Get quick tips that you can use in daily practice from Advances in Skin & Wound Care's Clinical Associate Editors, Elizabeth Ayello, PhD, RN, APRN,BC, CWOCN, FAPWCA, FAAN, and R. Gary Sibbald, BSc, MD, FRCPC (Med) (Derm), FAPWCA, MEd.
This month's clinical practice tip is on skin barriers for wound margins. Keep this handy for an easy reminder.
LOWER(R) SKIN BARRIERS FOR WOUND MARGINS: 20-SECOND ENABLERS FOR PRACTICE*
Wound exudate can be classified in 2 ways:
* Type (color and consistency)
* Serous or clear color that represents serum or transudate
* Sanguineous for blood
* Purulent for pus made up of inflammatory cells and tissue debris that can result from infection or an inflammatory process
Exudate may exist as a single form or in combinations (eg, serosangineous).
* Amount
* None
* Small: There is only a detectable discharge when the dressing is removed, less than 33%.
* Moderate: Discharge covers less than 67% of dressing surface.
* Large: Discharge covers more than 67% of the surface.
Exudate may indicate that the cause of the wound has not been treated (eg, edema due to venous insufficiency); congestive heart failure is present (look for bilateral involvement and extension above the knee); low albumin (malnutrition, or kidney or liver disease); or infection (check for symptoms or signs).
Periwound skin needs protection from exudate. This can be accomplished by using absorbent dressings over the wound and protecting the periwound skin. You can choose from 4 ways to protect the external skin of a wound. Try using this memory jogger to remember them: