‘‘Understanding Skin And Wound Care’Understanding Skin And Wound Care’Injecting Injuries and Wound CareInjecting Injuries and Wound Care

Causes and TreatmentCauses and Treatment

Alison CoullLecturer

Department of Nursing and Midwifery, University of StirlingHonorary Specialist Nurse, Harm Reduction Team, Lothian

Note- patient images have been removed to protect confidentiality and conform to consent agreements.

AimsAims

To provide context for skin problems in injectors

To identify main problems To differentiate between minor and

major wounds To discuss treatment options

ContextContext

86% of users attending medical clinics report cutaneous adverse effects

Access to wound care services may be poor

Perceived confidentiality related to service use

Some serious illness manifests itself initially in the skin

Injecting Drug UseInjecting Drug UseThe use of drugs to support

addiction which are injected through the skin.

People who are involved with drugs may have multiple social and

medical problems which may impact on skin

condition.

Background of Poor Systemic Background of Poor Systemic HealthHealth

Malnutrition Poor Hygiene Blood-borne viruses Thrombosis Mental health issues Low Self-esteem

Implications of Injecting Implications of Injecting

Breach of protective barrier Skin damage and scarring Vein and vascular damage Clostridia infection Necrotizing Fasciitis Osteomyelitis

Common types of wounds Common types of wounds seen in drug users include:seen in drug users include:

Lumps and bumps Abscesses Injuries related to

self harm Traumatic wounds Groin sinus Chronic leg ulcers

Vascular BackgroundVascular Background

Arteries have thicker walls and work at higher pressure – they carry blood to the peripheries

Veins have thinner walls and carry blood back to the heart and lungs

Vein valves stop blood pooling as a result of gravity

Women have thinner veins

Injecting technique: venepuncture, Injecting technique: venepuncture, skin and muscle poppingskin and muscle popping

Injecting into the vein allows the drug to go straight into the bloodstream. The blood contains many white cells to deal with ‘foreign’ organisms.

Injecting into the subcutaneous tissues or into muscle allows the drugs to linger causing micro-organisms to thrive and tissue death

Problems with injectingProblems with injecting

Drug – heroin / cocaine / benzodiazepines

Micro-organisms Skin hygiene Acid Undissolved particles Poor technique Filter materials

LumpsLumps Poor injecting technique

Layered vein wall

False Aneurysms

Raised hardened lumps

Usually not red, hot or painful

AbscessesAbscesses

Painful, red, raised lumps

Hot to touch Filled with pus Usually caused by

micro-organisms

Chronic Leg UlcerationChronic Leg Ulceration

Wounds on the leg which are present for 4 weeks or more

May be independent of injection site

Require different assessment

Chronic wound: Groin SinusChronic wound: Groin Sinus

Femoral vein is larger, and thicker

More tolerant of repeated venepuncture

A sinus can develop allowing repeated use

Occasional arterial misadventure

Life threatening symptomsLife threatening symptoms Necrotizing Fasciitis

(clostridia) Often begins with a cellulitic

response from an established break in the skin but may start in deeper tissues

Erythema, bruising, grey discolouration, purple areas.

Vesicles containing foul smelling watery fluid known as ‘dishwater pus’

Wound BotulismWound Botulism

Double vision / Drooping eyelids Slurred speech / Difficulty swallowing /Dry

mouth

Deep Vein ThrombosisDeep Vein Thrombosis

Injecting may cause inflammation

Inflammation may promote clotting

This leads to swelling

Vein valve damage Clot may break off

and lodge in lungs

Post-Thrombotic SyndromePost-Thrombotic Syndrome

Prolonged swelling Heavy aching leg Multiple venous ectasia May lead to ulceration Can be prevented /

relieved by compression therapy

Assessment 1Assessment 1History When was it

injected? What was injected? How was it injected? How is it now,

compared to yesterday?

Assessment 2Assessment 2

Examine the patient Any new changes Raised

temperature? Malaise? New systemic

signs? Compare limbs

Assessing lumps and Assessing lumps and bumpsbumps

Examine the area : warning signs

Redness heat swelling

Generally malaise Spreading redness Pus Malodour

Examine the wound: Examine the wound: InfectedInfected

Caused by micro-organisms which evade the victims immunological defences, enter and establish themselves within the tissues of the person and multiply successfully.

