Management of Skin Disorders

Protecting the Skin

\-Mild soap

\-Rinse skin completely and blot dry

\-Avoid fragrant soaps

\-Avoid hot water

\-Add moisture

\-Stay hydrated

\-Careful repositioning

\-Gentle removal of dressings

Identifying Inflammation in Darker Skin Tones

Purple-gray cast

Erythematous/Edematous/Wet

\-Moisture wicking dressings

\-Soothing lotions

Dry/Scaly

\-Emulsions

\-Creams

\-Ointments

\-Pastes

Administering Therapeutic Interventions

\-Therapeutic Baths

\-Topical Preparations

\-Intralesional Therapy

\-Systemic Medications

\-Dressings

Hemostasis Pathophysiology

Wound filled by fibrin clot

Inflammatory Pathophysiology

\-Neutrophils enter the wound to destroy bacteria and remove debris

\-Macrophages arrive to contenu clearing debris

Proliferative Pathophysiology

\-Granulation tissue fills wound bed with connective tissue

\-New blood vessels are formed

\-Epithelium starts to cover the wound

Remodeling Pathophysiology

\-Collagen matures

\-Structural integrity returns

\-Epidermis regrows

Primary Intention

\-Edges are minimally separated

\-Stitches, staples, skin glue, sterilization-strips

\-Rapid ingrowth of wound healing cells

\-Fast healing

\-Minimal scaring

Secondary Intention

\-Edges are separated and gap cannot be closed

\-Granulation from wound base to surface

\-Healing occurs slowly

\-Large scar

Tertiary Intention

\-Combination of primary/secondary

\-Edges are minimally separated

\-Wound is too heavily contaminated for primary closure

\-Wound allowed to drain, cleansed and then sutured after granulation has occurred

\-Creates more connective scar tissue than other intentions

Acute Wound

Less than 4 weeks

Chronic Wound

Greater than 4 weeks

Superficial Tissue Loss

Loss of epidermis only

Partial Thickness Tissue Loss

Loss of epidermis and dermis

Full Thickness Tissue Loss

\-Loss of dermis

\-SubQ fat

\-Sometimes fat

Pressure Ulcer Definition

\-Breakdown of skin due to prolonged pressure, friction, shearing, insufficient blood supply

\-Typically at bony prominences

Pressure Ulcer Risks

\-Prolonged immobility

\-Prolonged pressure on tissue

\-Altered skin moisture

\-Equipment

\-Altered sensory perception/cognition

\-Decreased nutritional status

\-Friction/shear forces

\-Skin changes related to aging

Pressure Ulcer Complications

\-Infection

\-Osteomyelitis

\-Quality of life impairment

Skin Tear: Clinical Manifestations

Separation of skin layers caused by friction, shear, or blunt force

Skin Tear Classification Type 1

\-No skin loss

\-Linear or flap

\-Be repositioned to cover the wound bed

Skin Tear Classification Type 2

\-Partial flap loss

\-Cannot be repositioned to cover the wound bed

Skin Tear Classification Type 3

\-Total flap loss

\-Exposes entire wound bed

Skin Tear: Risk Factors

\-Older adults

\-Patients who require assistance with ADLs

Skin Tear Treatment

\-Reduce shearing forces

\-Dressings: non adherent, foam, hydrogel

Braden Scale

\-On admission

\-Every 24 hours

\-With each significant change in patient condition

What should you implement if Braden Scale is

STAND skin bundle

Wounds must be evaluated within ____ hours of admission

24

When should photos of wound be attained?

\-On admission

\-Significant change

\-Discharge

S for STAND

Score on Risk Scale

T for STAND

Turn and Offload/Reposition Tubes and Devices

A for STAND

Apply barrier cream or border foam dressing

N for STAND

Nutritional Intervention: Oral Nutrition Supplement

D for STAND

Discuss with Specialist

What should you assess in Wound Assessment?

1. Type of wound
2. Stage (pressure injury only)
3. Location
4. Wound measurement
5. Tunneling
6. Undermining
7. Wound Description
8. Drainage Characteristics and Odor
9. Drainage Amount
10. Wound Progress
11. Pain during Evaluation

Tunneling

\-Destruction of fascial planes leading to a narrow passageway

\-Dead space form, which can lead to abscess formation

Undermining

\-Erosion under the wound edges, resulting in large wound with small opening

\-May occur in multiple directions

Measuring/Evaluating Tunneling

\-Gently probe with cotton applicator until resistance is felt

\-Depth=Distance from tip of probe to point where probe is level with wound edge

\-Clock terms are used to identify where tunnel is located

Measuring/Evaluating Undermining

\-Gently probe under wound edge with cotton applicator until resistance is felt

\-Depth=Distance from tip of probe to point where probe is level with wound edge

\-Clock terms are used to identify where undermining is located

Granulation

Pink or beefy red tissue with shiny, moist, granular appearance

Epithelial

New or pink shiny tissues that grow in for the edges or as islands on wound surface

Slough

Yellow to white tissue that may be stringy, thick, or moist in appearance

Necrotic/Eschar Tissue

Black or brown tissue that can be dry or moist in appearance

Peri-Wound

Tissue surrounding wound up to 4cm from edge of wound

Descriptive Words for Peri-Wounds

\-Blanchable vs. non-blanchable

\-Ecchymotic

\-Excoriated

\-Indurated

\-Petechiae

\-Redness

\-Warm

\-Dry

\-Intact

\-Pink

Descriptive Word for Wound Edge

\-Well approximated

\-Not approximated

\-Dehiscence

Serous Drainage Color

Clear/straw-colored

Serous Drainage Consistency

Thin, watery

Serous Drainage Example

Fluid inside a blister

Sero-sanguineous Drainage Color

Clear, pink tinged

Sero-sanguineous Drainage Consistency

Thin, watery

Sero-sanguineous Drainage Example

Fluid from surgical drain

Sanguineous Drainage Color

Red, bloody

Sanguineous Drainage Consistency

Thin

Sanguineous Drainage Examples

\-Hematoma

\-Bleeding after surgery

Purulent Drainage Color

Yellow, green

Purulent Drainage Consistency

Thick

Purulent Drainage Examples

\-Abscess

\-Cellulitis

\-Infection

Catarrhal Drainage Color

Mucus-like

Catarrhal Drainage Consistency

Thick

Catarrhal Drainage Examples

Nasal infections

Fibrinous Drainage Color

Cloudy

Fibrinous Drainage Consistency

Stringy

Fibrinous Drainage Examples

Adhesions

Mechanical Debridement

Wet-to-dry dressings or irrigation

Autolytic Debridement

Uses an occlusive dressing to trap moisture

Enzymatic Debridement

Topical ointments or dressings are used to dissolve necrotic tissue

Gauze

Dry woven material used in a wide variety of applications

What is gauze useful in?

Mechanical debridement

Normal Saline

Preferred cleanser for most wounds as it is physiologic (always safe)

Povidone Iodine

\-Broad spectrum antimicrobial

\-Drying effects, discolors skin

\-Can be cytotoxic to healthy cells

Hydrogen Peroxide

\-Effervescent cleaning action helps to lift debris from wound surface

\-Ineffective at killing bacteria

\-Cytotoxic to healthy cells

Dakin’s

\-Dilute solution of sodium hypochlorite (bleach)

\-Kills pathogenic microorganisms, can be mildly cytotoxic to healthy cells

Occlusive Dressings

\-Plastic film that covers a topical medication or is used as a secondary dressing

\-Enhances absorption

Occlusive Dressings Applications

\-Burns

\-Chest tube sites

Transparent Dressings

\-Thin, transparent, polyurethane, semi-permeable adhesive films

\-Permit visualization of the wound, reduce friction, promote autolysis

Transparent Dressings Uses

\-Partial thickness

\-Minimally draining or closed wounds

Foam Dressings

\-Non-adherent

\-Can be left in place for up to 7 days

\-Moisture is absorbed into foam layer

\-Helpful in bony prominences

Impregnated Dressings

\-Made from a variety of materials

\-Saturated with a solution, emulsion, oil, or other agent/compound

\-Moisture Retentive

\-Antimicrobial

Moisture-Retentive Dressings

\-Impregnated with saline-solution, petroleum, or zinc salts

\-Non-adherent, and helpful for wide partial thickness wounds with minimal exudate

\-Occlusive or semi-occlusive

\-Autolytic debridement

Antimicrobial Dressings

Impregnated with topical anti fungal or antibiotic agents

\-Silver, iodine, CHG, PHMB

Specialty Absorptive Dressings

\-Absorb copious amount of drainage

\-Non-adherent

\-Heavily exudating

Alginate Dressings

\-Seaweed and consist of absorbent calcium alginate fibers

\-Useful in highly irritated/macerated areas

\-Non-adherent

\-Heavily exudating

Hydrogel Dressings

\-Water content of 90-95%

\-Can be impregnated sheets or gel in a tube

\-High moisture content helps with autolytic debridement

\-Soothing

\-Non-adherent

\-Semi-permeable

Hydrocolloid

\-Water-impermeable, polyurethane outer covering separated from wound

\-As water evaporates over wound, it is absorbed into the dressing

\-Dressing is non-adherent, occlusive or semi-occlusive

\-Can be left in place for up to 7 days for non-infected stage 2 pressure ulcers

Collagen Dressings

\-Variety of materials, typically animal source

\-Stimulate wound and accelerate wound healing enzymatic debridement

\-Left in place for up to 7 days

\-Helps exudating wounds that are partial to full thickness

\-Non-adherent

What dressings are used for wound packing/covering?

\-Alginate

\-Antimicrobial

\-Collagen

\-Gauze

\-Specialty absorptive (not tunneling)

What dressings are used for wound covering?

\-Foam

\-Hydrocolloid

\-Hydrogel

\-Moisture-retentive

\-Transparent

\-Occlusive

Advanced Wound Care

\-Grafts

\-Debridement

\-Larval therapy

\-Drains

\-Negative-pressure Therapy

\-Hyperbaric Oxygen Therapy

Grafts

\-Tissue engineered skin

\-Cadaveric skin: skin donation, risk for infection

\-Autograft: no rejection, from patient’s own skin

Surgical Debridement

Used with large amount of non-viable tissue

Larval Therapy

\-Larvae produce secretions that induce proteolytic enzymes

\-Antibacterial action

Surgical Drains

Promote healing by keeping excess pressure off incision

\-Open system

\-Closed systems

Penrose Drain

Open

Jackson Pratt (JP)

\-Closed

\-Operates by self-suction

Hemovac

\-Closed

\-Operates by negative pressure. via spring-loaded canister

Negative Pressure Therapy

\-Wound vac creates negative pressure to help shrink wound

\-Remove fluid

\-Stabilize wound environment

Indicated for large, soft tissue wounds that cannot be repaired surgically

Hyperbaric Oxygen Therapy

Pt. breathes 100% oxygen while under an increased atmospheric pressure chamber

Hyperbaric Oxygen Therapy Utilization

\-Limb-threatening diabetic wounds of the lower extremities

\-Pressure ulcers

\-Hypoxic vascular wounds of the lower extremity