PSW: Wound Care & Skin Breakdown

• PSW responsibilities when caring for clients with wounds include:
  • Overall observation
  • Prevention of pressure sores
  • Pain and comfort
  • Movement and ambulation
  • Dressing
  • Nutrition and hydration
  • Oxygenation
  • Odour
  • Temperature
  • Skin care
  • Maintaining skin integrity
  • Addressing complications and concerns

Common Causes of Skin Breakdown

• Age-related changes in the skin
• Dryness
• Fragile and weak capillaries
• General thinning of the skin
• Loss of the fatty layer under the skin
• Decreased sensation to touch, heat, and cold
• Decreased mobility
• Sitting in a chair or lying in bed for most of the day
• Chronic diseases like diabetes and hypertension
• Diseases that decrease circulation
• Poor nutrition and hydration
• Incontinence
• Moisture in dark areas of the body
• Pressure on bony parts
• Poor care of fingernails/toenails
• Friction or shearing

Wound Care

• The skin is the body's first line of defense against microbes that cause infection
• Skin injury must be prevented and good skin care must be provided to help prevent skin breakdown
• Infants, older adults, and clients with disabilities are at the greatest risk of skin breakdown
• A wound is a break in the skin or mucous membrane
• Common causes of wounds:
  • Surgery
  • Trauma
  • Immobility
  • Poor blood circulation
• Infection becomes a major threat when injury occurs
• Wound care involves:
  • Preventing infection,
  • Preventing further injury to the wound and nearby tissues,
  • Preventing blood loss, and pain
• Your role in wound care depends on:
  • Job description,
  • The client's condition, and
  • Provincial or territorial laws

Types of Wounds

• Intentional wounds: wounds created for treatment, such as surgical incisions or sterile venipunctures
• Unintentional wounds: wounds that result from trauma, such as falls, vehicle accidents, gunshots, or stabbings
• Open wounds: a break in the skin or mucous membrane, categorized as intentional, and most unintentional
• Closed wounds: injury to tissues without breaking the skin, such as bruises, twists, and sprains
• Clean wounds: not infected, meaning microbes have not entered the wound, includes closed and created under surgically aseptic conditions with a reduced risk of infection
• Clean-contaminated wounds: result of the surgical entry of the urinary, reproductive, or digestive system; poses a greater risk for infection
• Contaminated wounds: are generally due to an unintentional wound (such as from a stabbing) that is not created under sterile conditions, with a high risk for infection
• Infected wounds (dirty wounds): wounds containing a large amount of bacteria and showing signs of infection, such as old wounds, surgical incisions into infected areas, and traumatic injuries that rupture the bowel
• Chronic wounds: wounds that do not heal easily in a timely manner, such as pressure ulcers or circulatory ulcers
• Partial-thickness wounds involve a break in the dermis and epidermis of the skin
• Full-thickness wounds involves penetrating the dermis, epidermis, and subcutaneous tissue, that can include muscle and bone

Wound Descriptions by Cause:

• Abrasion: Scraping away/rubbing of skin
• Contusion: A blow to the body (bruise)
• Incision: A 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 for skin tears are the hands, arms, and lower legs
• Causes include
  • Friction and shearing
  • Pulling or pressure on the skin
  • Bumping a hand, arm, or leg on any hard surface
  • Holding the client's arm or leg too tightly
  • Repositioning, moving, or transferring a client
  • Bathing, dressing, and other tasks
  • Pulling buttons or zippers across frail skin
• Skin tears are painful and are portals of entry for microbes
• When a skin tear, bruise, bump, or scrape is found or caused, tell the supervisor at once
• Persons at risk for skin tears:
  • Need moderate to complete help in moving,
  • Have poor nutrition or are very thin,
  • Have poor hydration,
  • Have altered mental awareness, and
  • Are older.
• Careful and safe care helps prevent skin tears and further injury

Preventing Skin Tears

• Keep client’s and your nails short or filed.
• Do not wear rings
• Gently transfer or position the client
• Use a turning sheet
• Prevent friction during moving or positioning

