Skin Integrity and Wound Care

Pressure Intensity: A classic research study identified capillary closing pressure as the minimal amount of pressure required to collapse a capillary (e.g., when the pressure exceeds the normal capillary pressure range of 15 to 32 mm Hg) (Burton and Yamada, 1951). Therefore, if the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur. If the patient has reduced sensation and cannot respond to the discomfort of the ischemia, tissue ischemia and tissue death result.

The clinical presentation of obstructed blood flow occurs when evaluating areas of pressure. After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, the skin turns red. The effect of this redness is vasodilation (blood vessel expansion), called hyperemia (redness). Evaluate an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia (Pieper, 2012). However, if the erythematous area does not blanch (nonblanching erythema) when you apply pressure, deep tissue damage is probable.

Blanching occurs when the normal red tones of the light-skinned patient are absent. It does not occur in patients with darkly pigmented skin. The Task Force on the Implications for Darkly Pigmented Intact Skin in the Prediction and Prevention of Pressure Ulcers (Bennett, 1995) defined darkly pigmented skin as skin that “remains unchanged (does not blanch) when pressure is applied over a bony prominence, irrespective of the patient’s race or ethnicity.” Characteristics of intact dark skin that alert nurses to the potential for pressure ulcers are in Box 48-2.

Pressure Duration: Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to duration of pressure. Both types of pressure cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death (Pieper, 2012). Clinical implications of pressure duration include evaluating the amount of pressure (checking skin for reactive hyperemia) and determining the amount of time that a patient tolerates pressure (checking to be sure after relieving pressure that the affected area blanches).

Tissue Tolerance: The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures. The extrinsic factors of shear, friction, and moisture affect the ability of the skin to tolerate pressure: the greater the degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from pressure. The second factor related to tissue tolerance is the ability of the underlying skin structures (blood vessels, collagen) to assist in redistributing pressure. Systemic factors such as poor nutrition, increased aging, hydration status, and low blood pressure affect the tolerance of the tissue to externally applied pressure.

Impaired Sensory Perception: Patients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity than those with normal sensation. Patients with impaired sensory perception of pain and pressure are unable to feel when a portion of their body undergoes increased, prolonged pressure or pain. Thus the patient who can’t feel or sense that there is pain or pressure is at risk for the development of pressure ulcers.

Impaired Mobility: Patients unable to independently change positions are at risk for pressure ulcer development. For example, patients with spinal cord injuries have decreased or absent motor and sensory impairment and are unable to reposition off bony prominences.

Alteration in Level of Consciousness: Patients who are confused or disoriented and those who have expressive aphasia or other inability to verbalize or changing levels of consciousness are unable to protect themselves from pressure ulcer development. Patients who are confused or disoriented are sometimes able to feel pressure but are not always able to understand how to relieve it or communicate their discomfort. Patients in a coma cannot perceive pressure and are unable to move voluntarily to relieve pressure.

Shear: Shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary (Bryant, 2012). For example, shear force occurs when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed (Fig. 48-3). It also occurs when transferring a patient from bed to stretcher and the patient’s skin is pulled across the bed. When shear is present, the skin and subcutaneous layers adhere to the surface of the bed, and the layers of muscle and the bones slide in the direction of body movement. The underlying tissue capillaries are stretched and angulated by the shear force. As a result, necrosis occurs deep within the tissue layers. The tissue damage occurs deep in the tissues, causing undermining of the dermis.

Friction: The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens is called friction (WOCN, 2010). Unlike shear injuries, friction injuries affect the epidermis or top layer of the skin. The denuded skin appears red and painful and is sometimes referred to as a “sheet burn.” A friction injury occurs in patients who are restless, in those who have uncontrollable movements such as spastic conditions, and in those whose skin is dragged rather than lifted from the bed surface during position changes.

Moisture: The presence and duration of moisture on the skin increases the risk of ulcer formation. Moisture reduces the resistance of the skin to other physical factors such as pressure and/or shear force. Prolonged moisture softens skin, making it more susceptible to damage. Immobilized patients who are unable to perform their own hygiene needs depend on the nurse to keep the skin dry and intact. Skin moisture originates from wound drainage, excessive perspiration, and fecal or urinary incontinence.

