Skin Integrity and Wound Care Management

By

Responsibilities

• Identify patients “at-risk” for wound healing

problems

• Initiate appropriate interventions for optimal

skin care

– Skin clean, dry, lubricated

• Recommend/initiate appropriate interventions

Skin Integrity Assessment

• During the first 24 hours of admission

• Involves the entire skin area, mucous

membranes, scalp, hair and nails.

• Observe color, temperature, moisture, skin

texture, vascularity and mobility.

Braden Risk Scale (1988)

• Initial assessment and re-assessment of a patient's risk for pressure ulcer development

• Six categories:– Sensory perception, skin moisture, physical

activity, nutritional intake, friction and shear, ability to change and control body positions.

• A Score of 6-12 is “High-Risk”– Scores range 6-23– Requires interventions

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK 

SENSORY Perception 

1. Completely Limited

2. Very Limited  3. Slightly Limited 4. No Impairment 

MOISTURE  

1. Constantly Moist

2. Very Moist  3. Occasionally Moist:

4. Rarely Moist 

ACTIVITY  

1. Bedfast  2. Chair fast 3. Walks Occasionally

4. Walks Frequently

MOBILITY 1. Completely Immobile

2. Very Limited 3. Slightly Limited 4. No Limitation

NUTRITION

1. Very Poor 2. Probably Inadequate

3. Adequate 4. Excellent

FRICTION & SHEAR

1. Problem 2. Potential Problem

3. No Apparent Problem

 BLANK

Braden Scale

• When:– Documented every 72 hours

– Significant change in clinical condition

• Where

– Nursing Notes or wound care sheet

Wound Assessment

• Assess wound color, size, depth, tunneling, and necrosis.

• Monitor for redness, firmness, pain, and swelling.

• Monitor dressings applied near the anus since they are difficult to keep intact.

• Types of wound exudate.

Documentation

• Document in the Nursing Assessment note:– Affected area – Patient's response to treatment.

• Measure wound (length x width x depth)• Describe tissue

– Red, Yellow, Black

• Drainage• Odor

Factors Affecting Wound Care• Older clients

• Premature infants

• Obesity

• Poor nutritional intake

• Compromised circulation

• Diabetes

Types of Wounds

• Blast injuries

• Penetrating trauma

• Burns

• Post-operative

• Pressure ulcers

Wound Dressings

Ideal Dressing– Protects wound– Keep wound bed moist– Keeps peri-wound skin dry

• Use basic dressing formulary– Meets institution’s needs– Consider caregiver’s time

Types of Dressings

• Gauze

• Wet to Dry

• Pressure bandage

• Telfa non-stick pad

Gauze

• Commonly used for abrasions and non-draining post-op incisions.

• Does not debride the wound.

• Moisten dressing with normal saline or water before removing woven gauze.

Wet-to-Dry

• Primary purpose is to mechanically debride a wound.

• Don’t apply a dressing that is too wet.

• Woven gauze should be used to pack wounds.

• Commonly used agents include normal saline and LR

Pressure Bandage

• Temporary treatment for control of excessive bleeding.

• Once pressure has been applied , it must continue until definitive actions can be executed.

• Bleeding source determines method and supplies needed

Transparent Dressing

• Clear, adherent, non-absorptive dressing that is permeable to oxygen and water vapor but not water.

• Pain and discomfort are diminished and the film conforms well to different body contours.

• Wound can be visualized without removing the dressing

Dressing Changes

• Use universal precautions; handwashing and change gloves.

• Know expected wound drainage.• Dispose of old dressing material

properly• Determine if drainage tubes are

present.• Done approximately 20min after an

analgesic is administered.

Protecting Skin

• Ensure surrounding skin remains clean, dry, and intact

• Apply skin protectant prior to applying dressing

• Use alternative dressing securing materials for sensitive skin

• Use adhesive removers as needed• Apply protective barriers to surrounding

skin as needed (Zinc Oxide)

Burn Wound Care

• One of two methods used for dressing burns.

• Open- burn remains open to air, covered only by a topical antimicrobial agent.

• Closed- antimicrobial agent is applied and then covered with gauze or a non-adherent dressing and wrapped with a gauze roll.

Wound Cleaning & Debridement

• Wash Hands• Use Appropriate precautions (clean

gloves, clean instruments)• Remove old dressing and dispose of

properly!• Remove wound care product residue.

(Betadine, Silvadene)• Pour saline directly from bottle or use a

bulb syringe

Debridement

• Mechanical- performed during dressing change; wounds should be rubbed sufficiently hard to remove debris.

• Enzymatic- use of topical agent to dissolve and remove necrotic tissue.

• Surgical- excising the wound to the level of the fascia

Questions

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References

• Brunner & Suddarth’s textbook of medical-

surgical nursing.-10th ed.

• Perry & Potter Clinical Nursing Skills &

Techniques: 3rd ed.

• Smith & Nephew: Skin & Wound Care A Hands-

On Guide.