Chapter 58: Special Skin and Wound Care (Complete)

KEY CONCEPT - Wound dressing

When applying any special dressing, make sure to adequately cover the wound. There should be at least a 1-inch margin of the dressing on ALL SIDES of the wound.

Wound tracing

Transparent paper may be laid over the wound and the edges lightly traced; this is effective for flat, irregular wounds

laceration

a wound with torn, ragged edges

The nurse is preparing a client for discharge and is reinforcing wound care instructions with the caregiver. What should the nurse be sure to have the caregiver report immediately? Select all that apply. a. Pink wound edges b. Redness around the wound c. Excess wound drainage d. Severe pain e. Hardness around the wound

b, c, d, e Explanation: Teach the client or caregiver to observe for excess drainage, severe pain, redness, or hardness around the wound. Include any other pertinent observations. The client's observations may alert staff to problems, resulting in quick action. Pertinent observations may assist the team in further care planning and treatment. Pink wound edges demonstrate adequate wound healing and sufficient circulation to the wound.

Drainage and wound debris slow the ________________ process.

healing

Types of skin breakdown

• IAD - Incontinence-Associated Dermatitis • Pressure wound • Venous stasis ulcer - Venous insufficiency wound • Diabetic ulcers

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

KEY CONCEPT - PRESSURE INJURY

A shallow wound on an area such as the nose, ear, occiput, or malleolus may be stage 3 or 4, even though it's not deep.

gauze dressing

A woven, flexible absorbent cloth applied to a wound **May stick to wound bed, may shred or give off lint in wound bed Examples: Kerlix, packing gauze, Telfa nonadhesive dressings

An ______________ is rubbing off of the skin's surface.

ABRAISON

Causes of Skin Breakdown

* Immobility, low level of activity * 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, * advancing age, friable skin * Impaired immune system, circulatory disorders; anemia * Presence of cancer or other neoplasms

stage 2 pressure injury

*partial thickness skin loss with exposed dermis. *the wound bed is pink or red and moist, may appear as an intact or ruptured blister. Swollen and painful. Several weeks needed to heal after pressure is relieved.

wound edges

-rolled under= top layer of epidermis is rolled down over the lower edge of the wound -macerated= softened by moisture. -calloused= very hard, yellow to white. -open= healthy, evidence of tissue growth at the rim

Things to chart about wounds

-type of drainage -serous, sanguineous, serosanguineous, purulent, color, odor -amount of drainage -None, scant, small, moderate, large/copious

Stereophotogrammetry

A special video camera downloads to a computer. This method allows for color images and is noninvasive. It gives some indication of wound depth.

Eschar

A thick, leathery black crust of necrotic tissue

Which client does the nurse determine is at greatest risk for impaired skin integrity? a. A client who is paralyzed on the right side after a stroke b. A client with pneumonia c. A client receiving a blood transfusion for anemia d. A client having a colonoscopy

A Rationale: Disruption of skin integrity, nonintact skin, commonly called skin breakdown, 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 is paralyzed or otherwise cannot move without assistance. A client with a short-term illness, a client receiving a blood transfusion, and a client having a colonoscopy are not at greatest risk for having an interruption in skin integrity.

NURSING PROCEDURE: CHANGING A DRY, STERILE DRESSING

CLEAN gloves may be used to remove the used dressing. Lift the soiled side away from the patient's view.

A nurse observes a reddened area that does not return to a normal hue after pressure is removed on the lower back of a postoperative patient. Which action should the nurse take?

Report to the physician RATIONALE: The nurse should report to the healthcare provider the presence of a reddened area that does not return to its normal hue after pressure removal because it may possibly lead to skin breakdown. Massaging an already reddened area may worsen the condition by causing breakdown of small blood vessels. Dietary protein intake of the client should be increased, and not decreased, to prevent skin breakdown.

______________________ draining is composed of serum and blood.

SEROSANGUINEOUS

A client has developed a painful shallow pressure injury. How will the nurse document this ulcer to be in which stage?

