Skin care... what dressing for what?

Txnursekristi · Mar 18, 2010

The problem is, the answer to your question can change with every dressing change!

You want to absorb drainage, but not dry out a wound.

I've found that if i use any kind of an ointment under a non-adhesive dressing, it macerates the surrounding skin, so i only use gauze if i'm using an ointment.

The best advice I can give is, try something, and if it doesn't work, try something else!

As far as pressure ulcers, the NPUAP has recently released guidelines for Tx of pressure ulcers, which are very helpful and can be found at http://www.npuap.org/

The federal regulations state to follow the recommendations of the NPUAP...so you're covered there!

chris_at_lucas_RN, RN · Mar 18, 2010

Is there a guidelines for skin care? Our facility doesn't have the protocols handy (our instructor should have ones, but she got into car accident and we don't have a replacement yet) We have dozens of dressing types and creams. I have no idea what to put when. Sometime we get orders, sometimes not, sometimes the orders come later after you already took care of it. For example, surgical incision. Or stage 1-2 ulcers. Or cut. Or abrasion. Or scab. Or PICC site. Or bili site. Or peg tube site. Or some other type of wound/lesion. I've been working only 2 weeks, but this is one simple but at the same time puzzling part of my work. Our med room is stocked with 3 218 879 types of dressings, bandages and what not, and when the time comes to change the dressing (when it's not written in the TAR) I'm really scratching my head. Should it be adhesive or non-adhesive? Transparent or regular gauze? How many layers? What cream? Changed how often? I feel stupid for asking about what kind of dressing the new pt needs/has and how it needs to be done. I would really appreciate some structured info on what to use when and how.

Dressings and wound care were always my buggaboos too, but doing is learning. And lately I've been doing a lot. I used to not like it, and now I've come to see it as something I can do well to help a patient, and for me, that's always fun.

My first rule of thumb is, who put the last dressing on. The physician? Do what he or she did. Is the dressing neat and tidy? if so, the last putter-onner probably knew what he or she was doing, follow their example.

Does it look like the last dressing worked? If it did, do it that way again. If not, identify the problem. I always am concerned about putting 4 x 4 gauze directly on a wound, seems like it would get stuck in the goo of the healing process. BUT you can generally remove them easily, without pulling anything out that ought to be left there, if you saturate the old dressing with warm saline (cold shocks the patient, they really don't like that!). Protect under the patient with an waterproof pad of some sort, and a wadded up towel. Let the saline saturate a bit, then gently try it. If it comes off easily, go for it. If not, wait a little bit more and try again.

For any dressing change, the major concern is, is sterile technique an issue? For PICC lines and mediports, and for many wounds, absolutely yes. The IV sites, people don't get too concerned about, and I'm not saying you need to glove, gown and spray a lot of disinfectant around, but keep in mind it is a huge (for bacteria) straight path into the circulatory system, so within seconds, the bacteria can be everywhere you don't what them to be. Usually, just using a very good clean technique will keep the area good and clean. Don't forget to put the clear dressing over it--keeps down the exposure to the site while allowing you to observe for s/s of infection or perfusion. The good thing is, immune systems are great for the little bit of exposure that comes with an IV. But if you have a compromised patient: AIDS, cancer patient, chronically ill with anything, very good technique becomes even more important.

The PICC line and mediport dressing changes come in kits with everything you need. Do observe all you know about sterile technique. Open the packages properly and carefully. Keep the package away from being under your arm, head or any part of your body as you are opening it. Might help to have the tray table higher to keep that under control. Wear the mask. Don't forget to have the patient turn away from the site. Remember to scrub from the entrance point outward, and don't go back with the same scrubber. You want to make a big clean field and get the job done before it dries and the bacteria can wander back to what must be for them a big neon sign that says "enter here!"

The next tidbit I can offer you is find a nurse on your floor that you respect and who seems to take good care of patients. (There are those who are not, and you do not want to be learning from them.) Ask that nurse to holler at you whenever she or he has a dressing change to do, watching is the next best thing to doing it yourself.

You can also search online for guides to dressings. I like to google and then wander around among the CREDIBLE sites that come up. (Hint, if they misspell words like wound or infection, or start with my son has or my daughter had, move to the next site. Lay people can be a wonderfully wrong as they are well intentioned.) Here is (I hope, if it "takes") a good list of online articles about dressings and wound care.

