Skin Integrity and
Wounds
Types of Wound Dressings & Pressure Ulcer Stages
Dressings:
• Gauze: For moderate drainage wounds, can be wet-to-dry for
debridement.
• Hydrocolloid: Maintains moist wound environment, used for partial-
thickness wounds.
• Foam: Highly absorbent, used for heavy exudate wounds.
• Transparent film: Protects wounds with minimal drainage.
• Alginate: Highly absorbent, used for moderate to heavily draining
wounds.
• Wet-to-dry dressing: Used for mechanical debridement, removes
necrotic tissue.
Pressure Ulcer Stages:
• Stage 1: Non-blanchable redness, intact skin.
• Stage 2: Partial-thickness skin loss, blister or shallow ulcer.
• Stage 3: Full-thickness tissue loss, may see fat.
• Stage 4: Full-thickness loss with muscle, bone, or tendon exposure.
• Unstageable: Covered by slough/eschar, depth unknown.
Clinical Judgment Considerations
• Hot & Cold Therapy:
• Hot Therapy: Increases circulation, relaxes muscles, but avoid in
bleeding wounds or deep vein thrombosis (DVT).
• Cold Therapy: Reduces inflammation & swelling, but avoid in
impaired circulation (Raynaud’s, diabetes, arterial disease, open wounds).
Binders & Bandages:
• Provide support, immobilization, and compression.
, •Risks: Skin irritation, impaired circulation, improper application leading
to pressure injuries.
Drains & Drainage Devices: JP Drain, Hemovac, Negative Pressure Wound
Therapy (NPWT)
Jackson-Pratt (JP) Drain: Closed-suction drain with a small bulb attached to a tube.
o Removes excess fluid and blood from surgical wounds.
o Prevents hematoma or seroma formation.
o Empty the bulb when it is half full to maintain suction.
o Measure and record output—excessive drainage could indicate bleeding.
o Notify provider if: Sudden increase or decrease in drainage, foul-smelling or
purulent drainage.
Hemovac Drain: A larger, spring-loaded suction drain, usually used for orthopedic
or abdominal surgeries.
Purpose:
• Removes moderate to large amounts of fluid.
• Provides continuous suction to prevent fluid buildup.
Care & Considerations:
• Compress the drain after emptying to restore suction.
• Monitor for kinks in the tubing that can block drainage.
• Notify provider if: Drain output significantly changes, becomes cloudy or foul-
smelling.
Negative Pressure Wound Therapy (NPWT) (Wound VAC): Used for continuous
or intermittent suction through a vacuum dressing system.
Purpose:
• Removes excess fluid, decreases swelling.
• Reduces bacterial load, lowering infection risk.
• Stimulates granulation tissue formation and faster wound healing.
Contraindications:
• Exposed blood vessels, untreated osteomyelitis, necrotic tissue with
eschar, active bleeding.
Care & Considerations:
• Ensure an airtight seal—check for leaks.
Monitor for signs of infection (fever, redness, warmth, foul odor).
Wounds
Types of Wound Dressings & Pressure Ulcer Stages
Dressings:
• Gauze: For moderate drainage wounds, can be wet-to-dry for
debridement.
• Hydrocolloid: Maintains moist wound environment, used for partial-
thickness wounds.
• Foam: Highly absorbent, used for heavy exudate wounds.
• Transparent film: Protects wounds with minimal drainage.
• Alginate: Highly absorbent, used for moderate to heavily draining
wounds.
• Wet-to-dry dressing: Used for mechanical debridement, removes
necrotic tissue.
Pressure Ulcer Stages:
• Stage 1: Non-blanchable redness, intact skin.
• Stage 2: Partial-thickness skin loss, blister or shallow ulcer.
• Stage 3: Full-thickness tissue loss, may see fat.
• Stage 4: Full-thickness loss with muscle, bone, or tendon exposure.
• Unstageable: Covered by slough/eschar, depth unknown.
Clinical Judgment Considerations
• Hot & Cold Therapy:
• Hot Therapy: Increases circulation, relaxes muscles, but avoid in
bleeding wounds or deep vein thrombosis (DVT).
• Cold Therapy: Reduces inflammation & swelling, but avoid in
impaired circulation (Raynaud’s, diabetes, arterial disease, open wounds).
Binders & Bandages:
• Provide support, immobilization, and compression.
, •Risks: Skin irritation, impaired circulation, improper application leading
to pressure injuries.
Drains & Drainage Devices: JP Drain, Hemovac, Negative Pressure Wound
Therapy (NPWT)
Jackson-Pratt (JP) Drain: Closed-suction drain with a small bulb attached to a tube.
o Removes excess fluid and blood from surgical wounds.
o Prevents hematoma or seroma formation.
o Empty the bulb when it is half full to maintain suction.
o Measure and record output—excessive drainage could indicate bleeding.
o Notify provider if: Sudden increase or decrease in drainage, foul-smelling or
purulent drainage.
Hemovac Drain: A larger, spring-loaded suction drain, usually used for orthopedic
or abdominal surgeries.
Purpose:
• Removes moderate to large amounts of fluid.
• Provides continuous suction to prevent fluid buildup.
Care & Considerations:
• Compress the drain after emptying to restore suction.
• Monitor for kinks in the tubing that can block drainage.
• Notify provider if: Drain output significantly changes, becomes cloudy or foul-
smelling.
Negative Pressure Wound Therapy (NPWT) (Wound VAC): Used for continuous
or intermittent suction through a vacuum dressing system.
Purpose:
• Removes excess fluid, decreases swelling.
• Reduces bacterial load, lowering infection risk.
• Stimulates granulation tissue formation and faster wound healing.
Contraindications:
• Exposed blood vessels, untreated osteomyelitis, necrotic tissue with
eschar, active bleeding.
Care & Considerations:
• Ensure an airtight seal—check for leaks.
Monitor for signs of infection (fever, redness, warmth, foul odor).
