Textbook Of Basic Nursing (Rosdahl) Chapter 58 - Special Skin And Wound Care

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four stages of a decubitus ulcer

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NANDA diagnoses related to wounds

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Impaired skin integrity
Acute pain
Fear
Imbalanced Nutrition

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barrier to protect the body from potentially harmful external environment

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the skin

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any abnormal break in the skin

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wound

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inspect the client's skin carefully upon admission to a facility, and frequently thereafter...

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for any signs of pressure or skin breakdown

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It is important to prevent skin breakdown

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and if it occurs, notify PCP

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* a physical injury causing a break in the skin or mucous membrane

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wound

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* rubbing off of the skin's surface, i.e. skinned knee

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abrasion

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* stab wound

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puncture

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* wound with torn edges, i.e. an accidental or self-inflicted cut

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laceration

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intentional, non-self inflicted wound

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surgical incision

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other types of abnormal skin conditions

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infections, rashes, lesions, and burns

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skin inspection includes both

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visual and palpation, with emphasis on bony prominences

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do not massage any discolored or reddened pressure points

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this can add to the irritation and accelerate skin breakdown

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Inspection sites include

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head, ears, heels, coccyx, shoulder blades, elbows, etc. as well as IV sites, NG tubes, tracheostomy tubes

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vascular ulcers may be evaluated with

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angiograms or laser Doppler, lab testing (biopsy, and wound culture)

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clear, thin, watery drainage

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serous

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composed of some serum and some blood

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serosanguineous

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contains pus

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purulent

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green, tan, yellow, red

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puss colors

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malodorous, no odor, sweet smelling

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puss odors

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drainage containing a great deal of protein and cellular debris

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exudate

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25% of dressing

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small

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30-60% of dressing

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moderate

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60-75% of dressing

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large/copious

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tunneling

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undermining

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can be rolled under, macerated, calloused, open

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wound edges

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intact, pink, erythema (redness), excoriated (scratch or abrasion), blistered, ecchymotic (hemorrhage spot), denuded (skin stripped away), macerated (moistened) etc.

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periwound area

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a ruler is used to measure the length and width of a wound

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linear measurement

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graph paper is used to duplicate the shape of a wound, include scale

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planimetry

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special video camera downloads to a computer, provides color images and some indication of depth

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stereophotogrammerty

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photos of the wound

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wound photography

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transparent paper may be laid over the wound and edges lightly traced

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wound tracing

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causes of skin breakdown

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immobility, inadequate nutrition, hydration levels, external moisture, mental status, sensory loss, fever, low bp, infancy

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moisture, meticulous skin care, located anywhere on the body, diffuse pattern, limited to dermis/epidermis

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Incontinence associated dermatitis

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pressure, turn often, bony prominances, surrounding bony areas only, may extend to muscle or bone

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pressure ulcer

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the rubbing of one surface against another

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friction

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the interaction of friction and gravity when tissue is moved across material

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shear

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develop most often in lower extremities as a result of local hypoxia

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venous stasis ulcer

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may occur in people who have diabetes mellitus

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diabetic ulcer

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pressure ulcers can also be complicated by

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yeast infections

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how to document pressure ulcers on a person at the time of admittacne

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"present on admission"

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primary factors of pressure ulcer development

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intensity and duration of pressure...and tissue tolerance of pressure

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these factors are considered in pressure ulcer development

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sensory perception, moisture level, activity, mobility, nutrition, friction/shear

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If the outside of a would is sealed before the before the area underneath has healed

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an abscess often forms, which may be sterile or infected

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new tissue that forms when old destroyed tissue is sloughed off

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granulation tissue

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if a client is transferring, with a wound...

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alert department and take steps to protect wound and prevent infection

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if an area is already reddened, do not

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rub or massage it

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to promote wound healing, a client should eat

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a high calorie, high protein diet with extra vitamin C

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many immobile clients can be aided by what devices to help prevent skin breakdown

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special beds or mattresses

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wounds with minimal tissue loss, such as surgical incision

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first intention (primary intention)

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occurs with tissue loss, the wound edges are widely separated, deep lacerations , burns and pressure ulcers

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second intention (secondary intention)

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there is a delay between the injury and the closure of the wound

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third intention (tertiary intention)

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Telfa pads, ABD pads and Surgi-pads function

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to collect drainage and protect the wound

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dressing intended to protect a wound from contamination

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dry, sterile dressing (dry-to-dry)

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debridement or cleansing or a wound by saturating a sterile dressing with normal saline or sterile solution, placing it on or into the wound, allow it to dry.

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wet-to-dry dressings, commonly used for infected wounds by secondary intention

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done most often with a puncture wound that has a sinus tract

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wound packing, which may be dry or impregnated with petrolatum or medication, special gel-foam or sponge material may also be used for this purpose.

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used on clean, open wounds or on wound that are granulating in

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wet-to-wet dressing

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When using duo-derm, be sure to get adequate coverage of the wound

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at least a 1 inch margin

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Penrose drain

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A. Jackson-Pratt B. Hemovac

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negative pressure device

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Vacuum Assisted Closure

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Infected wounds are still irrigated with sterile fluid because

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this helps prevent the introduction of additional pathogens

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suture staple removal after

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7-10 days

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When removing staples or interrupted sutures, remove

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every other one and inspect for dehissance

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antiseptic is applied to the skin prior to placement of steri strips

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because the antiseptic cleans the wounds and dries to help steri strips stick better

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clients with steristrips are encouraged to shower instead of baths

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to allow the steristrips to fall off naturally

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intact skin, firm/boggy/mushy skin, persistent redness ( blue/purple in darker skinned people)

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Stage I

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loss of epidermis, damaged dermis, partial thickness loss, shallow crater, blister-like appearance

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Stage II

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full thickness loss, subcutaneous tissue involved, fat may be visible, not painful, possible odor, may show undermining/tunneling

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Stage III

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full thickness loss, exposed bone, muscle, tendons, often extensive tunneling

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Stage IV

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(A) Occiput, rim of ear, dorsal thoracis area, elbow, sacrum/coccyx, heel
(B) side of head, shoulder, ischium, trochanter, anterior knee, malleolus,
(C) shoulder blade, sacrum coccyx, ischial tuberosity, foot, posterior knee