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CHAPTER 32 Skin Integrity & Wound Healing
Procedure Steps 1. Place the patient in a comfortable position that provides easy access to the wound. Applying the Dressing 2. If a dressing is present, perform hand hygiene, don clean nonsterile gloves, and remove the old dressing. 3. Dispose of the soiled dressing and gloves in the biohazard waste container. Observe universal precautions, preventing transfer of pathogens. 4. Don clean nonsterile gloves and cleanse the skin surrounding the wound with normal saline or a mild cleansing agent. Be sure to rinse the skin well if you use a cleanser. Allow the skin to dry. Cleansing prepares the skin for applica- tion of the dressing. Skin must be dry for the dressing to adhere. 5.Cleanse the wound with saline or wound cleanser as prescribed or according to agency procedure. Cleansing of wounds removes bacteria and necrotic debris from wound beds. 6. Consider placing a skin barrier around the wound before transpar- ent film dressing application. Skin sealants may be applied to skin before tape to protect fragile skin from tears or epidermal stripping. 7. Remove the center backing liner from the transparent film dressing.
8.Holding the dressing by the edges, apply the transparent film to the wound without stretching or pulling the dressing or the skin. This reduces the risk of skin damage. 9. Remove the edging liner from the dressing. 10. Gently smooth and secure the dressing to skin. Allows the dressing to adhere fully to the patient’s skin. 11.Dispose of soiled equipment and remove your gloves. Removing the Dressing Transparent film dressings are typically changed every 3 days. Change dressing sooner if drainage extends beyond the edges of the wound onto periwound skin. To remove the dressing, do the following: 12.Grasp one edge of the film dressing. 13. Gently lift the edge. 14. Stabilize the skin underneath the elevated edge with your finger. Stabilizing the skin as the adhesive is taken off will prevent epidermal stripping. 15.With the other hand, slowly peel the dressing back over itself, “low and slow,” in the direction of hair growth. Use of an adhesive removal pad is recommended espe- cially for sensitive skin. Removing the dressing at an angle will increase the risk of pulling on the epidermis and causing mechanical trauma. 16.As dressing is removed, keep moving your finger as necessary to avoid newly exposed skin.
What if . . . ■ The adhesive will not adhere to the patient’s skin because of excess hair? Hair may be removed with clippers/ scissors. Do not shave the site with a razor. Shaving can cause nicks or abrasions to the skin that could become a portal of entry for bacteria. ■ The patient’s skin is diaphoretic or excessively oily? Cleanse the skin with soap and water before the dressing change. Allow the skin to dry before continuing with the dressing.Also, polymer skin barriers may be used to place a seal over the skin and allow the tape adhesive to adhere. ■ The patient has fragile skin (older adults)? Skin sealant preparations may be used under adhesives. The junction between the epidermis and dermis on the older adult is not as strong as with a younger person. Less pressure or tension is needed to break those bonds and cause skin damage. ■ The dressing sticks to itself before it can be applied? If a small portion of the dressing is stuck to itself, gently stretch, or pull the edges in opposite directions. If a large portion is involved, throw the dressing away and start over. Transparent dressings can be difficult to apply because they are polyurethane sheets coated on one side with an acrylic, hypo- allergenic adhesive and are flimsy, making them clumsy to work with at times. ■ Purulent-appearing fluid has collected underneath the film dressing? This does not necessarily mean the wound is infected. Remove the dress- ing and clean the wound per policy. Select an alternative dressing that will be more absorbent. Because films do not have absorptive capabilities, any drainage produced by the wound will pool underneath.
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