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Skin & Wound Care Primer
Introduction
Skin breakdown can be unfairly equated with poor nursing care. However, an aging
patient population requires a new look at the skin’s capability. These facts show the
importance of learning more:
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15% of hospital patients have pressure ulcers.1
25% of hospitalized patients have perineal dermatitis. 2
15% of diabetics develop at least one foot ulcer.3
Healing of venous ulcers takes 9 to 24 months to heal and recurs in 60% of
cases. 3
8% of those over 70 have peripheral arterial disease, the primary cause of
arterial ulcers.3
Skin vulnerabilities change throughout life. Age-specific examples are the diaper rash of
babies, the acne of adolescence, and skin cancers cropping up after middle-age. This
course focuses on the geriatric population. Normal skin changes associated with aging
are:
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Drying of skin due to decline in sweat and sebaceous gland function.
Thinning of the epidermis, dermis, and subcutaneous fat layer.
Increase in vulnerability to ultraviolet rays and infection.
Emergence of age spots, wrinkles and skin growths.
Decrease in vitamin D production.
Increase in capillary fragility
Delayed wound healing.
Decrease in blood flow.
Loss of elasticity. 3, 4, 5, 6
The magnitude of these natural changes increases with time. The percentage of older
adults with skin infections, for example, rises with age.7 Contributing factors are:
 Functional decline in all systems, especially the immunological and
cardiovascular systems.
 Increased vulnerability to accidents from co-morbidities and polypharmacy.
 Accumulation of lifelong exposure to the sun.
 Increasing likelihood that chronic infections will to go undetected and
therefore, untreated.
Skin Repair
The skin heals in three phases:
1. Inflammation.
After the formation of a clot, the inflammatory response lasts about five
days. It is characterized by pain, warmth, redness, swelling and exudate.
2. Proliferation.
This generally takes weeks. Partial-thickness wounds regenerate; whereas
full-thickness wounds heal with scar formation. During this phase
epithelialization, granulation, collagen synthesis, and revascularization
occur. New cells migrate from the edges to the center of the wound,
creating a new matrix.
3. Maturation.
This phase takes anywhere from three weeks to two years. Fibers
remodel, resulting in contracted, stronger tissue. 3, 5, 6
Chronic wounds are those that do not heal within six weeks. Most often these are
pressure ulcers and vascular ulcers of the lower extremities. The majority take up to six
months to heal. Some may take years to heal, and then are likely to reoccur.8, 9
The inflammatory phase of healing is prolonged in chronic wounds.6 The size of the
wound may increase over time, edges may look irregular, exudate and necrotic tissue
may be present, and tissue destruction may extend under the skin into the surrounding
area, a phenomenon known as undermining and/or tunneling.5
Several factors can underlie a diminished healing capacity:
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Obesity.
Incontinence.
Immobility.
Chronic pain.
Malnutrition.
Cigarette smoking.
Immunosuppression.
Poor diabetic control.
Scratching due to intolerable itching.
Inadequate oxygenation and/or tissue perfusion.
Failure to increase calories and protein needed to heal wounds, infections, and
injuries.
Wound damage from excessive moisture or dryness; mechanical trauma,
pressure, friction; and/or radiation.
Skin Problems
Dermatitis
Dermatitis shows up where skin is irritated. It is common in body folds, especially in the
perineal area. Post-menopausal women have diminished estrogen that creates atrophy of
vaginal and vulvar tissues. Pruritis often initiates unconscious scratching that leads to
infection. More than half of nursing home residents are incontinent of urine and/or
feces.10, 11 Incontinence irritates and inflames the whole area, extending to the buttocks.
Antiseptics, soaps and topical ointments may further aggravate the condition.
Infection
Infection can occur in several ways:
 Skin integrity is lost through scratching, injury, ulceration, or insertion of an
invasive device.
 Skin is colonized with MRSA (methicillin-resistant staph aureus).
 Immune function weakens and dormant viruses become activated.
 Unhealthy skin supports a chronic or recurring fungal infection. 4, 7, 12
Skin Tears
Skin tears occur when aging skin becomes vulnerably paper-thin. Older adults are also
increasingly accident-prone from cognitive impairment, diminished perceptual ability,
gait and balance problems, and dizziness. The prevalence of senile purpura and xerosis
causes skin to tear more easily.4 Older skin tears easily when adhesive dressings are
hastily removed.
Skin Cancers
Life-long exposure to ultraviolet radiation is the cause of over 90% of non-melanoma
skin cancers, affecting almost half of Americans over 65.13 Actinic keratosis, precancerous lesions, are commonly seen on sun-exposed areas of the head, neck and upper
body. Among cancerous lesions, most are basal cell carcinomas. They are slow growing
and curable if detected early. Squamous cell carcinoma is seen in people who have had
chronic sun exposure. Melanomas are life-threatening because of their tendency to
metastasize. The occurrence of skin cancer among North Americans is:
 One in five for basal cell carcinoma.
 One in twenty for squamous cell carcinoma.
 One in sixty for melanomas. 14
Ulcers
Pressure ulcers occur over bony prominences subject to pressure and/or friction. They
may go undetected until development penetrates the surface skin. The skin over a healed
ulcer is likely to breakdown again because scarring weakens the tissue.15 Skin integrity
deteriorates in just a few hours, making prevention of pressure ulcers a critical task.
Pressure ulcers can occur when:
 Patients are in surgeries lasting over three hours.
 Patients are immobile due to spinal cord injuries or strokes.
 Patients are recovering from hip fractures.
 Patients do not move because of pain.
 Devices assert continual pressure on skin.
 Patients on bed-rest are dehydrated or malnourished. 16, 17
Diabetic ulcers are due to neuropathy which occurs in 2/3 of diabetics within 5-10 years
after diagnosis.3; 17 Normal protective sensation in the feet is lost and structural changes
occur that contribute to injuries. Ulcers develop from either a single trauma, repetitive
damage from improper shoes, or bath water that is too hot.18
Arterial ulcers occur when peripheral artery disease becomes severe. This can stem from
atherosclerosis, blood clots, vasculitis, or Raynaud’s disease. Critical limb ischemia
eventually creates full-thickness ulceration that turns gangrenous and necessitates
amputation if untreated.19
Venous ulcers develop from deep vein thrombosis, faulty valves, and/or inadequate calf
muscle pumping function.
Burns
Most burn injuries in older adults come from scalding accidents. The prognosis for
survival is poor in older adults. The percent of full-thickness injury is higher in older
people because their skin is more susceptible. Full-thickness burns require surgery, a
high risk for traumatized, older, and frail people.20
Skin Assessments
Inspecting the skin, hair, and nails is routine for nurses. Skin changes can occur within a
few hours, making frequent re-inspection a preventive measure. Visual assessments
include:
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Color: redness, pallor, cyanosis, jaundice.
In darker skinned people, inflammation may not look red but the inflamed
area may be firmer than surrounding tissue. A halogen light can show skin
hue differences between the affected area and the surrounding skin.21
Texture: smooth, rough, or cracked.
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Moisture: dry, or covered in sweat.
Temperature.
Edema of the body part, rated from one to four if pitting and/or measured by
taking a limb circumference.
Turgor.
Exudate.
Hemorrhage.
Lesions.
Before choosing terms to describe lesions, wounds have to be palpated and measured,
and distribution patterns determined. Basic terms used to describe lesions are:
 Macule.
 Papule.
 Patch.
 Plaque or scale.
 Wheal.
 Nodule.
 Vesicle.
 Pustule.
 Cyst.
 Scar.
 Abrasion.
 Tear.
 Fissure.
 Burn.
 Ulcer.
It may be difficult for nurses to make an accurate assessment of skin wounds. Current
guidelines recommend that facilities choose terms, tools, and perimeters that staff will
agree to use consistently. Whereas accuracy of assessment is crucial for determining
initial treatment, the goal of daily wound measurement is to identify change as an
evaluation of treatment.22
An assessment begins with:
1. Differentiating between superficial, partial-thickness, and full-thickness
wounds.
A typical sunburn is a superficial wound. A second degree burn is a
partial-thickness wound. It is red, painful, swollen, and blistered. The
wound base of a partial-thickness wound is bright or pearly pink with red
“islets”. A full-thickness wound has extensive damage and necrotic tissue.
Its wound base is beefy red but the wound may have black eschar, yellow
slough, or white margins indicating maceration.
2. Estimating the wound size.
There are three ways to do this: take a two-dimensional measurement, take
a three-dimensional measurement, or calculate the total surface area.
Planimetry calculates the size of a wound in cm2 by multiplying length
and width of the actual wound, a tracing, or a photo.
Some wounds are irregular in shape and have tunnels beneath the surface
of surrounding skin. To get a three-dimensional measurement an
applicator has to be inserted to read depth and direction of the wound and
its tunnels. Another way is to create molds made with alginate or pour
fluid into the wound to determine volume.
Total surface area of a wound such as a burn can be estimated through
either the Rule of Nines or, more accurately, with a Lund and Bower Chart
that takes age-related differences of body proportions into consideration.
(R)
3. Determining between critically colonized and infected wounds.
Chronic wounds are typically colonized with many different microbes. A
microbial count can be obtained by swabbing the wound or having a
biopsy done. Clinical signs may differentiate a poorly healing wound
from an infected wound. Both critically colonized and infected wounds
have clear yellow or straw-colored exudates. They may both have a foul
smell and be expanding in size. However, the critically colonized wound
will show red granulation tissue and the infected wound will generate an
inflammatory response including increased temperature.23, 24
Tests that determine the healing capacity for wounds are:
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Tests of blood flow and tissue oxygenation.
CBC: RBCs, WBCs, hemoglobin, hematocrit, platelet count, and mean
corpuscular volume.
TcPO2 (transcutaneous oxygen): Less than 20 mmHg indicates an inability
to heal.
ABI (ankle-brachial index): calculation is derived from the ratio between
pressure at the ankle and pressure in the arm. Severe ischemia is indicated
when the measurement is less than 0.5. Elevations above the normal of
0.9 to 1.1 occur when calcification is present.25
A handheld Doppler ultrasound is used to take an ABI . Doppler
ultrasound is also used for color duplex imaging that can identify
occlusions and restrictions in veins and arteries.
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Nutritional status.
More than 15% loss of usual body weight is significant. Obesity is also a
marker for poor healing capacity, due to diminished tissue perfusion.
Significantly poor healing capacity is indicated in these values:
A prealbumin level under 9 mg/dl.
An albumin level under 2.7g/dl.
A transferrin level under 149 mg/dl.
A total lymphocyte count under 1200 mm3. 3
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Neuropathy.
The Semmes-Weinstein monofilament test assesses the protective function
of nerves in diabetics.
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Glucose control.
A fasting blood glucose over 400 mg/dl shows lack of homeostasis.
An Hb A1c (glycosylated hemoglobin) over 8% shows poor long-term
diabetic control.
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Bacterial status of wound.
A microbial count of over 100,000 cfu (colony forming units) indicates
infection that will prevent healing. However, some bacteria such as
streptococcus will prevent healing even with a smaller number of colonies.
Wound cultures and sensitivities may be necessary to direct treatment.
Specific Assessments
Skin cancer
Skin cancer is suspected when there is a visible change in the skin. Skin cancer is usually
painless but may bleed regularly. The change may be a new growth or an old growth that
starts to change in appearance. Although diagnosis of skin cancer is made by biopsy, a
preliminary differentiation may be attempted by appearances:
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Actinic keratosis: reddened, scaly papules, often in clusters.
Basal cell carcinoma: superficial, smooth, pigmented nodules or papules.
Squamous cell carcinoma: scaly, red papules, often concurrent
with actinic keratosis.
Melanoma: varied appearances but follows the ABCDE rule:
A: asymmetrical
B: borders are irregular
C: colors are multiple within same lesion
D: diameter over 6mm.
E: evolving/changing lesion 5, 14
Skin tears
Skin is easily torn in the geriatric population and may go unnoticed by the patient. A tear
may be mistaken as a pressure ulcer if it occurs over a pressure point (B-D). The PayneMartin System is helpful in classifying tears for documentation purposes:
I: A flap-type tear without tissue loss.
II: A tear with scant to moderate tissue loss.
III: A tear with complete tissue loss. 4
Skin infections
Differentiation between common diseases is often made by clinical signs and symptoms.
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Shingles: skin manifestations preceded by tingling, numbness and burning.
Within days, clusters of blisters occur, embedded in a rash. This appears in a
line on one side of the trunk. It progresses to plaques and pustules.
Cellulitis: a red, warm, hardened, tender area. Borders are not sharply
demarcated. The WBC count is elevated.
Impetigo: an inflamed patch that progresses to clusters of rupturing blisters
filled with honey-colored liquid. 12
Perineal dermatitis
This is characterized by redness over a diffuse area. It may extend from groin to buttocks
to thighs. There may be erosion of superficial skin layers, scaling, blisters, or weeping.
If the condition continues, secondary infection commonly occurs, usually from fungi.
The patient complains of discomfort, itching, pain and burning.2, 10
Perineal dermatitis can be caused by allergic reactions, contact with irritants in laundry
soaps, or skin cleansing and moisturizing products. Most often it is associated with
incontinence. Risk assessment tools identify patients needing preventive measures.
However, use of the tools is problematic because of the frequent need for re-assessment.
A re-assessment is needed after each perineal cleaning, as often as every two hours.
Clinical experts recommend using a simple three question check:
 Is the skin color or firmness different from that of the surrounding area?
 Is the skin blistered or weeping?
 Is the area causing pain or itching? 11
Diabetic ulcers
Assessment includes observation, popliteal and pedal pulse checking, and classification
of the wound according to severity.
Diabetic ulcers usually occur on the ball of the foot, on top of the toes, or under the heel.
The ulcer can be shallow, or deep with undermining. The edges will be even and the bed
will show granular, red tissue. The foot will be warm and there will be slight to moderate
drainage.3, 18, 26
The University of Texas Diabetic Foot Classification System is a useful tool: 6
