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nursing |
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nursing |
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SKIN CARE
After enlisting for three years in the Army, I became highly proficient in cleaning, stripping and waxing floors. No one could operate a floor buffer as well as I did. Similarly, after working as a Registered Nurse for twelve years, I have become highly proficient at taking care of patients' skin. What have I learned? Above all, soap and water are the best skin care products available on the market. Applying soap and water with gentle scrubbing:
removes filth and dead skin
decreases odor
improves circulation to skin
maintains/improves patient self-image
DRY SKIN
For patients with dry sloughing skin, for example a CHF patient who was recently diuresed, I have applied the following skin care with success: Apply liberal amounts of an emollient1 cream (I use Moisture Barrier at work. If nothing else, use petroleum jelly) to dry skin just before the patient's bath. After washing, the skin will not appear as greasy but enough of the cream stays on to keep the skin looking moist and rehydrated. A dramatic improvement will show in two days with this care. I do not use plain body lotion in this case as the patient's skin is so dry, the lotion is absorbed into the skin soon after it is applied looking just as dry before.
WOUNDS
I have seen the practice of many nurses to apply dressings such as OpSites or Tegaderm to open skin tears. I have also seen skin break down result from using these interventions. In wound care, I do not use these transparent dressings because the drainage from the wound has nowhere to escape. I have observed skin ulcers form as the result of drainage accumulating under the dressing for several days. The skin underneath becomes necrotic. Also, these dressings adhere directly to the wound. Healthy skin is often removed when changing these dressings. Furthermore, nurses are not likely to change these dressings as long as they remain intact. Regardless of what the package says, they are not semi-permeable.
I believe it is safer to use gauze dressings (2x2s, 4x4s) applied with paper tape over skin tears. These dressings allow enough air through for drainage to dry. At very least, if the dressing becomes saturated, excess drainage can escape. Also, these dressings keep the wounds cleaner and drier since they are changed with more frequency compared to OpSites.
Although I don't use OpSites or Tegaderm for wound care, I do use these products as IV/A-line dressings. In general IV sites don't produce that much drainage. However, when they are used with IV/A-line sites that ooze significantly, the same results with skin tears may occur. The skin underneath becomes macerated and begins to break down (Jones & Milton, 2000). These occurrences are not as prevalent as with skin tears because IV/A-line sites are:
assessed more frequently for possible complications
cleansed aseptically during dressing changes
changed frequently according to hospital policy
more likely to be changed if fluid accumulates at the site (it just doesn't sound right to chart "IV site asymptomatic except for a large pool of drainage under dressing)
PRESSURE WOUNDS (DECUBITUS ULCERS)
It is remarkable what a modest amount of turning and repositioning does to prevent or improve pressure ulcers. If a pressure ulcer does exist, then additional measures are needed.
A few days ago, I was taking care of a bedridden patient2. When I turned him, I discovered he had a Allevyn dressing on his coccyx. Even with a rectal tube, his linen were soiled and the Allevyn dressing was coming off. Despite using care in removing his dressing, some healthy skin came off. Underneath this dressing was a large deep stage IV decubitus, involving his muscle tissue. Approximately, 1/2 inch thickness of saturated necrotic tissue was loosely covering this wound and needed debridement. It is impossible to tell how long the Allevyn dressing had been there. But it was clear the wound now needed surgical treatment. After thoroughly cleansing this wound, I applied a wet-to-dry dressing consisting of fluffed saline gauze, 4x4s, an ABD pad cut down to the size of the wound, and paper tape. The next day the nurse that gave me report had followed suite and placed a similar dressing on the wound. Within 24 hours the appearance of the wound had dramatically improved even though it still needed surgical debridement.
I believe that topical DuoDerm-type dressings do not belong on pressure ulcers because they:
hide the condition of the wound
trap drainage inside the wound
promote further tissue break down
are difficult to remove
pull off healthy tissue during changing
are not changed frequently (very common orders such as: change dressing p.r.n. or q.o.d. or every third day)
The greatest flaw of topical DuoDerm-type dressings is their inability to make a perfect seal over the sacral area near the buttocks. This is where most pressure ulcers occur and is unfortunately an area exposed to high moisture and contamination from urine and feces. DuoDerm-type dressings are difficult to apply. They must be held firmly in place for several minutes until they bond with the skin. Unless they make a perfect seal at the buttocks, urine and feces can enter the wound. Or if the dressing did seal, moisture can loosen the dressing's seal. In either case, the dressing must be removed for cleaning and redressing of the wound. It is this constant removal and reapplication that causes trauma to the skin. Most of the trauma is due to the fact that only part of the dressing has become loose while the rest is firmly bonded to the skin. Removing a firmly bonded Duoderm dressing is both painful for the patient and difficult to do since the adhesive was designed to last for a week.
On the other hand, wet-to-dry/wet-to-moist dressings can be applied with paper tape. Paper tape is kinder to the patient since it is easier to remove. Also, paper tape is easier to apply since it is thin and conforms easily to body contours. If the dressing does become soiled from incontinence, contamination can be contained by the many layers of a wet-to-dry/wet-to-moist dressing whereas fecal matter goes directly into wounds with topical DuoDerm-type dressings.
