skin integrity and wound care

aka integument, the largest organ of the body and has mult fx. Has two layers, and an underlying layer, subcut layer, sometimes described as the third layer. (1) Top layer/outermost portion, the epidermis, and (2) the second layer of the skin, the dermis.

made up of the skin, the subcut layer directly under the skin, and the appendages of the skin including glands in the skin, hair, and nails. Also includes the blood vessels, nerves, and sensory organs of the skin. Skin is essential for maintaining life.

sometimes included in descriptions as the third layer of the skin. it's the underlying layer that anchors the skin layers to the underlying tissues of the body. Consists of adipose tissue, made up of lobules of fat cells, and connective tissue. This layer stores fat for energy, serves as heat insulator for the body, and provides a cushioning effect for protection. Contains blood and lymph vessels and fat cells.

the top layer/outermost portion. Composed of layers of stratified epithelial cells. These cells fuse to form a protective, waterproof layer of keratin material. Epithelial cells have no blood vessels of their own and depend on underlying tissues for nourishment and waste removal. When well nourished, epithelium regenerates relatively easily and quickly.

second layer of skin consists of a framework of elastic connective tissue. Nerves, hair follicles, glands, and BVs are located in this layer. Each hair consists of the shaft which projects through the dermis beyond the surface of the skin and the hair follicle, which lies in the dermis.

• 1. protection:
• - acts as a barrier to water, microorgs, and damaging UV rays of the sun
• - protection against infection
• - injury to underlying tissue and organs is decreased by intact skin
• - prevents loss of moisture from the surface and underlying structures
• 2. temp regulation:
• - evaporation of perspiration draws heat from the skin
• - BVs in the skin dilate to dissipate the heat
• - in cold conditions, BVs in skin constrict to diminish heat loss
• - in cold conditions, contraction of pilomotor muscles cause the hair to stand on end, forming a layer of air on the body for insulation (goosebumps/gooseflesh)
• 3. psychosocial:
• - external appearance is a major contributor to self-esteem
• - important role in ID and communication
• 4. sensation:
• - millions of nerve ends in the skin provide the sense of touch, pain, pressure, and temp
• - sensory impulses from the skin allow the body to adjust to the environment in conjunction w/the brain and spinal cord
• 5. vit D production:
• - a precursor for vit D is present in skin, which, in conjunction w/UV rays from the sun, produces vit D
• 6. immunological:
• - a breach in the surface of the skin triggers immunological responses in skin
• 7. absorption
• - substances, such as meds, can be absorbed through the skin for local and systemic effect
• 8. elimination:
• - water, electrolytes, and nitrogenous wastes are excreted in small amounts in sweat

line body cavities that open to the outside of the bod, joining w/the skin. can also be found in the digestive passages and the urinary and reproductive tracts. Epithelium covers the mucous membrane surfaces and contains cells that secrete mucus. The mucous membranes have receptors that offer the body protection. They're sensitive to temp, except in the mouth and rectum, but are sensitive to pressure. Also fx to absorb substances from their surface.

covers the mucous surfaces and contains cells that secrete mucus. Mucous membranes have receptors that offer the body protection. For example, an irritating substance in the upper resp tract causes a person to sneeze, and food caught in the larynx/trachea causes a person to cough. Sneezing and coughing are protective mechanisms that help rid the body of foreign materials.

• - unbroken and healthy skin and mucous membranes serve as the first lines of defense against harmful agents
• - resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, amount of underlying tissues, and illness conditions
• - adequately nourished and hydrated body cells are resistant to injury. The better nourished the cell is, the better able it is to resist injury and dz
• - adequate circulation is necessary to maintain cell life. When circulation is impaired for any reason, cells receive inadequate nourishment and cannot remove wastes efficiently

• - Lifestyle variables: 
• * homosexuality, hx of mult sexual partners; IV drug users; homophiliacs; bisexual male; partners of the above
•    > assessment needs to include careful exam of the skin for purple blotches that maybe indicative of Kaposi's sarcoma
•    > increase risk for infection with HIV and AIDS
• * occupation/any activity that gives an individual prolonged exposure to the sun
•    > Places individual at high risk for developing skin cancer, which has an excellent prognosis if detected and treated in its early stages but which may be fatal if treatment is delayed.
•    > Assessment needs to include careful examination for a sore that does not heal or a change in size or color of a wart or mole.
• * body piercing
•    > Potential interference with airway management. Potential risk for bacterial and viral infections, scarring, nerve damage, tissue trauma, and deformity.
•    > Assess patient’s knowledge of symptoms of infection at the site and when to seek medical care.
•    > Assess piercing site(s) for redness, swelling, discharge, or excessive pain at the site.
• - changes in health state
• * dehydration/malnutrition
•    > If fluid, protein, and vitamin C intake is deficient, skin loses elasticity and becomes prone to breakdown
•    > Nursing care is directed toward preventing skin breakdown: frequent changes of patient’s position with skin assessment at each change, special mattresses and protection of bony prominences, use of lotions, and attention to fluid and nutritional status.
• * reduced sensation (paralysis, local nerve damage, circulatory insufficiency)
•    > pt's inability to sense temp extremes, pressure, friction, and other such factors can easily result in injury 
•    > nursing care incorporates special attention to safety
• - Illness
• * Diabetes mellitus
•    > numerous factors combine to cause skin probs in diabetes mellitus pts; cuts and sores that don't heal, lesions on the lower extremities that ulcerate and become necrotic, and recurrect bact and fungal infections.
•    > Diabetic pt must be taught special hygiene measures to prevent trauma to the skin and learn to assess the skin carefully to detect any alterations
• - Diagnostic measures
• * GI series
•    > The GI cleansing preparations administered to patients having GI studies done may result in diarrhea, which irritates the sensitive skin in the perianal area—especially if the patient had bouts of diarrhea before the studies; anticipating the problem,noting redness and inflammation, and beginning warm baths and ointments are welcome nursing measures that patients may be too embarrassed to seek.
• - Therapeutic Measures
• * Bed rest
•     > Bed rest predisposes patients to skin breakdown; the harsh detergents used onhospital laundry compound this problem.
•     > Pressure points need to be examined frequently and protected.
• * Casts
•     > Casts easily irritate the skin; careful assessment, covering the rough edges of thecast, and skin care are indicated.
• * Aquathermia unit
•     > Wet heat has therapeutic benefit but, if applied to the skin for too long, maymacerate the skin; follow protocol in length of application, examine skin carefullybetween treatments, and allow to dry.
• * meds
•    > Medications may cause allergic skin reactions, such as rashes.
•    > When evaluating the patient’s response to a new drug, examine the skin for redness and itching.
• * Radiation Therapy
•    > Radiation therapy exposes normal skin cells as well as cancer cells in treatment field to effects of radiation, with the potential for erythema and moist desquamation (loss of skin integrity).

