Infection is a major threat. Wound care involves preventing infection and further injury to the wound and nearby tissues. Blood loss and pain also are prevented.

The nurse uses the nursing process to keep the person’s skin healthy. Some centers have a skin care team to manage all skin problems. The team includes an RN, physical therapist, and a dietitian.

See Focus on Rehabilitation: Wound Care.

FOCUS ON REHABILITATION

Wound Care

Some persons have poor or delayed wound healing. Others have complications from wound healing. Rehabilitation and subacute care units often provide special wound care.

Types of wounds

Types of wounds are described in Box 35-1. Wounds also are described by their cause:

• Abrasion—a partial-thickness wound caused by the scraping away or rubbing of the skin (Fig. 35-1).

• Contusion—a closed wound caused by a blow to the body (a bruise) (Fig. 35-2).

• Incision—a cut produced surgically by a sharp instrument. It creates an opening into an organ or body space (Fig. 35-3, p. 538).

• Laceration—an open wound with torn tissues and jagged edges (Fig. 35-4, p. 538).

• Penetrating wound—an open wound that breaks the skin and enters a body area, organ, or cavity (Fig. 35-5, p. 538).

• Puncture wound—an open wound made by a sharp object (knife, nail, metal, wood, glass). Entry of the skin and underlying tissues may be intentional or unintentional. See Figure 35-6, p. 538.

• Ulcer—a shallow or deep crater-like sore of the skin or a mucous membrane (p. 539).

Fig. 35-1 An abrasion. (From Kumar V, Abbas AK, Fausto N: *Robbins and Cotran pathologic basis of disease,* ed 7, Philadelphia, 2005, Saunders.)

Box 35-1

Types of Wounds

Intentional and unintentional wounds

• Intentional wound—is created for therapy. Surgical incisions are examples. So are venipunctures for starting intravenous therapy and for drawing blood specimens.

• Unintentional wound—results from trauma.

Open and closed wounds

• Open wound—when the skin or mucous membrane is broken. Intentional and most unintentional wounds are open.

• Closed wound—tissues are injured but the skin is not broken. Bruises, twists, and sprains are examples.

Clean and dirty wounds

• Clean wound—is not infected. Microbes have not entered the wound. Closed wounds are usually clean. So are intentional wounds created under surgical asepsis. The reproductive, urinary, respiratory, and gastro-intestinal (GI) systems are not entered.

• Clean-contaminated wound—occurs from the surgical entry of the reproductive, urinary, respiratory, or GI system. Some or all parts of these systems are not sterile and contain normal flora.

• Contaminated wound—has a high risk of infection. Unintentional wounds are generally contaminated. Wound contamination occurs from breaks in surgical asepsis and spillage of intestinal contents. Tissues may show signs of inflammation.

• Infected wound (dirty wound)—contains large amounts of microbes and shows signs of infection. Examples include old wounds, surgical incisions into infected areas, and traumatic injuries that rupture the bowel.

• Chronic wound—does not heal easily. Pressure ulcers and circulatory ulcers are examples.

Partial- and full-thickness wounds (describe wound depth)

• Partial-thickness wound—the dermis and epidermis of the skin are broken.

• Full-thickness wound—the dermis, epidermis, and subcutaneous tissue are penetrated. Muscle and bone may be involved.

Skin tears

A skin tear is a break or rip in the outer layers of the skin (Fig. 35-7). The epidermis (top skin layer) separates from the underlying tissues (Chapter 9). The skin is “peeled back.” The hands, arms, and lower legs are common sites for skin tears. Very thin and fragile skin is common in older persons. Slight pressure can cause a skin tear.

Fig. 35-7 Skin tear. (Used with permission from Dr. Rosemary Kohr, RN, PhD, ACNP (cert), www.lhsc.on.ca/wound)

Causes

Skin tears are caused by:

• Friction, shearing (Chapter 17), pulling, or pressure on the skin.

• Falls or bumping a hand, arm, or leg on any hard surface. Beds, bed rails, chairs, wheelchair footplates, and tables are dangers.

• Holding the person’s arm or leg too tight.

• Removing tape or adhesives.

• Bathing, dressing, and other tasks.

• Pulling buttons and zippers across fragile skin.

• Jewelry—yours or the person’s. Rings, watches, and bracelets are examples.

Skin tears are painful. They are portals of entry for microbes. Infection is a risk. Tell the nurse at once if you cause or find a skin tear.

Persons at risk

Persons at risk for skin tears:

• Need some to total help in moving

• Have poor nutrition

• Have poor hydration

• Have altered mental awareness

• Are very thin

See Residents With Dementia: Persons at Risk (Skin Tears).

RESIDENTS WITH DEMENTIA

Persons at Risk (Skin Tears)

Some persons are confused and may resist care. They often move quickly and without warning. Or they pull away from you during care. Some try to hit or kick. These sudden movements can cause skin tears.