Partial-Thickness Wound Repair: Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers.

Tissue trauma causes the inflammatory response, which in turn causes redness and swelling to the area with a moderate amount of serous exudate. This response is generally limited to the first 24 hours after wounding. The epithelial cells begin to regenerate, providing new cells to replace the lost cells. The epithelial proliferation and migration start at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells only migrate across a moist surface. In a dry wound the cells migrate down into a moist level before migration can occur (Doughty and Sparks-Defriese, 2012). New epithelium is only a few cells thick and must undergo reestablishment of the epidermal layers. The cells slowly reestablish normal thickness and appear as dry, pink tissue.

Full-Thickness Wound Repair: The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and remodeling.

Hemorrhage: Hemorrhage, or bleeding from a wound site, is normal during and immediately after initial trauma. Hemostasis occurs within several minutes unless large blood vessels are involved or the patient has poor clotting function. Hemorrhage occurring after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (e.g., a drain). Hemorrhage occurs externally or internally. For example, if a surgical suture slips from a blood vessel, bleeding occurs internally within the tissues, and there are no visible signs of blood unless a surgical drain is present. A surgical drain may be inserted into tissues beneath a wound to remove fluid that collects in underlying tissues.

You detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock. A hematoma is a localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because pressure from the expanding hematoma obstructs blood flow.

External hemorrhaging is obvious. The nurse observes dressings covering the wound for bloody drainage. If bleeding is extensive, the dressing soon becomes saturated, and frequently blood drains from under the dressing and pools beneath the patient. Observe all wounds closely, particularly surgical wounds, in which the risk of hemorrhage is great during the first 24 to 48 hours after surgery or injury.

Infection: Wound infection is the second most common health care–associated infection (nosocomial) (see Chapter 28). According to the Centers for Disease Control and Prevention (CDC) (2001), a wound is infected if purulent material drains from it, even if a culture is not taken or has negative results. A sample of drainage from an infected wound does not always reveal bacteria because of poor culture technique or administration of antibiotics. Positive culture findings do not always indicate an infection because many wounds contain colonies of noninfective resident bacteria. In fact, all chronic dermal wounds are considered contaminated with bacteria. What differentiates contaminated wounds from infected wounds is the amount of bacteria present. It is generally agreed that wounds with more than 100,000 (10⁵) organisms per gram of tissue are infected (Stotts, 2012b). The chances of wound infection are greater when the wound contains dead or necrotic tissue, there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced. Bacterial wound infection inhibits wound healing.

Some contaminated or traumatic wounds show signs of infection early, within 2 to 3 days. A surgical wound infection usually does not develop until the fourth or fifth postoperative day. The patient has a fever, tenderness and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism (Table 48-2).

Dehiscence: When a wound fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing (e.g., poor nutritional status, infection, or obesity) is at risk for dehiscence. However, obese patients have a higher risk because of the constant strain placed on their wounds and the poor healing qualities of fat tissue (Camden, 2012). Dehiscence frequently involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. When there is an increase in serosanguineous drainage from a wound, be alert for the potential for dehiscence. A strategy to prevent dehiscence is to place a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure.

Evisceration: With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) occurs. The condition is an emergency that requires surgical repair. When evisceration occurs, the nurse places sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues is compromised. The presence of an evisceration is a surgical emergency. Immediately contact the surgical team, do not allow the patient anything by mouth (NPO), observe him or her for signs and symptoms of shock, and prepare him or her for emergency surgery.

Economic Consequences of Pressure Ulcers: Pressure ulcers are a continual problem in acute and restorative care settings. For adult patients with pressure ulcers, 56.5% were 65 years and older (WOCN, 2010). Paralysis and spinal cord injury are common preexisting conditions among younger adults with primary diagnosis of pressure ulcers. Older adults admitted to acute and long-term facilities are a vulnerable population. Among persons admitted to long-term care, 10.3% to 18.4% had one or more pressure ulcers on admission (Baumgarten et al., 2003; Siem et al., 2003).

When a pressure ulcer occurs, the length of stay in a hospital and the overall cost of health care increase. The actual cost of treatment is difficult to estimate. About 1.6 million patients each year in acute care settings develop pressure ulcers, representing a cost of $11 to $17.2 billion to the U.S. health care system (Pieper, 2012). Adult inpatient hospital stays with a diagnosis of pressure ulcers totaled $11 billion in 2006 (WOCN, 2010). Although it is difficult to get a handle on the exact numbers of pressure ulcers, the number of patients with pressure ulcers, and the cost, the occurrence of pressure ulcers is costly to patients in terms of disability, pain, and suffering and in the costs to institutions and third-party payers. The Centers for Medicare and Medicaid Services (CMS) implemented a policy effective October 1, 2008 whereby hospitals no longer receive additional reimbursement for care related to eight conditions, including stage III and IV pressure ulcers that occur during the hospitalization. This policy was put in place to provide additional incentives for hospitals to improve quality of care. Using guidelines such as the WOCN Guidelines (WOCN, 2010) helps reduce or eliminate the occurrence of pressure ulcers and prevent the expense that will not be reimbursed.

Predictive Measures: On admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities, assess individuals for risk of pressure ulcer development (WOCN, 2010). Perform pressure ulcer risk assessment systematically (WOCN, 2010). Use an assessment tool such as the Braden scale (see Table 48-3). The interpretation of the meaning of the total numerical scores differs with each risk-assessment scale. Lower numerical scores on the Braden scale indicate that a patient is at high risk for skin breakdown. A benefit of the predictive instruments is to increase a nurse’s early detection of patients at greatest risk for ulcer development. Once you identify these patients, institute the appropriate interventions to maintain skin integrity and implement prevention strategies (WOCN, 2010). Perform reassessment for pressure ulcer risk on a scheduled basis.

Mobility: Assessment includes documenting the level of mobility and the potential effects of impaired mobility on skin integrity. Documenting assessment of mobility also includes obtaining data regarding the quality of muscle tone and strength. For example, determine whether the patient is able to lift weight off of the sacral area and roll the body to a side-lying position. Some patients have adequate range of motion to move independently into a more protective position. Finally note the patient’s activity tolerance (see Chapter 38).

You must assess mobility as part of baseline data. If a patient has some degree of mobility independence, reinforce the frequency of position changes and measures to relieve pressure. The frequency of position changes is based on ongoing skin assessment; revise it as data change. Be meticulous when assessing pressure sites.

Nutritional Status: An assessment of patients’ nutritional status is an integral part of the initial assessment data for patients at risk for impaired skin integrity and wounds (Stotts, 2012a). Malnutrition is a risk factor for pressure ulcer development (Posthauer and Thomas, 2008). A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 pounds in a brief period are all signs of actual or potential nutritional problems (Stotts, 2012a).

Body Fluids: Continual exposure of the skin to body fluids increases a patient’s risk for skin breakdown and pressure ulcer formation (Box 48-6). Some body fluids such as saliva and serosanguineous drainage are not as caustic to the skin, and the risk of skin breakdown from exposure to these fluids is low. However, exposure to urine, bile, stool, ascitic fluid, and purulent wound exudates carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. Finally exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Again, it is important to prevent and reduce the patient’s exposure to body fluids; and, when exposure occurs, you need to provide meticulous hygiene and skin care.

Pain: Until recently there has been little research about pain and pressure ulcers. The WOCN (2010) has recommended the assessment and management of pain be included in the care of patients with pressure ulcers (Dallam et al., 2008). Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.

Emergency Setting: You see wounds in any setting, including clinics, emergency departments, youth camps, or your own backyard. The type of wound determines the criteria for inspection. For example, you do not need to inspect for signs of internal bleeding after an abrasion, but you should inspect in the event of a puncture wound.