Advantages of wet-to-dry dressings:
help débride the wound
can be tailor made (as opposed to one size fits all)
able to absorb more drainage than thin DuoDerm-type dressings
as a standard, are changed more frequently keeping the wound cleaner
WHICH DRESSING IS BEST?
"Controlled studies that examined various types of wound dressings showed no significant differences in healing outcomes. Therefore dressing selection should be determined by clinical judgment" (Cervo et al., 2000). Most nurses know through experience which dressings are best for treating different stages of pressure ulcers. There are many types of dressings available for pressure ulcers (see table). It is up to the nurse to decide which dressing is the most appropriate for the patient. I know through my experience that wet-to-dry/wet-to-moist dressings work best on my patients, depending on the stage of the wound.
In consideration of what types of dressings to use, several authors have stated that the wound cavity must be filled with dressing or that the dressing must make contact with all surfaces of the wound to promote proper healing (Hess, 1998; Maklebust & Sieggreen, 1996). For this reason, it is obvious that topical DuoDerm-type dressings would not be appropriate for deep penetrating wounds. Another reason not to use topical DuoDerm-type dressings is that they are unable to absorb excessive amounts of drainage and according to Maklebust (1995), "excessive drainage slows the healing process."
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WOUND DRESSING TYPES AND THEIR USES |
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| Dressing Type | Débride | Absorb | Fill | Shield from bacteria | Insulate | Moisten | Guidelines for use* |
| Transparent adhesives | x A | N/A | N/A | x | x | x | Change 3 x week |
| Hydrocolloids 1) wafer 2) paste |
x A x A |
x x |
N/A x |
x N/A |
x x |
x x |
Change up to 3 x week |
| Absorption or filler dressings | x A | x | x | N/A | N/A | x | Change once daily |
| Semipermeable polyurethane foam | N/A | x | N/A | x | x | x | Change 3 x week |
| Gauze | x A** | x | x | N/A | N/A | x | Change up to 4 x daily |
| Hydrogels | x A | x | x | N/A | x S | x | Change daily or 3 x week for cover dressing with tape border |
*Utilization guidelines are drawn
from the Health Care Financing Administration and Medicare usage guidelines.
**If kept moist.
A: autolytic débridement; S: Sheet form; N/A: not applicable
Note: This table isn't meant to be all-inclusive and inclusion doesn't imply
endorsement.
Table adopted from Walker, D., (1996).
Manufacturers of Allevyn and DuoDerm both claim that their products have been proven effective with years of clinical studies. It is of my opinion that these studies were probably funded with their money and are not objective. Furthermore, a study conducted by Xakellis and Chrischilles (1992), and a subsequent study by Chang et al. (1998), both found that there was no statistical evidence to support the use of hydrocolloid (DuoDerm) dressings over wet-to-dry dressings except that it was less time consuming for nurses to slap on a DuoDerm.
SUMMARY
Patient skin care should be a matter of common sense. I base my opinion of these products on twelve years of clinical experience as a Registered Nurse. I have written this web page because time after time I have seen nurses applying skin care products such as DuoDerm and OpSites with devastating results. I believe hospitals, doctors, and wound-care nurses are in favor of using these products because their manufactures make claims that are simply not true.
Manuel Villanueva RN, BSN
REFERENCES
Cervo, F. A., Cruz, A. C., & Posillico, J. A., (2000). Pressure ulcers: Analysis of guidelines for treatment and management. Geriatrics, 55 (3), 55-60.
Chang, K. W., Alsagoff, S., Ong, K. T., & Sim P. H. (1998). Pressure ulcers--Randomised controlled trial comparing hydrocolloid and saline gauze dressings. Medical Journal of Malaysia, 53 (4), 428-431.
Hess, C. T. (1998). Treating a stage 3 pressure ulcer. Nursing, 28 (2), 20.
Jones, V., & Milton, T. (2000). When and how to use adhesive film dressings. Nursing Times Plus, 96 (14).
Maklebust, J. (1995). Pressure ulcers: What works. RN, 58 (9), 46-51.
Maklebust, J., & Sieggreen, M. (1996). How to conquer pressure ulcers. Nursing, 26 (12), 34-40.
Taylor, C., Lillis, C. & LeMone, P. (1989). Fundamentals of nursing: The art and science of nursing care. Philadelphia: J. B. Lippincott Company.
Xakellis, G. C., & Chrischilles, E. A., (1992). Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: A cost-effective analysis. Archives of Physical Medicine and Rehabilitation, 73 (5), 563-569.
Walker, D. (1996). Back to the basics: Choosing the correct wound dressing. American Journal of Nursing, 96 (9), 35-39.
FOOTNOTES
1) Listed as a suggestion for dry skin by Taylor, Lillis & LeMone (1989):
Use an emollient, which is an agent used to soften, soothe, and protect dry skin after it is cleansed. Emollient or moisturizing creams do not add moisture to the skin. Rather, the film they leave on the skin retards normal moisture evaporation and helps to hold down scaly skin surfaces. Cocoa butter, petroleum jelly, and lanolin are effective emollients and are used in many emollient creams.