Cutting or sharp instrument; wound edges in close approximation and aligned

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruisingand/or hematoma

Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skinand tissue

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental

Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possiblyscattering throughout tissues

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Secretion of exotoxins or release of endotoxins by living organisms

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

High or low temperatures; cellular necrosis as a possible result

Ultraviolet light or radiation exposure

Compromised circulation secondary to pressure or pressure combined with friction

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction

Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure

• - in children younger than 2 yrs, the skin is thinner and weaker than it is in adults
• - an infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to and infection of the skin and mucous membranes
• - a child's skin becomes increasingly resistant to injury and infection
• - the structure of the skin changes as a person ages. The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

• - Proper nutrition, adequate circulation, and good overall health are important for healthy skin.
• - very thin and very obese people tend to be more susceptible to skin irritation and injury
• - fluid loss through fever, vomiting, or diarrhea reduces the fluid vol of the body. this is termed "dehydration" and makes the skin appear loose and flabby
• - excessive perspiration, often associated w/being ill, predisposes the skin to breakdown, esp in skin folds
• - jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. the skin is often itchy and dry, and pts w/jaundice are more likely to scratch their skin and cause an open lesion w/the potential for infection
• - dz of the skin such as eczema and psoriasis may have a genetic predisposition and often cause lesions that require special care

a break or disruption in the normal integrity of the skin and tissues. That disruption may range from a small cut on a finger to a third-degree burn covering almost all of the body. Wounds may result from mechanical forces (such as surgical incisions) or physical injury (such as a burn).

the result of planned invasive therapy or treatment. These wounds are purposefully created for therapeutic purposes. Examples of intentional wounds include those that result from surgery, intravenous therapy, and lumbar puncture. The wound edges are clean, and bleeding is usually controlled. Because the wound was made under sterile conditions with sterile supplies and skin preparation, the risk for infection is decreased, and healing is facilitated.

are accidental. These wounds occur from unexpected trauma, such as from accidents, forcible injury (such as a stabbing or a gunshot), and burns. Because the wounds occur in an unsterile environment, contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. These factors create a high risk for infection and a longer healing time.

occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.

results from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash. The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur.Examples include ecchymosis and hematomas.

such as surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is lessened. Acute wounds usually move through the healing process without difficulty.

do not progress through the normal sequence of repair. The healing process is impeded. The wound edges are often not approximated,the risk of infection is increased, and the normal healing time is delayed. Chronic wounds remain in the inflammatory phase of healing. Chronic wounds include any wound that does not heal along the expected continuum, such as wounds related to arterial or venous insufficiency, and pressure ulcers.

is a process of tissue response to injury. Injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue. The healing process fills the gap caused by tissue destruction, restoring the structural integrity of the damaged tissue through the orderly release of growth factors and chemical mediators. These substances help to increase the blood supply to the damaged area, wall off and remove cellular and foreign debris, and initiate cellular development. Normally, the healing process occurs without assistance.However, interventions can help to support the process. For example, tissue healing is promoted by keeping the injured area free of debris through proper cleaning. Positioning the wounded area to promote circulation to that part helps to promote tissue healing. Wound repair occurs by primary intention, secondary intention, or tertiary intention. Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention.Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing, although differences occur in the length of time required for each phase and in the extent of granulation tissue formed. Wounds healed by tertiary, or delayed primary, intention are those wounds left open for several days to allow edema or infection to resolve or exudate to drain, and then are closed.

wounds are approximated (skin edges tightly together). Intentional wounds w/minimal tissue loss, such as those made by a surgical incision w/sutured approximated edges, usually heal by primary intention.

wounds have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary. Wounds by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing, although differences occur in the length of time required for each phase and in the extent of granulation  tissue formed.

are those wounds left open for several days to allow edema or infection to resolve or exudate to drain, and then are closed

• • Intact skin is the first line of defense against microorganisms. A break in the integrity of the skin increases the risk for infection. Careful hand hygiene before caring for a wound is probably the single most effective method for preventing wound infections.
• • The body responds systemically to trauma in any of its parts. For example, a surgical incision can cause a variety of systemic reactions, including increased body temperature, increased heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes.
• • An adequate blood supply is essential for the body’s normal response to any injury. The blood transports increased numbers of leukocytes, erythrocytes, and platelets to the site of injury. Antibodies are carried by the plasma. Increased circulation to the injured part removes toxins and debris and provides nutrients and oxygen. Areas of the body with a good blood supply, such as the head and the neck, heal faster than areas in which the blood supply is not as great, such as the distal part of an extremity.
• • Normal healing is promoted when the wound is free of foreign material, such as excessive exudate, dead or damaged tissue cells, pathogenic organisms, or embedded fragments of bone, metal, glass, or other substances. In some situations,a collection of pus or foreign body is walled off and healing occurs around it to form an abscess.
• • The ability to handle altered skin integrity depends on theextent of the damage and the person’s general state ofhealth. The capacity to deal adequately with a wound islimited when a healthy person sustains a massive injury,when the patient has a chronic illness or a depressed immunesystem, or when the patient is very young or very old.
• • The body’s response to a wound is more effective if proper nutrition has been maintained.
•    • Undernourished patients are at greater risk for developing a wound infection because they have difficulty mounting their cell-mediated defense system associated with T lymphocyte activity, and some leukocytic functions are diminished in the presence of protein deficiency.
•    • Although the role of fatty acids in wound healing is not well understood, certain quantities of glucose are necessary to meet the energy requirements for wound healing.
•    • Various vitamins, minerals, and trace elements are also needed for efficient wound healing. Vitamin A is necessary for collagen synthesis and epithelialization. Vitamin B complex serves as a cofactor of enzyme reactions needed for wound healing. Vitamin C is needed for collagen synthesis, capillary formation, and resistance to infection.Vitamin K is needed for the synthesis of prothrombin. Zinc, copper, and iron assist in collagen synthesis. Manganese serves as an enzyme activator.

The wound healing process can be divided into phases; depending on the reference, healing occurs in three or four phases. These four phases systematically lead to repair of the injury: hemostasis, inflammation, proliferation, and maturation. If three stages are identified, hemostasis is included as part of the inflammatory stage.

occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing.

any fluid that filters from the circulatory system into lesions or areas of inflammation. Can be a pus-like or clear fluid.

follows hemostasis and lasts about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise.

a larger phagocytic cell; enters the wound area and remain for an extended period. They're essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels.

important for the growth of epithelial cells and new blood vessels (released by macrophages), and also attract fibroblasts that help to fill in the wound, which is necessary for the next stg of healing.

also known as the fibroblastic, regenerative, or connective tissue phase. The proliferation phase lasts for several weeks. New tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted. The new tissue, called granulation tissue, forms the foundation for scar tissue development. In wounds that heal by first intention, epidermal cells seal the wound within 24 to 48 hours, so the granulation tissue is not visible. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. Depending on the size of the wound, collagen deposit continues for several weeks or even years. By the end of the second week following the injury, the majority of white blood cells have left the wound area, and the wound is lighter in color. The systemic symptoms now typically disappear. During this phase, adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important patient care considerations. Wounds that heal by secondary intention eventually follow the same process but take longer to heal and form more scar tissue. Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue. Connective tissue healing and repair follow the same phases in healing, although differences occur in the length of time required for each phase and in the extent of granulation tissue formed.