Stage
A
Grade 0
Epithelialized
B
C
D
Infected
Ischemic
Infected +
ischemic
Grade I
Superficial
wound
↓
Grade II
Wound
penetrating to
tendon or
capsule
↓
Grade III
Wound
penetrating to
bone or joint
↓
Another useful tool is the Wagner Grading System: 6
Grade
0
1
2
3
4
5
Pre-ulcerative lesion
Healed ulcers
Bone deformity
Superficial ulcer
Wound penetrating through subcutaneous
tissue
Osteitis, abscess, or osteomyelitis
Gangrene of digit
Gangrene of foot
Vascular ulcers
Venous ulcers typically occur in the lower legs, between the ankle and mid-calf area.
They are flat, shallow wounds with irregular edges and a beefy color. There is firm
edema and moderate to heavy drainage. The skin around the wound is dry, thin, and
scaly, with visibly dilated superficial veins. The patient complains of minimal to severe
pain. This lessens when the affected leg is elevated and increases when resting at night.
3, 8, 18
Some diagnostic tests for patients with venous ulcers are:
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ABI checks for arterial insufficiency, present in 25% of patients with venous
disease. If arterial insufficiency is found, it contradicts compression therapy
as a treatment for venous disease.
Contrast venogram rules out deep vein thrombosis (DVT).
Doppler ultrasound studies check for venous reflux, obstructions and
restrictions.
Venous cuff pressure readings below the knee can be obtained by air or a
photoelectrode. They rule out DVT, check for venous reflux and calf muscle
pump ability, and assess the severity of the disease. 3, 6
Arterial ulcers tend to occur in the distal part of the leg, on the sides of the feet, at the
ankle, between the toes or on their tips, or places subject to trauma or constant rubbing.
They are small, round, wounds that looks “punched out”. They may be shallow or deep
but have even, smooth edges and pale wound beds. Drainage is minimal. The patient
complains of severe pain that worsens when the leg is elevated and lessens when the leg
is lowered. The surrounding skin is thin, shiny, cyanotic, dry and cold. 3, 18, 19
Clinical assessments of arterial ulcers include:
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The pain history.
How and where did the pain start?
How long does the pain last? (Is there intermittent claudication?)
Has the pain progressed to another location, for example from the calf to
across the foot?
Perfusion test.
Check capillary refill by observing skin temperature and color upon
elevating and lowering the leg.
Pulse checks.
Take the dorsalis, posterior tibial, bilaterial femoral and poplilteal
pulses.19, 25
Diagnostic tests are:
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ABI identifies arterial insufficiency.
Segmental cuff pressure readings (high thigh, low thigh, below knee and
above ankle) confirm arterial insufficiency or identify calcification of arteries.
Toe pressures identify poor healing potential.
Doppler ultrasound studies measure blood flow and determine the severity of
arterial disease. These include skin perfusion pressure study, waveform
analysis, and color duplex imaging.
TcPO2 identifies micro-vascular insufficiency/perfusion problems.
MRA identifies and rates the severity of arterial obstruction.
Angiography is the gold standard for diagnosis of arterial disease. The test is
associated with risks but is necessary before revascularization procedures.3, 6
Pressure ulcers
Hospitals are required to prove wounds existed prior to admission, or that preventive
measures were taken. Medicare and Medicaid reimbursement requires staging and
documentation of all pressure ulcers on admission, or proof that hospital-acquired
pressure ulcers were unavoidable.1, 27 Documentation is also critical at transition times:
between settings or whenever the patient is gone for more than a few hours.15
The Braden Scale is the most widely used pressure ulcer risk assessment tool.3, 16, 28 It is
a one-minute tool that rates the following risk factors:
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Impaired sensory perception.
Exposure to moisture.
Inactivity.
Immobility.
Poor nutritional status.
Friction and shear.
Within a range of six to 23, high risk patients score less than 16.5 For elderly and for
dark-skinned people, a score less than 18 is considered high risk.21
A risk assessment for pressure ulcers is done on admission. Experts claim it is more
predictive when done 48 to 72 hours later.27 They recommend re-assessments at these
times:
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Every 24 hours in ICU.
On every RN visit in home care.
Weekly for a month for new long-term care residents;
monthly or quarterly afterwards. 21, 29
Pressure ulcers require measuring, staging, and documentation. Pressure ulcers are often
worse than their initial appearance shows. 16 One study of nursing home residents used
ultrasound to identified deep tissue damage under the skin’s surface. Pressure ulcers
were found in over half of the residents. In comparison, nurses were able to spot only
18% of these ulcers.2 Staging of pressure ulcers is equally challenging. Sometimes
necrotic tissue has to be removed first in order to see the wound bed.1
The National Pressure Ulcer Advisory Panel updated the staging system in 2007.30 The
system does not reverse its classification as ulcers heal. A stage IV ulcer will still be
