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Lecture Notes

Skin Integrity and Wound Care


  1. Anatomy of the skin
    1. composed of three layers
      1. epidermis
        1. composed of several thin layers:
          1. stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, stratum corneum
        2. the several thin layers of the epidermis contain the following:
          1. melanocytes, which produce melanin, a pigment that gives skin its color and protects it from the damaging effects of ultraviolet radiation
          2. keratinocytes, which produce keratin, a water-repellent protein that gives the epidermis its tough, protective quality
      2. dermis
        1. composed of a thick layer of skin that contains collagen and elastic fibers, nerve fibers, blood vessels, sweat and sebaceous glands, and hair follicles
      3. subcutaneous tissue
        1. composed of a fatty layer of skin that contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells
  2. Functions of the integument
    1. protection
      1. intact skin prevents invasion of the body by bacteria
    2. thermoregulation
      1. intact skin facilitates heat loss and cools the body when necessary through the following processes:
        1. production of perspiration which assists in cooling the body through evaporation
        2. production of vasodilatation to increase the blood supply to the skin surface which assists in facilitating heat loss from the body through radiation and conduction
      2. intact skin prevents heat loss and warms the body when necessary through the following processes:
        1. prevention of the production of perspiration which inhibits cooling the body through evaporation
        2. production of vasoconstriction to decrease the blood supply to the skin surface which assists in preventing heat loss from the body through radiation and conduction
        3. production of gooseflesh by contraction of the arrector pili muscles attached to hair follicles in order to stand skin hairs on end thus allowing them to entrap a thick layer of "insulator air" next to the skin which assists in preventing heat loss from the body through radiation and conduction
    3. fluid and electrolyte balance
      1. intact skin prevents the escape of water and electrolytes from the body
    4. vitamin D synthesis
      1. intact skin facilitates the synthesis of vitamin D through conversion of the initial precursor of the vitamin to the second precursor of the vitamin in the skin by the sun's ultraviolet rays
    5. sensation
      1. intact skin assists the body in receiving sensory stimuli from the environment by activation of skin receptors for pain, touch, pressure, and temperature
    6. psychosocial
      1. intact skin contributes to a positive body image
  3. Classification of wounds
    1. by cause
      1. intentional
        1. involves a wound that is the result of planned therapy
      2. unintentional
        1. involves a wound that is the result of unexpected trauma
    2. by status of skin integrity
      1. open
        1. involves a break in skin integrity or mucous membrane
      2. closed
        1. involves no break in skin integrity or mucous membrane
    3. by severity of injury
      1. superficial
        1. involves only the epidermal layer of skin
      2. penetrating
        1. involves penetration of the epidermal and dermal layers of skin and deeper tissues or organs
    4. by degree of contamination
      1. clean
        1. uninfected wounds in which no inflammation is encountered and the respiratory, gastrointestinal, genital, and/or urinary tracts are not entered
      2. clean/contaminated
        1. uninfected wounds in which no inflammation is encountered but the respiratory, gastrointestinal, genital, and/or urinary tract have been entered
      3. contaminated
        1. open, traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation
      4. infected
        1. old, traumatic wounds containing dead tissue and wounds with evidence of a clinical infection (e.g., purulent drainage)
    5. by depth
      1. partial-thickness
        1. involves only the epidermal and dermal layers of skin
      2. full-thickness
        1. involves the epidermal and dermal layers of skin, subcutaneous tissue and, possibly, muscle and bone
    6. by descriptive qualities
      1. laceration
        1. involves tearing apart of tissues resulting in irregular wound edges
      2. abrasion
        1. involves scraping or rubbing the surface of the skin by friction
      3. contusion
        1. involves a blow from a blunt object resulting in swelling, discoloration, bruising, and/or eccymosis
      4. incision
        1. involves cutting the skin with a sharp instrument
      5. puncture
        1. involves penetration of the skin and, often, the underlying tissues by a sharp instrument
  4. Phases of wound healing
    1. defensive (inflammatory) phase
      1. begins immediately after injury, lasting 3-4 days, and consists of two major processes: hemostasis and inflammation
      2. hemostasis
        1. vasoconstriction of severed blood vessels
        2. aggregation of platelets along damaged blood vessel walls to form a platelet plug
        3. invasion of fibrin fibers into the platelet plug to form a fibrin clot
        4. contraction of the fibrin clot to express fluid (serum) out of the clot and form a scab which provides external protection from invasion by microorganisms
      3. inflammation
        1. process of inflammation
          1. injury to tissues resulting in secretion of multpile products of inflammation into the blood stream from the injured tissues, e.g.: histamine, bradykinin, serotonin, prostaglandins
            1. leads to a clinical sign of inflammation:
              1. dolor (pain)
          2. vasodilation of local blood vessels, resulting in excess local blood flow and an increase in nutrients to the injured tissues
            1. leads to two clinical signs of inflammation:
              1. calor (warmth)
              1. rubor (hyperemia)
          3. increased permeability of capillaries, resulting in leakage of large quantities of fluid into the interstitital spaces to cushion the injured tissues and dilution of the concentration of microorganisms or toxic products that may have entered the injured tissues
            1. leads to a clincial sign of inflammation:
              1. tumor (swelling or edema)
          4. chemotaxis (attraction of white blood cells [WBCs] to injured tissues), resulting in migration of tissue macrophages, neutrophils, and monocytes to the injured tissues and phagocytosis of microorganisms and debris in the injured tissues
            1. 1st line of defense in wound healing by WBCs
              1. description
                1. tissue macrophage invasion of the injured tissue
              2. white blood cell(s) involved
                1. tissue macrophage
              3. time of response
                1. minutes after injury
              4. response
                1. fixed tissue macrophages break away from their attachments near injured tissues, migrate to the injured tissues, and begin phagocytosis of about:
                  1. 100 bacteria per macrophage
                  2. large diameter debris
            2. 2nd line of defense in wound healing by WBCs
              1. description
                1. neutrophil invasion of the injured tissues
              2. white blood cell(s) involved
                1. neutrophil
              3. time of response
                1. few hours after injury
              4. response
                1. within the first hours after inflammation begins, circulating neutrophils migrate to the injured tissues and begin phagocytosis of about:
                  1. 5 - 20 bacteria per neutrophil
                  2. small diameter debris
            3. 3rd line of defense in wound healing by WBCs
              1. description
                1. second macrophage invasion of the injured tissues
              2. white blood cell(s) involved
                1. monocyte
              3. time of response
                1. several days after injury
              4. response
                1. stored monocytes in the bone marrow are mobilized into the blood stream, migrate to the injured tissues where they attach themselves to the injured tissues, spend around 8 hours or more maturing into a tissue macrophages, and after the maturation process, begin phagocytosis of about:
                  1. 100 bacteria per macrophage
                  2. large diameter debris
            4. 4th line of defense in wound healing by WBCs
              1. description
                1. increased proliferation of granulocytes and monocytes by the bone marrow
              2. white blood cell(s) involved
                1. granulocyte
                2. monocyte
              3. time of response
                1. 3 - 4 days after injury
              4. response
                1. bone marrow greatly increases production of granulocytes and monocytes which are mobilized into the blood stream to injured tissues and begin phagocytosis
          5. encouragement of actions to avoid further injury to or inflammation of the injured tissues
            1. leads to a clinical sign of inflammation:
              1. functiolaesa (loss of function)
          6. walling off injured tissues and lymphatics from remaining tissues to delay spread of microorganisms or toxic products
    2. proliferative phase
      1. begins 3 or 4 days after injury, lasting up to 3 weeks
      2. macrophages stimulate the migration of fibroblasts to the wound to synthesize collagen and ground substance (proteogylcan)