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

final stage of healing begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited, which compresses the blood vessels in the healing wound, so that the scar. Wounds that heal by secondary intention take longer to remodel and form a scar smaller than the original wound; if the scar is over a joint or other body structure, it may limit movement and cause disability.

an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line. Scar tissue is strong but less elastic than uninjured tissue.

dehydration; the process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing. Wounds that are kept moist and hydrated experience enhanced epidermal cell migration, which supports epithelialization (epithelial cell migration to the wound bed).

overhydration of cells r/t urinary and fecal incontinence can lead to impaired skin integrity. This damage is r/t moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on the moist skin.

repeated trauma to a wound area results to delayed healing or the inability to heal.

edema at a wound site interferes w/the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.

bacteria in a wound increase stress on the body, requiring increased energy to deal w/the invaders. Infection requires large amounts of energy be spent by the immune system to fight the microorgs, leaving little or no reserves to attend the job of repair and healing. In addition, toxins produced by bact and released when bact die interfere w/ wound healing and cause cell death.

death of tissue; dead tissue appears as slough, moist, yellow stringy tissue, and eschar appears as dry, black, leathery tissue. Healing of the wound will not take place w/necrotic tissue in the wound. Removal of the dead tissue must occur for healing to begin.

this at the wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.

bacteria in a wound increase stress on the body, requiring increased energy to deal with the invaders. Infection requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job of repair and healing. In addition, toxins produced by the bacteria and released when bacteria die interfere with wound healing and cause cell death.

repeated trauma to a wound area results in delayed healing or the inability to heal.

disrupts the blood supply to the wound area. Persistent/excessive pressure interferes w/blood flow to the tissue and delays healing.

those occurring directly in the wound, include pressure, desiccation, maceration, trauma, edema, infection, and necrosis.

those occurring throughout the body, include age, circulation to and oxygenation of tissues, nutritional status, wound condition, health status, immunosuppression, and medication use.

The major skin layers arise from different embryologic origins, resulting in poor adherence between the epidermis and the dermis. This loose binding between the layers causes the layers to separate easily during an inflammatory process, placing infants and small children at risk for impaired skin integrity. Epidermal stripping, the unintentional removal of the epidermis with tape removal, is one type of such injury. Care should be taken to minimize tension, traction, and wrinkles on the skin when using tape on these patients. Children and healthy adults, however, heal more rapidly than do older adults, in whom physiologic changes caused by aging result in diminished fibroblastic activity and circulation. Older adults are more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process.

adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing. Certain physical conditions, because of their effect on circulation and oxygenation, can affect wound healing. Large amounts of subcut and tissue fat (which has fewer BVs) in ppl who are obese may slow wound healing because fatty tissue is more difficult to suture, is more prone to infection, and takes longer to heal. Circulation may be impaired in older adults and in ppl with PVDs, CVs, HTN, or diabetes mellitus. Oxygentation of tissues is decreased in ppl with anemia/chronic respiratory disorders and in those who smoke.

wound healing requires adequate proteins, carbs, fats, vitamins, and minerals. Calories and protein are necessary to rebuild cells and tissues. Vit A and C are essential for epithelialization and collagen synthesis. Zinc plays a role in proliferation of cells. Fluids are necessary for optimal fx of cells. All phases of wound healing process are slowed/inadequate in the pt w/poor nutritional status and fluid balance.

the condition of the wound also affects how quickly and effectively it heals. For example, large, contaminated, infected wounds/wounds that retain foreign bodies heal slowly. Sutures are needed to close surgical wounds. However, sutures also act as foreign bodies, so they are removed as soon as possible.

pts who are taking corticosteriod drugs/require postop radiation therapy are at high risk for delayed healing and wound complications. Coricosteriods decrease the inflammatory process, which may delay healing. Radiation depresses bone marrow fx, resulting in decreased leukocytes and an increased risk of infection. The prescence of a chronic illness (such as CVD or diabetes mellitus) or impaired immune fx can impair wound healing. Chemotherapeutic agents impair or stop proliferation of all rapidly growing cells, including cells involved in wound healing. Prolonged antibiotic therapy increases a pt's risk for secondary infection and superinfection.

suppression of the immune system as a result of dz (e.g., AIDS, lupus), meds (e.g., chemotherapy), or age (e.g., changes associated with advanced age) can delay wound healing.

complications include infection, hemorrage, dehiscence, evisceration, and fistula. These complications increase the risk for generalized illness and death, lengthen the pt's need for HC interventions, and add to HC costs.

bacteria can invade a wound at the time of trauma, during surgery, or at any time after the initial wound is more likely to become infected than one that is not contaminated. Additionally, the risk of infection is increased in a surgical wound created during a procedure involving the intestines because the risk for contamination with fecal material is high. Wound infections also occur as a result of HAIs. Symptoms of wound infection usually become apparent within 2 to 7 days after the injury/surgery; often the pt is at home. Symptoms of infection include purulent drainage; increased drainage, pain, redness, and swelling in and around the wound; increased body temp; and increased WBC count. Wound infections can lead to other complications, including osteomyelitis (bone infection) and sepsis (presence of pathogenic organisms in the blood/tissues)

may occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a BV by a foreign body, such as a drain. Check the dressing and the wound under the dressing, if possible, frequently during the first 48 hrs after the injury, and no less than every 8 hrs thereafter. If excessive bleeding does occur, additional pressure dressings/packing may be necessary, fluid replacement is probably necessary, and surgical intervention may be required. Internal hemorrhage causes the formation of a hematoma. If the bleeding leads to a a large accumulation of blood, it can put pressure on surrounding BVs and cause tissue ischemia (deficiency of blood to an area).

serious postop wound and serious medical emergency; is the partial/total separation of wound layers as a result of excessive stress on wounds that are not healed.

serious postop wound complication and a medical emergency; the most serious complication of dehiscence. The wound completely separates, with protrusion of viscera through the incisional area. Pts at greater risk for these complications include those who are obese/malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting or straining. An increase in the flow of fluid from the wound between postop days 4 and 5 may be a sign of an impending dehisence. The pt may say that "something has suddenly given way." If dehisence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Place pt in the low Fowler's position and cover the exposed abdominal contents, as discussed previously. Do not leave the pt alone. Notify the PCP immediately. This situation requires prompt surgical repair.