When I was a nursing student, I went to a wound care workshop (everyone was surprised to find a student there, which seems sad, but off topic) and two things I did take away from that workshop was that patient comfort is very important and that sometimes we "clean" away healing tissue and that's not good. Irrigation fluids that are body temperature or perhaps a tiny bit warmer are much more comfortable than cold fluids. Using a chlorox solution (yeah, there is one, and it is called something I cannot remember--you can find recipes for making it up and I find it strange but they are big on not contaminating the fluid; wouldn't the chlorox kill off everything? LOL) or peroxide will in fact remove healing tissue. Saline is generally fine for irrigating wounds (unless otherwise ordered, and if it seems to be the doc wants peroxide or chlorox, you might ask if perhaps saline might be OK....). It is isotonic, so it won't burn or sting, or deprive the healing tissues of the electrolytes, etc. that it needs. It doesn't add anything, since saline only has NaCl, and the body already has that.

Any creams or ointments have to be ordered, since they are medications.

I hope I've helped. I cannot tell if you are a new nurse, a student, or someone in the profession for a long time and just now getting around to the joys of wound care. I hope I have not offended you with the basics I've shared. I'm no expert, just learned a lot from taking care of my husband, and, sadly, from seeing how others took care of him, and from the occasional med/surg patient I had the honor and good luck to care for. There are a lot of fools out there who are unkind and uncaring. That you ask a basic question on a public forum says a lot of good things about your professionalism and your nursing soul. I'd have you take care of me anytime--and ask my friends here, I've had some bad experiences with bad nursing, and I'm picky.... :)

Nuieve · Mar 18, 2010

Thank you so very much Chris! I'm a 2 weeks old nurse... new graduate. I kind of expected wound care to be addressed during my orientation, but due to the acuity of pts (or lack of thereof to be precise) we don't have many wounds. Maybe one or two per shift. Most of the time day shift nurse changes it. So I just don't have any exposure at all. Yesteday we had a fall, pt cut/teared his arm and I was wondering what the heck I was supposed to choose to cover it up. I did clean it with saline, but then I just pulled the first thing that I saw in the tx cart - some adhesive 2x4 patches. They were a bit too large, but when you have a bleeding pt you don't feel like spending 10 minutes pulling out stuff out of cart and evaluating it whether it would be any good, you just grab whatever will work. I'm afraid the day shift nurse will be appalled by my decision, but I feel I did the best I could at the situation.

Anyway, thanks again for helpful writeup.

ProBeeRN, BSN, RN · Mar 18, 2010

Does your facility have a wound care nurse on staff? They can be an invaluable resource for things like this, and probably have tons of books and literature they can give you- even if it's a pocket guide on types of dressing, what kind of drainage they're meant for (alginates for heavy drainage, hydrogels for minimal drainage), and the products available.

Most docs unless they're surgeons, vascular or ID specialists like to stick to ordering 1 or 2 basic dressing types. More often, they have no idea and leave it to you to determine appropriate tx.

I do advise you to CYA and properly document all dressing changes, describing the products used, and add it to to TAR if needed. It really can take some extra effort to get consistent and appropriate wound care for the patient

mauxtav8r · Mar 18, 2010

Ummmm, am I missing something??? Where I work this is all considered to be medications that are prescribed by an md or ap nurse. Dressings that contain medication, medications in ointments, gels, etc., as well as equipment like vacs, are all prescribed as are wound orders in general, down to the type of tape.

In our facility, exotic (read: big, or messy, or dangerously infected) wounds usually get referred to either an advanced practice nurse who writes orders for the hospitalists to sign, or as out patients to a wound care center.

Otherwise, nurses on the floors are communicating recommendations to the md's (these are usually very much appreciated), so the info you seek is definitely needed, but the responsibility lies with the prescriber.

mauxtav8r · Mar 18, 2010

Does your facility have a wound care nurse on staff?....
Most docs unless they're surgeons, vascular or ID specialists like to stick to ordering 1 or 2 basic dressing types. More often, they have no idea and leave it to you to determine appropriate tx. ...

ditto.

chris_at_lucas_RN, RN · Mar 18, 2010

And when it hasn't been prescribed specifically (I've certainly seen orders that read: change dressing q shift), and there's no one around to help, which would sadly be the case with many new nurses... Aren't new nurses such a bother? I found that to most they are that or worse. I like helping and I like teaching.

So did ya'll have something to share with this new nurse who is unsure of herself and wanting some general directions about wound care? After all, we are supposed to be able to discern whether an order is appropriate....

I just know she'd appreciate more help that my pitiful efforts, and you seem to have a lot of experience! I'll be interested in reading your suggestions too. I'm always interested in learning from more experienced nurses.