When you judge a patient’s condition to be stable because of the presence of spontaneous breathing, a clear airway, and a strong carotid pulse (see Chapters 30 and 40), inspect the wound for bleeding. An abrasion is superficial with little bleeding and is considered a partial-thickness wound. The wound often appears “weepy” because of plasma leakage from damaged capillaries. A laceration sometimes bleeds more profusely, depending on the depth and location of the wound. For example, minor scalp lacerations tend to bleed profusely because of the rich blood supply to the scalp. Lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep cause serious bleeding. Puncture wounds bleed in relation to the depth and size of the wound (e.g., a nail puncture does not cause as much bleeding as a knife wound). The primary dangers of puncture wounds are internal bleeding and infection.

Inspect the wound for foreign bodies or contaminant material. Most traumatic wounds are dirty. Soil, broken glass, shreds of cloth, and foreign substances clinging to penetrating objects sometimes become embedded in the wound.

The size of the wound is the next step in assessment. A deep laceration requires suturing. A large, open wound may expose bone or tissue that needs to be protected.

When the injury is a result of trauma from a dirty penetrating object, determine when the patient last received a tetanus toxoid injection. Tetanus bacteria reside in soil and in the gut of humans and animals. A tetanus antitoxin injection is necessary if the patient has not had one within 5 years.

Stable Setting: When a patient’s condition is stabilized (e.g., after surgery or treatment), assess the wound to determine progress toward healing. If the wound is covered by a dressing and the health care provider has not ordered it changed, do not directly inspect it unless you suspect serious complications. In such a situation inspect only the dressing and any external drains. If the health care provider prefers to change the dressing, he or she assesses the wound at least daily. When removing dressings, take care to avoid accidental removal or displacement of underlying drains. Because removal of dressings can be painful, consider giving an analgesic at least 30 minutes before exposing a wound.

Wound Appearance: Observe whether wound edges are closed. A surgical incision healing by primary intention should have clean, well-approximated edges. Crusts often form along the wound edges from exudate. A puncture wound is usually a small, circular wound with the edges coming together toward the center. If a wound is open, the edges are separated, and you inspect the condition of tissue at the wound base. Also look for complications such as dehiscence and evisceration. The outer edges of a wound normally appear inflamed for the first 2 to 3 days, but this slowly disappears. Within 7 to 10 days a normally healing wound resurfaces with epithelial cells, and edges close. Table 48-5 lists assessment characteristics for abnormal wound healing in primary and secondary wounds. If infection develops, the area directly surrounding the wound becomes brightly inflamed and swollen.

Skin discoloration usually results from bruising of interstitial tissues or hematoma formation. Blood collecting beneath the skin first takes on a bluish or purplish appearance. Gradually, as the clotted blood is broken down, shades of brown and yellow appear.

Character of Wound Drainage: Note the amount, color, odor, and consistency of drainage. The amount of drainage depends on the location and extent of the wound. For example, drainage is minimal after a simple appendectomy. In contrast, it is moderate for 1 to 2 days after drainage of a large abscess. When you need an accurate measurement of the amount of drainage within a dressing, weigh the dressing and compare it with the weight of the same dressing when clean and dry. The general rule is that 1 g of drainage equals 1 mL of volume of drainage. Another method of quantifying wound drainage is to chart the number of dressings used and the frequency of change. An increase or decrease in the number or frequency of dressings indicates a relative increase or decrease in wound drainage. The color and consistency of drainage vary, depending on the components. Types of drainage include the following: serous, sanguineous, serosanguineous, and purulent (see Table 48-2). If the drainage has a pungent or strong odor, you should suspect an infection. Describe the appearance of the wound according to characteristics observed. An example of accurate recording follows:

Abdominal incision is 5 cm in length in RLQ; edges well approximated without inflammation or exudate. 1.2-cm diameter circle of serous drainage present on one 4 × 4 gauze changed every 8 hours.

Drains: The health care provider inserts a drain into or near a surgical wound if there is a large amount of drainage. Some drains are sutured in place. Exercise caution when changing the dressing around drains that are not sutured in place to prevent accidental removal. A Penrose drain lies under a dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into a wound (Fig. 48-10). It is usually the health care provider’s responsibility to pull or advance the drain as drainage decreases to permit healing deep within the drain site.

