounds / skin color. the rationale is that fluorescent lights May create and incorrectly diagnosed abnormal skin color or may mask variations in the client's skin tone
key points
good skin care and prevention of pressure areas are nursing priorities
key concept
if Adrian is present, the provider often orders Skin Barrier protection to be applied around the drain. Dressings may also be used in conjunction with a drainage system, to further protect the skin
key points
careful skin inspection on admission and periodically thereafter is vital, to protect the client from deformities and discomfort
key points
careful technique is required when dressing any wound
demonstrate how to change a dry, sterile dressing; how to apply a wet to dry dressing; and how to irrigate a wound
changing a dry sterile dressing 1. check the orders for type of dressing to apply. Check previous nursing notes to determine the presence or absence of drainage, it's character and amount, and size and condition of the wound. Place a waterproof pad under the client if necessary 2. prepare a marked biohazard bag for soiled dressings. Fold back the cuff and place it within reach of your working area, often it is Handy to tape it to the end of the overbed table. If you are using tape on the new dressing, tear strips of the appropriate size and lightly tape the ends to the overbed table 3. put on clean gloves. Untie the Montgomery straps or gently loosen the tape on the use dressing. Remove the used dressing, being careful not to tear the wound or dislodge any dreams. Use sterile saline to moisten the dry dressing, if it is sticking to the wound, lift the soiled side of the dressing away from the clients View 4. determine the amount, color, odor, and consistency of any drainage. Observe the condition of the wound and surrounding tissues. Measure and describe the wound. Draw a picture of an irregular wound. If ordered, draw a line around the wound with a waterproof marker and date it 5. remove gloves and place in The Biohazard bag. Wash hands. Prepare a sterile field on the bedside or overbed table and open sterile dressings on to it. Uncap the sterile saline or other prescribed Solutions and pour it into a sterile receptacle. Place additional sterile dressings or swabs for cleaning onto the sterile field 6. put on sterile gloves as ordered. 7. moisten sterile dressings or swabs and cleanse the wound. If ordered, moving from top to bottom or from the center of the wound outward. use a new swab or gauze pad for each cleansing motion and discard the used materials in The Biohazard bag. If necessary, cleanse the area around the wound as well. Do not use alcohol or soap 8. if necessary use a gauze pad to dry the wound with the same emotions as in Step 7. Carefully inspect the wound. Be prepared to describe the wound accurately. 9. apply any ointment or medications to the wound, as ordered. Do not touch the wound with your hands. Apply a layer of dry sterile dressing over the incision and wound area, as ordered. Pad with additional dressings and cover with a sterile ABD pad if the wound is large or heavily draining 10. if tape is to be used, use the previously torn strips. Apply at least one piece of tape immediately, to hold the dressing in place. In some situations you may then remove your gloves and complete the taping of the dressing. An alternate method is to tie the dressing with a Montgomery strap 11. remove gloves and wash hands. Reposition and cover the client, while preventing pressure on the wound. Handle only the outside of The Biohazard bag, keeping hands inside, under, the cuff on the outside of the bag, and carefully closing it dispose of the bag according to agency policy. Wash hands again performing a sterile wound irrigation 1. put on clean gloves and a nice Shield or face guard 2. position the client so the solution will run from the upper end of the wound downward. Place the waterproof bed pad and clean Basin or irrigating pouch under the area to be irrigated 3. Drake the client with a bad blanket to expose only the wound 4. remove the use dressing and discard it 5. open the irrigation tray, using sterile technique. Open the irrigation solution, place the cover on the table, with the inside facing upward. Carefully pour the solution from the supply Bottle Into the irrigation bottle. If the bottle has been opened previously, poor off a small amount of the solution into a trash receptacle. Leave the cover off the irrigation supply bottle, with the inside of the cover pointing upward 6. place the bottle close to the