Skin and Wound Care - PowerPoint PPT Presentation


PPT – Skin and Wound Care PowerPoint presentation | free to view - id: 3c7244-MWVmN


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Skin and Wound Care


Braden Scale & Prevention Section 2 of 7 RN and LPN Self-learning Module DMC Adv Wound Care and Specialty Bed Committee Original authors 1997: Maria Teresa Palleschi ... – PowerPoint PPT presentation

Number of Views:1190
Avg rating:3.0/5.0
Slides: 30
Provided by: dmcOrgup
Tags: care | skin | wound


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Skin and Wound Care


Skin and Wound Care Braden Scale
Prevention Section 2 of 7
RN and LPN Self-learning Module

DMC Adv Wound Care and Specialty Bed Committee

  • 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


Purposes and Objectives
  • Purposes
  • To communicate DMC standards and policies in skin
    and wound care practice.
  • To provide a study module and source of
  • To prepare RN and LPN orientees for clinical
    validation of skin and wound care.
  • Directions
  • All staff are responsible to read the content of
    these modules 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
  • Objectives
  • By completing this module, the RN and LPN
  • 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.


Pressure Ulcer Risk Assessment
  • Epidemiology and Economics
  • The National Pressure Ulcer Advisory Panel
    (NPUAP) reported that in 2003 there were 455,000
    hospital stays during which pressure ulcers were
    noted-a 63 percent increase from 11 years
  • Patients 65 years and older accounted for 72.3
    percent of all those hospitalizations.
  • LOS for primary diagnosis of pressure sores
    lasted nearly 13 days and varied by patients age.
  • The average charge for hospital stay for pressure
    ulcers was 37,800.
  • Reference Statistical Brief 3, April 2006.
    Agency for Healthcare Research and Quality.
  • Timely, accurate identification of patients at
    risk for pressure ulcers provides opportunity for
    early preventive interventions. Pressure ulcer
    risk assessment is the basis for planning patient
    treatment, evaluating its effects, and
    communicating with others.
  • The Braden Scale for Predicting Pressure Sore
    Risk is a formal, valid, internationally
    recognized tool for predicting patient risk for
    pressure ulcers.
  • Identifying patients at risk using the Braden
    Scale involves assessing six subscales
  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and shear


Braden Schema Pressure Ulcer Development
Sensory Perception
Pressure Ulcer Development
Extrinsic Factors Moisture Friction Shear
Tissue Tolerance
Intrinsic Factors Nutrition Arteriolar
pressure Age Other Hypothetical
factors Interstitial fluid flow Emotional
stress Smoking Skin temperature
Braden, B., Bergstrom, N. (1987).

Braden Scale Predicting Pressure Sore Risk
  • The Braden Scale score ranks patients according
    to their level of risk for pressure ulceration.  
    Lower scores indicate a lower functional status
    and, therefore, a higher level of risk
  •            9 or less     Very high risk
  •       10 - 12        High risk
  •            13 - 14        Moderate risk
  •            15 - 18       Mild risk
  •            19 - 23       Generally not at risk
  • A total Braden Scale score of 18 or below in
    an adult patient is predictive for the
    development of a pressure ulcer unless preventive
    measures are taken. If the total Braden scale
    score is lt 18, the patient must have preventive
  • Preventative measures must focus on those Braden
    subscales in which a patient has a low score.
  • Low subscales indicate risk even if total score
  • The intensity of interventions is based on the
    level of risk.
  • Target the reason the scale is low in the
    interventions you select for your patient.
  • All patients who have a Braden Score of 18 or
    below must have interventions initiated that will
    lower the risk for pressure ulcer development.
  • Initiate a Plan of Care for Risk for Impaired
    tissue Integrity and corresponding EMR Pressure
    Ulcer Prevention Order Set

Braden Scale Predicting Pressure Sore Risk
  • Successful use of the Braden Scale for
    Predicting Pressure Sore Risk has been shown to
    improve patient outcomes by reducing the number
    of hospital acquired pressure ulcers.

Braden Q Scale Predicting Pressure Sore Risk
The Braden Q scale is a modification of the
original Braden Scale used in adult populations.
This modification of the Braden was developed by
two nurses, Dr. Martha Curley and Dr. Sandy
Quigley. Braden Q is very reliable in predicting
pressure ulcer risk in children lt 5 years old.

Pressure Ulcer Prevention
  • Basic tenets of pressure ulcer prevention are
    managing nutrition, pressure (friction/shear)
    and incontinence / excessive moisture.
  • If nutrition deficits exist, RN may enter an EMR
    Healthcare Provider order to consult a dietitian.
  • Protect skin from excessive moisture and fecal /
    urinary drainage.
    Be proactive, start with petrolatum or other
    barrier creams immediately.
  • To manage pressure, control both the intensity
    and duration.
  • Pressure duration is time spent in one position.
    Manage by repositioning frequently.
  • Pressure intensity is the amount of pressure.
    Manage by using a special pressure redistribution
    support surface e.g., SofCare, Isoflex, Acucair.
  • Avoid massaging bony prominences. Massage does
    not increase circulation or prevent pressure
    ulcers. It may cause more damage to compromised
  • Use a lift pad to move patients up in the bed to
    avoid friction and shear
  • While reclining - use the rule of 30
  • Unless medically contraindicated, the HOB is
    kept at a 30? angle or lower to reduce shear
    force. When the HOB bed is elevated, shear force
    results in the skin and superficial fascia
    remaining fixed against the bed linen while the
    deep fascia and skeleton slide down toward the
    foot of the bed over bony prominences. This can
    stretch the blood vessels and result in sacral
    shear ulcers. Use of an overhead trapeze is
    helpful if a patient has enough upper body
    strength to lift self off the bed.

