Skin Integrity & Wound Care

Skin Integrity & Wound Care

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

Wound ComplicationsInfection

Hemorrhage

Dehiscence

Evisceration

Pressure Ulcers and Preventive Measures

DefinitionA wound caused by unrelieved pressure that results in damage to underlying tissue

Pressure-relieving measures:Frequent turning

Pressure-relieving devices

Positioning

Pressure Ulcer StagesStage I

Observable pressure-related alteration of intact skin

Stage IIPartial-thickness skin loss involving epidermis/dermis

Stage IIIFull-thickness skin loss involving damage of subcutaneous tissue, extending to, but not through, underlying fascia

Stage IVFull-thickness skin loss with extensive destruction or damage to muscle, bone, or supporting structures

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.

Assessments Made When Applying a Saline Moistened

DressingAssess 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.

Hydrocolloid DressingsDefinition

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

IndicationShallow to moderate-depth wounds with minimal drainage; stay in place for 3 to 7 days

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.

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

Securing Montgomery Straps to a Dressing

DefinitionPrepared strips of nonallergenic tape with ties inserted through holes at one endA skin barrier is often applied before the straps to protect the skin

IndicationsWounds that require frequent dressing changes, such as wounds with increased drainageThe straps allow for wound care without removing adhesive strips, decreasing skin irritation and injury

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

Biliary Drains or T Tubes

UsesPlaced 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

CareThe drainage amount is measured every shift, recorded, and included in output totals

A Biliary Drain or T-Tube Drain

Caring for a Jackson-Pratt Drain

UsesCollects 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

A Jackson-Pratt Drain

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

A Hemovac Drain

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

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

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.

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.

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.

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