client on the overbed table. Date and initial the bottle after opening it. Include the client's name and facility ID number 7. open the sterile dressing tray, if one is to be used, and put on sterile gloves 8. prepare the inside of the irrigation and dressing trays. Please the irrigation syringe into the bottle. Open dressing packages and prepare other items 9. carefully assess the amount and character of drainage and the size and condition of the wound and surrounding tissue 10. while explaining the following steps of client as you proceed, draw up solution into the syringe 11. hold the syringe just above the wounds top Edge, and force fluid into the wound, slowly and continuously. Use sufficient Force to flush out debris, but do not squirt or Splash fluid. Irrigate all portions of the wound. Do not force solution into the wounds Pockets. Continue irrigating until the solution draining from the wounds bottom and is clear 12. using sterile 4 by 4 pads, gently pat dry the wounds edges, if the wound is to have a wet to dry dressing, then dry only the surrounding skin. Work from the cleanest to the most contaminated area 13. apply sterile dressings as ordered
nursing alert
if a client is admitted to a facility with an existing wound or pressure area, this must be carefully documented as present on Administration. As stated before, if this is not documented, the facility will become liable for this and any additional skin breakdown. In addition, if a wound exists, plans can be made to begin immediate treatment. A facility acquired pressure area is considered to be a sentinel event and must be reported to the appropriate authorities. If a stage 3 4 or 9 stageable wound ulcer develops within a facility, it usually must be reported to health department and investigated. It is important to note that pressure wounds usually occur within 12 to 24 hours in a compromised client. The wound begins deep in the tissue and may not be observed on the skin surface for several days. Signs of any involving pressure wound or non blanching erythema or redness that does not lighten when pressed, pain, and induration or swelling
key points
many products are available to care for wounds. be sure to follow manufacturer's recommendations and primary providers orders for wound care
explain three purposes of wound dressings
many types of dressings are used to treat Williams these include compression dressings and various types of manufactured dressing materials. Dressing serve to protect wounds from contamination, collect wound exudate, drainage and exuded materials, assist in debridement, and protect against further damage during healing
key points
open wounds may be irrigated to cleanse the wound and promote healing
key concept
deep open wounds must granulate in or heal from the inside out word. If the outside becomes sealed before the area underneath has healed, and abscess often forms. This abscess may be sterile or infected, containing pathogens. An abscess is painful and dangerous and must be treated. Reporting of granulation tissue is a part of pressure wound documentation
nursing alert
do not rub or massage any area if the above signs / symptoms are present. This added pressure may cause breakdown of small blood vessels, thereby worsening the Skins condition
describe nursing measures that help prevent skin breakdown
pressure reduction techniques -- very frequent client examinations -- turn or reposition client at least every 2 hours, with specific, documented, turning schedule -- use of log roll turns, prevent shear -- use of client lift, prevent shear and nurse injury -- Elevate heels off bed, better than padding heels -- Elevate head of bed no more than 30 degrees, prevent shear -- nutritional consult, to determine best dietary plan -- careful perianal care, use of protective creams, ointments, sitz baths, skin barriers -- careful personal hygiene, examples hair removal, Nail Care, oral hygiene -- careful use of standard precautions for all staff pressure reducing devices -- chair cushion, gel pads, heel elevators -- padding of chin and nose -- elbow protectors -- mechanical lifts -- transfer boards -- trapeze over bed -- use of turning sheet -- positioning supports -- specialty beds and mattresses example air mattress, rotating mattress
concept Master alert
puncture wound prevention and use of donut devices For a client at risk for pressure wound development, nurse should turn and reposition this client every 2 hours, elevate bony prominences with pillows, and limit the amount of Linens under the client.
key points
removal of Staples or sutures maybe performed by the nurse after specific in-service education and practice
describe the concept of skin breakdown, including the causes, most common locations, and staging of pressure wounds
skin breakdown is a disruption of Skin Integrity, non-intact skin. it is a potential complication for any client, but particularly those confined to a bed or wheelchair. This also includes the person with a body cast, traction, or the person who was paralyzed or otherwise cannot move without assistance. In other cases, skin breakdown can occur as a result of factors such as moisture, external pressure, infection, or rash, in any client. A common cause is shearing force or friction caused by clothing, bed linens, or client safety devices conditions contributing to skin breakdown are as follows -- immobility, low level of activity, lying or sitting in one position for extended periods of time, paralysis -- inadequate nutrition, very thin person, inadequate protein, insufficient calories -- hydration levels, inadequate fluid intake, excess fluid retention / edema -- presence of external moisture, including perspiration, urine, and feces, incontinence -- impaired mental status, alertness, or cooperation, heavy sedation and or anesthesia, mental illness, intellectual impairment -- sensory loss or coma -- fever, low blood pressure, particularly diastolic less than 60 mm -- advancing age, friable skin -- infancy -- impaired immune system, AIDS, cancer chemotherapy -- presence of cancer or other neoplasms -- circulatory disorders, anemia -- diabetes most common areas of skin breakdown / pressure wounds: certain body areas, including bony prominences examples shoulder blades, elbows, coccyx, hips, knees, sides of ankles, and the back of the head, as well as areas such as the heels and ears are more likely to break down than others. These areas are not covered by pads of fat that normally cushion blood vessels. When blood vessels are compressed and blood flow is reduced, oxygen supply diminishes, skin breaks down, and the tissue beneath is destroyed, tissue necrosis. insertion sites of tubes can also become irritated and contribute to skin or mucous membrane breakdown. And also rayshun can also develop in an obese person, under pediculus breast or abdominal Folds. This type of wound is often Complicated by yeast infection. It is important to keep all these areas as clean and dry as possible
key concept
skin breakdown is a particular problem in the bariatric or obese client
special considerations on culture and ethnicity
skin observation, color changes caused by pressure wounds -- Darkly pigmented skin, damage may show as purplish, bluish, or gray and shiny -- olive-toned skin, not likely to have red tones, compared with surrounding skin or opposite side -- light pigmented skin, defined areas of persistent redness or purple appearance
staging of pressure wounds
stage one: includes pressure related changes in intact skin, when compared to adjacent skin. may include changes in one or more of the following conditions, skin temperature, tissue consistency, induration, or sensation. the wound or ulcer appears as a defined area of persistent redness and lightly pigmented skin, in Darker skin, it may appear as persistent red, blue or purple hue. the color does not blanch or lighten when pressed. Reversible, if pressure is relieved by frequent turning, positioning, and pressure-relieving devices stage two: loss of epidermis with damage into dermis, partial thickness tissue loss. It appears as shallow crater or blister with red / pink wound bed, with no sloughing. may also appear as an intact or ruptured serum filled blister or abrasion. Swollen and painful, several weeks needed to heal after pressure relieved, Often by maintenance of a moist environment. example would be saline irrigation or special occlusive dressing. stage three: subcutaneous tissue involved, full thickness tissue loss, subcutaneous fat may be visible, no bone tendon or muscle exposed. maeshowe undermining or tunneling. Usually not painful, possible foul-smelling drainage, months may be needed to heal after pressure relieved. examples include debriding with wet to dry dressing, surgery, or proteolytic enzymes stage four: extensive damage to underlying structures, full thickness tissue loss, with exposed bones, tendons, or muscles. Wound possibly appearing small on Surface, but with extensive tunneling underneath. sloughing or Eschar may be present. Usually foul-smelling discharge, months or years may be needed for healing, and often requires skin grafting non stageable wounds Dash the base of a full thickness wound, covered by sloughing and/or eschar
key points
standard precautions are used when changing any dressing, to help prevent the spread of infection to the nurse or others and to avoid contaminating the wound. Wear gloves and properly dispose of all use dressing
describe how sutures and staples are removed
suture and staple removal is generally done 7 to 10 days after surgery to remove sutures, a sterile suture removal kit is used. sterile scissors are used to cut the suture close to the skin, while sterile tweezers firmly grip the knot. Then, the knot is pulled firmly, straight up. Be sure to pull on the knot. Staples are used frequently to close surgical incisions, because they are inert, do not cause infection, and are quickly inserted. A special staple remover is required. Staples are removed following the manufacturer's recommendations and specific facility protocol. the staple remover is placed with the two Lower Side tips of the scissor like instrument under the staple and moved upward, while the upper Center tip presses down on the center, when the handles are depressed. this Benz the staple and causes the prongs to become vertical, so they can be easily pulled out
key concept