Infection: Common signsInfection: Common signs

Infection tends to be painful and hot

Redness is spreading

Sometimes pus / malodour

Requires antibiotics

Healthy WoundsHealthy Wounds

Aim for this! Clean Healthy Bright red Normal surrounding

skin Granulating

Principles of wound healingPrinciples of wound healing

Moist and warm environment speeds healing by improving cell division and migration

Always dress a wound that is wet Very small scabbed areas or dry

surgical stitch lines can be left exposed to the air

Managing wounds : Managing wounds : cleansingcleansing

Tap water Irrigate Don’t clean with

anything that leaves fibres behind

Do not rub Do not dry wounds

Slough Slough

A mixture of dead white cells, dead bacteria, re-hydrated necrotic tissue and fibrous tissue.

Can be soft or fibrous Often yellow, green

or grey

Black necrotic / red healingBlack necrotic / red healing Dead Tissue May be due to

ischaemia, infection, disease, or injury.

May appear blue-black, grey, or yellow.

InfectionInfection

May be managed with a topical antiseptic

Antibiotics – need to be taken at regular intervals and often don’t mix with alcohol

Open AbscessesOpen Abscesses

Pack with dressing such as alginate

Cover with absorbent foam or low adherence dressing

Keep moist and warm

Filling SpaceFilling Space

Wounds heal from the base up

Cavities should be filled loosely with packing material - NOT ribbon gauze.

This allows the wound to drain, and for the base to fill with granulation tissue, but prevents a pocket forming with skin healing over.

AlginatesAlginatese.g. Kaltostat, Seasorb, Sorbsan, e.g. Kaltostat, Seasorb, Sorbsan, Algisite MAlgisite M

Manufactured from seaweed

Forms soft flexible gels Causes mild

inflammatory reactions Highly absorbent Haemostatic Lowers bacterial count

HydrocolloidsHydrocolloidsGranuflex, Duoderm, Granuflex, Duoderm, Comfeel,TegasorbComfeel,Tegasorb

Waterproof Absorbent - light to

moderate exudate Can be left in

place for 7 days Suitable for

desloughing / debridement

‘‘Holes’Holes’

Moist and warm If large enough to ‘fill’ pack with alginate If small, cover with a low adherence dressing

Low-adherence DressingsLow-adherence Dressingse.g. Mepore, Melolin,Releasee.g. Mepore, Melolin,Release

Simple fibrous absorbent layer enclosed in porous plastic film

Minimal absorbency May shed fibres Suitable for temporary

cover Cheap

Black and red inflamed Black and red inflamed woundwound

Aim to remove black necrosis

Soften with water based hydrogel

Treat spreading red cellulitis with antibiotics

HydrogelsHydrogelse.g. Granugel, Intrasite, Purilon, e.g. Granugel, Intrasite, Purilon, SterigelSterigel

In contact with the wound, creates a moist environment, absorbing exudate and allowing rehydration of necrotic tissue.

80% water Can be left in place

for 3 days

FoamsFoamse.g. Allevyn, Lyofoam, Tiellee.g. Allevyn, Lyofoam, Tielle

Polyurethane foam Highly absorbent Non-adherent May reduce pain Comfortable

Legs may be different!Legs may be different!

Leg wounds tend to become chronic in drug users because of venous damage

If remaining unhealed at 4 weeks they require vascular assessment

Usually require compression bandaging

Typical characteristics of Typical characteristics of venous disease in injecting venous disease in injecting

drug usersdrug users

Multiple small puncture sites

Skin staining ‘Congested’ feet High ABPI

Compression TherapyCompression Therapye.g 4-layer bandaging, hosierye.g 4-layer bandaging, hosiery

Managing woundsManaging wounds Universal precautions – gloves and

apron Stop any bleeding with pressure Cleanse any debris Cover with a simple dressing (mimic the

skin) Provide a barrier against micro-

organisms

SummarySummary

Injecting Drug Users have both minor and major skin problems

Assessment is important – injection, history, cause, site

Infection can be serious Referral should be considered but may

not always be appropriate.