Stage 2 RATIONALE: The nurse will document the ulcer as stage 2 because it is a painful shallow ulcer. In stage 1, there are pressure- related changes of intact skin. In stage 3, there is a painless pressure injury associated with foul- smelling discharge. In stage 4, there is a small wound with extensive underlying damage and foul- smelling discharge

A client with a pressure injury has developed tunneling. When collecting data, how will the nurse measure the amount of tunneling? a. Insert a cotton-tipped application into the tunnel and measure the distance of insertion. b. Measure the width of the tunnel with a measuring tape. c. Estimate the depth according to the width. d. Pack the tunnel with a sterile 4×4 gauze pad and determine how much drainage is on the dressing.

a Explanation: Tunneling is measured by inserting a sterile cotton-tipped applicator into the tunnel and measuring the distance of insertion. Each tunnel is measured and documented separately. The other measures are not accurate

Puncture

a small hole made by a pointed object; puncture

surgical incision

a wound with clean edges

The nurse is caring for a client at risk for skin breakdown. What priority nursing actions may help prevent this development? Select all that apply. a. Apply moisture barrier cream to the skin. b. Determine the presence of dehydration and report findings. c. Immediately report any sign of skin redness. d. When skin redness is observed, massage vigorously. e. Turn an immobile client every 4 hours

a, b, c Explanation: Moisture barrier cream applied to the skin of an incontinent patient can help avoid moisture from attaching to the skin and causing breakdown. Any sign of dehydration, which can be a risk factor for skin breakdown, should be immediately reported so that rehydration methods can be started. Skin redness can be an early sign of skin breakdown and should be immediately reported so that measures can be taken to prevent further damage. The area should not be massaged because it may cause further tissue damage. The client who is immobile should be turned, at a minimum, every 2 hours around the clock.

____________________ refers to the presence of one or more channels within or underlying an open wound.

TUNNELING

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

Wound Cause: Pressure - External force sufficient to occlude blood in capillaries, resulting in tissue anoxia and tissue death.

Preventive Measures: -Establish a turning schedule at least every 2 hrs -Use supportive measures to relieve pressure (particularly over bony prominences and other vulnerable areas -Have a minimum of linens under the patient -Assist the patient to be out of bed and/or walking as soon as possible

Wound Cause: Friction - Superficial abrasion, resulting from the skin rubbing another surface (results in scrape, abrasion, or blister)

Preventive measures: -Apply transparent dressings to areas of friction -Move patient carefully. Use trapeze, lift, transfer boards, etc. -Use elbow protectors and elevate heels off bed. -Keep skin adequately hydrated -Use friction-reducing sheets for turning andpositioning

Wound Cause: Arterial insufficiency

Preventive measures: -Avoid compression -Provide adequate remoisturizing -Elevate edematous feet and legs

Wound Cause: Perspiration

Preventive measures: -Keep areas of skin folds dry -Use barrier ointments as prescribed -Use anti-fungal powder or other prescribed medication, if yeast infection is present.

Wound Cause: Urine or Stool

Preventive measures: -Use containment equipment -Keep perianal skin cleansed, moisturized, and protected with barrier ointments or creams -Offer bedpan/urinal and fluids each time the patient is turned.

Wound Cause: Shear - Interaction of gravity and friction against the skin's surface (appears as a tear or cut)

Preventive measures: -Use draw sheet and lifting/turning sheet or a lift -Use logroll turns -Limit elevation of bed to 30 degrees -Position feet against footboard before head elevation -Request assistance when necessary

Wound Cause: Stripping - Unintentional removal of epidermis by mechanical means, such as with tape removal.

Preventive measures: -Use only porous tapes and apply without tension, if possible. -Use saline to help remove dressings that adhere to the skin -Use tube-gauze dressing, rather than tape.

Wound cause: Burns/Frostbite

Preventive measures: -Wash thoroughly at least once per day -Expose to air, if possible -Encourage female client to wear a bra when up, if possible

A nurse needs to handle a closed-drainage system. What is the correct order for the steps in working with a closed-drainage system?

