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CHAPTER 32 Skin Integrity & Wound Healing
Procedure Steps 1. Place the patient in a comfort- able position that provides easy access to the wound. Provides for patient comfort and proper nurse body mechanics during dressing change. 2. If a dressing is present, perform hand hygiene, don clean nonsterile gloves, and remove the old dressing. Prevents transfer of pathogens. 3. Dispose of the soiled dressing and gloves in the biohazard waste container. Dressings may contain body fluids and other contaminants, so they must be dis- posed of in moisture-proof containers. 4. Perform hand hygiene. Don non- sterile 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 or pat wound dry with sterile gauze. Do not attempt to remove residue that is left on the skin from the old dressing. Cleansing and drying prepare the skin for application of the dressing. Removing resi- due irritates the surrounding skin. 5. Apply skin prep to the area cov- ered by tape. Skin prep protects intact skin from break- down from tape removal. 6. Cleanse the wound as directed. Wound cleansing may be performed with clean or sterile technique, depending on the type of wound. Cleansing the wound removes microbes and necrotic debris from wound bed. Stud- ies show using either saline or tap water is similarly effective for cleansing.
7. Remove soiled gloves and assess the condition of the wound. Note the size, location, type of tissue pres- ent, amount of exudate, and odor. Granulating tissue is beefy red with a velvety appearance. It appears with the growth of new blood vessels and connec- tive 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.A hydrocolloid dressing will interact with wound drainage to produce a thick, yellow gel that may have a foul odor. Clean the wound before assessing for exudate and odor. 8. With the backing still intact, cut the hydrating dressing, if necessary, to the desired shape and size. Size the hydrocolloid dressing so it will extend 3 to 4 cm (1.5 in.) beyond the wound margin on all sides and cover all areas of nonintact skin. Provides complete coverage of the wound. 9.Don clean nonsterile gloves. Hold hydrocolloid dressing between hands to warm it so that it adheres better. Then remove the backing of the hydrocolloid dressing, starting at one edge. Place the exposed adhe- sive portion on the patient’s skin. Position the dressing to cover the wound.
10. Gradually peel away the remain- ing liner; smooth the hydrocolloid dressing onto the skin by placing your hand on top of dressing and holding in place for 1 minute. Warmth helps the dressing adhere to the skin.
11. Assist the patient to a comfort- able position. 12.Remove your gloves. Perform hand hygiene. What if . . . ■ Signs of infection are noted? Notify healthcare provider. Cultures may be prescribed. A different type of dressing may be prescribed, as well. ■ The surrounding skin is not intact? Choose a larger size of hydrocolloid dressing to cover the nonintact area. Document your observations and report new findings to the healthcare provider.
Evaluation ■ Verify that a hydrocolloid dressing is still appropriate for the wound. ■ Note whether the dressing adheres comfortably to the skin. ■ Ensure the patient verbalizes understanding of treatment. ■ Inspect the dressing daily. Change it if it becomes dislodged, leaks, or wrinkles or if it develops an odor.
Patient Teaching ■ Teach the patient about the expected healing process. ■ Inform the patient and caregiver about signs and symptoms of infection and the need to report these findings. Home Care ■ Hydrating dressings may be required in the home setting. Teach caregivers to use the appropriate size and change the
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