Prevention of Pressure Ulcers
Always remain alert for signs of pressure on the client’s body (see Box 58-1). Be particularly observant when giving a bath or a backrub. The client may talk about painful spots. Report any signs of pressure or reddened/darkened areas that do not return to normal hue (color) after pressure is removed. Follow the suggestions in the text for all clients at risk and those with obvious skin breakdown (see also discussion of Braden Scale).
Nursing Alert Massage of the skin can help avoid skin breakdown. However do not rub or massage an already reddened or darkened area, because this added pressure may cause breakdown of small blood vessels, thereby worsening the skin’s condition.
BOX 58-2. Other Wounds Treated in a Manner Similar to That Used for Pressure Ulcers
♦ Frostbite (often treated as a burn)
♦ Thermal burns
♦ Venous stasis ulcers
♦ Diabetic ulcers (difficult to treat because of high blood sugar; compromised circulation, poor kidney function, and other complications of diabetes)
♦ Large gunshot wounds or other large open wounds (may be left open to heal from the inside outward)
♦ Surgical incisions that have become seriously infected or that have opened (dehiscence)
Turn and reposition immobile clients frequently to prevent pressure on any one body area. Lift clients who cannot lift themselves. Do not pull the client across bed linens, which could cause a shearing-force injury.
Assist clients to obtain adequate nutrition and hydration. Clients at risk should have a nutrition consult. To promote wound healing, a high-calorie, high-protein diet with supplemental vitamins (particularly vitamins A, C, and E) may be ordered. The client at risk often requires protein supplements between meals as well. It is also important to maintain adequate cellular hydration. The nurse is often ordered to encourage fluids (of varying types) for these clients. Rationale: It is important to maintain skin hydration and elasticity. Dry, scaly skin is more subject to breakdown than is well-hydrated skin.
Keep the skin free of external moisture and body fluids, such as urine and feces. External moisture, particularly when combined with continuous pressure, predisposes the skin to breakdown. Pathogens from an infected wound or feces can be dangerous, particularly where a skin break exists. The pelvic area is particularly vulnerable to skin breakdown in the incontinent client. Always wear gloves when caring for any wound. Wash hands thoroughly before and after any treatment.
Table 58-2 and Box 58-3 list preventive measures used for the client at risk for skin breakdown. It is important to remember that as soon as a skin break occurs, the path to infection is open. In addition, the individual client’s physical condition and probable extent and duration of illness or disability help determine the most effective prevention efforts. Many immobile clients are placed on special beds or mattresses, to help reduce pressure and prevent skin breakdown.
Key Concept Encourage all clients to move themselves as much as possible.The major consideration with regard to pressure ulcers is prevention. After an ulcer has developed, it is usually very difficult to treat.
WOUND HEALING
Wound healing differs according to how much tissue has been damaged. Wound healing occurs by first, second, and third intention (Fig. 58-6).
First-intention healing (healing by primary intention) occurs in wounds with minimal tissue loss, such as surgical incisions or wounds sutured (stitched) soon after injury. Edges are approximated (close to each other); thus, they seal together rapidly. Scarring and infection rates with firstintention healing are low.
BOX 58-3.
Prevention of Skin Breakdown
Skin, Mucous Membrane Protection
♦ Careful skin cleansing
♦ Drying powder and dry lubricants
♦ Humidification
Gauze or other protection between skin folds
♦ Heel protectors, if heel elevation not possible
♦ Hydrocolloids
♦ Incontinence pads
♦ Lip lubricant and careful oral hygiene
♦ Protective mittens (prevent scratching)
♦ Protective footwear for ambulatory clients
♦ Pouching devices (to catch drainage)
♦ Skin sealant/moisture barrier
♦ Topical antibiotics
♦ Transparent film to cover wounds
♦ Minimum layers of linens under the client
♦ Use of products such as Oxi-Ears and InterDry Silver nitrate
Pressure-Reducing Techniques
♦ Very frequent client examinations
♦ Turn/reposition client at least every 2 hours (with specific turning schedule)
♦ Use of logroll turns (prevent shear)
♦ Elevate heels off bed (better than padding heels)
♦ Elevate head of bed no more than 30 degrees (prevent shear)
♦ Nutritional consult, to determine best dietary plan
♦ Careful perianal care (use of protective creams, ointments, sitz baths, skin barriers)
♦ Careful personal hygiene (e.g., hair removal, nail care, oral hygiene)
♦ Careful use of Standard Precautions for all staff
Pressure-Reducing Devices
♦ Chair cushion
♦ Padding of chin and nose
♦ Elbow protectors
♦ Mechanical lifts
♦ Transfer board
♦ Trapeze over bed
♦ Use of turning sheet
♦ Positioning supports
♦ Specialty beds and mattresses
Second-intention healing (healing by secondary intention) occurs with tissue loss; the wound edges are widely separated. Secondary intention healing occurs in injuries such as deep lacerations, burns, and pressure ulcers. Because edges do not approximate (come together), openings fill with granulation tissue that is soft and pinkish. The granulation tissue grows in slowly and must grow in from the inside outward, to prevent abscess. When the granulation tissue is in place, epithelial cells grow over the top. (Drainage or other wound debris slows the healing process.) Scarring often occurs, and the risk of infection is greater than that for first intention healing. New technologies have been developed to treat such wounds more successfully; some of these are discussed in this topic.
FIGURE 58-6 · Wound healing. (A) First intention (most surgical incisions). Clean incision, early suturing, hairline scar. (B) Second intention (tissue must granulate in). Irregular wound, granulation, skin grows over scar (C) Third intention (wound edges brought together some time after wound occurs). Open wound, increased granulation. late suturing, wide scar.
Third-intention healing (healing by tertiary intention) occurs when there is a delay in the time between the injury and the closure of the wound. For example, a wound may be left open temporarily to allow for drainage or removal of infectious materials. This type of healing sometimes occurs after surgery when there is an infection, or in a large open wound when the wound is closed later. In the meantime, wound surfaces start to granulate in. Deep scarring almost always occurs.
Hundreds of products and procedures are in use today to assist in the healing of wounds. These include procedures such as electrical stimulation, diathermy, and hyperbaric chamber treatment; discussion of many of these is beyond the scope of this topic.
Medications
Some of the available wound care products are medications, such as antibiotics and antiseptics. Usually, the wound is cleaned and then patted dry with sterile gauze or other dressing.
Follow the provider’s orders carefully; in addition, read the instructions packaged with the medication. Apply the medication to the wound itself, but not to the skin’s edges unless ordered otherwise. Rationale: The medication may be damaging to surrounding tissues. In many cases, an open wound will be filled in with a prescribed cream or ointment. In the case of a large wound, this application is most often performed with a tongue blade. For smaller wounds or sinus tracts, a cotton-tipped applicator is used. (Oral or intravenous antibiotics and other medications are often given as well, to speed the healing process.) Table 58-3 presents wound care product categories, and Table 58-4 outlines the objectives of wound care and the products used.
Dressings
Many types of dressings are used to treat wounds. These include compression dressings and various types of manufactured dressing materials. Dressings serve to protect wounds from contamination, collect wound exudate (drainage, exuded material), assist in debridement, and protect against further damage during healing. The type of wound and its condition determine the type of dressing ordered and the frequency of dressing changes. The primary healthcare provider often orders the type and time for dressing changes; the team may be involved in this decision as well. Follow the policies of the healthcare agency. Always follow Standard Precautions for any wound care.
Key Concept The technique used for most dressing changes is clean technique, using sterile dressings. Unless otherwise ordered, the surgeon does the first dressing change after surgery or other procedure to close a wound. Rationale: It is important for the surgeon to assess the wound and determine if healing is taking place or if there is a concern.
Dry, Sterile Dressing
A dry, sterile dressing is often ordered for a wound to protect it from contamination (also known as a dry-to-dry dressing). This type of dressing is most often used for clean wounds healing by primary intention, such as surgical incisions. The materials used for this type of dressing include gauze (e.g., 2 X 2 or 4 X 4 gauze), Telfa pads, and larger abdominal (ABD) pads, also called Surgi-Pads (Fig. 58-7). These materials collect drainage and protect the wound. The used dressing is removed to evaluate healing, and a new, dry dressing is applied. In Practice: Nursing Procedure 58-1 outlines steps to follow when changing a dry, sterile dressing.
Nursing Alert All used dressings are disposed of in red biohazard bags, according to agency protocol. This is particularly important if there is any drainage or blood on the dressing, or if it has been used as a packing.
Wet-to-Dry Dressing
In some cases, debridement or cleansing of a wound can be accomplished by saturating a sterile dressing with normal saline or another sterile solution, placing the dressing on or packing it into the wound, and leaving it to dry.
TABLE 58-3. Wound Care Product Categories
|
PRODUCT CATEGORY |
EXAMPLES |
|
Hydrocolloid (comfortable, moderate absorption, used in shallow partial thickness wounds with minimal to moderate exudate). Promotes debridement of slough/soft eschar Do not use in infected or heavily draining wounds. |
Tegasorb, Duoderm, Comfeel |
|
Foam (absorption of exudates; used in full-partial thickness wounds and infected wounds). Does not stick to wound bed. Protects periwound skin. If used in tunneled wound, must also pack/fill sinus tract. Helps keep a shallow wound moist. |
Optifoam, Allevyn, Biatain nonadhesive |
|
Alginate and hydrofiber (minimal to heavy absorption, wound packing; used in moderate to heavily draining wounds). Gels as it absorbs; maintains moist wound bed; does not cause maceration of periwound skin; must be irrigated out of wound. |
Maxorb, Kaltostat, Seasorb Calcium Alginate |
|
Hydrogel—Amorphous (used in full-thickness wounds; dry to minimal exudates; necrotic and infected wounds). Used to promote debridement of dead tissue, to keep wound packing moist between dressing changes, and to add moisture to dry or necrotic wound bed. Best in cavity-type wound, but may cause maceration. |
Woun’Dres Hydrogel |
|
Hydrogel—Sheet (best in shallow [partial thickness] and necrotic, dry wounds). Will not stick to wound bed. Used in lightly draining wounds or to prevent moist wound bed from drying out—adds small amount of moisture to wound; bacteriostatic; will not cause maceration. Limited ability to absorb exudate. Usually requires a cover dressing. |
DermaGel sheet hydrogel |
|
Antimicrobial products (control or decrease microbes; used in contaminated wounds and in partial or fullthickness wounds). Preparations include alginate, hydrofiber hydrogel, foam, gauze, hydrocolloid, and so forth. |
AMD packing gauze, SeaSorb Ag |
|
Gauze (packing, absorption; used to pack full- or partial-thickness wounds, sinus tracts, cavities). Dries out unless used with another product, such as amorphous hydrogel or impregnated layer May stick to wound bed; may shred or give off lint in wound bed. |
Kerlix, Kerlix fluffs, packing gauze, Telfa nonadhesive dressings |
|
Impregnated gauze (used to pack cavity or to cover a dressing, to maintain moisture; used to dress full- or partial-thickness wounds; packing in cavities or sinus tracts). Easily conforms to shape of wound. |
Oil emulsion dressing |
This is called a wet-to-dry dressing. Wet-to-dry dressings are commonly used for infected wounds healing by secondary intention. An infected wound has exudate composed of serum, tissue debris, and infectious material or pus. The wound will not heal unless these substances are removed. The removal of infected or dead tissues to expose healthy tissues is called debridement. When the dried dressing is removed, tissue debris and drainage that sticks to it also are removed. Follow the steps outlined in In Practice: Nursing Procedure 58-1 to remove the old dressing and complete the dressing change.
FIGURE 58-7 · A large sterile ABD (abdominal) pad is used for a large wound. The "clean" nurse on the left holds the sterile package open so the nurse on the right can remove the ABD without contaminating it .
Key Concept The primary provider determines if debridement is appropriate or not. If a wound or pressure ulcer does not have adequate arterial blood flow to heal the ulcer, or if an ulcer contains stable, dry eschar and the circulation is questionable; current practice is to dry the wound and not debride. If a wound has adequate circulation to heal, it is kept moist and cleaned by debridement.
Nursing Alert Do not loosen a wet-to-dry dressing with normal saline or any other solution before removing the dried dressing material. Rationale: This would defeat the purpose of the intended debridement.
