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
NUTRITIO
N
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 nondraining 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 nonadherent 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 HandsOn Guide.