the primary provider determines if debridement is appropriate or not. If a wound does not have adequate arterial blood flow to heal it, or if the womb contains stable, dry Eschar and the circulation is questionable, current practice is to dry the wound and not debride. If a wound has adequate circulation to heal, it is usually kept moist and cleaned by debridement
key points
the skin is a barrier that protects the body's internal environment from Invasion by external pathogens
key concept
the technique used for most dressing changes is clean technique, using sterile dressings. Unless otherwise ordered, the surgeon does the first dressing change after surgery or other procedures to close a wound. Rationale is that it is important for the surgeon to assess the wound and determine if healing is taking place or if there is a concern
NCLEX alert
this chapter provides information on your role in inspecting clients skin integrity and describing wounds. This information may be integrated into test scenarios and must be considered as you answer test questions
describe common types of wound Drainage Systems, including the VAC
vacuum-assisted closure negative pressure wound therapy the vacuum assisted closure machine, which resembles a suction machine, applies controlled localized negative pressure to a wound site. This speeds the growth of granulation tissue and decreases healing time. The VAC is particularly useful in the treatment of stage 3 and stage 4 pressure wounds or ulcers and other types of deep wounds. The system uses a special dressing that is applied within a wound or over a graft. The VAC is turned on and the vacuum draws the wound edges toward the center. The direct pressure of the dressing on the wound also assist in removal of fluids, reducing swelling, stimulating growth of healthy cells, and increasing blood flow, that's promoting faster healing
give examples of procedures and equipment used to care for a pressure wound or other open wound
vacuum-assisted closure negative pressure wound therapy the vacuum assisted closure machine, which resembles a suction machine, applies controlled localized negative pressure to a wound site. This speeds the growth of granulation tissue and decreases healing time. The VAC is particularly useful in the treatment of stage 3 and stage 4 pressure wounds or ulcers and other types of deep wounds. The system uses a special dressing that is applied within a wound or over a graft. The VAC is turned on and the vacuum draws the wound edges toward the center. The direct pressure of the dressing on the wound also assist in removal of fluids, reducing swelling, stimulating growth of healthy cells, and increasing blood flow, that's promoting faster healing
key concept
when applying any special dressing, make sure to adequately cover the wound. There should be at least a one-inch margin of dressing on all sides of the wound
nursing alert
when removing Staples or interrupted sutures, first remove every other one and carefully inspect the wound edges after removal of each. In some cases, this is all that is done on the first day. The rationale is that inspection will show if there is any evidence that the wound edges are pulling apart. If this happens, stop the procedure and report this immediately. The procedure may need to be postponed. If alternate stitches / Staples are left in place, the wound has a chance to heal more, with the additional support.
key points
wounds heal by first, second, or third intention
Wound
Any abnormal opening or break in the skin
Arterial Insufficiency
Arterial perfusion jeopardized
Sinus tract
An abnormal tube-like channel or fistula, usually draining pus
Sanguineous
Bloody, containing a great deal of blood and some serum
Skin breakdown
Disruption of skin integrity, nonintact skin
Exudate
Drainage containing a great deal of protein and cellular debris, usually as a result of inflammation
Moderate
Drainage on about 30% to 60% of dressings
Ecchymotic
Hemorrhagic spot, blue or purple
Olive tone skin
Not likely to have red tones; compare with surrounding skin or opposite side
Undermining
If tissue recedes beneath the skin, creating a shelf of skin or free edge with a space underneath
Tunneling
Refers to the one or more channels within or underlying an open wound
Abrasion
Rubbing off of the skin's surface (e.g., a skinned knee)
Excoriated
Scratch or abrasion
Puncture
Stab wound
Suture
Stitches
describe the three types of wound healing
first intention healing, healing by primary intention -- occurs in wounds with minimal tissue loss, such as surgical incisions or wound sutures or stitches soon after injury. Edges are approximated, close to each other, thus, they seal together rapidly. Scarring and infection rates with first intention healing are low second intention healing or healing by secondary intention --occurs with tissue loss, the wound edges are widely separated. Secondary intention healing occurs in injuries such as deep lacerations, Burns, and pressure wounds. Because the edges do not approximate, openings fill with granulation tissue that is soft and pinkish. This tissue grows slowly and must grow in From the Inside Out word, to prevent abscess. When the granulation tissue is in place, epithelial cells grow over the top. Scarring all often occurs, and the risk of infection is greater than that for first intention healing. New technologies have been developed to treat such wounds more successful. third intention healing or healing by tertiary intention -- occurs when there is a delay in the time between the injury and the closure of the wound. for example, a wound may be left open temporarily to allow for drainage or removal of infection materials. Tertiary intention healing sometimes occurs after surgery when there is an infection, or in a large open wound when the wound is closed later. In the meantime, womb services start to granulate and, deep scarring almost always occurs.