Christine

chris_at_lucas_RN, RN · Mar 18, 2010

Thank you so very much Chris! I'm a 2 weeks old nurse... new graduate. I kind of expected wound care to be addressed during my orientation, but due to the acuity of pts (or lack of thereof to be precise) we don't have many wounds. Maybe one or two per shift. Most of the time day shift nurse changes it. So I just don't have any exposure at all. Yesteday we had a fall, pt cut/teared his arm and I was wondering what the heck I was supposed to choose to cover it up. I did clean it with saline, but then I just pulled the first thing that I saw in the tx cart - some adhesive 2x4 patches. They were a bit too large, but when you have a bleeding pt you don't feel like spending 10 minutes pulling out stuff out of cart and evaluating it whether it would be any good, you just grab whatever will work. I'm afraid the day shift nurse will be appalled by my decision, but I feel I did the best I could at the situation.
Anyway, thanks again for helpful writeup.

You are so very welcome. I was surprised that something as basic as wound care was not covered in nursing school, myself. But then on orientation is it nearly impossible to get a preceptor to help, at least that was my experience. I pride myself on never having an "it's not my job" attitude. Maybe hoping someone would take that attitude with me.... Hang in there, girl. You are great! You will keep learning and keep it fresh and good. Your patients and your colleagues will appreciate you. (And the ones that don't, don't know what they are missing!)

ProBeeRN, BSN, RN · Mar 18, 2010

There's a sticky under the Home Health Nursing category called "Wound care words of wisdom"- ignore the stuff about payors as it won't apply to you in a facility, the rest is a really good overview of the need-to-knows. There's a million billion differed dressing types. Your facility probably goes by one brand of product though. I can go into more detail about what is appropriate for what, but unless you specifically want that, I won't write you a book here.

In a nutshell:

What kind of wound is it? What caused it? If it's a pressure ulcer, you can put a solid gold dressing on it, but if you don't alleviate the pressure, it won't get any better. Venous stasis ulcers probably need compression tx and/or elevation, but first you need to get a Dopplar ordered to make sure arterial blood flow is sufficient. You should also familiarize yourself with the pressure ulcer staging scale.

How big is it? If you don't have accurate measurements you don't know if it's getting better or worse. Wounds should be measured weekly.

How much drainage is there? This will determine whether you need a dressing that absorbs moisture or add moisture.

What does the wound bed look like? Beefy red? Yellow slough? Eschar? Is the periwound inflamed? Is there an odor? Is there tunneling or undermining?

So, you are helping Mrs. Little-Old-Lady to the commode and notice a wound right at the top of her butt. It's 1cm x 2cm x 0.1cm, pink base, scant amount serous drainage, periwound pink. You call the Doc and tell him "Hey we've got what I think is a Stage 2 pressure ulcer on her coccyx, tiny bit of serous drainage. I think she'd do well with a hydrocolloid dressing, changing it every 3-4 days. " Doc says "ok, whatever you think", you do your documentation, all is right with the world.

It takes a lot of practice to figure all this out. Don't be afraid to grab another nurse to look at the wound and bounce an idea off of them first.

Haha, I had to go to a 4 hour inservice on wounds today!!! How appropriate! :yeah:

SuesquatchRN, BSN, RN · Mar 18, 2010

Thank you so very much Chris! I'm a 2 weeks old nurse... new graduate. I kind of expected wound care to be addressed during my orientation, but due to the acuity of pts (or lack of thereof to be precise) we don't have many wounds. Maybe one or two per shift. Most of the time day shift nurse changes it. So I just don't have any exposure at all. Yesteday we had a fall, pt cut/teared his arm and I was wondering what the heck I was supposed to choose to cover it up. I did clean it with saline, but then I just pulled the first thing that I saw in the tx cart - some adhesive 2x4 patches. They were a bit too large, but when you have a bleeding pt you don't feel like spending 10 minutes pulling out stuff out of cart and evaluating it whether it would be any good, you just grab whatever will work. I'm afraid the day shift nurse will be appalled by my decision, but I feel I did the best I could at the situation.
Anyway, thanks again for helpful writeup.

Cleanse and approximate the edges and use steri-strips.

CoffeeRTC, BSN, RN · Mar 21, 2010

Your facility should have a P and P in place for dressings. Most places only use certain products due to payment issues and cost involved. This does help cut down on the tons of types of dressings that you have to pic from.

Every dressing order should be specific and should list where the wound is, what to cleanse with apply xyz to wound and cover with xyx and secure with xyz (if the top dressing isn't adhesive) and it should also list how often to change the dressing. Those are the very basics.

Don't reinvent the wheel if you don't have to. Ask to see if you have a wound care nurse and get the info from them.