RATIONALE: Wear gloves when working with any wound drainage; double-gloving may be used if there is excessive drainage or if the drainage is bloody or purulent. Check for leaks in the closed drainage system, which would hamper the suction. Empty the drainage receptacle if it is full; otherwise, the suction will be lost. Measure and record the amount of drainage.

KEY CONCEPT - PRESSURE INJURY 2

Deep open wounds must granulate in from the inside outward. If the outside becomes sealed before the area underneath has healed, an abscess often forms. This abscess may be sterile or infected. An abscess is painful and dangerous and must be treated. Reporting of granulation tissue is part of pressure injury documentation.

drainage

Discharge from a wound

A nurse is required to apply a dressing to the incision area, healing by primary intention, of a client who has undergone an appendectomy. Which dressing should the nurse apply to this client?

Dry Sterile Dressing RATIONALE: The nurse should apply a dry sterile dressing to the client because this type of dressing is used mostly for clean wounds, such as surgical incisions, that heal by primary intention. Wet-to- dry dressings are used for infected wounds healing by secondary intention. Wet- to- wet dressings are used on clean, open wounds or on granulating wounds. Hydrocolloid dressings are used in wounds of shallow to moderate depth with minimal drainage.

Drainage from a wound containing a great deal of protein and cellulardebris is called _________________.

EXUDATE

T/F: Inadequate nutrition does not contribute to skin breakdown.

FALSE

A client admitted to a healthcare facility develops a pressure injury in the gluteal region. Which nursing measure would have prevented the occurrence of this pressure injury?

Frequent change of position RATIONALE: Frequently changing the position of the client would have prevented the occurrence of a pressure injury. Application of antifungal powder or transparent dressing does not help in preventing pressure injuries. Application of a wet cloth should not be done because external moisture is a risk factor for pressure injury development.

stage 4 pressure injury

Full thickness skin and tissue loss, exposed fascia, muscle, tendon, ligament, cartilage, or bone. Slough or eschar may be present. Usually foul-smelling discharge. Months to years may be needed for healing.

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

A ________________ is a wound with torn, ragged edges.

LACERATION

A 25 y/o client who is paralyzed from below the hips is put on a special mattress to prevent skin breakdown. Which factor contributes to skin breakdown?

Low level of activity RATIONALE: A low level of activity contributes to skin breakdown. Advancing and not younger age contributes to skin breakdown. Insufficient, not excessive, calories contribute to skin breakdown. Inadequate fluid intake contributes to skin breakdown, but a fluid intake of 2 L/day is adequate.

The nurse is obtaining data from a newly admitted client with a sacral pressure wound and observes a full-thickness ulcer with tissue loss, subcutaneous damage, and a purulent drainage. How will the nurse document the classification of this wound? a. Stage I b. Stage II c. Stage III d. Stage IV

c Explanation: A Stage III wound has full-thickness tissue loss, with subcutaneous damage and drainage. It may also show tunneling or undermining. A Stage I (reversible) wound includes pressure-related changes in intact skin, when compared with adjacent skin. Some pressure wounds are not stageable. A Stage II wound has partial-thickness tissue loss with no sloughing and may appear as blister. A Stage IV wound shows full-thickness tissue loss, extensive destruction of muscle, bone, or other structures.

Drainage containing a great deal of protein and cellular debris is called _______________.

exudate

stage 3 pressure injury

full thickness loss, looks like deep crater extend to fascia. Subcutaneous fat may be visible, No bone, tendon, or muscle exposed. Undermining/tunneling may be present. Usually not painful. Possible foul-smelling drainage. Months may be needed to heal after pressure is relieved.

Hydrocolloid dressing

comfortable, moderate absorption, used in shallow, partial-thickness wounds, with minimal to moderate exudate. **Do not use in infected or heavily draining wounds Examples: Tegasorb, DuoDERM, Comfeel, Tegaderm

wound drain

created by inserting a wick inside of the wound to provide drainage

A surgical incision is a/an _______________ wound.

intentional

Enzymatic debridement

involves the use of a topically applied chemical substance that breaks down and liquefy wound debris

packing

material placed into a wound to assist healing from the inside -out and to prevent pockets of infection fro forming. **packing material should be no thicker than the wound bed

Third intention healing

method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by opposing areas of granulation

Second intention healing

method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation

First-intention healing

method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation.

