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CHAPTER 32 Skin Integrity & Wound Healing
Procedure Steps 1. Perform hand hygiene and don clean nonsterile gloves. Gloving prevents cross-contamination. 2.Cleanse the skin at least 5 cm (2 in.) around the wound with saline-moistened gauze. Pat the skin dry, allowing it to dry thoroughly. The skin surrounding the wound must be clean and dry for the strips to adhere. 3. Apply a skin preparation prod- uct and allow it to dry (or follow agency procedures). Avoid benzoin on fragile skin. Because the strips are prone to peeling off with moisture, benzoin enhances adhesion of the strips. 4. Do not allow skin preparation product to come into contact with the wound. It may impair healing. 5. Peel back package tabs to access the adhesive closures. 6. Remove the card from the pack- age using modified sterile technique as necessary. Careful technique should be followed when applying to a surgical wound to min- imize contamination and promote healing. 7. Grasp end of the skin closure with forceps or gloved hand and peel strip from the card at a 90° angle.
Closures lifted at a lesser angle or directly back on themselves may “curl,” complicat- ing handling. 8.Starting at the middle of the wound, apply strips perpendicular to the wound, drawing the wound edges together.Apply closures without ten- sion; do not stretch or strap closures. a.Apply half of the closure to the wound margin and press firmly in place. b. Using fingers or forceps, ensure skin edges are approximated. c.Press the free half firmly on the other side of the wound in a lad- der fashion. d.Place the strips so that they extend at least 2 to 3 cm (¾ to 1 in.) on either side of the wound to ensure closure. e.Place the wound closure strips 3 mm ( 1 ∕ 8 in.) apart along the wound.
What if . . . ■ A flap of skin rolls up on the edges?
Cleanse the wound with normal saline and reapproximate the edges of the skin flap with the intact epidermis. Apply skin closures across the flap. ■ The skin around the wound is swollen? Apply skin closures without tension and reapply as swelling increases. This prevents pulling on the skin that can delay healing or disrupt the approximated borders of the wound, which is more likely to lead to scarring. ■ Edges are not accurately approximated or tension has been placed on the skin? Remove the closure over the affected area, peeling each side toward the wound, and reapply. Use of adhesive products can cause super- ficial skin damage if the skin is stretched during application or with edema formation. Tension blisters are the most common prob- lem associated with taping.
Evaluation ■ Verify that skin closures are appropriate for the wound. ■ Note whether the closures adhere comfortably to the skin. ■ Ensure the patient verbalized understanding of the treatment. ■ Inspect the wound daily. Lifted closure edges may be trimmed or closures replaced if less than half of the strip remains. Patient Teaching ■ Teach the patient about the expected healing process. ■ Inform the patient or caregiver about signs and symptoms of infection and the need to report these findings. ■ Instruct patient not to pull or tug on the strips. Improper removal may damage the underlying skin or the wound itself. ■ Instruct the patient that they do not need to keep the strips dry.They can bathe and shower as directed by the health- care provider. ■ Instruct the patient that adhesive strips are often kept in place until they begin to separate from the skin on their own.
Documentation Sample Documentation 00/00/0000 2040
Skin closures applied to surgical incision along right forearm.Wound edges are well approximated with slight erythema noted 4 mm from incisional site. Periwound skin is dry and intact with no drainage, induration, or odor noted.Wound cleansed with normal saline using sterile technique. Patient educated on the purpose of the closures and expected time and course of healing.Will continue to monitor. —S.Wong, RN
Practice Resource Takayama et al. (2016).
Thinking About the Procedure
The video Placing Skin Closures, along with questions and suggested responses, is available on the Davis’s Nursing Skills Videos Web site on FADavis.com.
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