Local skin assessment 1. Surgical site infection (SSI) This complication occurs after a medical procedure, causing the surgical wound, tissue or nearby organ space to become infected. Description • The area may be preceded by tissue that is painful, firm, mushy, or boggy, or warmer or cooler than adjacent tissue. Recognise damaged skin, maceration, erythema, oedema, blistering 3. • Describe the differences of wound healing by primary and secondary intention. 4. Blue-green drainage combined with a musty odor usually indicates presence of Pseudomonas in the wound. Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Here are some terms referring to wounds that you should become familiar with. Close. 3. If the skin is very fragile, consider using a non-adhesive dressing such as Biatain Non-adhesive or Biatain Alginate. Wound assessment and dressing choice for venous ulcers Visual summary Dressings should be selected based on the properties of the wound and surrounding skin. Wound Strength Skin wounds At the end of first week,wound strength is approximately 10% of unwounded skin Wound strength increases rapidly over next 4 weeks and then slows down at approximately at third month,reaches a plataue at about 70- 80% of the tensile strength of unwounded skin Scar tissue is ne ve r as stro ng as the o rig inal tissue !! Skin tears can be partial- or full-thickness. ANS: 2. Compare and contrast a normal and an… Clean and or irrigate the wound. The periwound area has been defined as the area of skin extending to 4 cm beyond the wound (ie, the surrounding skin extending from the wound bed). hydrocolloids (indications) pressure ulcers stage II-IV, autolytic debridement of eschar, partial-thickness wounds. The bed is the base of the wound, often tissue that contains viable cells. 5. Near infrared spectroscopy (NIRS) is one of the newer options for evaluating oxygen delivery and usage in the microvasculature. In everyday parlance, wounds typically refer to skin injuries. What is the description of a Stage 2 pressure injury? • Skin tear. 2. Show More Wound Terminology. SURROUNDING SKIN????? Distinguish cellulitis from dermatitis 4. 4. NEW Skin Condition, Wound(s)/Pressure Ulcers(s) ONLY Identification This front section (Identification) is to be completed by the person(s) who observe any NEW skin condition, wound(s)/pressure ulcer(s). If the skin flap is viable (category 1 or 2), gently ease it back into place to use as a dressing (using a gloved finger, dampened cotton tip, tweezers or silicone strip). 2. Assess wound bed and skin 2. pink / red tissue on the edges may indicate epithelialisation; maceration may be indicative of an ineffective dressing regime. WOUND/SKIN RECORD (Cont’d.) 5. Define partial-thickness and full-thickness tissue loss. Maceration, inflammation, erythema and heat, oedema, induration and pain are all signs and symptoms of a potentially non-healing wound. During the process of wound healing, pus and other discharged fluids accumulate in the skin surrounding the wound. Infection: Wounds are often prone to infection, which can significantly disrupt the healing process. • Discuss the normal process of wound healing. In a closed wound or bruise, the soft tissue below the skin surface is damaged, but there is no break in the skin. The classic description of wound healing involves a 3-stage process in which debridement is followed by inflammation, proliferation, ... it is difficult to determine the overall blood flow to a larger region of the surrounding skin. Table 1. Utilize correct anatomical descriptions and verbiage for documentation. Secondary Intention. • Describe the pressure ulcer staging system. Chapter 48 Skin Integrity and Wound Care Objectives • Discuss the risk factors that contribute to pressure ulcer formation. This wound occurs when shearing, friction or trauma causes a separation of skin layers. Peri Wound Skin Classification Grade Type Description 0 Normal skin 1 At risk skin 2 (Exudate Centred) A Dessication B Maceration C Allergy 3 Inflammed 4 Infection 5 Atypical Dr. Harikrishna K.R.Nair 2015 49. a. Start antibiotics. Medical professionals classify skin wounds in several ways, such as whether they are short- or long-term, and whether they are contaminated with bacteria. Room/Bed DATE SIZE IN CM(Length x Width) DEPTH (cm) EXUDATE TYPE/AMOUNT Record text where indicated (line). • Evolution may include a thin blister over dark wound bed. The weighting recognises that the ear is more sensitive to sound in the range 1–4 kHz than at higher or lower frequencies. C. Physical Characteristics 1. Assess for new skin breakdown. Determine anatomical wound location. skin. Accurate wound assessment is a critical component of effective wound management, and requires solid observational skills, knowledge and judgment. The wound bed is viable, pink or red, and moist, or injury may manifest as an intact or ruptured serum-filled blister. Induration: An abnormal firmness or thickness with definite margins palpated under skin, often surrounding a wound or localized injury. The A weighting is widely used. Overgrowth of microorganisms in sufficient quantities to overwhelm the body’s defenses. WOUND/SKIN HEALING RECORD DIRECTIONS: Use a separate sheet for each pressure injury site. It is just as important to clean this area of the wound as it is to clean the wound itself. Hint: Chronic wounds may not exhibit classic signs of infection. The description of the spectrum as a single number is obtained by adding a weighting number to each octave band and logarithmically adding the octaves together. Inferior – Down c. Anterior – Front d. Posterior – Back e. Medial - Towards middle f. Lateral - Away from middle D. Wound Measurement - Linear 1. Wound bed . The skin contains abundant nerve endings and receptors to detect stimuli related to temperature, touch, pressure and pain. Wound edge protection is an accepted part of wound bed preparation models, yet only a handful of published studies have evaluated interventions. Record measurements to the nearest 1/10th centimeter. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. When a wound has sustained a degree of tissue loss it may seem impossible to close the wound as the edges cannot be bought together or undesirable if infection is still present. Wound edge Periwound skin Wound A holistic wound assessment framework, introducing an intuitive way to asses and manage all three areas of the wound:1,2 • Wound bed • Wound edge • Periwound skin Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address patient, wound and skin problems that impact healing. A periwound is simply the area of skin surrounding a wound. Wound Assessment & Management Plan Please use ID Label or block print _____ Hospital / Health Service Wound Assessment & Management Plan Ward: Doctor: Surname UMRN / MRN Given Name DOB Gender Address Postcode Telephone Identify location of wound on diagram below. The resulting single number is given as A, B or C weighted sound level. The wound may further evolve and become covered by thin eschar. In people with incontinence, urine and feces may also come into contact with skin. A wound generically refers to a tissue injury caused by physical means. 2.3.5 S - Surrounding skin The integrity of fragile skin around a wound can be impaired if the conditions of the wound are not managed appropriately; excess exudate can cause maceration, repeated dressing changes skin stripping. Hydrogel sheets and nonadhesive forms are useful for securing a wound dressing when the surrounding skin is fragile. • Deep tissue injury may be difficult to detect in individuals with dark skin tone. (1) Abrasion. Distinguish between wound assessment and evaluation of healing. 3. The condition of the skin surrounding the wound provides important information about underlying disease and the effectiveness of current treatment regimes, e.g. 1 Patients with wounds, irrespective of their etiology, have the propensity for developing vulnerable periwound skin that may be associated with disease processes or their treatment regimens. 17. Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity. Surrounding skin: The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken to protect it from injury. Approximate the skin flap. Differentiate between skin inspection and skin assessment. 4) Predispose to hematoma formation. Several studies have examined the impact of chronic wound fluid on the wound environment. List six factors to consider when assessing darkly pigmented skin. 25-27 Polymer-based film-forming barriers provide a beneficial approach for protection of the wound edge and surrounding skin. CHAPTER 6 Skin and wound inspection and assessment Denise P. Nix Objectives 1. Gently pat the surrounding skin dry; the wound itself should be left to air dry. 48. Granulation tissue, slough, and eschar are not present. 3) Delay wound healing. Note any signs of edema or induration, as well as any lesions, scarring, rashes, staining, moisture, or variations in texture. WOUND/SKIN RECORD NAME–Last First Middle Attending Physician Record No. A wound is a cut or opening in the skin. If multiple wounds, use a separate form for each. Superior – Up b. Presence of infection: Wound infection may be defined as the presence of bacteria or other organisms, which multiply and lead to the overcoming of host resistance. 2) Increase the risk of ischemia. Wound exudate, particularly from chronic wounds, contains not only water, but often cellular debris and enzymes (Chen and Rogers, 1992), and this mixture can be very corrosive to the intact skin surrounding the wound (Coutts et al, 2001). Select the response that best describes the wound. surrounding 5.Assessment of pain caused by inflammation, erosions, deep ulcers, oedema, scars around the wound, vasculitis, neuropathy, angiopathy B. Infected: Invasion of organisms into tissue and systemic response noted. Source: International advisory board of wound bed preparation 2003 50. ODOUR Wound odour may be caused by infection, necrotic tissue or the use of certain dressings. WOUND COLOUR MODEL 51. Dressings can help symptom control and promote healing. However, compression therapy remains the Important Growth factors responsible … Consider the wound location, size, depth, exudate level, and presence of infections. Adipose (fat) is not visible, and deeper tissue is not visible. Surrounding Tissue: Describe the color, firmness, and pallor of the surrounding skin. If this is difficult, rehydrate the flap using a moistened non-woven swab for 5-10 minutes. The skin surrounding a wound is particularly vulnerable and although it may appear healthy, periwound problems occur frequently. absorb exudate; to produce a moist environment that facilitates healing but does not cause maceration of surrounding skin; protect the wound from bacterial contamination, foreign debris, and urine or feces; prevent shearing. In the presence of infection the surrounding skin may appear red, hot to – Surrounding skin The condition of the periwound can tell a great deal about the state of a wound and its potential for healing. It can be just a scratch or a cut that is as tiny as a paper cut.. A large scrape, abrasion, or cut might happen because of a fall, accident, or trauma. With proper wound treatment and use of dressings with superior absorption and exudate management, the skin surrounding a wound may be perfectly healthy and suitable for adhesive dressings such as Biatain Adhesive or Biatain Super Adhesive. 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