Assess the number of drains, drain placement, character of drainage, and condition of collecting equipment. Observe the security of the drain and its location with respect to the wound. Next note the character of drainage. If there is a collecting device, measure the drainage volume. Because a drainage system needs to be patent, look for drainage flow through and around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you need to notify the health care provider. When a drain is connected to suction, assess the system to be sure that the pressure ordered is being exerted. Evacuator units such as a Hemovac or Jackson-Pratt (Fig. 48-11) exert a constant low pressure as long as the suction device (bladder or container) is fully compressed. These types of drainage devices are often referred to as self-suction. When the evacuator device is unable to maintain a vacuum on its own, notify the surgeon, who then orders a secondary vacuum system (such as wall suction). If fluid accumulates within the tissues, wound healing does not progress at an optimal rate, and this increases the risk of infection.

Wound Closures: Surgical wounds are closed with staples, sutures, or wound closures. A frequent skin closure is the stainless-steel staple. The staple provides more strength than nylon or silk sutures and tends to cause less irritation to tissue. Look for irritation around staple or suture sites and note whether closures are intact. Normally for the first 2 to 3 days after surgery the skin around sutures or staples is edematous. Continued swelling may indicate that the closures are too tight. The skin can be cut by overly tight suture material, leading to wound separation. Early suture removal reduces formation of defects along the suture line and minimizes chances of unattractive scar formation.

Dermabond is a tissue adhesive that forms a strong bond across apposed wound edges, allowing normal healing to occur below. It can be used to replace small sutures for incisional repair. A vial containing the Dermabond solution is used to apply the product to approximated tissue. The wound edges are held together until the solution dries, providing an adhesive closure. Although generally used for small superficial lacerations, some surgeons use it on larger wounds where subcutaneous sutures are needed (Bruns and Worthington, 2000).

Palpation of Wound: When inspecting a wound, observe swelling or separation of wound edges. While wearing gloves, lightly press the wound edges, detecting localized areas of tenderness or drainage collection. If pressure causes fluid to be expressed, note the character of the drainage. The patient is normally sensitive to palpation of wound edges. Extreme tenderness indicates infection.

Wound Cultures: If you detect purulent or suspicious-looking drainage, obtaining a specimen of the drainage for culture may be necessary (see Chapter 28). Never collect a wound culture sample from old drainage. Resident colonies of bacteria from the skin grow within exudate and are not always the true causative organisms of a wound infection. Clean a wound first with normal saline to remove skin flora. Aerobic organisms grow in superficial wounds exposed to the air, and anaerobic organisms tend to grow within body cavities. Use a different method of specimen collection for each type of organism per agency policy (Box 48-7).

Gram stains of drainage are often performed as well. This test allows the health care provider to order appropriate treatment earlier than when only cultures are done. No additional specimens are usually required. The microbiology laboratory needs only to be notified to perform the additional test.

The gold standard of wound culture is tissue biopsy. A health care provider or wound care specialist with special training obtains the biopsy (Stotts, 2012b).

• Higher percentage of granulation tissue in the wound base

• No further skin breakdown in any body location

• An increase in the caloric intake by 10%

Prevention of Pressure Ulcers: When a patient is immobile, the major risk to the skin is the formation of pressure ulcers. Nursing interventions focus on prevention. The first step in prevention is to assess the patient’s risk factors for pressure ulcer development (Table 48-6). Plan on reducing or eliminating the identified risk factors.

Early identification of patients at risk and their risk factors helps you prevent pressure ulcers. Prevention minimizes the impact that risk factors or contributing factors have on pressure ulcer development. Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3) education (WOCN, 2010).

Management of Pressure Ulcers: Treatment of patients with pressure ulcers requires a holistic approach that uses the expertise of several multidisciplinary health care professionals (WOCN, 2010). In addition to the nurse, the health care provider, the wound care nurse specialist, physical therapist, occupational therapist, nutritionist, and pharmacist are involved. Aspects of pressure ulcer treatment include local care of the wound and supportive measures such as adequate nutrients and redistribution of pressure (Skill 48-2 on pp. 1215-1217).