Granulation

new tissue that forms when old destroyed tissue is sloughed off.

dry sterile dressing (dry-to-dry dressing)

often ordered for a wound to protect it form contamination

Vacuum assisted closure

device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together

Exudate

drainage containing a great deal of protein and cellular debris, usually as a result of inflammation

undermining

process in which tissue recedes beneath the skin, creating a shelf of skin or free edge with a space underneath

Debridement

removal of foreign material and dead or damaged tissue from a wound

The Braden scale rating considers the following factors: ___________________, perception, moisture, activity, mobility, nutrition, and friction/shear.

sensory

Types of drainage

serous: made up of serum; clear, thin, and watery sanguineous: bloody, containing a great deal of blood and some serum serosanguineous: composed of serum and some blood purulent: containing pus color: green, tan, yellow, red odor: malodorous, no odor, sweet-smelling

A nurse is emptying the drainage container of a client with a closed drainage system. Which are closed drainage systems?

the Jackson-Pratt the Hemovac the Davol RATIONALE: The closed drainage systems are the Jackson- Pratt, the Hemovac, and the Davol. Penrose is an open- drainage system. EnzySurge is a wound irrigation system.

sharp debridement

the removal of necrotic tissue using scissors, scalpel or laser

Slough

to cast off/shed (often tan or yellow)

autolytic debridement

using body's enzymes to break down tissue

The _______________-assisted closure machine applies controlled localized negative pressure to a wound site.

vacuum

A client develops discoloration on their left big toe due to arterial insufficiency. Which measures are used to prevent development of a wound in the area of discoloration?

Adequately remoisturizing elevating the feet and legs avoiding compression RATIONALE: Adequately remoisturizing, elevating the feet and legs, and avoiding compression prevent the development of a wound in the area of discoloration due to arterial insufficiency. Applying powder will not help. Steri- strips are applied to a wound after staples or sutures have been removed.

stage 1 pressure injury

An area of intact skin that is red, deep pink, or mottled skin that does not blanch with fingertip pressure. Reversible if pressure is relieved.

foam dressings

Allow for exudates to be absorbed into the foam. The dressings are most commonly available in sheets or pains with varying degrees of thickness. Semipermeable foam dressings are produced in adhesive and non-adhesive forms. Non-adhesive forms require a secondary dressing **marked with "T" if used for treatment and with "P" if used for prevention Examples: Optifoam, ALLEVYN, Mepilex

Wound

Any abnormal opening or break in the skin

wet to dry dressing

Damp gauze dressing placed on a wound and removed after the dressing dries to the wound, providing microdebridement

Abrasion

Rubbing off of the skin's surface

A client's abdominal wound is draining clear, thin, and watery discharge. Which term will the nurse use to describe the drainage?

Serous RATIONALE: The nurse will describe the drainage as serous because it is clear, thin, and watery. Sanguineous drainage is composed of blood. Serosanguineous drainage is composed of serum and blood. Purulent drainage contains pus.

T/F: Debridement is the removal of dead or infected tissues allowing healthy tissue to grow, progressing from internal tissue outward.

TRUE

T/F: Shearing force is the friction caused by linens or clothes that promotes skin breakdown.

TRUE

T/F: Venous stasis ulcers are typically found in the lower extremities and are a result of local hypoxia to tissues.

TRUE

T/F: When removing staples, one must be certain to rotate every other one initially, inspecting for proper wound closure.

TRUE

Amounts of drainage

None: Dressings dry Scant: Wound tissue moist, no visible exudate Small: Wound moist throughout, drainage on less than 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

Tunneling

One or more channels within or underlying an open wound

A large, infected wound of a client is temporarily kept open until debridement is performed. How will wound healing most likely occur?

Third-intention healing RATIONALE: Wound healing will most likely occur by third- intention healing because there is a time delay between the injury and the closure of the wound. Cutaneous stimulation and thermal (heat) application are unlikely to aid in wound healing. First- intention healing occurs in wounds that are closed immediately after injury.