Pressure Ulcers

• Decubitus ulcers, bed sores, and pressure sores are injuries caused by unrelieved pressure to the skin and/or underlying tissue
• Pressure ulcers usually occur over a bony prominence or pressure points
• Shoulder blades, elbows, hips, sacrum, knees, ankles, heels, and toes are bony prominences and considered pressure points
• Pressure points that are moist are especially prone to developing a pressure ulcer
• Common causes of pressure ulcers are pressure, shearing, and friction
• Risk factors include:
  • Breaks in the skin,
  • Poor circulation to an area,
  • Moisture,
  • Dry/flaky skin, and
  • Irritation by urine and faeces
• Clients at risk for pressure ulcers:
  • Confined to a bed or chair.
  • Require moderate to complete help in moving
  • Have loss of bowel or bladder control.
  • Have poor nutrition,
  • Have altered mental awareness,
  • Have problems sensing pain or pressure,
  • Have circulatory problems,
  • Are older, and
  • Are obese or very thin
• Signs of pressure ulcers:
  • Pale or greyed sin,
  • Warm reddened area,
  • Complaints of pain,
  • Burning, itching, or tingling in the area Some clients with pressure ulcers may not feel anything unusual
• Supervisor must be notified immediately with and signs of a pressure ulcers have been found
• Pressure usually occurs over bony areas called pressure points
• Pressure on the ears is caused by the use of eyeglasses and oxygen tubing and mattress when in the side-lying position
• In obese people, pressure ulcers can occur in areas where skin has contact with skin:
  • Between abdominal folds,
  • The legs,
  • The buttocks,
  • The thighs, and
  • Under the breasts

Stages of Pressure Ulcers:

• Stage 1: The skin is intact, with redness over a bony prominence that does not return to normal when skin is relieved of pressure
• Stage 2: There is partial-thickness skin loss/ cracks, blisters, or peels
• Stage 3: There is full-thickness skin loss/ skin is gone. There may be drainage from the area
• Stage 4: There is full-thickness tissue loss, with muscle, tendon, and bone exposure
• Stage 5: A pressure ulcer cannot be staged due to necrosis

Preventing Pressure Ulcers

• Preventing pressure ulcers is much easier than healing them
• Good support care, cleanliness, and skin care are essential
• The health team must develop a plan of care for each person at risk
• The client at risk for pressure ulcers is placed on a surface that reduces or relieves pressure
• The doctor, NP, or wound care nurse orders wound care products, drugs, treatments, and special equipment to promote healing

Protective Devices

• These protective devices are used to prevent and treat pressure ulcers and skin breakdown:
  • Special beds
  • Bed cradles
  • Elbow protectors
  • Heel elevators
  • Flotation pads
  • Gel or fluid-filled pads and cushions
  • Egg crate-like mattress
  • Pillows
  • Trochanter rolls
  • Foot boards

Leg and Foot Ulcers

• Some diseases affect blood flow to and from the legs and feet
• Edema: Swelling caused by fluid collecting in tissues
• Gangrene: A condition that causes death of tissue
• Infection and gangrene can result from an open wound and poor circulation

Circulatory Ulcers

• Circulatory ulcers (vascular ulcers) are open sores on the lower legs or feet
• They are caused by decreased blood flow through the arteries or veins
• People with diseases affecting the blood vessels are at risk
• These wounds are painful and hard to heal

Venous Ulcers

• Venous ulcers (stasis ulcers) are open sores on the lower legs or feet caused by poor blood flow through the veins
• These Ulcers Can develop when the veins cannot pump blood back to the heart in a normal way causing; blood and fluid collect in the legs and feet.
• The heels and inner aspect of the ankles are common sites for venous ulcers
• They can occur from skin injury and without trauma.
• Venous ulcers are painful and make walking difficult with infection as a risk

Arterial Ulcers

• Arterial ulcers are open wounds on the lower legs or feet caused by poor arterial blood flow
• They are caused by diseases or injuries that decrease arterial blood flow to the legs and feet
• Smoking is a risk factor
• The doctor treats the disease causing the ulcer and orders; drugs, wound care, a walking and exercise program and, professional foot care
• You should never provide foot care to a client with an arterial ulcer unless it is specified in the client’s care plan to prevent further injury