an abnormal passage from an internal organ to the outside body or from one internal organ to another. Fistulas may be created purposefully; for example, an arteriovenous fistula is created surgically to provide circulatory access for kidney dialysis. However, fistula formation is often the result of infection that has developed into an abcess, which is a collection of infected fluid that has not drained. Accumulated fluid applies pressure to surrounding tissues, leading to the formation of the unnatural passage. The prescence of a fistula increases the risk for delayed healing, additional infection, f/e imbalances, and skin breakdown.

a collection of infected fluid that has not drained

stressors include pain, anxiety, fear, and changes in body image.

is part of almost any trauma, from a small cut on a finger to a large incision made during abdominal surgery. Although pain can be considered a physical complication, it also has a large psychological component. Pain from wounds is often increased by activities such as ambulating, coughing, moving in bed, and dressing changes. The actual pain might be worsened by the pt's apprehension about such activities. Nursing interventions to reduce pain can greatly reduce emotional stress.

are common responses to a wound. Pts are apprehensive about the possibility of the wound opening, how much privacy will be lost as the wound is being cared for, and how they and others will react to the appearance and smell of the wound. When caring for pts with wounds, demonstrating acceptance and empathy, encouraging the expression of feelings, answering questions accurately and honestly, and avoiding excessive exposure to body parts when giving wound care are essential.

body image reflects a person's view of him/herself as a whole entity. When the skin and tissues are traumatized, that image is changed, requiring the person to adapt and reformulate the concept of self. Wounds and scars that are visible to others, esp on the face, can result in feelings of conspicuousness, ugliness, and diminished self-worth. Large scars, such as from removal of a breast or from creation of a colostomy opening, can seriously affect the person's sexuality, social relationships, and self-concept. Referral to support groups/counselors may be necessary to facilitate coping and acceptance of changes in body structure/function.

is a wound with a localized area of tissue necrosis. Depending on the depth of the ulcer, a pressure ulcer may be an acute wound/chronic wound. The underlying cause is pressure. Most pressure ulcers develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction. The terms "decubitus ulcer," "pressure sore," and "bedsore" are also used to refer to this type of wound. The term "pressure ulcer" is considered the most appropriate term because pressure is the most prominent underlying cause. Pressure ulcers are costly in terms of pt discomfort, disfigurement, decreased quality of life, and HC expenditures. Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, and altered lvl of consciousness. Other significant at-risk populations include individuals with spinal cord injuries, traumatic brain injuries, or neuromuscular disorders. When pressure ulcers occur, aggressive intervention and treatment can spare the pt unnecessary pain and discomfort,  prevent further tissue deterioration, hasten wound healing, and save million of HC dollars.

• 1. external pressure that compresses BVs
• 2. friction and shearing forces that tear and injure BVs and abrade the top layer of skin

• - occipital bone
• - scapula
• - vertebra
• - sacrum
• - coccyx
• - calcaneus
• - frontal bone
• - mandible
• - humerus
• - sternum
• - tuberosity of pelvis
• - patella
• - tibia
• - ribs
• - iliac crest
• - greater trochanter of femur
• - lateral knee
• - lateral malleolus
• - medial malleolus
• - posterior knee
• - ischium
• - sole of foot
• They occur over bony prominences. Of the most susceptible areas, most pressure ulcers occur over the sacrum and coccyx, followed by the trochanter and the calcaneous (heel).

deficiency of blood in a particular area

inadequate amount of oxygen available to cells.

occurs when two surfaces rub against each other. The injury, which resembles an abrasion, also can damage superficial BVs directly under the skin. A pt who lies on wrinkled sheets is likely to sustain tissue damage as a result of friction. The skin over the elbows and heels often is injured due to friction when pts lift and help move themselves up in bed w/the use of their arms and feet. Fiction burns can also occur on the back when pts are pulled/slid over sheets while being moved up in bed or transferred onto a stretcher.

results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small BVs and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Pts who are pulled, rather than lifted, when being moved up in bed or from bed to chair or stretcher are at risk for injury from shearing forces. A pt who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a pt who sits in a chair but slides down.

in addition to pressure, friction, and shear, these include immobility, nutrition and hydration (protein deficiency, protein-calorie malnutrition, vit C deficiency, and dehydration), skin moisture, mental status, and age. Additional risks include dehydration, incontinence, skin hygiene, diabetes mellitus, diminished pain awareness, fractures, hx of corticosteriod therapy, immunosuppression, multisystem trauma, poor circulation, previous pressure ulcers, and significant obesity/thinness.

becoming pale and white

is a blanchable reddening of the skin that occurs when pressure is removed. The body literally floods the area with blood to nourish and remove wastes from the cells. The area appears red and feels warm, but blanches when slight pressure is applied. Reactive hyperemia is not a pressure ulcer. After a pt who has been lying supine for 2 hrs is repositioned onto the side, any reddened area due to reactive hyperemia should fade within 60 to 90 mins. In pts w/ darkly pigmented skin, it may be best to assess for hyperemia by touch; the skin feels warm. Also, assess for some change in color relative to the surrounding skin. If the pressure continues after ischemia occurs, circulation is further impaired and a pressure ulcer develops. Appropriate intervention depends on early recognition of the stg of development of the pressure ulcer.

presents as purple/maroon localized area of discolored intact skin/blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. It may initially present as a painful, firm, mushy, boggy, warmer, or cooler area as compared to adjacent tissue.

is a defined area of intact skin w/nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may to have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

partial thickness loss of dermis presenting as a shallow open ulcer w/ a red pink wound bed, w/o slough. Presents as a shiny/dry shallow ulcer w/o slough/bruising (which indicates suspected deep tissue injury). May also present as an intact or open/rupture serum-filled blister. This stg should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

presents with full thickness tissue loss. Subcut fat may be visible but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of the tissue loss depends on the anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcut tissue, and stg II ulcers at these locations can be shallow. In contrast, areas with significant adipose tissue can develop extremely deep stg III pressure ulcers.

involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough/eschar may be present on some part of the wound bed and often include undermining and tunneling.

pressure ulcers are classified as unstageable when the basee of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, and must be removed. However, stable eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

a thick, leathery scab/dry crust that is necrotic (dead tissue) and must be removed before the stg can be determined accurately. Is tan, brown, or black in color.

generalized malaise, increased pain, anorexia, and an elevated body temp and pulse rate. Lab data indicating infection would be elevated WBC count and, if a wound culture has been done, a causative org.

an aggressive approach to prevent a pressure ulcer/manage the care of a pt who already has impaired skin integrity begins with a risk assessment form, which should be simple to use, reliable, and cost-effective. Several different scales are available to assess risk, such as the Norton scale and Braden scale. With these tools, a numeric score is assigned to each assessment area. The degree of risk is based on the pt's total score. Once a pt's risk has been IDed, agencies use different approaches. Appropriate interventions are initiated based on the pt's IDed risk. Many HC facilities use a specialized pressure ulcer assessment form. Documenting assessments is essential to ensure continuity of care, providing the foundation on which to develop the skin plan of care. All caregivers in the home/HC agency need to be aware of specific assessments,  including mobility, nutritional status, and moisture and incontinence.

physical condition, mental condition, activity, mobility, incontinence

mental status, continence, mobility, activity, nutrition; using the Braden scale, a score of 19 or 23 indicates no risk; 15 or 18, mild risk; 13 or 14, moderate risk; 10 or 12, high risk; and 9 or lower, very high risk.