classified as a stage IV ulcer after it heals.1
The updated staging system is:
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Suspected deep tissue injury.
This shows a reddened or purple color, blistering over a dark wound bed,
or differences from surrounding tissue in pain response, firmness or
temperature.
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Stage I.
This shows a red or purple colored area that doesn’t blanch. It is
accompanied by pain, firmness and temperature differences from the
surrounding area.
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Stage II.
This is a shallow, open ulcer or ruptured blister.
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Stage III.
The presentation varies by anatomical location. Subcutaneous fat may be
visible, as well as undermining and tunneling.
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Stage IV.
This also varies by anatomical location. This wound may have slough or
eschar. Bone, tendon or muscle is seen. It often has undermining and
tunneling.
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Unstageable.
This wound cannot be staged because it is covered by slough and/or
eschar.
Management & Treatments
Ulcers
Interventions for pressure ulcers focus on wound care and neutralization of contributing
causes. It is strongly recommended to turn patients in bed every two hours, reposition
patients in wheelchairs hourly, use devices to keep pressure off bony prominences, and
keep the head of the bed as low as possible.
Dressing changes may be necessary for ulcers every four hours if the ulcer is advanced,
or as infrequently as once a week in the beginning stages.5 If the ulcer is continually
exposed to urine or feces, and indwelling catheter or rectal appliance may be required to
allow the wound to heal.26
The treatment for venous ulcers is often compression therapy to improve venous flow and
reduce edema. However, many patients also have congestive heart failure or arterial
disease. Ischemia, indicated by an ABI over 0.8, puts them at risk with compression
therapy. Compression therapy in a very low pressure range may still be used,
cautiously.6 Ways compression therapy can be applied are:
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Through paste bandages, rigid or elastic, or through a boot. These stay on for
four to seven days.
With stockings or elastic wraps that are intended for long-term use and allow
showering.
With a pneumatic pump system that inflates and deflates on a cycle. 3
Diabetic foot ulcers can usually be effectively treated with hyperbaric oxygen therapy.31
However, only a thousand hospitals in this country have this therapy available.
Half of those with critical limb ischemia require revascularization.19 Their treatment
includes antibiotic therapy for infected ulcers, endovascular procedures, or bypass
surgery. Eschar over an arterial ulcer may or may not require surgical debridement done
at the same time.25
Infectious diseases
Antibiotics, antifungals, and antivirals are primary treatment for infectious skin
conditions. The choice of topical, oral, or intravenous administration depends on the
severity of the infection and the size of the affected area. It also depends on the virulence
and drug susceptibility of the infectious agent, determined through wound culture and
sensitivity.
Impetigo requires a soaking in warm, soapy water to dissolve scabs. Topical antibacterial
ointment is applied to small areas. Oral antibiotics are necessary for more severe cases.
Candidiasis is treated by reducing moisture in the affected area. Burrow’s solution soaks
are soothing. Topical antifungals in powder or cream are then applied.
Cutaneous abscesses caused by MRSA require incision and drainage. Antibiotics are
given only if there are systemic complications or extensive surrounding cellulitis.32, 33
Necrotizing fasciitis, a rare life-threatening condition often associated with MRSA,
necessitates immediate surgical debridement.
Shingles is best treated with an antiviral administered within 72 hours after the rash
appears. This shortens the duration of the disease and minimizes frequently occurring
post-herpetic neuralgia. Pain management is a major concern and involves
experimentation with oral and topical medications.
Skin cancer
Actinic keratosis may or may not be treated. There is a small risk that it will evolve into
squamous cell carcinoma.14 Treatments include topical medications, blue light, and
liquid nitrogen.
Basal and squamous cell carcinoma may be removed during the biopsy procedure. If not,
the patient is scheduled for a surgical incision, the Mohs micrographic procedure for
sensitive areas, electrodessication and curettage, or liquid nitrogen. Non-surgical options
include chemotherapy, photodynamic therapy and radiation. 13, 14
Skin tears
Skin tears require gentle cleansing with normal saline solution, drying, and gentle
repositioning of torn skin flaps. Caution is crucial with dressings. Removing them can
easily tear skin further. Protective ointments and skin sealants can be useful.21
Burns
Immediate treatment goals for burns are fluid resuscitation, pain management, and
closure of the wound. Full-thickness burns must be grafted because they will not
regenerate without contracting scar tissue. The options include:

Autografts.
Grafts can be in sheet or meshed form. They are stapled in place and an
antimicrobial dressing is laid over it. A dry dressing and gauze netting is
wrapped around the area. The site is irrigated every four to eight hours
and left undisturbed for three to five days. Simultaneously, the donor site
heals within the same time period and can then be reharvested.34

Allografts (from a human cadaver), xenografts (from another species), and
skin substitutes.
These are eventually rejected but useful to cover the wound when there is
not enough of the patient’s donor skin available. Some skin substitutes
combine skin with a synthetic material that promotes matrix building and
healing.34
Burns healed from the initial stages require cocoa butter or mineral oil to be massaged
into them for six months to keep tissue soft. Itching is managed with antihistamines.
New skin is protected from sun exposure and temperature extremes.
Dermatitis
It may take over two weeks to resolve incontinence-associated dermatitis. Monitoring
the condition and doing consistent skin care are more important than the condition’s
severity in predicting how long it takes to clear this condition up.10 Care includes gentle
cleansing after each episode of incontinence, preferably with an all-in-one wipe that
cleanses, moisturizes, and protects skin.11
Other types of dermatitis may be treated accordingly:
 Allergic contact dermatitis is treated with topical cortisone and/or oral
antihistamines.
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Candida requires topical and/or oral antifungal medication.
Bacterial infection requires antibiotic therapy.
Eczema may be managed with daily baths or wipes using a pH balanced or
very dilute bleach solution, followed by topical application of cortisone or
other skin cream.
Vulvar dermatitis is treated with topical estrogen cream. Lichenization is
treated with clobetasol propionate ointment, or immunosuppressants in cases
of lichen planus. 35
Wound Care
Debridement of necrotic tissue may be necessary to visualize the wound bed for staging
purposes, to lower the risk of infection and sepsis, or to interrupt the cycle of chronicity
in an old wound.6, 36 However, unless the wound is infected, debridement of eschar is
contraindicated on heels; over dry, stable ischemic ulcers; or in dry gangrenous wounds.
In these situations eschar provides protection.17
Methods of debridement include:

Autolytic.
This is the natural method of allowing WBCs and the body’s own
enzymes to slowly and painlessly dissolve necrotic tissue.

Enzymatic.
This speeds up the autolytic process and may be combined with surgical
debridement. Two commonly used agents are collagenase ointment and
papain-urea-based ointment. These two products should not be combined
or used with metallic products such as silver.

Surgical/sharp.
A scalpel or laser may be used in surgery, or sequential debridement with
a forceps and scissors may be done at the bedside with each dressing
change.

Mechanical.
Pulsed lavage or high pressure water jet combined with suctioning may be
done in surgery to remove necrotic tissue. The method of putting patients
in a whirlpool is no longer recommended because of the risk of crosscontamination. Wet-to-dry dressings are no longer recommended either
because of the pain and bleeding they cause. 36, 37, 38
Routine wound cleansing is done to remove debris consisting of purulent and necrotic
tissue. Universal precautions are required. Some dressings require saline soaks before
removal (Br). Wounds are washed with soap and water or an antiseptic, using fine mesh
gauze. Normal saline or sterile water are the best choices to use.5, 24 Hydrogen peroxide
is useful as a debriding agent but it does not act as an antibacterial. For antibacterial
action, vinegar, chlorhexidine, silver solutions, and cadexomer iodine formulations are
sometimes used.24, 38 However, these are cytotoxic to granulation tissue and may only be
appropriate for infected wounds with compromised healing capacity.
Dressings
Choosing the best dressing is a challenge because the market is flooded with options.
One objective is to maintain a moist wound environment to promote healing. Additional
objectives might be:
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To provide visibility without disturbing matrix formation.
To stimulating healing with growth factors and collagen.
To fill dead space and conform the dressing to the wound shape.
To reduce pain and prevent injury to the wound.
To prevent premature closure of the wound.
To control bleeding and fluid loss.
To lower bacterial count.
To hydrate a dry wound.
To absorb exudate.
New dressing choices are needed when the objective is not met within two to four weeks,
or a clean wound becomes infected.26 Some dressings require customization to fit into
body folds or conform to heels or elbows. Other dressings require inventive ways of
securement.
Basic categories of wound dressings are:

Gauze.
This can be woven or nonwoven. Topicals such as silver sulfadiazine,
antibiotic ointment, or caldexomer iodine may be applied directly to the
wound and then covered in gauze. Gauze also comes impregnated with
petroleum or slow-release silver or iodine.
Note that most of the following dressing categories are usually
contraindicated for third degree burns.6, 39, 40 Soaking gauze-wrapped
burns with silver nitrate solution is a historically standard practice in burn
units.

Transparent films.
These are for clean wounds to allow visibility without disturbance.
Exudate passes through the porous texture. Films are changed every five
to seven days, or if soiled.39, 40

Alginates and hydrofibers.
These have highly absorptive properties. A shape-conforming gel forms
upon contact with exudate. They are used for post-operative wounds and
heavily draining, infected wounds.

Foams.
These sheets contain cells that hold fluid. They combine absorbent
qualities while maintaining a moist wound environment.

Hydrocolloids.
These foam dressings hold moisture too but are intended for clean
wounds. They stay in place for three to seven days.38, 40 The dressings
may be used under a compression wrap to reduce pain, provide warmth,
and enhance autolytic debridement.

Hydrogels.
These also rehydrate wounds, reduce pain, and enhance autolytic
debridement. However, they can be used in infected wounds. They
require daily changing.38, 40

Composites.
These combine properties, such as antimicrobial action, absorbency,
moisture retention, and provision of healing enhancers. They come in a
full variety of forms: sheets, particles, gels, etc.
Conclusion
Skin breakdown is not always avoidable, especially in an aging population. However,
nurses can assess risks and carry out effective, preventive interventions. Skin and wound
care requires maximum creativity. General practice nurses can embellish their knowledge
by consulting with clinical nurse specialists who offer the benefit of vast experience.
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