Wound Healing

• The healing process occurs in three phases:
  • Inflammatory phase (3 Days) - bleeding stops, a scab forms over the wound, blood supply increases bringing nutrients healing occurs
  • Proliferative phase (day 3 to day 21) - tissue cells multiply to repair the wound
  • Maturation phase (day 21 to 1-2 years) - the scar gains strength

Prevention and Treatment

• Injury must be prevented and The client must be handled, moved, and transferred carefully and gently
• Clients at risk need professional foot care
• The doctor may order drugs for infection and to decrease swelling. Medicated bandages wound care will be ordered also
• Devices used for pressure ulcers are often ordered. The doctor may order elastic stockings or elastic bandages

Complications of Wounds

• Many factors affect healing and increase the risk of complications:
  • The type of wound, the patients age, general health, and lifestyle, their circulation, nutrition, immune system changes and, medications

Hemorrhage

• Hemorrhage is the excessive loss of blood in a short period of time that can be internal or external
• When Internal bleeding is not visible blood occurs into tissues and body cavities causes Hematoma meaning that; tissues appearing swollen, reddish-blue, or grey in colour
• Signs and symptoms of internal bleeding: Shock, vomiting blood, coughing up blood, and loss of consciousness
• External bleeding: visible bloody drainage and dressings soaked with blood

Shock

• Results when there is not enough blood supply to organs and tissues
• Signs and symptoms of shock:
  • Low or falling blood pressure
  • Rapid and weak pulse, rapid respirations
  • Cold, moist, and pale or graying skin
  • Restlessness and thirst
  • Confusion and loss of consciousness
• Hemorrhage and shock are emergencies

Dehiscence and Evisceration

• Dehiscence and evisceration are surgical emergencies
• Dehiscence is the separation of wound layers
• Evisceration is the separation of the wound along with the protrusion of abdominal organs
• Coughing, vomiting and abdominal distension place stress on the wound
• Sterile dressing saturated with sterile saline is placed over the wound

Wound Appearance

• Doctors and nurses observe the wound and its drainage
• You (as a PSW) need to make certain observations when assisting with wound care and report/record such observations for your agency
• The amount and type of wound drainage depend on wound size and location, and bleeding and infection

Wound Drainage

• Wound drainage is observed and measured
• Serous: Clear and watery
• Sanguineous: Bloody drainage meaning blood in Latin
• Serosanguineous: Thin. watery drainage that is blood tinged
• Purulent: Thick drainage that is yellow green or brown
• Drainage must leave the wound for healing
• When large amounts of drainage are expected, the doctor inserts a drain
• A Penrose drain is a rubber tube that drains onto a dressing. It is an open drain, microbes can enter in it
• Closed drainage systems prevent microbes from entering the wound: a drain is placed in the wound and attached to suction

Drainage Measurement

• Drainage is measured in two ways:
  • Noting the number (how many), and size of dressings with drainage (amount and type of drainage is noted)
  • Measuring the amount of drainage in the collection container if closed drainage is used

Wound Dressings

• Wound dressings have the following key functions
  • Protect the wounds from injury
  • Absorb drainage
  • Remove dead tissue, and promote comfort
  • Cover unsightly wounds
  • Provide a moist environment for wound healing, and control bleeding

Sterile Dressings

• Dressing type and size depend on many factors:
  • Types of wound, wound sizes, wound location
  • Amount of drainage
  • Presence or absence of infection
  • Dressing functions, and the frequency of dressing changes
• Each particular wound requires to be assessed by the physician so a particular plan can be prepared by the nurse
• Dressings are described by the material used in application method

Types of Dressings

• Gauze: comes in squares, rectangles and can be rolled to fit the wound
• Non adherent Gauze: Are made for dressings that will have contact to the skin, reduces damages to healing
• Vapour-permeable transparent adhesive film: Wounds observation is very important when healing with these can be seen through
• Securing Dressings: Microbes can enter the wounds if the dressing does not secure the wound from being dislodged
• Use Tapes, to stick onto the skin and around the wound
• Elastic Tape: Is used around moveable areas so no damage occurs, such as joints and limbs