• - albumin lvl <3.2 mg/dL (norm, 3.5-5 mg/dL)
• - prealbumin <19 mg/dL (norm, 16/-40 mg/dL)
• - body weight decrease of >15%
• additional lab tests to consider in pts at risk for or presenting w/pressure ulcers include:
• - total lymphocyte count <1,800/mm³ (norm, 1,000-4,000/mm³)
• - hemoglobin A1C >8% (norm, <6%)
• - glucose >120 mg/dL (norm, 70-120 mg/dL)

softening/disintegration of the skin in response to moisture

• - location of any lesion/ulcer
• - ID of the stg
• - size of the ulcer: length, width, depth; presence of undermining, a hollow between the skin surface and the wound bed, resulting from death of the underlying tissue
• - color and type of wound tissue
• - presence of any abnormal pathways in the wound, such as a sinus tract (a cavity/channel underneath the wound that has the potential for infection) or tunneling (a passageway or opening that may be visible at skin lvl, but with most of the tunnel under the surface of the skin). 
• - visible necrotic tissue; necrotic tissue that is in the process of separating from viable portions of the body is referred to as slough
• - prescence of an exudate/drainage (amount and type
• - presence of an odor
• - presence/absence of granulation tissue
• - visible evidence of epithelialization
• - periwound skin condition
• - RYB Wound Classification can be used as well

• can be used to aid in assessment and description of the pressure ulcer appearance. It's a color classification system termed "R(red) Y(yellow) B(black)" for open wounds (healing by secondary intention). This classification, w/related interventions, is based on the assessment of wound color. However, many wounds have red, yellow, and black components and are categorized as mixed wounds. When all colors are present, the wound is treated first for the most serious color: black, followed by yellow, and finally red.
• - R = Red = Protect
• Red wounds are in the proliferation stg of healing and reflect the color of normal granulation tissue. Wounds in this stg need protection w/nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations.
• - Y = Yellow = Cleanse
• Yellow color in the wound may indicate the presence of exudate (drainage) or slough and requires wound cleaning. These wounds are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage. Drainage can be whitish yellow, creamy yellow, yellowish green, or beige. To cleanse these wounds, nursing interventions include the use of wound cleansers and irrigating the wound.
• - B = Black = Debride
• Black in the wound may indicate the presence of an eschar (necrotic tissue), which is usually black but may also be brown, gray, or tan. The eschar require debridement (removal) before the wound can heal. These wounds are often cared for by advanced practice nurses who are educated in the care of more complex wounds. After debridement, the wound is treated as a yellow wound and then, as healing progresses, a red wound.

involves inspection (sight and smell) and palpation for appearance, drainage, odor, and pain. Wound assessment determines the status of the wound, identifies barriers to the healing process, and signs of complications.Accurate assessment provides essential baseline data and information to judge the effectiveness of treatment and wound healing progression. Skin integrity and wound assessment are performed at regular intervals, based on the nature of the wound and facility policy.

is composed primarily of the clear, serous portion of the blood and from serous membranes. Is clear and watery.

consists of large #'s of RBCs and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

a mixture of serum and RBCs. It is a light pink to blood tinged.

is made up of WBCs, liquefied dead tissue debris, and both dead and live bact. Purulent drainage is tick often has a musty/foul odor, and varies in color (such as a dark yellow/green), depending on the causative org.

used to hold tissue and skin together. Sutures may be black silk, synthetic material, or fine wire. Sutures are removed when enough tensile strength has developed to hold the wound edges together during healing. The time frame varies depending on the pt's age, nutritional status, and wound location. Frequently, after skin sutures are removed, small wound-closure strips of adhesive are applied across the wound to give additional support as it continues to heal.

are used to provide extra support for pts who are obese and for wounds w/an increased risk for dehiscence

provides sinus tract; example: after incision and drainage of abscess, in abd surgery. A Penrose drain is soft and flexible. This drain does nothave a collection device. It empties into absorptive dressingmaterial. It promotes drainage passively, with the drainage moving from the area of greater pressure, in the wound orsurgical site, to the area of less pressure, the dressing. Theyare not sutured in place. A sterile, large safety pin is oftenattached to the outer portion to prevent the drain from slippingback into the incised area. Care is necessaryto ensure that these drains are not dislodged during dressingchanges. Sometimes the physician orders a Penrose drainthat is to be shortened each day. To do so, grasp the end ofthe drain with sterile forceps, pull it out a short distancewhile using a twisting motion, and cut off the end of thedrain with sterile scissors. Place a new sterile pin at the baseof the drain, as close to the skin as possible.

for bile drainage; example: after gallbladder surgery

Closed drainage systems consist of a drainage tube thatmay be connected to an electrical suction device or have aportable built-in reservoir to maintain constant low suction.Examples include Jackson-Pratt drainage tubes and Hemovacs. These tubes are usually sutured to the skin. The closed drainage system prevents microorganismsfrom entering the wound from saturated dressings.Closed drainage systems also allow accurate measurementof drainage. Be sure to know which type of drain or tube wasinserted during surgery to ensure accurate assessments andinterventions. These systems must be emptied and the suctionreestablished according to the directions for eachdevice. This usually involves compressing the containerwhile the port is open, then closing the port after the deviceis compressed. Weargloves when emptying the drainage and do not touch theopen port to avoid contaminating the port.

decrease dead space by collecting drainage; example, after breast removal, abd surgery

decrease dead space by collecting drainage; example: after abd surgery, orthopedic surgery

allow healing from base of wound; example: infected wounds, after removal of hemorrhoids

• - disturbed body image
• - deficient knowledge r/t wound care
• - acute pain
• - chronic pain
• - impaired tissue integrity
• - readiness for enhanced knowledge: wound care may be appropriate for pts who request info about wound care at home
• - impaired skin integrity
• - activity intolerance
• - self-care deficit
• - risk for impaired skin integrity
• - risk for trauma

