Transcript Development of a Competency-based Framework to Define

‘Understanding Skin And Wound Care’
Injecting Injuries and Wound Care
Causes and Treatment
Alison Coull
Lecturer
Department of Nursing and Midwifery, University of Stirling
Honorary Specialist Nurse, Harm Reduction Team, Lothian
Note- patient images have been removed to protect confidentiality and conform to consent
agreements.
Aims
 To
provide context for skin problems in
injectors
 To identify main problems
 To differentiate between minor and
major wounds
 To discuss treatment options
Context
 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 Use
The 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
Health
Malnutrition
 Poor Hygiene
 Blood-borne viruses
 Thrombosis
 Mental health issues
 Low Self-esteem

Implications of Injecting
Breach of protective barrier
 Skin damage and scarring
 Vein and vascular damage
 Clostridia infection
 Necrotizing Fasciitis
 Osteomyelitis

Common types of wounds
seen in drug users include:
 Lumps
and bumps
 Abscesses
 Injuries related to
self harm
 Traumatic wounds
 Groin sinus
 Chronic leg ulcers
Vascular 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,
skin 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 microorganisms to thrive and tissue
death
Problems with injecting
Drug – heroin /
cocaine /
benzodiazepines
 Micro-organisms
 Skin hygiene
 Acid
 Undissolved particles
 Poor technique
 Filter materials

Lumps
 Poor
injecting
technique
 Layered vein
wall
 False
Aneurysms
 Raised
hardened
lumps
 Usually not
red, hot or
painful
Abscesses
Painful, red, raised
lumps
 Hot to touch
 Filled with pus
 Usually caused by
micro-organisms

Chronic 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 Sinus
 Femoral
vein is
larger, and thicker
 More tolerant of
repeated
venepuncture
 A sinus can develop
allowing repeated
use
 Occasional arterial
misadventure
Life 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 Botulism
 Double
vision / Drooping eyelids
 Slurred speech / Difficulty swallowing /Dry
mouth
Deep 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 Syndrome
Prolonged swelling
 Heavy aching leg
 Multiple venous ectasia
 May lead to ulceration
 Can be prevented /
relieved by compression
therapy

Assessment 1
History
 When was it
injected?
 What was injected?
 How was it injected?
 How is it now,
compared to
yesterday?
Assessment 2
Examine the patient
 Any new changes
 Raised
temperature?
 Malaise?
 New systemic
signs?
 Compare limbs
Assessing lumps and
bumps
Examine the area :
warning signs
 Redness heat
swelling
 Generally malaise
 Spreading redness
 Pus
 Malodour
Examine the wound:
Infected
Caused by microorganisms which evade
the victims immunological
defences, enter and
establish themselves
within the tissues of the
person and multiply
successfully.
Infection: Common signs
Infection tends to be
painful and hot
 Redness is
spreading
 Sometimes pus /
malodour
 Requires antibiotics

Healthy Wounds
Aim for this!
 Clean
 Healthy
 Bright red
 Normal surrounding
skin
 Granulating
Principles 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 :
cleansing
 Tap
water
 Irrigate
 Don’t clean with
anything that leaves
fibres behind
 Do not rub
 Do not dry wounds
Slough
A mixture of dead
white cells, dead
bacteria, rehydrated necrotic
tissue and fibrous
tissue.
 Can be soft or
fibrous
 Often yellow, green
or grey

Black necrotic / red healing
 Dead
Tissue
 May be due to
ischaemia,
infection, disease,
or injury.
 May appear blueblack, grey, or
yellow.
Infection
May be managed
with a topical
antiseptic
 Antibiotics – need to
be taken at regular
intervals and often
don’t mix with
alcohol

Open Abscesses
 Pack
with dressing
such as alginate
 Cover with
absorbent foam or
low adherence
dressing
 Keep moist and
warm
Filling 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.
Alginates
e.g. Kaltostat, Seasorb, Sorbsan,
Algisite M
Manufactured from
seaweed
 Forms soft flexible
gels
 Causes mild
inflammatory reactions
 Highly absorbent
 Haemostatic
 Lowers bacterial count

Hydrocolloids
Granuflex, Duoderm,
Comfeel,Tegasorb
 Waterproof
 Absorbent
- light to
moderate exudate
 Can be left in
place for 7 days
 Suitable for
desloughing /
debridement
‘Holes’
 Moist
and warm
 If large enough to ‘fill’ pack with alginate
 If small, cover with a low adherence dressing
Low-adherence Dressings
e.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
wound
 Aim
to remove black
necrosis
 Soften with water
based hydrogel
 Treat spreading red
cellulitis with
antibiotics
Hydrogels
e.g. Granugel, Intrasite, Purilon,
Sterigel
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

Foams
e.g. Allevyn, Lyofoam, Tielle
Polyurethane foam
 Highly absorbent
 Non-adherent
 May reduce pain
 Comfortable

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
venous disease in injecting
drug users
 Multiple
small
puncture sites
 Skin staining
 ‘Congested’ feet
 High ABPI
Compression Therapy
e.g 4-layer bandaging, hosiery
Managing 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 microorganisms
Summary
 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.