Clean off the dead skin!

[Gizmopup1]

A big part of my job is doing wound care. I work in Home Health, and I like floating versus case managing, so I see a lot of patients in a lot of different circumstances.

One thing that comes my way a lot is cellulitis wound care.

In most cases, cellulitis follows a pattern: The onset stage, where the leg is swollen and red. The stage where the cellulitis is weeping and possibly blistering (usually the patient is in the middle of or completing treatment for the condition. And then at the end is the recovery stage where the legs shrink back down and scab over.

Normally, in the case of someone who is able to get up and move around afterwards, the scabs will fall off on their own over time and with normal washing.

But with bed bound patients, they don't get that movement and activity to cause normal slough. So these old scabs and huge chunks of dead skin stay on unless a nurse spends a little energy and attention on cleaning off the dead skin. This can be done with soaking the skin with wound wash or water and rubbing (not dabbing!) gently with a gauze or soft washcloth. Most of the time the dead skin and old scabs slide right off.

What I am finding is too many nurses are afraid to do this. They believe if they cause any of this dead skin or old scabbing to come off, they are going to damage the healthy skin below.

But this dogmatic approach to all skin at all stages of healing is leaving elderly patients with skin like pine tree bark, covered in layers and layers of barrier cream and gauze when they don't have to be!

And we are performing ongoing wound care on wounds that healed months ago!

Why are we lightly washing and treating dead, stuck scabs?

Assess the skin: If the skin scales appear dry and flake off easily with intact skin underneath, this is a good indicator that some of this dead skin can be removed.

Asses the chart: If the cellulitis or edema resolved weeks ago, there is a very good chance the scabs and old skin have done their job and just need a little coaxing to come off.

Now does this apply universally to all patients? Of course not!

But I am seeing too many nurses afraid of really cleaning and assessing wounds.

[amoLucia]

To OP - I prob would have been one of THOSE nurses of whom you speak. Even as I retired with nearly 40 yrs experience, wound care was always intimidating to me. I'd rather help "to birth a baby" with Prissy and Ms Mellie !!!

Wound care is NOT emphasized in school, nor in post-school practice. And except for a few educ programs by vendors or DME providers, there's not much to pique my interest. So to ask, are the care plans in your area cases clearly explicit re cleansing? Have you offered to share your knowledgeable expertise with others? I'm sure it would be welcomed.

[MunoRN, RN]

I completely agree that debridement is a good thing, however in my experience the majority of wound care nurses will scold and even threaten 'regular' nurses for doing anything they consider to be debriding including a good scrubbing, even if the wound needs it.

[Gizmopup1]

This is such as shame, and I agree there seems to be a fear and intimidation towards wounds that I would love to see regular nursing not have. A little caution is good, but fear and avoidance is not. Confident wound care is such an important piece of nursing! How do we get past this intimidation?

[ChryssyD]

If I can give my humble opinion: Don't create a problem you can't fix. Yes, dead skin is a nuisance and a medium for bacterial growth, so we want it to come off as soon as possible. Just don't tear it off before it's ready to come loose. There is no good reason to traumatize healthy tissue (which the dead skin is attached to), as it creates openings in the skin barrier, which can lead to infinitely worse infection than simply leaving the dead skin on until it comes off with the most minimal of "coaxing." I'm not saying you shouldn't clean the wounds, but you should respect the integrity of the surrounding skin; don't open anything up unless you have no other choice. Remember your mom telling you not to pick at or pull off a scab? Same principle with wounds: When it's ready to come off, it really won't take any coaxing, just a light wipe. (Mind you, I'm addressing cellulitis, not decubiti--that's a slightly different ball game).

Sorry, I'm old school. I never, never rip or tear anything if I can possibly help it. They have cellulitis because of breaks in skin integrity (sometimes tiny ones); don't give the skin flora new opportunities to get inside.

[CoffeeRTC, BSN, RN]

^^^^ This a thousand times!

My pet peeve is how areas around a wound are neglected. We are treating an area on a heel or ankle, why do we need to neglect cleaning between their toes on the top of their foot?

[ChryssyD]

^^^^ This a thousand times!

My pet peeve is how areas around a wound are neglected. We are treating an area on a heel or ankle, why do we need to neglect cleaning between their toes on the top of their foot?

Toe jam!

[MunoRN, RN]

This is such as shame, and I agree there seems to be a fear and intimidation towards wounds that I would love to see regular nursing not have. A little caution is good, but fear and avoidance is not. Confident wound care is such an important piece of nursing! How do we get past this intimidation?

It's not about confidence with wound care, it's that wound care nurses tend to be territorial, and sometimes scold "regular" nurses for doing things they consider to be their territory, such as routine cleaning that also results in debridement.

[mmc51264, BSN, MSN, RN]

I have had experiences where I am doing a dressing change, and I always clean the area and have had ore than one patient tell me I am the first nurse that has actually washed off the old "stuff" (whatever that was in each case) before putting a new bandage on. I don't understand that.

We had a pt that had been neglected/abused and this pt's feet like that person on A&E they call the the tree bark man. I went in to see what wound nurse had to say. It was just LAYERS of dead skin on feet and toes. We just picked it off gently and when we were done, the feet looked almost normal. Some nurses were really grossed out, but I am one of those that loved to peel sunburn when I was a kid LOL

So much common sense missing these days. Our limb loss nurse is very explicit about WASHING and patting DRY stumps when we have to change bandages. Sad that it has to be expressly stated in an order.