When treating a pressure ulcer, reassess the wound for location, stage, size, tissue type and amount, exudate, and surrounding skin condition (Nix, 2012). Acute wounds require close monitoring (every 8 hours). Sometimes chronic wound assessment occurs less frequently. Depending on the topical management system, evaluate the wound with every dressing change, usually not more than 1 time per day.

The use and documentation of a systematic approach to monitor progress of an actual pressure ulcer leads to better decision making and optimum outcomes (Nix, 2012). Several healing and documentation tools are available to document wound assessments over time. Using a tool helps link assessment to outcomes so an evaluation of the plan of care follows objective criteria (Nix, 2012). For example, the Bates-Jensen Wound Assessment Tool (Harris et al., 2010) addresses 15 wound characteristics. You score individual items and calculate the sum total, providing an overall indication of wound status. The scoring assists in evaluating whether the goals of the wound management are effective.

Wound Management: Maintenance of a physiological local wound environment is the goal of effective wound management (Rolstad, Bryant, and Nix, 2012). To maintain a healthy wound environment, you need to address the following principles: prevent and manage infection, clean the wound, remove nonviable tissue, manage exudate, maintain the wound in a moist environment, and protect the wound.

A wound does not move through the phases of healing if it is infected. Preventing wound infection includes cleaning and removing nonviable tissue. Clean pressure ulcers only with noncytotoxic wound cleaners such as normal saline or commercial wound cleaners. Noncytotoxic cleaners do not damage or kill fibroblasts and healing tissue (Rolstad, Bryant, and Nix, 2012). Some commonly used cytotoxic solutions are Dakin’s solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide. These are not used in clean, granulating wounds.

Irrigation is a common method of delivering a wound-cleaning solution to the wound. Studies have shown that there is an optimal effective range of irrigation pressures that ensures adequate removal of bacteria (Gardner and Frantz, 2008). One method to ensure an irrigation pressure within the correct range is to use a 19-gauge needle or an angiocatheter and a 35-mL syringe that delivers saline to a pressure ulcer at 8 psi (Fig. 48-17).

Debridement is the removal of nonviable, necrotic tissue. Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.

The method of debridement depends on which is most appropriate to the patient’s condition and care goals (WOCN, 2010). It is important to remember that during the debridement process some normal wound observations to make include an increase in wound exudate, odor, and size. You need to assess and prevent or effectively manage pain that occurs with debridement (WOCN, 2010).

Methods of debridement include mechanical, autolytic, chemical, and sharp/surgical. One method of mechanical debridement is the use of wet-to-dry saline gauze dressings. Place moistened gauze into the wound and allow the dressing to dry thoroughly before “pulling” the gauze that has adhered to the tissue out of the pressure ulcer. This is a nonselective method of debridement because devitalized and viable tissues are both removed; thus it is not used routinely. Never use this method in a clean, granulating wound. Other methods of mechanical debridement are wound irrigation (high-pressure irrigation and pulsatile high-pressure lavage) and whirlpool treatments (Ramundo, 2012).

Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. You accomplish this by using dressings that support moisture at the wound surface. If the wound base is dry, use a dressing that adds moisture; if there is excessive exudate, use a dressing that absorbs the excessive moisture while maintaining moisture at the wound bed. Some examples of these dressings are transparent film and hydrocolloid dressings.

You can accomplish chemical debridement with the use of a topical enzyme preparation, Dakin’s solution, or sterile maggots. Topical enzymes induce changes in the substrate resulting in the breakdown of necrotic tissue (Ramundo, 2012). Depending on the type of enzyme used, the preparation either digests or dissolves the tissue. These preparations require a health care provider’s order. Dakin’s solution breaks down and loosens dead tissue in a wound. Apply the solution to gauze and apply to the wound. Sterile maggots are used in a wound because it is thought that they ingest the dead tissue.

Surgical debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument. Health care providers and in some states trained advanced practice nurses perform surgical debridement of an ulcer or wound. Nurses should check the Nurse Practice Act for their state to see if surgical debridement is a nursing function. It is the quickest method of debridement. It is usually indicated when the patient has signs of cellulitis or sepsis.

A moist environment supports the movement of epithelial cells and facilitates wound closure. A wound that has excessive exudate (drainage) provides an environment that supports bacterial growth, macerates the periwound skin, and slows the healing process. If excessive wound exudate is present, evaluate the volume, consistency, and odor of the drainage to determine if signs and symptoms of infection are present.

Remember, the wound will not heal unless the contributory factors are controlled or eliminated. Therefore it is critically important for you to address the causative factors (e.g., shear, friction, pressure, and moisture), or it is unlikely that the wound will heal despite topical therapy (Rolstad, Bryant, and Nix, 2012).

The treatment plan needs to be altered as a wound heals. For example, a transparent film dressing is used initially to autolytically debride (liquefy the tissue using body moisture) a necrotic wound. Once the wound is cleaned of necrotic tissue, discontinue the transparent film dressing; and, based on the wound base characteristics, choose a new dressing. A wound with excessive drainage requires a dressing with a high absorptive capacity. Continued reassessment is key to supporting the wound as it moves through the phases of wound healing.

First Aid for Wounds: In an emergency setting use first aid measures for wound care. Under stable conditions a variety of interventions ensure wound healing. When a patient suffers a traumatic wound, first aid interventions include stabilizing cardiopulmonary function (see Chapter 40), promoting hemostasis, cleaning the wound, and protecting it from further injury.

Dressings: The more extensive the wound, the larger the dressing required. In the home a clean towel or diaper is often the best secondary dressing. A bulky dressing applied with pressure minimizes movement of underlying tissues and helps immobilize the entire body part. A bandage or cloth wrapped around a penetrating object should immobilize it adequately.

Alternative dressings are available to cover and protect certain types of wounds such as large wounds, wounds with drainage tubes or suction catheters in the wound, and wounds that need frequent changing because of excessive drainage. Pouches or special wound collection systems cover these wounds and collect their drainage. Some of these devices have a plastic door on the front of the wound pouch, allowing you to change the packing without removing the pouch from the skin.

The use of dressings requires an understanding of wound healing. A variety of dressing materials are commercially available. The correct dressing selection facilitates wound healing (Rolstad, Bryant, and Nix, 2012). The dressing type depends on the assessment of the wound and the phase of wound healing. When you identify the objectives for the wound care, the dressing choice becomes clear. A wound that requires infection management requires a different set of dressings than one requiring the removal of nonviable tissue.

For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops. In contrast, when dressing a wound healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or assisting in debridement.

Comfort Measures: A wound is often painful, depending on the extent of tissue injury. Use several techniques to minimize discomfort during wound care. Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound. Administering analgesic medications 30 to 60 minutes before dressing changes (depending on the time of peak action of a drug) also reduces discomfort.

Cleaning Skin and Drain Sites: Although a moderate amount of wound exudate promotes epithelial cell growth, some health care providers order cleaning a wound or drain site if a dressing does not absorb drainage properly or if an open drain deposits drainage onto the skin. Wound cleaning requires good hand hygiene and aseptic techniques (see Chapter 28). You sometimes use irrigation to remove debris from a wound.

Suture Care: A surgeon closes a wound by bringing the wound edges as close together as possible to reduce scar formation. Proper wound closure involves minimal trauma and tension to tissues with control of bleeding.

Sutures are threads or metal used to sew body tissues together (Fig. 48-25). The patient’s history of wound healing, the site of surgery, the tissues involved, and the purpose of the sutures determine the suture material used. For example, if the patient has had repeated surgery for an abdominal hernia, the health care provider can choose wire sutures to provide greater strength for wound closure. In contrast, a small laceration of the face calls for the use of very fine Dacron (polyester) sutures to minimize scar formation.

Sutures are available in a variety of materials, including silk, steel, cotton, linen, wire, nylon, and Dacron. They come with or without sharp surgical needles attached. Steel staples are a common type of outer skin closure that causes less trauma to tissues than sutures while providing extra strength.

