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CHAPTER 32 Skin Integrity & Wound Healing
Preprocedure Assessment NOTE: When you begin, the wound will likely be covered with a dressing. You will make these assessments when you remove the soiled dressing and after cleansing the wound. ■ Assess the amount and type of tissue present in the wound bed. Granulating tissue is beefy red with a velvety appearance. It appears with the growth of new blood vessels and connective tissue. Pale pink tissue may indicate compromised blood supply to the wound bed. Necrotic tissue, which is black, brown, or yellow in appearance, is nonviable and inhibits healing. ■ Assess the type and amount of exudate. Exudate may be a sign of infection.
■ Assess the wound for odor. A foul odor may indicate infection. Clean wounds before you assess for odor, because some dressings interact with wound drainage to produce an odor. ■ Assess the tissue surrounding the wound edge. Surrounding tissue that is red, warm, and/or edematous may indi- cate infection. ■ Assess for pain. Wounds may be painful.Assess for pain and provide prescribed pain medication 30 minutes before performing procedure, if needed. A change in the quality or intensity of pain may be a sign of infection.
➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation.
Removing the Wet-to-Damp Dressing 1. Place the patient in a comfort- able position that provides easy access to the wound. Provides for patient comfort during dress- ing change. 2. Perform hand hygiene and don clean, nonsterile gloves. Hand washing complies with standard precautions, helping to prevent transfer of pathogens. 3. Gently loosen the edges of the tape of the old dressing. Hold that edge with one hand and gently raise the edge until it is taut but not pulling on the skin. Using your other hand, push down on the exposed skin at the point where the tape and skin meet. Push the skin from the tape. Use adhesive remover pads to avoid tearing fragile skin. The pull–push method will help prevent skin stripping from the adhesive and reduce discomfort and skin trauma as you remove the tape. 4.Beginning with the top layer, lift the dressing from the corner toward the center of the wound. If the dressing sticks, moisten it with normal saline or sterile water before completely removing it. Remove first from one side of the wound toward the wound, and then from the other side. Continue to remove layers until you have removed the entire dressing.
8. Don clean procedure gloves. Avoids introducing microorganisms into the wound. 9. Gather a gauze pad by pulling the four corners up toward the middle. Use the center of the gauze to cleanse the wound. Prevents contamination of your gloves during wound cleansing. 10.Using gauze moistened with saline or filtered water, gently wipe a section of the wound from the center toward the wound edge. Discard the gauze in a biohazard receptacle and repeat in the next section using a new piece of gauze with each wiping pass. Removes surface bacteria and exudate. Prevents transfer of microorganisms from the skin to the wound. 11. Reassess the wound for location, amount of tissue present, exudate, and odor. Allows for determination of most effec- tive treatment and type of dressing. 12.Discard the gloves and soiled gauze into a biohazard bag. Perform hand hygiene. Soiled gauze contains contaminants and should be disposed of as biohazardous waste. Applying a Wet-to-Damp Dressing 13. After establishing a sterile field using a sterile impermeable barrier, open a sterile gauze pack tray and a thick surgical pad. The amount of
Moistening the dressing decreases the risk of bleeding and/or removal of granulating tissue.
5.Assess the type and amount of drainage present on the soiled dressing. Type of drainage is an indication of the stage of healing. Purulent drainage is an indication of infection. 6. Dispose of the soiled dressing and gloves in a biohazard container. Wash your hands. Soiled dressings contain body fluid con- taminants and should be disposed of as biohazardous waste. 7. Remove the cover of a tray of sterile 4 in. × 4 in. gauze. Moisten the gauze with sterile saline or water. The sterile container tray is impermeable and allows you to moisten the gauze while maintaining sterility. Gauze will not shed fibers into the wound (as do cotton balls). Fibers and any other foreign bodies in a wound promote inflammation and delay healing.
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