      3. the collagen and proteogylcan synthesized by fibroblasts forms a scaffold, or framework, for final repair of the wound and can be felt as a "healing ridge" under the suture
        1. the more collagen and ground substance added to the scaffold, or framework, the greater the tensile strength of the wound
      4. macrophages also stimulate the formation of "buds" in capillaries surrounding the wound that grow into new blood vessels (angiogensis) and reestablish blood flow across the wound
      5. the collagen and proteogylcan deposits and capillary "buds" form the new granulation tissue in the wound, which is translucent red, fragile, and bleeds easily
      6. proliferation of epithelial cells across the wound as granulation tissue matures
    3. maturation phase
      1. begins after 21 days after injury, lasting months and even years
      2. firbroblasts continue to synthesize collagen and proteoglycan and add it to the wound to increase its tensile strength
      3. the collagen and proteogylcan fibers, laid haphazardly during the proliferative phase, reorganize into a more orderly structure
  5. Types of wound drainage
    1. serous exudate
      1. consists chiefly of serum derived from blood and serous membranes of the body
    2. sanguineous
      1. consists of serum and red blood cells
    3. purulent
      1. consists of serum and pus (leukocytes, liquefied living and dead bacteria, dead tissue debris)
  6. Types of wound healing
    1. healing by primary intention
      1. characterized by:
        1. approximated (closed) skin edges
        2. minimal granulation tissue
        3. early suturing
        4. minimal scarring
        5. minimal tissue loss
        6. rapid healing
        7. minimal risk of infection
    2. healing by secondary intention
      1. characterized by:
        1. open skin edges
        2. extensive granulation tissue
        3. no suturing
        4. extensive scarring
        5. extensive tissue loss
        6. delayed healing
        7. extensive risk of infection
    3. healing by tertiary intention
      1. characterized by:
        1. open skin edges that are sutured later
        2. moderate granulation tissue
        3. delayed suturing
        4. moderate scarring
        5. moderate tissue loss
        6. delayed healing
        7. moderate risk of infection
  7. Complications of wound healing
    1. hemorrhage
      1. persistent arterial and/or venous bleeding from a wound
      2. usually occurs in the first 24 - 48 hours after a wound
      3. signs/symptoms:
        1. decreased blood pressure
        2. rapid thready pulse
        3. restlessness
        4. diaphoresis
        5. clammy, pale, cold skin
        6. oliguria
    2. infection
      1. invasion of a wound by microorganisms
      2. usually occurs by the 2nd to 11th day after a wound
      3. signs/symptoms:
        1. increased temperature
        2. tenderness and pain around wound site
        3. increased WBCs
        4. inflamed wound edges
        5. purulent drainage
    3. dehiscence
      1. partial or total rupturing of a wound
      2. usually occurs by the 4th to 5th day after a wound
      3. in abdominal wounds, it often occurs after a sudden strain, such as coughing, vomiting, sitting up in bed, and sneezing which makes it important to support the abdomen during these activities
      4. signs/symptoms:
        1. partially or totally disrupted (open) wound edges
        2. appreciable increase in discharge of serosanguineous drainage from the wound
        3. sensation that "something gave or let go"
        4. increased sanguineous drainage
    4. evisceration
      1. protrusion of the internal viscera and/or organs through a ruptured wound
      2. usually occurs by the 3rd to 5th day after a wound
      3. in abdominal wounds, occurs after a sudden strain, same as a dehiscence
      4. signs/symptoms:
        1. totally disrupted (open) wound edges
        2. appreciable increase in discharge of serosanguineous drainage from the wound
        3. sensation that "something gave or let go"
        4. protrusion of viscera and/or organs through a ruptured wound
        5. medical emergency with surgical repair necessary; if occurs, place sterile towels soaked in sterile normal saline solution over extruding tissue to decrease chance of invasion by microorganisms and drying
    5. fistula
      1. abnormal passage between two organs or between an organ and the outside of the body
      2. name of the fistula designates the site of the abnormal communication; e.g., a rectovaginal fistula is an abnormal opening between the rectum and vagina that permits feces to enter the vagina
      3. signs/symptoms:
        1. chronic drainage (type depends on communication)
        2. skin breakdown (if fistula opens to the skin, and the drainage is gastric or intestinal in nature, so contains digestive enzymes)
  8. Factors affecting wound healing
    1. impaired circulation and oxygenation, e.g.:
      1. advanced age
      2. anemia
      3. peripheral vascular disorders
      4. diabetes mellitus
      5. smoking
      6. obesity
      7. chronic lung disease
    2. malnourishment
      1. results in inadequate intake of nutrients essential for wound healing, e.g.:
        1. protein: essential for building new tissue
        2. vitamin A: essential for collagen synthesis and epithelialization
        3. B complex vitamins: act as cofactors in enzyme reactions necessary for wound healing
        4. vitamin C: essential for collagen synthesis, capillary formation, resistance to infection
        5. vitamin K: essential for synthesis of prothrombin which assists in hemostasis
        6. zinc, copper, and iron: essential for collagen synthesis
    3. drugs and therapies that effect the inflammatory response, blood clotting, and cell mitosis, e.g.:
      1. adrenocorticoidsteriods
      2. acetylsalicylic acid (aspirin)
      3. warfarin sodium (Coumadin)
      4. heparin
      5. antineoplastics (anti-cancer drugs)
      6. radiation
    4. contamination and infection
  9. Decubitis ulcers
    1. any skin lesion caused by unrelieved pressure that results in damage to underlying tissues
    2. etiology of decubitus ulcers
      1. localized ishcemia
        1. tissue is caught between two hard surfaces
        2. blood cannot reach the tissues
        3. cells are deprived of oxygen and nutrients
        4. waste products of metabolism accumulate in cells
        5. cells eventually die
      2. friction
        1. rubbing the patients skin against the sheets when pulling him/her up in bed
      3. shearing
        1. adherence of the patient's skin to the sheets, while layers of subcutaneous tissues slide in the direction of the body movement and underlying capillaries are severed, when a patient slides down in bed
    3. risk factors for development of decubitus ulcers
      1. immobility
        1. results in the inability to relieve pressure by changing position
      2. malnutrition
        1. results in weight loss which reduces the padding between the skin and bones
      3. hypoproteinemia
        1. precipitates the formation of edema which makes skin more susceptible to pressure
      4. fecal and urinary incontinence
        1. causes maceration (tissue softened by prolonged wetting and soaking) which makes skin more susceptible to pressure
      5. decreased mental status
        1. results in inability to respond to pain from increased pressure by changing position
      6. diminished sensation
        1. results in inability to respond to pain from increased pressure by changing position
      7. advanced age
        1. results in the following:
          1. loss of lean body mass
          2. thinning of the epidermis
          3. decreased elasticity of the skin due to loss of collagen,
          4. decreased vascularity
          5. reduced skin turgor
          6. increased dryness and scaliness
          7. decreased pain perception
    4. common locations of decubitus ulcers
      1. over bony prominences while lying in a supine position in bed, e.g.:
        1. back of head (occipital bone), scapulae, elbows (olecranon process), sacrum, heels (calcaneous)
      2. over bony prominences while lying in a lateral position in bed, e.g.:
        1. side of head (parietal and temporal bones), ear, shoulder (acromion process), ilium, greater trochanter, knee (medial and lateral epicondyle)
      3. over bony prominences while lying in a prone position in bed, e.g.:
        1. cheek and ear (zygomatic bone), shoulder (acromion process), breasts (women), genitalia (men), knees (patellas), toes (phalanges)
      4. over bony prominences while in a sitting position in bed, e.g.:
        1. spinous processes, sacrum, pelvis (ischial tuberosity), heels (calcaneous)
      5. over bony prominences while sitting in a wheelchair, e.g.:
        1. shoulder blade, sacrum and coccyx, ischial tuberosity, posterior knee, foot
    5. staging/grading decubitus ulcers
      1. stage/grade one
        1. nonblancable erythema of intact skin
      2. stage/grade two
        1. partial-thickness skin loss involving the epidermis and/or dermis
        2. presents clinically as an abrasion, blister, or shallow crater
      3. stage/grade three
        1. full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
        2. presents clinically as a deep crater with or without undermining of adjacent tissue
      4. stage/grade four
        1. full-thickness skin loss with extensive destruction, tissue necrosis or damage to the muscle, bone, or supporting structures, such as a tendon or joint capsule
  10. The nursing process and wounds
    1. assessing
      1. treated wounds
        1. pain
        2. appearance of wound, e.g.:
          1. approximation of wound edges
          2. color of the wound and surrounding area