Sutures are placed within tissue layers in deep wounds and superficially as the final means for wound closure. Deep sutures are usually composed of an absorbable material that disappears over time. Sutures are foreign bodies and thus are capable of causing local inflammation. The surgeon tries to minimize tissue injury by using the finest suture possible and the smallest number necessary.

Policies vary within institutions as to who is able to remove sutures. If it is appropriate that the nurse remove them, a health care provider’s order is required. An order for suture removal is not written until the health care provider believes that the wound has closed (usually in 7 days). Special scissors with curved cutting tips or special staple removers slide under the skin closures for suture removal (Fig. 48-26). The health care provider usually specifies the number of sutures or staples to remove. If the suture line appears to be healing in certain locations better than in others, some health care providers choose to have only some sutures removed (e.g., every other one).

To remove staples, insert the tips of the staple remover under each wire staple. While slowly closing the ends of the staple remover together, squeeze the center of the staple with the tips, freeing it from the skin (see Fig. 48-26).

To remove sutures, first check the type of suturing used (Fig. 48-27). With intermittent suturing the surgeon ties each individual suture made in the skin. Continuous suturing, as the name implies, is a series of sutures with only two knots, one at the beginning and one at the end of the suture line. Retention sutures are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal. Never pull the visible portion of a suture through underlying tissue. Sutures on the surface of the skin harbor microorganisms and debris. The portion of the suture beneath the skin is sterile. Pulling the contaminated portion of the suture through tissues can lead to infection. Clip suture materials as close to the skin edge on one side as possible and pull the suture through from the other side (Fig. 48-28).

Drainage Evacuation: When drainage interferes with healing, evacuation is achieved by using either a drain alone or a drainage tube with continuous suction. You may apply special skin barriers, including hydrocolloid dressings similar to those used with ostomies (see Chapter 46), around drain sites. The skin barriers are soft material applied to the skin with adhesive. Drainage flows on the barrier but not directly on the skin. Drainage evacuators (Fig. 48-29) are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder and immediately reset the evacuator to apply suction.

Bandages and Binders: A simple gauze dressing is often not enough to immobilize or provide support to a wound. Binders and bandages applied over or around dressings provide extra protection and therapeutic benefits by the following:

Bandages are available in rolls of various widths and materials, including gauze, elasticized knit, elastic webbing, flannel, and muslin. Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation to prevent skin maceration. Elastic bandages conform well to body parts but are also for exerting pressure.

Binders are bandages that are made of large pieces of material to fit a specific body part. Most binders are made of elastic or cotton. An abdominal binder and a breast binder are examples.

Heat and Cold Therapy:

• Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified; and did the plan of care decrease the contribution of each of these components?

• Was wound healing supported by providing the wound base with a moist protected environment?

• Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing?

1. Because of the foul-smelling tan-colored drainage from Mrs. Stein’s hip incision, the staples were removed by the health care provider, and an order was written for moist saline gauze dressing to the area 3 times a day. When the dressing is removed, which factors are critical to assess?

2. A head-to-toe skin assessment is done per institutional policy on a daily basis. At the most recent assessment of Mrs. Stein’s skin, redness was noted over the sacral area; on direct examination a small area of denuded tissue was noted. The area was assessed and was found to have minimal depth and a red, moist base. How would you describe the impairment in skin integrity in your charting?

3. What will you include in your plan of care for Mrs. Stein to address the impairment in skin integrity in the sacral area?

4. Mrs. Stein will be discharged tomorrow. Which issues must be assessed regarding her care before discharge? Describe why these issues are of importance.

1. When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

2. Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

3. When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

4. After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

5. Which description best fits that of serous drainage from a wound?

6. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

7. Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

8. Which of the following describes a hydrocolloid dressing?

9. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

    10. When is an application of a warm compress indicated? (Select all that apply.)

    11. What is the removal of devitalized tissue from a wound called?

    12. Name the three important dimensions to consistently measure to determine wound healing.

    13. What does the Braden Scale evaluate?

    14. On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient’s pressure ulcer?

    15. Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.