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‘‘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.