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with no breach of the epidermis. The second stage is partial loss of the epidermis or dermis, often with a blistering or abrasion. The third stage involves damage to the dermis and subcutaneous layers of tissue and clinically appears as an ulcer but does not involve the underlying fascia. The fourth stage involves tissue necrosis and full-thickness skin loss, often with tunnelling sinus tracts (Hess 2005).

Evidence-based approaches

Bryant (2000) lists four principles of wound care for pressure sore assessment.

Eliminate the source (i.e. cause of pressure damage).

Ensure the microenvironment is optimal (to promote wound healing).

Support the host (using appropriate pressure-relieving aids and ensuring adequate nutritional balance and skin care regimen).

Provide education (explaining to the patient and caregivers the principles of caring for their skin and pressure areas).

Wound dressings that maintain a moist environment facilitate healing and after a thorough assessment, selections can be made according to the depth of the ulcer and degree of damage from the dressings (see Table 15.3).

Preprocedural considerations

Nurses must consistently question whether they are employing measures for preventing pressure ulcers and whether the patient and caregivers are following the care plan (recording tools are listed in Chapter 4). Documentation should be made if the patient refuses care and/or evaluation of whether the patient improves or deteriorates should be recorded to keep the care plan up to date (Bryant 2000). Nutritional status and the patient’s ability to self-care and mobilize should also be evaluated and documented (EPUAP 2009).

Assessment using the TIME principles (Dowsett and Ayello 2004) and following the procedure for changing a dressing should be practised.

Administration of analgesia as prescribed and the setting of a time frame with the patient’s agreement are recommended to improve the experience for the patient (EPUAP 2009). Nurses should consult additional guidance if unfamiliar with the patient or regimen (www.epuap.org/guidelines/Final_Quick_Treatment.pdf).

Assessment

The EPUAP (2009) recommends the use of a pressure ulcer classification system to estimate tissue loss, and that the skin is assessed by colour, temperature and consistency (i.e. firm/turgid or soft/boggy).

Stages 1–2 with light exudates: for reddened areas, barrier cream and relief of pressure are recommended, whilst superficial ulcers require dressing with transparent films (e.g. Opsite, Tegaderm) as they effectively retain moisture and prevent friction (Bluestein and Javaheri 2008). For fragile skin, a skin barrier (e.g. Cavilon) may be used under the film or a light hydrocolloid (e.g. Duoderm Thin). Appropriate measures such as removal of pressure, positioning the patient and protective dressings will prevent the condition from worsening (Falanga 2000).

Stage 3 ulcers should be dressed with synthetic dressings rather than gauze as these cause less pain and require less frequent changes (Bluestein and Javaheri 2008, EPUAP 2009). These dressings include alginates, hydrocolloids and foams and are often available in site-specific shapes to ease application and removal and minimize leakage.

Surgical wounds

Evidence-based approaches

Methods of wound closure

There are four main methods of wound closure:

sutures

adhesive skin closure strips

tissue adhesive

staples.

See Table 15.4 for advantages and disadvantages of each method.

Table 15.4 Advantages and disadvantages of methods of wound closure

Method Advantages Disadvantages

Sutures: interrupted sutures are separate sutures each with its own knot and are used on the majority of wounds because they are the most versatile

A continuous suture is one long thread that spirals along the entire suture line at evenly spaced intervals

Non-absorbable sutures are more widely used for skin closure where the material causes little reaction or rejection. A monofilament nylon is a strong single-stranded nylon providing continued strength; silk is a braided strand and fairly easy