PSW wound care and skin breakdown

• PSW responsibilities when caring for clients with wounds include overall observation, prevention of pressure sores, and ensuring pain and comfort.
• Also included are movement and ambulation, dressing, nutrition and hydration, oxygenation, odour management, and temperature regulation.
• Additional responsibilities are skin care, maintaining skin integrity, and being aware of complications and concerns.

Common Causes of Skin Breakdown

• Age-related changes, dryness, and fragile capillaries can cause skin breakdown.
• General skin thinning and loss of the fatty layer under the skin also contribute.
• Decreased sensation, decreased mobility, and prolonged sitting or lying down increase the risk.
• Chronic diseases like diabetes and hypertension and conditions that decrease circulation are also causes.
• Poor nutrition, hydration, incontinence, and moisture in dark body areas are risk factors for skin breakdown.
• Pressure on bony parts and poor care of fingernails/toenails can lead to skin breakdown.
• Friction and shearing forces can also damage the skin.

Wound Care

• The skin is the body's first line of defense against microbes and infection.
• Preventing skin injury and providing good skin care are crucial in preventing skin breakdown.
• Infants, older adults, and clients with disabilities are at the greatest risk for skin injuries.
• A wound is a break in the skin or mucous membrane and can result from surgery, trauma, immobility, or poor circulation.
• Infection is a major threat when an injury occurs.
• Wound care involves preventing infection, preventing further injury, preventing blood loss, and preventing pain.
• The role in wound care depends on job description, client's condition, and provincial or territorial laws.

Types of Wounds

• Wounds are described as intentional or unintentional, open or closed, and clean, clean-contaminated, contaminated, or infected.
• They are also classified as chronic or partial- and full-thickness wounds.
• Intentional wounds are created for treatment (e.g., surgical incisions).
• Unintentional wounds result from trauma (e.g., falls).
• Open wounds involve a break in the skin or mucous membrane.
• Closed wounds involve injury to tissues without breaking the skin (e.g., bruises).
• Clean wounds are uninfected, and microbes have not entered.
• Clean-contaminated wounds result from surgical entry into the urinary, reproductive, or digestive system.
• Contaminated wounds are unintentional and not created under sterile conditions, with a high infection risk.
• Infected (dirty) wounds contain a high amount of bacteria with signs of infection.
• Chronic wounds do not heal easily in a timely manner (e.g., pressure ulcers).
• Partial-thickness wounds involve broken dermis and epidermis.
• Full-thickness wounds involve penetrated dermis, epidermis, and subcutaneous tissue, possibly involving muscle/bone.

Wound Descriptions

• Abrasion: Scraping away or rubbing of the skin.
• Contusion: Blow to the body causing a bruise.
• Incision: Clean, intentionally cut into the skin.
• Laceration: Torn, jagged edges.
• Penetrating wound: Skin and underlying tissues pierced.
• Puncture wound: Open wound caused by a sharp object.

Skin Tears

• A skin tear is a break or rip in the skin, where the epidermis separates from the underlying tissues.
• Common sites include the hands, arms, and lower legs.
• Causes of skin tears include friction, shearing, pulling, pressure, bumping, and tight holding.
• Repositioning, bathing, dressing, and zippers across frail skin can also cause skin tears.
• Skin tears are painful and act as portals for microbes to enter.
• Tell the supervisor if a skin tear, bruise, bump, or scrape is caused or found.
• People at risk for skin tears need help moving, have poor nutrition or hydration, altered mental awareness, or are older.
• Careful and safe care helps prevent skin tears and further injury.

Guidelines for Preventing Skin Tears

• It is important to keep nails short and filed.
• Do not wear rings when providing care to a client.
• A turning sheet can be used to help reposition the client to avoid skin tears.
• Prevent friction during moving or positioning.
• Transfer or position the client gently.

