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CHAPTER 32 Skin Integrity & Wound Healing
EXAMPLE CLIENT CONDITION: Pressure Injury—cont’d
Support Surfaces • Specialty mattresses, integrated bed systems, mattress overlays—consist of air, gel, foam, water • Various sizes and shapes for beds, chairs, and examination and surgical tables • These surfaces and systems redistribute pressure and moisture to prevent bacterial growth on the skin. • Use products that raise the heels off the bed. Pillows may not redistribute the weight of the patient’s foot. • Use pressure-redistributing devices for chairs and wheelchairs. Avoid foam rings and donut-type devices. Optimize Nutrition and Hydration Patients at risk: rapid weight loss, ↑ metabolic demands, limited intake, or ↓ serum albumin 1. Monitor hydration status and offer water (if appropriate) whenever you reposition the patient. Teach the at-risk patient and family the following measures for preventing pressure injury: • Characteristics of healthy skin • Appearance of skin that has experienced unrelieved pressure • Protection of the skin and prevention of pressure injury • Skin care and hygiene
2. Provide adequate calories (30–35 kcal/ kg/day) and protein (2 g/kg in an under- nourished patient with a wound). Add protein or amino acid supplementation to reduce wound size. 3. Consider the consistency of the diet (soft diet for a patient who is frail or missing teeth). 4. Tube feeding or parenteral nutrition to supplement oral intake; dietary referral as needed.
• Importance of adequate nutrition • Techniques for turning and positioning • Importance of frequent position changes • Use of pressure-redistributing devices • Healthy diet with adequate calorie and protein intake • Skin changes that should be reported to healthcare professionals
TEACHING
W-O-U-N-D Tips for taking care of wounds at home:
HOME CARE
W et → Dry it O pen → Cover it U nclean → Clean it N ecrotic → Don’t scrub it D ry → Moisten it
not harm injured or healing tissue. It will cleanse most wounds if enough is used to thoroughly flush the wound. Note: Normal saline should be used within 24 hours of opening the container to avoid bacterial growth within the solution. ■ Sterile water and distilled water are clean, contain no additives, and are less expensive than normal saline. However, they are hypotonic (lower concen- tration of solute than the blood and other cells in the body), which means they can cause fluid shifts to damaged cells. When large volumes of sterile water are used, water toxicity to an open wound can occur.
■ Potable (drinkable) tap water can also be used to cleanse wounds, especially in the community setting. Studies have shown that tap water is as effective for cleansing as saline (Fernandez & Griffith, 2012; Chan et al., 2016; Burch & Köpke, 2018). Key Point: However, the decision to use tap water should be based on the nature and complexity of the wound and the patient’s general condition, including the presence of comorbid conditions (e.g., diabetes) and immunological status (Burch & Köpke, 2018; Chan et al., 2016; Fernandez & Griffiths, 2012). ■ Purified water (instead of tap water) should be used for cleansing wounds to reduce the risk of microbial
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