Never force care on a person. Chapter 44 describes how to care for persons who are confused and resist care. Always follow the care plan.

Prevention and treatment

Careful and safe care helps prevent skin tears and further injury. Follow the measures in Box 35-2. Also follow the care plan and the nurse’s directions. They may include dressings (p. 550) and elastic bandages (p. 543) to protect the skin and promote healing.

Box 35-2

Measures to Prevent Skin Tears

• Keep your fingernails short and smoothly filed.

• Keep the person’s fingernails short and smoothly filed. Report long and tough toenails.

• Do not wear rings with large or raised stones. Do not wear bracelets.

• Be patient and calm when the person is confused or agitated or resists care.

• Follow the care plan and safety rules to handle, move, turn, position, or transfer the person.

• Prevent shearing and friction.

• Use an assist device to move and turn the person in bed.

• Use pillows to support arms and legs. Follow the care plan.

• Pad bed rails and wheelchair arms, footplates, and leg supports. Follow the care plan.

• Follow the care plan and safety rules to bathe the person.

• Dress and undress the person carefully.

• Dress the person in soft clothes with long sleeves and long pants.

• Provide good lighting so the person can see. The person needs to avoid bumping into furniture, walls, and equipment.

• Provide a safe area for wandering (Chapter 44).

• Keep the skin moisturized. Apply lotion according to the care plan.

• Offer fluids. Follow the care plan.

• Remove tape carefully (p. 551).

• Do not apply adhesive tape (p. 551).

Circulatory ulcers

Some diseases affect blood flow to and from the legs and feet. Such poor circulation can lead to pain, open wounds, and edema. Edema is swelling caused by fluid collecting in tissues. Infection and gangrene can result from the open wound and poor circulation. Gangrene is a condition in which there is death of tissue.

Circulatory ulcers (vascular ulcers) are open sores on the lower legs or feet. They are caused by decreased blood flow through the arteries or veins. Persons with diseases affecting the blood vessels are at risk. These wounds are painful and hard to heal.

The doctor orders drugs and treatments as needed. The nurse uses the nursing process to meet the person’s needs (Box 35-3, p. 540). You must help prevent skin breakdown on the legs and feet.

Box 35-3

Measures to Prevent Circulatory Ulcers

• Remind the person not to sit with the legs crossed.

• Re-position the person according to the care plan—at least every 2 hours.

• Do not use elastic or rubber band–type garters to hold socks or hose in place.

• Do not dress the person in tight clothes.

• Provide good skin care daily. Keep the feet clean and dry. Clean and dry between the toes.

• Do not scrub or rub the skin during bathing and drying.

• Keep linens clean, dry, and wrinkle-free.

• Avoid injury to the legs and feet.

• Make sure shoes fit well.

• Keep pressure off the heels and other bony areas. Use pillows or other devices as the nurse and care plan direct.

• Check the person’s legs and feet. Report skin breaks or changes in skin color.

• Do not massage over pressure points (Chapter 36). Never rub or massage reddened areas.

• Use protective devices as the nurse directs. Follow the care plan.

• Follow the care plan for walking and exercise.

Venous ulcers

Venous ulcers (stasis ulcers) are open sores on the lower legs or feet. Stasis means stopped or slowed fluid flow. These ulcers are caused by poor venous blood flow (Fig. 35-8, p. 540).

Venous ulcers can develop when valves in the leg’s veins do not close well. The veins do not pump blood back to the heart in a normal way. Blood and fluid collect in the legs and feet. Small skin veins rupture. This allows hemoglobin to enter the tissue, causing the skin to turn brown. (Hemoglobin gives blood its red color.) The skin is dry, leathery, and hard. Itching is common.

The heels and inner part of the ankles are common sites for venous ulcers. They can occur from skin injury. Scratching is an example. Or they can occur without trauma.

Venous ulcers are painful and walking is difficult. Fluid may seep from the wound. Infection is a risk. Healing is slow.

Risk factors

Risk factors for venous ulcers include:

• History of blood clots

• History of varicose veins (Fig. 35-9)

• Decreased mobility

• Obesity

• Leg or foot surgery

• Advanced age

• Surgery on the bones and joints

• Phlebitis (inflammation [itis] of a vein [phleb])

Prevention and treatment

To prevent venous ulcers:

• Follow the care plan to prevent skin breakdown. See the measures in Box 35-3.

• Prevent injury. Do not bump the legs and feet.

• Handle, move, and transfer the person carefully and gently.

Persons at risk need professional foot care. Attention is given to toenails, corns, calluses, and other toe and foot problems. You do not cut the toenails of persons with diseases affecting the circulation.

Venous ulcers are hard to heal. The doctor may order drugs for infection and to decrease swelling. Medicated bandages and other wound care products are often ordered. So are devices used for pressure ulcers. The doctor may order elastic stockings or elastic bandages to:

• Promote comfort

• Promote circulation by providing support and pressure to the veins

• Promote healing

• Prevent injury

Elastic stockings.

Elastic stockings exert pressure on the veins. The pressure promotes venous blood return to the heart. The stockings help prevent venous ulcers and blood clots in leg veins.

APPLYING ELASTIC STOCKINGS

Quality of life

Remember to:

• Knock before entering the person’s room.

• Address the person by name.

• Introduce yourself by name and title.

• Explain the procedure to the person before beginning and during the procedure.

• Protect the person’s rights during the procedure.

• Handle the person gently during the procedure.

Pre-procedure

1 Follow Delegation Guidelines: Elastic Stockings, p. 541. See Promoting Safety and Comfort: Elastic Stockings, p. 541.

2 Practice hand hygiene.

3 Obtain elastic stockings in the correct size and length.

4 Identify the person. Check the ID (identification) bracelet against the assignment sheet. Also call the person by name.

5 Provide for privacy.

6 Raise the bed for body mechanics. Bed rails are up if used.

Procedure

7 Lower the bed rail near you if up.

8 Position the person supine.

9 Expose the legs. Fan-fold top linens toward the thighs.

10 Turn the stocking inside out down to the heel.

11 Slip the foot of the stocking over the toes, foot, and heel (Fig. 35-11, A). Make sure the stocking heel is properly positioned on the person’s heel.

12 Grasp the stocking top. Pull the stocking up the leg. It turns right side out as it is pulled up. The stocking is even and snug (Fig. 35-11, B).

13 Remove twists, creases, or wrinkles.

14 Repeat steps 10 through 13 for the other leg.

Post-procedure

15 Cover the person.

16 Provide for comfort. (See the inside of the front book cover.)

17 Place the signal light within reach.

18 Lower the bed to its lowest position.

19 Raise or lower bed rails. Follow the care plan.

20 Unscreen the person.

21 Complete a safety check of the room. (See the inside of the front book cover.)

22 Decontaminate your hands.

23 Report and record your observations.

A blood clot is called a thrombus. If blood flow is sluggish, blood clots may form. They can form in the deep leg veins in the lower leg or thigh (Fig. 35-10, A). A thrombus can break loose and travel through the bloodstream. It then becomes an embolus. An embolus is a blood clot that travels through the vascular system until it lodges in a vessel (Fig. 35-10, B). An embolus from a vein lodges in the lungs (pulmonary embolism). A pulmonary embolus can cause severe respiratory problems and death. Report chest pain or shortness of breath at once.

Elastic stockings also are called AE stockings (AE means anti-embolism or anti-embolic). They also are called TED hose (TED means thrombo-embolic disease). Persons at risk for thrombi include those who:

• Have heart and circulatory disorders

The person usually has two pairs of stockings. Wash one pair while the other pair is worn. Wash them by hand with a mild soap. Hang them to dry.

See Delegation Guidelines: Elastic Stockings.

DELEGATION GUIDELINES

Elastic Stockings

Before applying elastic stockings, you need this information from the nurse and the care plan:

• What size to use—small, medium, or large

• What length to use—thigh-high or knee-high

• When to remove them and for how long—usually every 8 hours for 30 minutes

• What observations to report and record:

• The size and length of stockings applied

• When you applied the stockings

• Skin color and temperature

• Leg and foot swelling

• Skin tears, wounds, or signs of skin breakdown

• Complaints of pain, tingling, or numbness

• When you removed the stockings and for how long

• When you re-applied the stockings

• When you washed the stockings

• When to report observations

• What specific resident concerns to report at once

See Promoting Safety and Comfort: Elastic Stockings.

PROMOTING SAFETY AND COMFORT

Elastic Stockings

Safety

Apply the stocking so the opening in the toe area is over the top of the toes. Use the opening to check circulation, skin color, and skin temperature in the toes.

Stockings should not have twists, creases, or wrinkles after you apply them. Twists can affect circulation. Creases and wrinkles can cause skin breakdown.

Loose stockings do not promote venous blood return to the heart. Stockings that are too tight can affect circulation. Tell the nurse if the stockings are too loose or too tight.

Comfort

Apply stockings before the person gets out of bed. Otherwise the person’s legs can swell from sitting or standing. Stockings are hard to put on when the legs are swollen. The person lies in bed while they are off. This prevents the legs from swelling.

Gently handle and move the person’s foot and leg. Do not force the joints (toes, foot, ankle, knee, and hip) beyond their range of motion or to the point of pain.

Elastic bandages.

Elastic bandages have the same purposes as elastic stockings. They provide support and reduce swelling from injuries. Sometimes they are used to hold dressings in place. They are applied to arms and legs. When applying bandages: