Part 2 - Assessment, Terms and Skin Wound Care Products W 24(2)

Assessment, Terms and Wound/Skin Care Products

  • Course: PNR 220 Week 1

  • Date: 713099

Objectives

  • Recall skin, hair, nails & scalp assessments from PNR 116

  • Describe subjective and objective data in a skin and wound assessment

  • Differentiate between medical and surgical asepsis

  • Understand the purpose and types of wound care products

Skin Assessment

Key Characteristics

  • Colour: Evaluation of skin tone

  • Moisture: Assess hydration levels

  • Texture & Thickness: Observe surface quality and layer density

  • Temperature: Check warmth/coolness

  • Turgor: Assess skin elasticity

  • Mobility: Skin movement ease

  • Vascularity and Edema: Check blood flow and swelling presence

  • Lesions/Rashes: Identify any skin irregularities

Hair, Scalp & Nail Assessment

Hair Assessment

  • Colour: Assess natural or dyed pigmentation

  • Texture: Observe smoothness and brittleness

  • Distribution: Check hair coverage and patchiness

  • Lubrication: Evaluate natural oils

  • Lesions: Identify any skin issues on the scalp

  • Pest Inhabitants: Check for lice or pests

Nail Assessment

  • Shape/Contour: Inspect nail edges and curvature

  • Thickness: Assess nail strength

  • Capillary Refill: Evaluate blood circulation in nails

  • Cuticles: Assess condition and cleanliness

  • Cleanliness: General hygiene

Wound Assessment

Parameters to Evaluate

  • Size: Length, width, depth, tunneling, undermining

  • Base (Bed): Types of tissue present (granular, necrotic, etc.)

  • Drainage: Types (serous, sanguineous, purulent) and characteristics

  • Odour: Assess any unusual smells

  • Edges: Smoothness, definition (defined, jagged, unattached)

  • Periwound: Skin condition surrounding the wound

  • Pain: Scale of 1-10, quality, intensity, and triggers

Terms Used in Wound Care

Depth and Healing Types

  • Partial Thickness: Involves epidermis/dermis

  • Full Thickness: Extends into subcutaneous tissue

  • Acute: Normal healing process

  • Chronic: Delayed or failed healing process

Tissue Types

  • Eschar: Black/brown dry necrotic tissue

  • Slough: Yellow or white loose tissue

  • Granulation: Red-pink connective tissue

  • Epithelialization: Skin formation and contraction at the wound edge

Additional Terms in Wound Care

  • Maceration: Skin softening due to moisture

  • Induration: Firmness of tissue

  • Erythema: Redness from inflammation

  • Hyperkeratosis: Thickening of skin

  • Hemosiderin Staining: Discoloration indicative of venous issues

  • Lipodermatosclerosis: Thickened tissues under the skin, often in the legs

Examples of Wound Assessment

Documenting Incision Findings

  • Incision: 8cm long, well approximated with continuous suture intact.

  • Drainage: Scant amount, serous in nature.

  • Odour: No odour present.

  • Additional Observations: Yellow bruising on edges, pain rated 2/10 with specific triggers.

Documenting Pressure Ulcer Findings

  • Sacral Pressure Ulcer: 12cm x 8cm x 1.7cm, base 65% granular and 35% necrotic tissue.

  • Drainage: Large amount sero-sanguineous, no odour.

  • Edges: Defined and unattached.

  • Periwound Condition: Clear except for minor wound.

  • Pain: Rated 3-4/10, pain triggers documented.

Aseptic Technique

Overview

  • Aim: Minimize patient exposure to pathogens.

  • Medical Asepsis: Reduces micro-organism spread, includes hand hygiene and use of clean gloves.

  • Surgical Asepsis: Eliminates all organisms during procedures with sterile fields.

Principles of Medical Asepsis

  • Personal grooming practices

  • Frequent hand washing

  • Prevent contamination of clean items

  • Clean least soiled areas first

  • Proper disposal of soiled items

  • Limit exposure of hands to face

Principles of Surgical Asepsis

  • Maintain sterility of items and areas during procedures

  • Identify unsterile items

  • Aseptic principles must be strictly adhered to enhance patient care

Types of Wound Care Products

Categories

  • Wound Hydration: Hydrogels, Hydrocolloids, Films, Calcium Alginates, Hydro Fibers, Foams

  • Odour Management: Charcoal, Silvers, Cadexomer iodine

  • Specialty Products: Compression devices, Growth factors, Grafting options, Negative Pressure Wound Therapy (VAC)