          3. signs of dehiscence or evisceration
          4. wound drainage
          5. sutures and staples, e.g.:
            1. types of sutures in treated wounds
              1. absorbable
              2. used to attach tissues beneath the skin
              3. made of material that disappears in several days
            2. nonabsorbable
              1. used to attach tissues of the skin
              2. made of a variety of nonabsorbable materials, e.g.:
              3. silk, cotton, linen, wire, nylon, Dacron
            3. methods of suturing in treated wounds
              1. plain, interrupted sutures
                1. consists of one pass per stitch
                  1. pierces the near edge of the incision line (e.g., right) and exits the opposite edge of the incision line (e.g., left)
                  2. each stitch is tied and knotted separately
              2. mattress, interrupted sutures
                1. consists of two passes per stitch
                  1. lst pass
                    1. pierces the near edge of the incision line (e.g., right) and exits the opposite edge of the incision line (e.g., left)
                  2. 2nd pass
                    1. pierces the new near edge of the incision line (e.g., left) and exits the new opposite edge of the incision line (e.g., right)
                  3. each stitch is tied and knotted separately
              3. plain, continuous sutures
                1. one thread runs in a series of stitches in the plain suturing method (one pass per stitch) and is tied only at the beginning and end of the run
              4. mattress, continuous sutures
                1. one thread runs in a series of stitches in the matress suturing method (two passes per stitch) and is tied only at the beginning and end of the run
              5. retention sutures
                1. very large sutures used in addition to skin sutures that attach underlying tissues of fat and muscle as well as skin and are used to support in incisions in obese individuals when healing may be prolonged
          6. drains and tubes
            1. penrose
              1. provides a sinus tract
            2. t-tube
              1. provides for bile drainage
            3. Jackson-Pratt
              1. provides for decreased dead space by collecting drainage
            4. hemovac
              1. provides for decreased dead space by collecting drainage
      2. decubitus ulcers
        1. location of the decubitus ulcer
        2. estimation of the stage/grade of the decubitus ulcer
        3. color of the decubitus ulcer wound bed
        4. presence or absence and location of any necrosis or eschar in the decubitus ulcer wound bed
        5. condition of the decubitus ulcer wound margins
        6. integrity of the skin surrounding the decubitus ulcer
        7. clinical signs of infection
        8. dimensions of the decubitus ulcer
          1. length and width
            1. place a baggie, saran wrap, or a disposable measuring guide over the decubitus ulcer
            2. trace over the decubitus ulcer using a black marker
          2. depth
            1. insert a sterile cotton-tipped applicator at a 90 degree angle into the deepest part of the decubitus ulcer
            2. mark the point on the sterile cotton-tipped applicator that is even with the surrounding skin surface of the decubitus ulcer
            3. remove the sterile cotton-tipped applicator
            4. measure the depth against a centimeter ruler
          3. tunneling
            1. insert a saline-moistened sterile cotton-tipped applicator under the edges of the decubitus ulcer
            2. apply gentle pressure with the sterile cotton-tipped applicator
            3. assess for any abnormal pathways
            4. remove the sterile cotton-tipped applicator
            5. measure the depth of penetration against a centimeter ruler
      3. laboratory data
        1. albumin levels of less than 3.5 mg/dL
        2. total lymphoctye count of less than 1,000/mm3
        3. coagulation studies
        4. wound cultures
    2. Diagnosing
      1. impaired skin integrity
    3. Planning
      1. goal/expected outcomes:
        1. the patient will exhibit unimpaired skin integriy, as evidenced by:
          1. approximated wound edges
          2. a decrease in (or absence of) wound drainage
          3. a decrease in (or absence of) inflammation of skin surrounding the wound
          4. intact skin surrounding the wound
          5. absence of wound odor
          6. a decrease in length, width, and depth of the wound
          7. presence of granulation tissue in the wound
    4. Implementing
      1. support wound healing
        1. provide sufficient nutrition and fluids
        2. prevent wound infections
        3. proper positioning
      2. prevent decubitus ulcers
        1. provide sufficient nutrtion and fluids
        2. turn every 2 hours
        3. use positioning devices to keep weight off bony prominences, e.g.:
          1. gel flotation pads
            1. special polyvinyl, silicone, or silastic pads filled with a gelatinous substance similar to fat
          2. sheepskins
            1. special devices make of natural or artificial sheepskin
          3. pillows and wedges
            1. pillows or foam wedges used to raise a body part off the bed surface
          4. heel protectors
            1. special devices, such as sheepskin boots, padded splints, or foam wedges, that limit pressure on the heels
        4. prevent shearing forces by limiting the amount of time the head of the bed is elevated (if possible)
        5. prevent friction sources by using a trapeze or bed linens to transfer and/or change a patient's position
        6. use pressure-relieving support surfaces, e.g.:
          1. egg crate mattress
            1. special mattress made of polyurethane foam resembling an eggcrate
          2. foam mattress
            1. special mattress made of polyurethane foam that molds to a patient's body
          3. alternating pressure mattress
            1. special mattress composed of a number of cells in which the pressure is alternately increased and decreased
          4. water bed
            1. special mattress filled with temperature controlled water
          5. air-fluidized (AF) bed (static high air loss [HAL] bed)
            1. special bed consisting of a mattress in which forced, temperature controlled air is circulated around millions of tiny silicone-coated beads producing a fluid-like movement that also helps prevent maceration of the patient's skin in the following ways:
              1. body moisture penetrates the sheet
              2. the beads soak up the moisture
              3. the air forces the moisture laden beads away from the patient
              4. the beads fall to the bottom of the mattress
              5. the sheet is rapidly dried
          6. static low air loss (LAL) bed
            1. special bed consisting of many air-filled cushions divided into four or five sections in which separate control panels permit each section to be inflated to a different level of firmness in such a way that pressure can be reduced on bony prominences but increased under other body areas for support
          7. active or second generation low air loss (LAL) bed
            1. special bed similar to the static low air loss (LAL) bed except that it also gently pulsates or rotates side to side in order to stimulate capillary blood flow and facilitate movement of pulmonary secretions
        7. cleanse the skin routinely and whenever soiling occurs
        8. keep linens clean, dry, and wrinkle-free
        9. maintain skin hygeine
      3. dress wounds
        1. purposes of dressings
          1. provide physical, pyschological, and aesthetic comfort
          2. remove necrotic, or dead, tissue
          3. prevent, eliminate, or control infection
          4. absorb drainage
          5. maintain a moist wound environment
          6. protect the wound from further injury
          7. protect the skin surrounding the wound
        2. types of dressings
          1. type of dressing used depends on:
            1. the location, size, and type of the wound
            2. the amount of exudate
            3. whether the wound requires debridement, is infected, or has sinus tracts
            4. frequency of dressing change, ease or difficulty of dressing application, and cost
        3. type of dressings available:
          1. guaze
            1. 2 x 2
            2. 4 x 4
            3. Sof-WickÒ drain sponges
            4. Surgi-padÒ
            5. abdominal (ABD) pad
          2. transparent films
            1. clear, polyurethane film with an adhesive backing
            2. examples
              1. Op-siteÒ, TegadermÒ, BiocclusiveÒ, ACU-dermÒ
            3. purpose/properties
              1. provide moist wound environment
              2. no absorptive properties
              3. occlusive
              4. waterproof
              5. semi-permeable to oxygen
              6. provide good wound visualization
            4. uses
              1. partial-thickness wounds
              2. Stage I-II pressure ulcers
              3. protective cover for areas exposed to friction
              4. to secure a gauze pad or another type of absorbent dressing in place
          3. hydrocolloid wafers
            1. hydroactive wafers (usually tan) with an adhesive backing
            2. examples
              1. DuoDermÒ, ComfeelÒ, TegabsorbÒ, RestoreÒ
            3. purpose/properties
              1. provide moist wound environment
              2. absorb moderate amount of wound exudate
              3. occlusive
              4. waterproof
              5. impermeable to oxygen
              6. autolytic debridement
