Skin and Wound Care - PowerPoint PPT Presentation

1 / 23
About This Presentation
Title:

Skin and Wound Care

Description:

... frictions, and viral, fungal, or bacterial infections. A blister greater than 1 cm in diameter is a bulla and blisters less than 1 cm is a vesicle. – PowerPoint PPT presentation

Number of Views:170
Avg rating:3.0/5.0
Slides: 24
Provided by: dmcOrgup
Category:
Tags: blisters | care | skin | wound

less

Transcript and Presenter's Notes

Title: Skin and Wound Care


1

Skin and Wound Care Skin Care Wound
Healing Section 1 of 7
RN and LPN Self-learning Module

DMC Adv Wound Care and Specialty Bed Committee

2
Acknowledgements
  • Original authors 1997
  • Maria Teresa Palleschi, CNS-BC, CCRN
  • JoAnn Maklebust, MSN, APRN-BC, AOCN, FAAN
  • Kristin Szczepaniak, MSN, RN, CS, CWOCN
  • Karen Smith, MSN, RN, CRRN
  • The authors would like to acknowledge the efforts
    of the 1997 Critical Care Wounds Work Group in
    providing the basis for this self-learning
    module. We thank the following members for their
    expertise and dedication to the effort in
    formulating these recommendations and the ongoing
    work required to communicate wound care advances
    to our DMC staff
  • Cloria Farris RN
  • Evelyn Lee, BSN, RN, CETN, CRNI
  • Mary Sieggreen MSN, RN, CS, CNP
  • Patricia Clark MSN, RN, CS, CCRN
  • Bernice Huck, RN, CETN
  • James Tyburski, MD
  • Michael Buscuito, MD
  • In 2000 the authors acknowledge the following
    staff for assisting with reviewing and revising
    this learning module
  • Mary Gerlach MSN, RN, CWOCN, CS
  • Carole Bauer BSN, RN, OCN, CWOCN

3

Purposes and Objectives
  • Purposes
  • To communicate DMC standards and policies in skin
    and wound care practice.
  • To provide a study module and source of
    reference.
  • To prepare RN and LPN orientees for clinical
    validation of skin and wound care.
  • Directions
  • All staff members are responsible to read the
    content of each module and pass the tests.
  • If you are unable to finish reviewing the content
    of this course in one sitting, click the Bookmark
    option found on the left-hand side of the screen,
    and the system will mark the slide you are
    currently viewing. When you are able to return
    to the course, click on the title of the course
    and you will have button choices to either
  • Review the Course Material which will take you to
    the beginning of the course OR
  • Jump to My Bookmark which will take you to where
    you left off on your previous review of this
    module.
  • Objectives
  • By completing this module, the RN and LPN
    will
  • 1. Recognize the professional responsibility of
    licensed health care providers.
  • RNs will utilize the knowledge to make clinical
    decisions and enter EMR orders based on DMC
    evidenced based flowcharts found in Tier 2 Skin
    and Wound Policies.
  • 2. Review basic skin and wound care concepts.

4
Key Points
  • RNs are responsible for assessment, planning,
    documentation, and evaluation of skin and wound
    care. Under the direction of an RN, an LPN may be
    delegated aspects of skin and wound care. The
    following tasks may not be delegated to
    unlicensed personnel mechanical, chemical, and
    sharp debridement.
  • The following content and flow charts describe
    choices for topical or local care for various
    wounds and skin conditions. They do not represent
    the full scope of care.
  • Staff RN are responsible to
  • Document wounds on assessment forms
  • Enter EMR wound care orders for pressure ulcer
    prevention and management
  • Enter comments related to resolution in the
    corresponding Plan of Care
  • Document Patient Education related to prevention
    / treatment
  • When unsure of appropriate care or orders,
    investigate corresponding DMC evidenced based
    flowcharts found in Tier 2 policies. If still
    unsure, consult an APN / CWOCN
  • Consult APN / CWOCN for complex wounds or wounds
    that are deteriorating as well as for specialty
    beds / surfaces.
  • The Skin and Wound Module in its entirety is
    available in the DMC Net Learning Library as a
    reference.

5
More Key Points
  • Remember the old axiom Dont put anything in the
    wound you wouldnt put in your own eye. Wound
    tissue is as sensitive as the tissue in your eye.
  • Cleanse wounds with sterile normal saline to
    remove surface debris and decrease the bacterial
    load. Use a cap with irrigation tip attached to a
    soft plastic bottle of 250mL sterile normal
    saline. Hold the irrigation tip one inch from the
    wound bed and squeeze full force with one hand.
  • Povidone iodine, Dakins, and peroxide are
    cytotoxic and interfere with wound healing.
    These agents are not used in clean or granulating
    wounds.
  • Protect yourself from blood and body fluid
    exposure during saline wound irrigation by
    wearing a mask with shield and other personal
    protective equipment.
  • Most skin / wound care products are obtained from
    central supply and can be ordered independently
    through CIS.
  • Continuity across the continuum of care is
    important. Communicate interventions and
    intended patient outcomes in the medical record.
  • The occurrence of pressure ulcers among
    hospitalized patients is considered a sensitive
    indicator of quality nursing care. Experts assert
    that quality nursing interventions are paramount
    in order to prevent and expeditiously treat
    pressure ulcer.

6

Skin Care
  • Normal skin usually tolerates regular soap and
    warm water for cleansing.
  • Aging skin loses its elasticity. The skin becomes
    thin, dry, fragile and prone to tearing when
    handled roughly.
  • Avoid soap or chemical irritants on fragile skin.
  • Keep unbroken skin lubricated and protected from
    trauma.
  • Lotions or moisturizing creams are usually
    unnecessary for intact perineal / perianal
    tissue.
  • Avoid adhesives on fragile skin
  • Tape may cause friction burns.
  • Tape removal may strip the epidermis and/or cause
    skin tears.
  • Gently remove any adhesive dressing or tape from
    fragile skin.
  • Avoid massaging reddened areas of skin. Massage
    does not increase circulation and may damage
    underlying tissue.
  • Immediately protect perineal/perianal skin from
    feces and urine using barrier creams or
    ointments.
  • Areas denuded of skin are treated as open wounds.
    Saline is used for cleansing.

7

Skin Care Flow Chart
RN TO ASSESS SKIN
Trunk and Extremity
Weeping Skin or Rash
Perineal/ Perianal Care
Irritated Unbroken Skin
Normal Intact
Dry or Fragile Skin
Consult
Normal Intact Skin
Denuded / IAD
CLEANSING Normal Hygiene Soap and Water
CLEANSING Water Only
CLEANSING Normal Hygiene Soap and Water
CLEANSING Normal Saline or Cleanser
CLEANSING Normal Saline
MOISTURIZING Lotion or Petrolatum
MOISTURIZING Lotion or Petrolatum
MOISTURIZING Unnecessary
MOISTURIZING Unnecessary
MOISTURIZING Unnecessary
PROTECTION Prevent Trauma
PROTECTION Prevent Trauma Avoid Massage Avoid
Tape/ Adhesive Agents
PROTECTION Prevent Trauma
PROTECTION Petrolatum Barrier Paste
PROTECTION Barrier Paste Zinc Oxide
Incontinence Associated Dermatitis
  • .

These flow sheets do not represent the full scope
of care Refer to APN / CWOCN / Wound Care
Specialist when in doubt.
8
Goals of Care
  • Clinicians must focus on overall patient
    status.
  • Goals of care are established early and guide
    decision making at each patient contact so that
    wound care decisions are realistic and
    appropriate.
  • Wound healing changes depending on the condition
    of the host. During terminal illness, pressure
    ulcers and other wounds can develop despite
    excellent management. Comfort and symptom
    management rather than aggressive treatment of
    wounds may be the goal.
  • Ensure that adequate pain management plan is in
    place for all patients with skin / wound
    problems.
  • Delayed wound healing occurs in patients who are
    immunocompromised, diabetic, have renal failure,
    and / or sepsis.
  • Continuity in the evidenced based plan of care
    for these patients is essential to ensure quality
    care.

9
Wound Healing
  • Wound healing is a dynamic, complex, and delicate
    process that may be endangered at any point by
    improper or inadequate management. Normal
    healing progresses in a series of overlapping
    phases hemostasis, inflammation, granulation,
    re-epithelialization and maturation (Jones, et
    al, 2004) Bernie will find updated reference for
    this one
  •  
  • Hemostasis is the coagulation of blood leaking
    from a damaged, inflamed or dilated vessel.
    After hemostasis occurs, inflammation sets in.
  • Inflammation appears as erythema and swelling due
    to vascular dilation and the inflow of plasma.
    Signs of inflammation should start to resolve 48
    to 72 hours after the occurrence of a wound.
    Persistent inflammation implies the possibility
    of new tissue damage.
  • Granulation, the third phase of healing, requires
    the presence of growth factors released by
    macrophages during the inflammatory phase.
    Reproduction of local cells that make collagen
    cannot start without growth factors. Without
    collagen, the formation of new blood vessels
    cannot take place because the scaffolding needed
    for support is absent. Newly formed blood
    vessels and capillary buds, often visible as red
    granules on the surface of granulating wounds,
    provide oxygen and nutrients to fuel the repair
    process. While dermal repair progresses,
    granulation tissue begins to mature.
  • From Jones V, Bale S, Harding K Acute and
    Chronic Wound Healing in Wound Care Essentials,
    Practice Principles S. Baranoski and E. Ayello
    (eds), Philadelphia Lippincott, Williams and
    Wilkins, 2004

10
Wound Healing
  • Wound contraction occurs in deep wounds as
    margins are pulled together by the contraction of
    specialized fibroblasts. This process
    facilitates epithelial proliferation, migration,
    and differentiation (re-epithelialization) by
    decreasing the distance epithelial cells have to
    travel. Epithelial cells migrate mainly from the
    wound edges in deep wounds. In partial-thickness
    or superficial wounds, cells may migrate from
    surviving islands of epithelium in the wound bed.
  • The last step of re-epithelialization is
    differentiation, restoring the protective outer
    layer of the skin.
  • Closure of a wound does not mean that the healing
    process has been completed. The maturation
    phase, during which a wound gains tensile
    strength, may take several months. While
    superficial wounds heal by regenerating a perfect
    new epidermis, deeper wounds never achieve the
    former degree of dermal organization or strength.
    For this reason, pressure ulcer scars are at
    high risk for developing breakdown.
  • Obstacles that may impact wound healing include
    compromised circulation infection stress drug
    therapy (corticosteroids, chemotherapy) impaired
    nutrition chronic illness (diabetes, cancer)
    radiation therapy and advancing age.
  • From Jones V, Bale S, Harding K Acute and
    Chronic Wound Healing in Wound Care Essentials,
    Practice Principles S. Baranoski and E. Ayello
    (eds), Philadelphia Lippincott, Williams and
    Wilkins, 2004

11
Wound Irrigation
  • Optimal wound healing cannot take place
    until all foreign material is removed from the
    wound.
  • Wounds must be irrigated with enough force to
    enhance cleansing without traumatizing the wound
    bed. Wound cleansing has two components 1. A
    cleansing solution and 2. An irrigation force
    or mechanical means of delivering
    the solution to the wound bed.
  • Cleansing solution The most common and
    cost-effective wound cleanser is isotonic saline
    (0.9 sodium chloride). Skin cleansers should not
    be used on open wounds.
  • Irrigation Force The cleansing or irrigation
    pressure must be greater than the adhesion force
    holding the debris against the wound bed. Flush
    away any wound drainage or old dressing
    materials.
  • Studies show that irrigation pressures between 4
    and 15 pounds per square inch (PSI) are ideal for
    cleansing open wounds. Too little pressure e.g.,
    asepto syringe or 1000 mL saline bottle does not
    adequately cleanse a wound. (Bates-Jensen BM,
    Ovington LG. 2007)
  • Bottle of sterile normal saline with irrigation
    cap delivers up to 15 pounds per square inch
    (PSI) when the system is held 1 inch from the
    wound bed and the bottle is squeezed full force
    using one hand.


  • Label normal saline bottle with date and time.
    Discard opened normal saline solution after 24
    hours.

12
Wound Assessment and Documentation
SIZE AND DEPTH Measure or trace wound area.
Measure depth
SURROUNDING SKIN Assess for color, moisture,
suppleness
WOUND BED Assess for necrotic and granulation
tissue, fibrin slough, exudate
WOUND ASSESSMENT
WOUND EDGES Assess for undermining and
condition of margins
  • Careful initial and repeat assessment of
    the patient and the wound will help the clinician
    in selecting treatment modalities and evaluating
    progress. The examination includes notation of
    the location, depth, and dimensions of the wound,
    evaluation of the wound bed and the surrounding
    skin, and analysis of any odor or exudate that
    may be present. Important wound characteristics
    to be documented are
  • 1. Location
  • Anatomic location of the wound is
    important. The time required for complete
    healing is affected by the blood supply to the
    region. For this reason, wounds on the face
    generally heal faster than a similar wound in a
    peripheral area where the blood supply is poorer.
    The rate of healing is also affected by the
    extent to which the skin is tightly adherent to
    the underlying fascia. For example, wounds on
    the shin generally heal slower than comparable
    wounds anywhere else because skin adherence is so
    tight over the shin (Baranoski,S., Ayello, E.A.,
    2004).

13
Wound Assessment and Documentation
  • 2. Wound Dimensions
  • Size the initial size of a wound is an
    important factor in noting the rate of healing.
    Large deep wounds take longer to heal than small
    deep wounds. By contrast, large shallow wounds,
    like skin-graft donor sites, are covered with new
    epithelium at about the same rate as small
    shallow wounds, especially when kept moist.
    Measure and document the wound upon admission and
    every Monday using centimeters as follows
  • 1. Length - longest point on wound, from head
    to toe.
  • 2. Width - widest point on wound, from side
    to side. 3. Depth- the deepest point in the
    wound
  • Length x width x depth
  • 3. Depth The depth of a wound profoundly
    affects time to healing. Wounds left to heal by
    formation of granulation tissue are classified by
    depth. To measure the depth of deep wounds,
    gently insert a gloved finger into the deepest
    part of the wound bed. Mark and measure against
    a centimeter ruler (Kerstein, 1997). Document
    findings in the medical record.
  • 4. Undermining Tissue destruction that occurs
    around the wound perimeter under intact skin
    where edges have pulled away from wound base.
    Document the location and amount. (Baranoski
    Ayello, 2004)
  • 5. Wound Bed The condition and appearance of
    the wound bed provides information about the
    progress of healing and the effectiveness of
    treatment. The presence of granulation tissue
    indicates that healing is progressing. A
    significant amount of fibrin slough or necrotic
    tissue in the wound bed suggests inadequate wound
    debridement. Document appearance of the wound
    bed.

14
Wound Assessment and Documentation
  • 6. Necrotic Tissue Dead devitalized avascular
    tissue and may impede wound healing. It may be
    present in the wound as yellow, gray, brown or
    black. Yellow or tan stringy tissue is referred
    to as slough. Black devitalized tissue is
    eschar. Document color, type and percentage of
    tissue in the wound bed. (Baranoski Ayello,
    2004)
  • 7. Exudate Visual appraisal of the amount and
    character of wound drainage is generally regarded
    as an important parameter in wound assessment.
    One study showed the healing rate of wounds was
    slowed by two-thirds when exudate was present at
    baseline. The amount of exudate may be an
    important indicator of healing. (Xakellis
    Chrischilles, 1992). Document exudate color,
    consistency, odor and amount.
  • 8. Surrounding Skin Monitor and document wound
    margins for signs of inflammation (erythema,
    swelling, pain) or maceration (waterlogged).
    Inflammation may be caused by unrelieved
    pressure, infection or adverse reactions to wound
    care treatments. Skin maceration, caused by
    prolonged contact of wound fluid with the skin,
    may be a sign that the topical wound treatment is
    inappropriate for the patient. Document periwound
    condition.
  • 9. Induration Induration is an area of hardened
    tissue that can be palpated around a pressure
    ulcer or wound. Use fingertips to palpate for
    induration on intact skin surrounding a pressure
    ulcer or wound. Document induration and extent of
    wound margin.
  • 10. Infection Occurs in viable tissue beneath
    the wound surface. Clinical signs of wound
    infection are the presence of warmth, pain,
    erythema, swelling, induration, and/or purulent
    drainage. Infection occurs when the bacterial
    burden overwhelms the host. Assess the
    peri-wound tissue for cellulitis. A tissue
    biopsy should be obtained to confirm infection.
    Document signs of infection and contact APN /
    CWOCN and/or physician.
  • Documentation wound documentation is entered in
    the EMR integumentary and integumentary detailed
    section of the Admission Assessment and Ongoing
    Assessment. Tissue integrity is addressed in the
    Plan of Care.

15

Definitions
  • DEFINITIONS
  • The following definitions apply to the Skin and
    Wound Care Flow Charts
  • A
  • Abscess a circumscribed collection of pus that
    forms in tissue as a result of acute or chronic
    localized infection. It is associated with
    tissue destruction and frequently swelling.
  • Acute wounds those likely to heal in the
    expected time frame, with no local or general
    factor delaying healing. Includes burns,
    split-skin donor grafts, skin graft donor site,
    sacrococcygeal cysts, bites, frostbites, deep
    dermabrasions, and postoperative-guided tissue
    regeneration.
  • B
  • Bariatric Term applying to care, prevention,
    control and treatment of obesity.
  • Basic Wound Care RN identifies and orders
    treatment plan based on DMC Skin and Wound Care
    Flowcharts.
  • Blister elevated fluid filled lesions caused by
    pressure, frictions, and viral, fungal, or
    bacterial infections. A blister greater than 1
    cm in diameter is a bulla and blisters less than
    1 cm is a vesicle.
  • Bottoming Out determined by the caregiver
    placing an outstretched hand (palm up) under a
    mattress overlay, below the part of the body at
    risk for ulcer formation. If the caregiver can
    feel less than one inch of support material
    between the caregivers hand and the patients
    body at this site, the patient has bottomed
    out. Reinflation of the mattress overlay is
    required.
  • C
  • Cellulitis inflammation of cellular or
    connective tissue. Inflammation may be
    diminished or absent in immunosuppressed
    individuals.
  • Chronic wounds those expected to take more than
    4 to 6 weeks to heal because of 1 or more factors
    delaying healing, including venous leg ulcers,
    pressure ulcers, diabetic foot ulcers, extended
    burns, and amputation wounds.
  • Colonized presence of bacteria that causes no
    local or systemic signs or symptoms.
  • Community Acquired Pressure Ulcer Any pressure
    ulcer that is identified on admission and
    documented in the Adult or Pediatric Admission
    Assessment as being present on admission (POA).
  • Contaminated containing bacteria, other
    microorganisms, or foreign material. Term
    usually refers to bacterial contamination.
    Wounds with bacterial counts of 105 or fewer
    organisms per gram of tissue are generally
    considered contaminated those with higher counts
    are generally considered infected.
  • Cytotoxic Agents solutions with destructive
    action on all cells, including healthy ones. May
    be used by APN / CWOCN to cleanse wounds for
    defined periods of time. Examples of cytotoxic
    agents include Betadine, Dakins Peroxide, and
    CaraKlenz.
  • D
  • Debridement, autolytic disintegration or
    liquefaction of tissue or cells self-digestion
    of necrotic tissue.

5
16
Definitions
  • D
  • Denuded Loss of superficial skin / epidermis.
  • Drainage wound exudate, fluid that may contain
    serum, cellular debris, bacteria, leukocytes,
    pus, or blood.
  • Dressings, primary dressings placed directly on
    the wound bed.
  • Dressings, secondary dressings used to cover
    primary dressing.
  • Dressings, alginate primary dressing. A
    non-woven highly absorptive dressing manufactured
    from seaweed. Absorbs serous fluid or exudate in
    moderately to heavily exudative wounds to form a
    hydrophilic gel that conforms to the shape of the
    wound. May be used for hemorrhagic wounds. Non
    adhesive, nonocclusive primary dressing.
    Promotes granulation, epithelization, and
    autolysis.
  • Dressings, foam primary or secondary dressing.
    Low adherence sponge-like polymer dressing that
    may or may not be adherent to wound bed or
    periwound tissue e.g., Mepilex. Indicated for
    moderately to heavily exudative wounds with or
    without a clean granular wound bed, capable of
    holding exudate away from the wound bed. Not
    indicated for wounds with slough or eschar. Foam
    and low-adherence dressings are used in wounds
    for granulation and epithelialization stages as
    well as over fragile skin.
  • Dressings, continuously moist saline primary
    dressing. A dressing technique in which gauze
    moistened with normal saline is applied to the
    wound bed. The dressing is changed often enough
    to keep the wound bed moist and is remoistened
    when the dressing is removed. The goal is to
    maintain a continuously moist wound environment.
    Indicated for dry wounds or those with slough
    that require autolytic therapy.
  • Dressings, gauze primary or secondary dressing.
    a woven or non-woven cotton or synthetic fabric
    dressing that is absorptive and permeable to
    water, water vapor, and oxygen. May be
    impregnated with petrolatum, antiseptics, or
    other agents. Indicated for surgical and
    draining wounds.
  • Dressings, hydrocolloid primary dressing. Two
    kinds of wafer, thick and thin. Wafers contain
    hydroactive/absorptive particles that interact
    with wound exudate to form a gelatinous mass.
    Moldable adhesive wafers are made of carbohydrate
    with a semiocclusive film layer backing e.g.,
    DuoDerm.
  • Thick wafers are applied over areas with exudate
    while thin wafers are used over sites with
    minimal or no exudate.
  • Thin wafers may conform to sites easier than
    thick wafers. Contraindicated where anaerobic
    infection is suspected.
  • Dressing is not removed upon external soiling.
    Removing any intact product that adheres to skin
    strips the epidermis, causes damage and increases
    the risk for breakdown.
  • Cover hydrocolloid with a transparent film to
    decrease friction from repositioning patient or
    if dressing is at risk for soiling.
  • May be used for intact skin that requires
    protection against friction.
  • Hydrocydrocolloid and low-adherence dressings are
    for wounds in the epithelialization stage.
  • Used to cover a wound entirely, leaving
    approximately a 1.5 inch border around the wound
    margins.
  • Does not require a secondary dressing

17
Definitions
  • D
  • Dressings, hydrogel or hydrogel impregnated
    gauze primary dressing. A water-based
    non-adherent dressing primarily designed to
    hydrate the wound, may absorb small amount of
    exudate e.g., Skintegrity. Indicated for dry to
    minimally exudative wounds with or without clean
    granular wound base. Donates moisture to the
    wound and is used to facilitate autolysis. May
    be used to provide moisture to wound bed without
    macerating surrounding tissue. Requires a
    secondary dressing.
  • Dressings Primary dressing placed directly on
    the wound bed.
  • Dressings Secondary dressing used to cover
    primary dressing.
  • Dressings, silver Useful for colonized wounds or
    those at risk of infection and decreases wounds
    bacterial load. good for up to 5 - 7 days.
  • Alginate e.g., Aquacel Ag - Highly absorbent
    interacts with wound exudate and forms a soft gel
    to maintain moist environment. May be used in
    dry wounds covered with saline moistened gauze as
    secondary dressing to maintain moisture
  • Foam e.g., Mepilex Ag - Used for colonized wounds
    or those at risk of infection and decreases
    wounds bacterial load. Used in exudating
    colonized wounds
  • Textile e.g., InterDry Ag - Used for Intertrigo
    and other skin to skin surfaces with rash. May
    remain in place for 5 days.
  • Dressings, transparent primary or secondary
    dressing. A clear, adherent non-absorptive
    dressing that is permeable to oxygen and water
    vapor e.g., Tegaderm. Creates a moist
    environment that assists in promoting autolysis
    of devitalized tissue. Protects against
    friction. Allows for visualization of wounds.
    Indicated for superficial, partial-thickness
    wounds, with small amount of slough to enhance
    autolytic debridement. Used in wounds with little
    or no exudate
  • Dressings, wet-to-dry a debridement technique in
    which gauze moistened with normal saline is
    applied to the wound and removed once the gauze
    becomes dry and adheres to the wound bed.
    Indicated for debridement of necrotic tissue
    from the wound as the dressing is removed,
    however method is not selective and removes
    healthy tissue as well. Other methods of
    debridement are considered more effective. Wet
    to dry dressing orders that are changed at a
    frequency that does not allow drying are
    considered continuously moist dressings.
  • Dressing, xeroform primary dressing. Impregnated
    gauze with petrolatum and 3 bismuth. Indicated
    for skin donor sites and other areas to protect
    from contamination while allowing fluid to pass
    to secondary dressing.

18
Definitions
  • E
  • Enzymes protein catalyst that induces chemical
    changes in cells to digest specific tissue.
    Indicated for partial and full thickness wounds
    with eschar or necrotic tissue. Gauze is used as
    a secondary dressing, e.g.., Santyl and
    polysporin.
  • Epithelialization regeneration of epidermis
    across a wounds surface.
  • Erythema Blanchable (Reactive Hyperemia)
    reddened area of skin that turns white or pale
    when pressure is applied with a fingertip and
    then demonstrates immediate
    capillary refill. Blanchable erythema over a
    pressure site is usually due to a
    normal reactive hyperemic response.
  • Erythema Non-blanchable redness that persists
    when fingertip pressure is applied.
    Non-blanchable erythema over a pressure site is a
    sign of a Stage I pressure ulcer.
  • Excoriation loss of epidermis linear or
    hollowed-out crusted area dermis is exposed
    Examples  Abrasion scratch. Not the same as
    denuded of skin.
  • Exudate any fluid that has been extruded from a
    tissue or its capillaries, more specifically
    because of injury or inflammation. It is
    characteristically high in protein and white
    blood cells but varies according to individual
    health and healing stages.
  • G
  • Gangrene Gangrene is ischemic tissue that
    initially appears pale, then blue gray, followed
    by purple, and finally black. Pain occurs at
    the line of demarcation between dead and
    viable tissue. Consists of 3 types Dry, Wet,
    and Gas
  • Dry gangrene is tissue with decreased perfusion
    and cellular respiration. Tissue becomes dark
    and loses fluid. Area becomes shriveled /
    mummified. Not considered harmful and is not
    painful. Area requires protection, kept dry,
    avoid maceration. Alcohol pads may be used
    between gangrenous toes to dry tissue out.
  • Wet gangrene is dead moist tissue that is a
    medium for bacterial growth. Area requires
    protection, kept dry, do not use a wet to dry
    dressing. Monitor for erythema and signs of
    infection in adjacent tissue.
  • Gas gangrene is tissue infected with an anaerobic
    organism e.g., clostridium. Systemic antibiotics
    are required and tissue must be removed by
    physician in the OR. Keep moist tissue moist and
    dry tissue dry. Monitor adjacent tissue for
    signs of infection progressing
  • Granulation Tissue pink/red, moist tissue that
    contains new blood vessels, collagen,
    fibroblasts, and inflammatory cells, which fills
    an open, previously deep wound when it starts to
    heal.
  • H
  • Hospital acquired condition (HAC) condition
    that occurs during current hospitalization.
    Formerly known as nosocomial. Ulcers without
    assessment documentation in the patient medical
    record within 24 hours of admission are
    classified as hospital acquired even though they
    were present on admission (POA). Acceptable
    documentation of ulcer assessment for hospital
    acquired conditions / pressure ulcers includes a
    detailed description within any assessment record
    e.g., EMR Adult Ongoing Assessment, Progress
    Note, HP or consultative form.

19
Definitions
  • I
  • Incontinence-related dermatitis an inflammation
    of the skin in the genital, buttock, or upper leg
    areas that is often associated with changes in
    the skin barrier. Presents as redness, a rash,
    or vesiculation, with symptoms such as pain or
    itching. Associated with fecal or urinary
    incontinence.
  • Infection overgrowth of microorganisms causing
    clinical signs/ symptoms of infection
  • warmth, edema, redness, and pain.
  • Induration an abnormal hardening of the tissue
    surrounding wound margins, detected by
    palpation. It occurs following reactive
    hyperemia or chronic venous congestion.
  • J
  • K
  • L
  • M
  • Maceration excessive tissue softening by wetting
    or soaking (waterlogged).
  • N
  • Negative pressure wound therapy (NPWT) provides
    an occlusive controlled sub-atmospheric pressure
    (negative pressure) suction dressing that
    promotes moist wound healing. Controlled
    sub-atmospheric pressure improves tissue
    perfusion, stimulates granulation tissue, reduces
    edema and excessive wound fluid, and reduces
    overall wound size. Some indications for use
    include pressure ulcers, venous ulcers, diabetic
    foot ulcers, dehisced surgical incisions, partial
    thickness burns, grafts, split thickness skin
    grafts, traumatic wounds, fasciotomy,
    myocutaneous flaps, and temporary closure for
    abdominal compartment syndrome (V.A.C. ACS).
  • No Touch Technique Dressing change technique
    where only the outer layer of dressing is touched
    with clean gloves. The dressing surface against
    the wound bed is never touched.
  • O

20
Definitions
  • P
  • Pressure Ulcer Staging One of the most commonly
    used systems to classify pressure ulcers. This
    staging system was developed by the National
    Pressure Ulcer Advisory Panel (NPUAP) and is
    recommended by the AHCPR Guidelines for pressure
    ulcers.
  • Stage I Intact skin with non-blanchable redness
    of a localized area usually over a bony
    prominence. Darkly pigmented skin may not have
    visible blanching its color may differ from the
    surrounding area. The area may be painful, firm,
    soft, warmer or cooler as compared to adjacent
    tissue. Stage I may be difficult to detect in
    individuals with dark skin tones. May indicate
    "at risk" persons (a heralding sign of risk).
    Treatment Do not cover, assess frequently for
    progression.
  • Stage II partial thickness loss of dermis
    presenting as a shallow open ulcer with a red
    pink wound bed, without slough. May also present
    as an intact or open/ruptured serum-filled
    blister. Presents as a shiny or dry shallow
    ulcer without slough or bruising. This stage
    should not be used to describe skin tears, tape
    burns, perineal dermatitis, maceration or
    excoriation. Treatment Hydrogel / hydrogel
    impregnated gauze, or foam / Mepilex dependent on
    location.
  • Stage III full thickness tissue loss.
    Subcutaneous fat may be visible but bone, tendon
    or muscle are not exposed. Slough may be present
    but does not obscure the depth of tissue loss.
    May include undermining and tunneling. The depth
    of a stage III pressure ulcer varies by
    anatomical location. The bridge of the nose, ear,
    occiput and malleolus do not have subcutaneous
    tissue and stage III ulcers can be shallow. In
    contrast, areas of significant adiposity can
    develop extremely deep stage III pressure ulcers.
    Bone/tendon is not visible or directly palpable.
    Treatment Hydrogel / hydrogel impregnated gauze
    or continuously moist dressings.
  • Stage IV full thickness tissue loss with exposed
    bone, tendon or muscle. Slough or eschar may be
    present on some parts of the wound bed. Often
    include undermining and tunneling. The depth of a
    stage IV pressure ulcer varies by anatomical
    location. The bridge of the nose, ear, occiput
    and malleolus do not have subcutaneous tissue and
    these ulcers can be shallow. Stage IV ulcers can
    extend into muscle and/or supporting structures
    (e.g., fascia, tendon or joint capsule) making
    osteomyelitis possible. Exposed bone/tendon is
    visible or directly palpable. Treatment Hydrogel
    / hydrogel impregnated gauze, continuously moist
    dressings.
  • Unstageable full thickness tissue loss in which
    the base of the ulcer is covered by slough
    (yellow, tan, gray, green or brown) and/or eschar
    (tan, brown or black) in the wound bed. Until
    enough slough and/or eschar is removed to expose
    the base of the wound, the true depth, and
    therefore stage, cannot be determined. Stable
    (dry, adherent, intact without erythema or
    fluctuance) eschar on the heels serves as "the
    body's natural (biological) cover" and should not
    be removed. Treatment contact APN / CWOCN for
    enzymatic agent for areas outside of the heels.
  • Deep Tissue Injury Purple or maroon localized
    area of discolored intact skin or blood-filled
    blister due to damage of underlying soft tissue
    from pressure and/or shear. The area may be
    preceded by tissue that is painful, firm, mushy,
    boggy, warmer or cooler as compared to adjacent
    tissue. Bruising indicates suspected deep tissue
    injury. These lesions may herald the subsequent
    development of a Stage 3 or Stage 4 Pressure
    Ulcer even with optimal management. Treatment
    protect, reposition off area at all times,
    contact APN CWOCN, assess frequently for
    deterioration.
  • Although useful during initial assessment, the
    staging classification system cannot be used to
  • monitor progress over time. Pressure ulcer
    staging is not reversible. Ulcers do not heal in
  • reverse order from a higher number to a lower
    number and are not be described s such e.g.,
  • the ulcer was a Stage II but now looks like a
    Stage I). Wounds with slough or eschar cannot
  • be staged. The full extent or wound depth is
    hidden by slough or eschar.

21
Definitions
  • P
  • Present on Admission (POA) Any alteration in
    tissue integrity that is identified on admission
    is defined as community-acquired and documented
    in the Adult Admission History as present on
    admission (POA).
  • Acceptable documentation of ulcer assessment for
    community acquired conditions / pressure ulcers
    includes a detailed description within any
    assessment record e.g., EMR Adult Admission
    History, Progress Note, HP or consultative form.
  • Protective barrier film Clear liquid that seals
    and protects the skin from mechanical injury
    e.g., AllKare wipes (contains alcohol), Medical
    Adhesive Spray (alcohol free). Some contain
    alcohol and require vigorous fanning after
    application to avoid burning on contact.
  • Pustule Elevated superficial filled with
    purulent fluid.
  • Purulent forming or containing pus.
  • Q
  • R
  • Rash term applied to any eruption of the skin.
    Usually shade of red.
  • Shear friction plus pressure causing muscle to
    slide across bone and obstructing blood flow
    e.g., sitting with head of the bed (HOB) at gt 30?
    angle.
  • Skin Sealant clear liquid that seals and
    protects the skin.
  • Tissue Biopsy use of a sharp instrument to
    obtain a sample of skin, muscle, or bone.

22
Bibliography
  • Ayello, E.A. Braden, B.J. (2001). Why is
    pressure ulcer risk assessment so important?
    Nursing 2001 31(11) 75-79.
  • Ayello, E.A Lyder, C. (2007) Protecting
    patients from harm preventing pressure ulcers.
    Nursing 2007 Lippincott, Williams Wilkins New
    York. 36-40
  • Baharestani,M. (2007). An Ovedrview of neonatal
    and pediatric wound care knowledge and
    considerations. OstomyWoundManagement 53(6)
    34-55.
  • Baranoski, S Ayello,E. (2003) Wound Care
    Essentials Practice Principles Lippincott,
    Williams WilkinsNew York
  • Bates-Jensen BM, Ovington LG. (2007). Management
    of exudate and infection. In Sussman C,
    Bates-Jensen BM,(Eds.), Wound Care A
    Collaborative Practice Manual for Health
    Professionals. 3rd ed. Baltimore, MD Lippincott
    Williams Wilkins.
  •  
  • Bergstrom N, Bennett MA, Carlson CE, et al.
    (1994) Treatment of Pressure Ulcers. Clinical
    Practice Guideline, No. 15. Rockville MD U.S.
    Department of Health and Human Services. Public
    Health Service, Agency for Health Care Policy
    and Research. AHCPR Pub. No. 95-0652.
  • Bergstrom N, Braden B, Kemp M, Champagne M , Ruby
    E (1998). Predicting pressure ulcer risk a
    multisite study of the predictive validity of the
    Braden Scale. Nursing Research 47 (5) 261-9.
  • Bergstrom N, Braden B, Laguzza A, Holman V (1987)
    The Braden Scale for Predicting Pressure Sore
    Risk. Nursing Research, 36, 205-210.

23

Bibliography
  • Kinetic Concepts Inc. (2007). V.A.C. therapy
    clinical guidelines A reference for
    clinicians.San Antonio,Texas.
  • Kinetic Concepts Inc.(2006) Info V.A.C. User
    manual. San Antonio, Texas
  • Krasner, DL Rodeheaver, GT Sibbald, RG. (eds).
    (2001). Chronic wound care a clinical source
    book for healthcare professionals (3rd ed.).
    Wayne, PA HMP Communications.
  • Maklebust, J. Sieggreen, M. (2001). Pressure
    ulcers guidelines for prevention and management,
    (3rd ed.). Springhouse PA Springhouse
    Corporation.
  • Maklebust, J. (2005). Pressure ulcers The great
    insult. In M. Lorusso (Ed.), Nursing Clinics of
    North America,40(2) (365-89).Pennsylvania W.B.
    Saunders.
  • Maklebust, J.,Sieggreen, M., Sidor, D., Gerlach,
    M., Bauer, C., Anderson, C. (2005)
    Computer-based testing of the Braden Scale for
    Predicting Pressure Sore Risk. Ostomy Wound
    Management, 51(4) 40-42,44,46.
  • Panel for the Prediction and Prevention of
    Pressure Ulcers in Adults (1992). Pressure
    Ulcers in Adults Prediction and Prevention.
    Clinical Practice Guideline, No. 3. AHCPR
    Publication No. 92-0047. Rockville, MD Agency
    for Health Care Policy and Research, Public
    Health Service, US Department of Health and Human
    Services.
  • Sussman, C. Bates-Jensen, B. (2007). Wound
    care a collaborative practice manual for
    healthcare professionals. 3rd ed. Baltimore,MD
    Lippincott Williams Wilkins.
  • Van Rijswijk, L., Braden, B.J. (1999). Pressure
    ulcer patient and wound asssessment an AHCPR
    clinical practice guideline update. Ostomy Wound
    Management, 45 (1A Suppl) 56s-67s.
Write a Comment
User Comments (0)
About PowerShow.com