Pressure Ulcers

• Pressure ulcers, also known as decubitus ulcers or bedsores, are injuries from unrelieved pressure on the skin or underlying tissue.
• They usually occur over bony prominences, such as shoulder blades, elbows, hips, sacrum, knees, ankles, heels, and toes.
• Skin that are pressure points are moister and are especially prone to developing pressure ulcers.
• Pressure, shearing, and friction are common causes of pressure ulcers.
• Risk factors include breaks in the skin, poor circulation, moisture, dry skin, and irritation from urine and feces.
• Clients at risk include those confined to a bed or chair, needing help moving, with loss of bowel/bladder control or altered mental awareness.
• Risk also apply to those with poor nutrition, sensing pain or pressure problems, circulatory issues, older age, or are obese/very thin.
• Signs of possible pressure ulcers are pale or greyed skin, warm or reddened areas, and complaints of pain or itching.
• Some clients may not feel anything unusual.
• A supervisor must be notified of these signs.
• Pressure is most likely to be felt on bony areas called pressure points.
• Pressure on the ears can be caused by eyeglasses, tubing, or the mattress when in the side-lying position.
• Obese people may develop pressure ulcers where skin is in contact (abdominal folds, legs, buttocks, thighs, and breasts).

Pressure Ulcer Stages

• Stage 1: The skin is intact but there is usually redness over a bony prominence. The colour does not return to normal when pressure is relieved.
• Stage 2: Partial-thickness skin loss with skin cracks, blisters, or peels.
• Stage 3: Full-thickness skin loss where the skin is gone. There may also be drainage coming from the area.
• Stage 4: Full-thickness tissue loss with muscle, tendon, and bone exposure.
• Stage 5: Pressure ulcer cannot be staged due to necrosis.

Pressure Ulcer Sites

• Occipital bone
• Scapula
• Spinous process
• Elbow
• Iliac crest
• Sacrum
• Ischium
• Achilles tendon
• Heel
• Sole
• Ear
• Shoulder
• Anterior iliac spine
• Trochanter
• Thigh
• Medial knee
• Lateral knee
• Lower leg
• Medial malleolus
• Lateral malleolus
• Lateral edge of foot
• Posterior knee

Prevention and Treatment of Pressure Ulcers

• Preventing pressure ulcers is much more effective than trying to heal them.
• Essential aspects of prevention include good support care, cleanliness, and skin care.
• The health team must develop a plan of care for each person at risk.
• Clients at risk are placed on surfaces that reduce or relieve pressure.
• The doctor, NP, or wound care nurse can order wound care products, drugs, treatments, and special equipment to promote healing.

Protective Devices

• Special beds and bed cradles are used to prevent skin breakdown.
• Elbow protectors and heel elevators are also helpful to protect from this issue.
• Gel/fluid filled flotation pads and cushions, egg crate-like mattresses, pillows, trochanter rolls and foot boards help too.

Leg and Foot Ulcers

• Some diseases affect blood flow to and from the legs and feet, causing ulcers.
• Edema is swelling caused by fluid collecting in tissues.
• Gangrene is a condition in which there is death of tissue.
• Infection and gangrene can result from an open wound and poor circulation.
• Circulatory ulcers (vascular ulcers) is an open sore on lower legs or feet.
• Circulatory ulcers are from decreased blood flow through the arteries or veins.
• Those with blood vessel diseases are at risk of developing these painful and resistant-to-healing wounds.
• Venous ulcers, or statis ulcers, are open sores on the lower legs or feet caused by poor blood flow through the veins.
• They develop when valves in the legs do not close well.
• The veins cannot pump blood back to the heart in a normal way.
• Blood and fluid collect in the legs and feet.
• The heels and inner ankle are common sites for venous ulcers.
• Venous ulcers can occur from skin injure or without trauma which cause pain during walking and increase infection risk.
• Signs of venous ulcers are edema in tissue giving a swollen appearance.
• Skin may appear shiny or stretched.
• Walking may be difficult and painful
• If edema lasts long time, skin change appearance and texture where it becomes dry, brown, leathery, and hard

Arterial Ulcers

• Arterial ulcers are open wounds on the lower legs or feet caused by poor arterial blood flow.
• These are caused by diseases or injuries which decrease the arterial blood flow to the legs and feet.
• The doctor treats the disease to heal these ulcers.
• A doctor's orders for prevention and treatment are: drugs and wound care, walking and exercise, and/or professional foot care.
• Foot care can't be provided to those with an arterial ulcer unless specified in their care plan to prevent further injury.
• Arterial ulcers may cause the affected leg or foot to feel cool, and appear grey or blue or shiny.
• These may be painful during rest and usually worsen at night.
• Common sites for arterial ulcers are: between toes, on top of toe, outer side of ankle, and heels.