• - maintain skin integrity
• - demonstrate self-care measures to prevent pressure ulcer development
• - demonstrate self-care measures to promote wound healing
• - demonstrate evidence of wound healing
• - demonstrate increase in body weight and muscle size, if appropriate
• - remain free of infection at the site of the wound or pressure ulcer
• - remain free of s/s of infection
• - experience no new areas of skin breakdown
• - verbalize that the pain management regimen relieves pain to an acceptable lvl
• - be discharged to home within established parameters
• - demonstrate appropriate wound care measures before discharge
• - verbalize understanding of s/s to report and necessary follow-up care

Nurses have long recognized that pts w/alterations in skin integrity experience pain. Focus assessment on whether dressing changes, positioning in bed/in a chair/movements elicits any expressions of pain. Perform a pain assessment at each dressing change; measure and document the lvl of pain before, during, and after a procedure. Even if pain is never verbalized/expressed, always assume that pain is a definite possibility, and focus on comfort needs. Ask the pt about pain from the wound. If the pt experiences increased/constant pain from the wound, further assessments are necessary. Pain, esp when accompanied by an increased/purulent flow of drainage, may indicate delayed healing/infection. Surgical incisional pain is usually most severe for the first 2 to 3 days and then progressively diminishes.

• - assess the skin of pts at risk on a daily basis. pay particular attention to bony prominences.
• - cleanse the skin routinely and whenever any soiling occurs. Use a mild cleansing agent, minimal friction, and avoid hot water.
• - maintain higher humidity in the environment and use skin moisturizers for dry skin
• - avoid massage over bony prominences
• - protect the skin from moisture associated w/episodes of incontinence/exposure to wound drainage
• - minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin
• - investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional intervention as needed
• - continue efforts to improve mobility and activity. If this is unrealistic, attempt to maintain current lvl of activity, mobility, and ROM
• - document measures used to prevent pressure ulcers and the results of these interventions

an alternative to the side-lying position, results in significantly less pressure on the trochanter area.

such as pillows, foam wedges, or pressure-reducing boots can prove to be helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. Never use ring cushions, or "donuts," because they increase venous pressure. Minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.

an important part of managing pressure, friction, and shear on tissues. A support surface is a specialized device for pressure redistribution designed for management of tissue loads. Support surfaces are available in sizes and shapes to be used on beds, chairs, exam tables, and operating room tables. Support surfaces are pressure-reducing/pressure-relieving devices. The most common ones are seating devices (air, fluid-foam, or gel cushions), air-, gel-, or water-filled mattress overlays; static floatation mattresses; low-air-loss beds; and air-fluidized beds. It's important to individualize the type of support surface based on the pt's needs because none of these devices totally relieves pressure, continue to perform position changes at regular intervals.

wounds left open to the air heal more slowly because wound drying produces a dried eschar/scab. If the scab is removed accidentally before healing is complete, reinjury occurs, and the new delicate cells are exposed. Wounds left open are exposed to more environmental factors and potential injury. Closed wound care uses dressings to keep the wound moist, promoting healing. A moist environment is best for wound healing. Whe a dressing is placed over a wound, the wound fluid keeps the surface of the wound moist. As a result, epidermal cells migrate more rapidly, maximizing healing. In addition, covered wounds can help pts cope w/alterations in body image.

• - provide physical, psychological, and aesthetic comfort
• - prevent, eliminate, or control infection
• - absorb drainage
• - maintain a moist wound environment
• - protect the wound from further injury
• - protect the skin surrounding the wound
• - remove necrotic tissue, if appropriate

removal of devitalized tissue and foreign material

can be used to cover wounds, commonly closed surgical wounds. These dressings come in various sizes (2*2 inches, 4*4 inches, 4*8 inches) and are commercially packaged as single units or in packs. Gauze dressings often consist of 3 layers. The first layer of dressing material applied directly to a draining wound is often nonabsorbent but hydrophilic (i.e., capable of carrying moisture). This type of material allows drainage from the wound to move into overlying absorbent layers, helping to prevent maceration and reinfection. Moreover, this type of dressing is less likely to stick to the wound, making dressing changes more comfortable to the pt. Material to absorb and collect drainage is then placed over the first layer of nonabsorbant material. This material acts as a wick, pulling drainage out by capillary action. Absorbent cotton has far greater capillarity than untreated cotton. Therefore, cotton-lined gauze sponges soak up more liquid than do unlined sponges. The number of gauze sponges used in the dressing depends on the amount of drainage. Loosely packed gauze, the threads of which acts as numerous wicks, enhances capillarity and directs drainage upward and away from the wound. Fluffed and loosely packed dressings are more absorbent than tightly packed dressings. The top of the dressing may be further protected by surgical/abd pads, which are thick, absorbent pads that help to absorb profuse drainage.

Telfa's shiny outer surface is applied to the wound. These dressings allow drainage to pass through and be absorbed by the outer absorbent layer but prevent outer dressings from adhering to the wound and causing further injury when removed.

are placed over the smaller gauze dressings and absorb drainage and protect the wound from contamination/injury

are semipermeable membrane dressings that are adhesive and waterproof. These dressings are occlusive, decreasing the possibility of contamination, while allowing visualization of the wound. This type of dressing is often used over peripheral IV sites, central venous access device insertion sites, and noninfected healing wounds.

uses occlusive dressings, such as hydrocolloids/transparent films, and uses the body's own enzymes and defense mechanisms to loosen and liquefy necrotic tissue. This type of debridement can be used on any type of wound.

involves the use of sterile fly larvae. The larvae secrete an enzyme that liquefies dead tissue, which is ingested by the larvae, clearing the wound of bacteria and infection.

involves the application of commercially prepared enzymes to speed up the body's autolytic process.

uses external physical force to dislodge and remove debris and necrotic tissue. This could be achieved by wound irrigation with pulsed pressure lavage (washing), whirlpool therapy, ultrasound or laser treatment, or with surgical debridement.

in the past, it has been used to debride wounds, this is no longer considered good practice. This type of dressing dmages healthy wound bed tissue and can be painful. Concern exists that complete drying of the gauze disrupts angiogenesis. However, despite concerns by wound care experts, these dressings are often still prescribed by physicians for wound debridement.