              7. interact with wound exudate to form a hydrated gel that is thick, yellow and malodorous when removed
            4. uses
              1. partial-thickness wounds
              2. Stage I-II pressure ulcers
          4. hydrogels
            1. hydroactive polymer sheets, granules, or gels that are nonadhesive and require a secondary dressing to secure
            2. examples
              1. AquasorbÒ, ClearSiteÒ, ElastoGelÒ, IntrasiteÒ, VigilanÒ
            3. purpose/properties
              1. provide moist wound environment
              2. absorb moderate amount of wound exudate
              3. not occlusive unless covered by an occlusive secondary dressing
              4. not waterproof
              5. semi-permeable to oxygen
              6. autolytic debridement
              7. interact with wound exudate to form a hydrated gel that is thick, yellow and malodorous when removed
              8. conform to uneven wound surfaces
              9. decrease wound temperature, inflammation, and provide pain relief
            4. uses
              1. partial-thickness wounds
              2. Stage I-II pressure ulcers
          5. exudate absorbers
            1. hydrophilic powder, beads, granules, or paste that are nonadhesive and require a secondary dressing to secure
            2. examples
              1. Triad PasteÒ, Bard AbsorptionÒ, DebrisanÒ, CollagenÒ
            3. purpose/properties
              1. provide moist wound environment
              2. absorb significant amount of wound exudate
              3. not occlusive unless covered by an occlusive secondary dressing
              4. not waterproof
              5. permeable to oxygen
              6. autolytic debridement
              7. interact with wound exudate to worm a gelatinous mass
              8. can cause desiccation of tissue if minimal drainage is present
              9. must be irrigated out of the wound
            4. uses
              1. full-thickness, heavily draining, wounds
              2. Stage III-IV pressure ulcers
          6. alginates
            1. hydrophilic sheets or strips made of seaweed that are nonadhesive and require a secondary dressing to secure
            2. examples
              1. KalostatÒ, SorbsanÒ
            3. purpose/properties
              1. provide moist wound environment
              2. absorb significant amount of wound exudate
              3. not occlusive unless covered by an occlusive secondary dressing
              4. not waterproof
              5. permeable to oxygen
              6. autolytic debridement
              7. interact with wound exudate to form a hydrated gel that is thick, yellow and malodorous when removed
              8. can cause desiccation of tissue if minimal drainage is present
              9. hemostatic
            4. uses
              1. full-thickness, heavily draining wounds
              2. Stage III-IV pressure ulcers
          7. polyurethane foams
            1. hydroactive compressed foam pads that are nonadhesive and require a secondary dressing to secure
            2. examples
              1. LyofoamÒ, AllevynÒ, NudermÒ, FlexanÒ, Verous PolyfoamÒ
            3. purposes/properties
              1. provide moist wound environment
              2. absorb moderate amount of wound exudate
              3. not occlusive unless covered by an occlusive secondary dressing
              4. not waterproof
              5. autolytic debridement
              6. permeable to oxygen
            4. uses
              1. partial-thickness wounds
              2. Stage I-II pressure ulcers
        4. securing dressings
          1. tape
            1. adhesive
              1. used for strength, support, economy
            2. paper, plastic, acetate
              1. used for increased comfort, decreased allergic problems, and decreased skin problems
            3. microfoam
              1. used for compression or pressure dressings
          2. montgomery straps
            1. used for wounds requiring frequent dressing changes
        5. cleaning wounds
          1. most common cleaning agent used
            1. 0.9 % sodium chloride
        6. wound packing and irrigation
    5. Evaluating
      1. evaluating criteria:
        1. did the patient exhibit approximated wound edges?
        2. did the patient exhibit a decrease in (or absence of) wound drainage?
        3. did the patient exhibit a decrease in (or absence of) inflammation of skin surrounding the wound?
        4. did the patient exhibit intact skin surrounding the wound?
        5. did the patient exhibit absence of wound odor?
        6. did the patient exhibit a decrease in the length, width, and depth of wound?
        7. did the patient exhibit presence of granulation tissue in the wound?

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This page was last modified on 1/1/02