Wound Healing has Three Phases

• Inflammatory phase (3 days): Bleeding stops, with a scab forms over the wound which increases blood supply to bring nutrients. Redness, swelling, heat & warmth with loss of function & pain.
• Proliferative phase (Day 3 to Day 21): The tissue multiplies to repair the wound.
• Maturation phase (Day 21 to 1-2 years): the scar gains strength.
• Follow treatment as directed by a health professional to prevent and improve care for arterial ulcers.
• This includes specialized wound care, prescription heel protectors and shoes and elevating legs at rest.

Prevention and Treatment

• Prevent injury is essential for wound treatment along with good transferring techniques.
• People at risk need professional foot care to prevent potential wound development.
• A doctor may order drugs to prevent infection and decrease swelling.
• Medicated bandages and other wound care products can be ordered.
• Devices can be used to prevent pressure ulcers on patients in need.
• A doctor may order elastic stockings for patients to wear, and elastic bandages to help as well.

Complications of Wounds

• Many factors affect wound healing and increase the risk of complications
• Some of these factors include the type of wound, age & general health of client and/or their lifestyle, circulation, nutrition, immune system changes & medications.

Hemorrhage and Shock

• Hemorrhage is excessive blood loss in short period of time which can be internal/external.
• External internal bleeding is not seen but can lead to bloody tissues.
• Visible bloody draining occurs in external hemorrhaging where dressings are blood soaked in blood.
• Hemorrhage can lead to shock which leads to not enough blood supply to the organs where low/falling blood pressure with a rapid heartbeat.
• Shock leads to confusion and the client may be restless in need of thirst.
• External symptoms entail rapid respirations and moist skin.

Dehiscence and Evisceration

• Infection can occur at time in a wound which can entail tenderness to touch or drainage which may lead to fever.
• Dehiscence and evisceration are surgical emergencies.
• Dehiscence separation of wound layers.
• Evisceration and separation of wound and protrusion of organs can follow coughing.

Wound Appearance

• Doctors and nurses have to be able to observe wounds and any drainage.
• A support worker has to give accurate observations when giving wound care.
• The amount and type of drainage depend on wound size, wound location, bleeding etc.
• There are different methods of removing drainage from a wound for healing to prevent bacterial contamination.

Wound Drainage

• Serous: clear and watery drainage.
• Sanguineous: bloody drainage.
• Serosanguineous: thin, watery drainage that is mixed with blood.
• Purulent: Thick drainage that is green, or yellow/brownish in colour.

Penrose Drains

• A penrose Tubing is used to drain wounds of contaminants.
• Penrose allows microbes to enter and spread.
• A drain can be placed in the wound.

Drainage Management

• Two ways in measuring Drainage
  • Number of dressings measured with drainage.
  • Measuring what will be used in collection container after closed.

Wound Dressings

• Absorb fluids, remove dead tissue, and cover wounds.

Gauze, Non Adherent, and Vapour-Permeable Adhesive Film

• Used for rectangle pads and comes in squares.
• Allows you not to see a fluid and the fluids is to enter the wound
• Adhesive promotes good healing practices.

Dressings and Factors Determining Type

• Type of wound
• Size, location,Amount of drainage
• Is or it isnt infected
• dressings functioning and or is it for changing.
• Nurses pick the right dressing.

Microbe Entry

• Tape is needed to support the dressings.
• Adhesive is good and sticks to skin
• Elastic band allows the movement of the wound

Tape Comes in Two Sizes.

• Applying tape with bandage is what is required to support or help heal the wound, it shouldn't block off circulation