• Purposes:
• • Maintain a moist wound environment
• • Minimal absorption of drainage
• • Facilitate autolytic débridement
• • Do not adhere to wound
• • Reduce pain
• • Most require a secondary dressing to secure
• Use:
• • Partial- and full-thickness wounds
• • Necrotic wounds
• • Burns
• • Dry wounds
• • Wounds with minimal exudate
• • Infected wounds

• Purpose:
• • Absorb exudate
• • Maintain a moist wound environment
• • Facilitate autolytic débridement
• • Requires secondary dressing
• • Can be left in place for 1 to 3 days
• Use:
• • Infected and noninfected wounds
• • Wounds with moderate to heavy exudate
• • Partial- and full-thickness wounds
• • Tunneling wounds
• • Moist red and yellow wounds
• • Not for use with wounds with minimaldrainage or dry eschar

• Purpose:
• • Maintain a moist wound environment
• • Do not adhere to wound
• • Insulate wound
• • Highly absorbent
• • Can be left in place up to 7 days
• • Some products need a secondary dressing to secure
• Use:
• • Absorb light to heavy amounts of drainage
• • Use around tubes and drains
• • Not for use with wounds with dry eschar

• Purpose:
• • Antimicrobial or antibacterial action
• • Reduce infection
• • Prevent infection
• Use:
• • Draining, exuding, and nonhealing wounds to protect from bacterial contamination and reduce bacterial contamination
• • Acute and chronic wounds

• Purpose:
• • Absorbent
• • Maintain a moist wound environment
• • Do not adhere to wound
• • Compatible with topical agents
• • Nonadherent
• • Conform well to the wound surface
• • Require secondary dressing to secure
• Use:
• • Partial- or full-thickness wounds
• • Infected and noninfected
• • Skin grafts
• • Donor sites
• • Tunneling wounds
• • Moist red and yellow wounds
• • Wounds with minimal to heavy exudate

• Purpose:
• • Combine two or more physically distinctproducts in a single dressing with severalfunctions
• • Allow exchange of oxygen between woundand environment
• • May facilitate autolytic débridement
• • Provide physical bacterial barrier andabsorptive layer
• • Semiadherent or nonadherent
• • Primary or secondary dressing
• Use:
• • Partial- and full-thickness wounds
• • Wounds with minimal to heavy exudate
• • Necrotic tissue
• • Mixed (granulation and necrotic tissue)wounds
• • Infected wounds

• • Use Standard Precautions; use appropriate Transmission-Based Precautions when indicated.
• • Perform hand hygiene and put on clean (nonsterile)gloves.
• • Remove tapes and dressings in the direction of hairgrowth to minimize trauma to the skin. Use a push–pullmethod; lift a corner of the dressing away from the skin,then gently push the skin away from the dressing.
• • Carefully lift the adhesive barrier from the surroundingskin. If there is resistance, use a silicone-based adhesiveremover, as this allows for the easy, rapid, and painlessremoval without the associated problems of skin stripping(Rudoni, 2008; Stephen-Haynes, 2008).
• • Slowly remove the dressing, noting the amount, type,color, and odor of the drainage.
• • Discard the dressing according to facility policy.
• • Remove gloves and perform hand hygiene.

Normal salinesolution (0.9% sodium chloride) is usually the agent ofchoice, particularly when cleaning pressure ulcer wounds.There are also commercially prepared cleansing spraysavailable for use. Woundirrigation is a directed flow of solution over tissues. Sterileequipment and solutions are required for irrigating an openwound, even in the presence of an existing infection. Sterile0.9% sodium chloride or sterile water, an antiseptic, or anantibiotic solution may be used, depending on the condition ofthe wound and the primary practitioner’s order. A sterile,large-volume syringe is used to direct the flow of the solution.After irrigation, open wounds may be packed with appropriatedressing materials to absorb additional drainage and allowhealing by secondary intention to take place. Nonsterile solutions are generally used to clean the skin surfaceif the wound edges are approximated.

• • Check the wound care order or nursing care plan.
• • Perform hand hygiene
• • Use Standard Precautions; use appropriate Transmission-Based Precautions when indicated.
• • Check the patient’s identification.
• • Explain what you are going to do to the patient.
• • Provide privacy by closing the door to the room andpulling the bedside curtain.
• • Put on gloves.
• • Cleanse the wound, and periwound skin, as prescribed.
• • Apply a skin barrier, such as Skin Prep®, to the areas ofskin where the dressing adhesive or tape will be placed;to areas around wound where drainage may come in contactwith skin.
• • Gently place the dressing at the wound center and extendit at least 1 inch beyond the wound in each direction.Alternately, follow the manufacturer’s directions forapplication.
• • Remove gloves when the dressing is in place, beforehandling tape, if used.
• • Do not apply tape under tension to prevent blisters andskin shearing.
• • Perform hand hygiene.

This is particularly important if there isdrainage from the wound. The skin protectant prevents skinirritation and excoriation from tape, adhesives, and wounddrainage.

• • Check the wound care order or nursing care plan.
• • Perform hand hygiene
• • Use Standard Precautions; use appropriate Transmission-Based Precautions when indicated.
• • Check the patient’s identification.
• • Explain what you are going to do to the patient.
• • Provide privacy by closing the door to the room andpulling the bedside curtain.
• • Cleanse the wound and periwound skin, as prescribed.
• • Apply a skin barrier, such as Skin Prep, to the areas ofskin where the dressing adhesive or tape will be placed;to areas around wound where drainage may come incontact with skin.
• • Moisten packing material, as necessary and as indicatedby the manufacturer’s directions or medical orders.
• • Loosely pack the wound cavity just until the wound surfacesand edges are covered. If tunneling is present, pack the tunnelingarea first, then the base of the wound. Alternately,follow the manufacturer’s directions for application.
• • Ensure all wound surfaces are covered and kept moist.
• • Do not allow packing to overlap the wound edges; macerationof surrounding tissues could occur.
• • Cover with appropriate top dressing.

can be used to secure dressings in place. Tapecomes in a wide variety of sizes and types, ranging in widthfrom 1 to 4 inches (1-inch-wide tape is the most commonlyused). Care must be taken to protect the skin surrounding thewound from injury-related irritation or shearing, or tearingof the skin during tape removal

can cause occlusion, allergy, skin maceration, and shearing. Used for strength, support, and economy. To secure dressings and splints, to strap joints to prevent athletic injuries, to immobilize or stabilize body parts, to provide pressure, and to approximate wound edges.

increased comfort, decreased allergic and skin problems. to close small wounds and to secure dressings.

used for compression/pressure dressings

are strips of cloth, gauze (e.g., roller gauze, Kerlix,Kling), or elasticized material (e.g., Ace bandages) used towrap a body part. They come packaged in rolls and vary inwidth from 1 to 6 inches.

are designed for a specificbody part and include slings, abdominal binders, chestbinders, and T-binders. They may be made of cloth (flannel,muslin) or of an elasticized material that fastens together withVelcro.

A roller bandage is a continuous strip ofmaterial wound on itself to form a cylinder or roll. Plaingauze, elastic webbing, and stretchable roller bandages aremade in various widths and lengths. Begin applying thebandage to the distal part of the area. The free end is held inplace with one hand while the other hand passes the rollaround the body part. After the bandage is anchored, the rollis passed or rolled around the body part, taking care to exertequal tension in all turns and rolling toward the heart, toavoid causing venous stasis and resulting edema. The bandagecan be applied using a circular turn, spiral turn, or figureof-eight turn. For each technique, keep tension equal by unwinding the bandage gradually and only with asmuch of a length as is required. Evenly overlap one-half totwo-thirds the width of the bandage with each turn, exceptfor the circular turn.

A circular turn is used primarily toanchor a bandage. In a circular turn, the bandage is wrappedaround the body part with complete overlapping of the previousbandage turn. Once the circular turn anchors the bandage,application continues, ascending in a spiral mannerusing a spiral turn. Each turn overlaps the preceding one byone-half or two-thirds the width of the bandage. The spiralturn is useful for the wrist, fingers, and trunk.

The figure-ofeightturn consists of making oblique overlapping turns thatascend and descend alternately. It is effective for use aroundjoints, such as the knee, elbow, ankle, and wrist.

Whenremoving a roller bandage, cut the bandage with bandagescissors to prevent excessive manipulation of the part. Cuton the side opposite the injury or the wound, from one end tothe other, so that the bandage can be folded open for itsentire length. If the bandage is to be reused, it may beunwound by keeping the loose end together and passing it asa ball from one hand to the other while unwinding it.

When applying a recurrentstump bandage, a few circular turns are made to anchor thebandage, and the initial end of the bandage is placed in the centerof the body part being bandaged, well back from the tip tobe covered. The bandage is passed back and forth over thetip, first on the one side and then on the other side of the centerpieceof the bandage. then a figure-of-eight turn to finish the bandage. Recurrent bandages are used for fingers,for the head, and for the stump of an amputated limb.

Of the many different kinds of binders, thoseused most commonly include straight binders, T-binders,and slings.

A straight binder is a straight piece of material,usually about 15 to 20 cm (6 to 8 inches) wide and longenough to more than circle the torso. It is used for the chestand the abdomen. Straight binders may be pinned or, morecommonly, fastened with Velcro.

A T-binder might be used to secure dressings on the rectumand perineum and in the groin. The single T-binder is used forfemale patients, the double T-binder for male patients. Thebelt is passed around the waist and secured, and the tails arepassed between the legs and fastened to the belt.

A sling is used to support an arm. Most healthcare agenciesuse commercial strap slings or sleeve slings. In thehome, a large piece of cloth folded into a triangle can beused as a sling

Montgomery straps use ties attachedto an adhesive backing to hold dressings in place. Protect thepatient’s skin with a skin barrier, such as Skin Prep, or a hydrocolloid dressing, prior to applying the Montgomerystraps. The adhesive backing is applied to the skin adjacentto the wound, with the ties extending over the wound area.When the dressing is changed, the strips are untied andturned back to allow for wound care. After applying the newdressing, the straps are tied over the dressing to hold it in place. Montgomery straps can be useful in preventingskin irritation and damage due to constant retapingwith dressing changes. Montgomery straps should bechanged when they become moist or soiled.

If assessment of the wound indicates a possible infection, it isimportant to culture the wound. Culturing the wound allowsidentification of the infecting organism(s) and appropriate interventions.

Fibrin glues were initially mixtures of bovine or humanfibrinogen, thrombin, and calcium. Newer fibrin sealants areconcentrated human clottable proteins and human thrombin.The sealant is applied to tissues during an operative procedureto stop bleeding and glue together epidermal surfaces.This allows for wound closure with minimal drainage orscarring. The glue is eventually metabolized and absorbedby the body. Dressings are not needed over these woundsbecause the skin is closed completely.

promotes wound healing andwound closure through the application of uniform negative pressure on the wound bed, 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 vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin. Cautious use is indicated in the presence of unrelieved pressure, anticoagulant therapy, poor nutritional status,and immunosuppressant therapy. Assess candidates for pre-existing bleeding disorders or the use of anticoagulants and other medications or supplements that prolong bleeding times, such as aspirin or ginkgo biloba. 

The application of heat or cold is sometimes used as part of the treatment of wounds. The application of heat accelerates the inflammatory response to promote healing. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort.

• • Use sterile techniques, following recommended CDC guidelines for care of wounds.
• • Perform hand hygiene before and after the procedure.
• • Explain the procedure to the patient. Describe the sensation that will be experienced as a pulling or slightly uncomfortable experience.
• • Use proper technique to remove and dispose of old dressings.
• • Clean the incision from the center of the wound outward, according to agency policy and procedure for type of agent.
• • Remove every other suture or staple to be sure wound edges are healed; if they are, remove remaining sutures or staples as ordered.
• • Remove or reapply dressing, depending on physician preference and agency policy.
• • Remember that some physicians order Steri-Strip application to the healed wound after removal of staples or sutures to give additional support to the wound as it continues to heal. Follow agency protocol and physician preference for placement of these tapes.

• 1. Use a sterile suture removal kit.
• 2. Using the sterile forceps, grasp the knot of the first suture and gently lift the knot.
• 3. Using the sterile scissors, cut one side of the suture below the knot close to the skin.
• 4. Grasp the knot with the forceps and pull the cut suture through the skin (be sure to pull through the healed wound only the portion of the suture that has been inside the tissue).

• 1. As directed on the package, gently position the sterile staple remover under the staple to be removed.
• 2. Firmly close the staple remover to straighten the staple ends (do not lift upward while disengaging staple ends).
• 3. Carefully lift upward with the closed staple remover to remove the staple from the incision line. It may be necessary to remove one end of the staple and then the other if it does not easily lift out.

Documentation related to wound care is an important nursingresponsibility. Clear and accurate documentation isessential for communication of wound status and tracking ofthe progression of healing. Precise documentationcontributes to continuity of care, accurate evaluation ofcare, and appropriate changes in wound care, if necessary.Use a skin and wound assessment tool to accurately recordassessment findings and treatment interventions.

by cells in the hypothalamus in response to signals from thermal (heat and cold) receptors located close to the skin's surface). Stimulation of these receptors sends sensory messages to the anterior hypothalamus to initiate mechanisms to dissipate heat (through vasodilation and sweating) or to preserve warmth through vasoconstriction and piloerection (“goose bumps”). Pain receptors, also located near the skin’s surface, are also affected by heat and cold as painful stimuli, with excessive heat perceived as burning and excessive cold experienced as numbness followed by pain.

Wound edges are widely separated and brought together with closure material. (With third-intention healing, the wound edges are widely separated and are later brought together with some type of closure material. First-intention healing, also called healing by primary intention, is a reparative process in which the wound edges are directly next to each other. In second-intention healing, the wound edges are widely separated, leading to a more time-consuming and complex reparative process. However, edges that are near or close to each other do not require closure material.)

• • Insufficient protein and vitamin C intake 
• • Weak tissue and muscular support due to obesity 
• • Distension of the abdomen from accumulated intestinal gas 
• (The nurse should remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distension of the abdomen from accumulated intestinal gas are the likely causes of surgical complications. Premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; or compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complication. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are the factors that interfere with wound healing.)