Preventing Heel Ulcers
  • No support surface provides adequate pressure
    relief for heels.
  • Diabetic patients with normal Braden scale score
    are at increased risk for foot / heel ulcers due
    to peripheral neuropathy.
  • Elevate or float heels off sleep surface to
    prevent pressure ulcers.

Effect of pressure on heels
Elevate heels off the bed
All you need is one hand to fit between heels
and the sleep surface. Use Heel Lift Boots for
patients who will not keep heels off surface
Wound Care and Spec Bed Comm 9/08
Reducing the Duration of Pressure
  • While reclining - use the rule of 30
  • Patients are repositioned minimally every 2
    hours. Teach able patients to shift their body
    weight while in bed.
  • In addition, the patient is repositioned
    alternately from a right 30 degree lateral
    side-lying position to a left 30 degree lateral
    side-lying position. This will keep pressure off
    of the sacrum and the trochanter at the same
    time. Use a foam positioning device to support
    the body in this position.
  • Avoid positioning patients at a ninety degree
    angle. Placing them in 90 which is the degree
    side-lying positions places them on the
    trochanter most vulnerable bony prominence.
  • While chair sitting
  • Shear also occurs over the ischial tuberosities
    when chair sitting patients slide forward in the
  • Teach able patients to shift their body weight
    every 15-30 minutes while chair sitting.
    Patients who cannot shift themselves are
    repositioned / shifted by caregivers at least
    every hour and more often if breakdown exists.


Prevention Flow Chart
If patient has a Braden Score of lt 18
If patient has a history of pressure ulcers or
an actual pressure ulcer
Institute prevention flow chart, enter EMR
Pressure Ulcer Prevention / Management Order Set
Assess for nutritional deficits
Assess for incontinence, moisture problems
Assess mobility deficits, activity deficits and
sensory perception
If Braden score for nutrition is lt 2
Protect skin from fecal and urinary drainage
If patient is bedbound, chairbound, or
unable/ unwilling to reposition self
Refer to DMC Skin / Wound Care Flowchart
If Serum Albumin lt 3.5 or
Refer to Skin Care Flowchart
Determine potential for rehabilitation
Protect from effects of Pressure / shear
If weight change of 10 within 3 month period
If participates in therapy and
Reposition frequently to decrease pressure
Monitor effectiveness of plan
Provide pressure redistribution to decrease
pressure intensity
If patient has chronic disease
Consult APN / CWOCN for alternative pressure
relieving surfaces and further evaluation
Tolerates 15 minutes of activity and
Place in 30 degree lateral sidelying position.
Avoid the trochanter
Order Static Air Mattress and Q shift
Consult Dietitian for complete
nutritional assessment
Patient has potential for carryover
Protect bony prominences
Provide foam positioner wedge to maintain body
Suspend heels off bed with pillow or Heel
Lift Boot
Recommend PT/OT consult to maximize mobility
Avoid prolonged HOB elevation gt 30 degrees
Protect from tubes and equipment
Static Air Mattress not in use at CHM RIM.
Observed capacity to learn and follow through
with motor skills necessary for increased
functional independence.
Have patient use trapeze to move
Order Chair Cushion for sitting
These flow sheets do not represent the full scope
of care Refer to APN / CWOCN / Wound Care
Specialist when in doubt.

Reducing Intensity of Pressure
  • To be effective, support surfaces must mold to
    the body to maximize contact, then redistribute
    the patients weight as uniformly as possible
    pressure redistribution.
  • Surfaces are designed so that body weight
    floating on a fluid system is evenly distributed
    over the entire surface.
  • As pressure is increasingly distributed over more
    body surface area, the intensity of pressure
    decreases over all body areas.
  • Support surfaces also use the principle of
    deformation, meaning they
  • must be capable of deforming enough to permit
    prominent areas of the
  • body to sink into the support. The surfaces also
    must be able to transmit
  • pressure forces from one body area to another.
  • The degree of head elevation can affect the
    clinical effectiveness of a
  • support surface.
  • When the head of the bed is elevated, pressure is
    shifted to the sacral and ischial areas of the
  • The patient may bottom out if the seating area
    of the support surface flattens and loses volume.
    If bottoming out occurs, the support surface no
    longer provides therapeutic benefit.
  • Whether patients at risk for pressure ulcers are
    in bed or a chair, pressure points must be
    protected. Today, many types of special beds,
    mattresses, and cushions are available to reduce
    the intensity of pressure. Pressure
    redistribution surfaces include special foam and
    static air mattresses low air loss,
    air-fluidized, and oscillating beds.
  • There is no scientific evidence that one support
    surface consistently works better than all
    others. The best way to match a support surface
    to a particular patients needs is to learn the
    special characteristics of each type of surface.
    See the following pages for the DMC Decision
    Guidelines for Specialty Beds and Overlay

Mattress Overlays / Surfaces
  • Mattress overlays raise the level of the bed
    surface making getting in and out of bed more
    difficult. There is also less space between the
    mattress and the top of the side rail. Ensure
    patient safety when using these types of
  • Foam and air products are used for pressure ulcer
    prevention. For patients at risk for pressure
    ulcers who have excessive moisture against the
    skin from incontinence, wound drainage, or
    perspiration, a support surface that flows air
    across the skin is recommended.
  • Two inch foam mattress overlays are comfort items
    only and not suitable for pressure reduction
    (Bergstrom, et. al, 1994).
  • Geo-Matt? foam overlays, 3.5 inch thick, high
    density fire-retardant foam with contoured,
    cross-cut cells. Utilized occasionally at RIM,
    inexpensive, portable, pressure reducing, and
    facilitates patient self-movement from bed to
  • Gaymar Sof-Care? air mattresses are static air
    mattresses used for patients at risk for pressure
    ulcers. Sof-Care mattresses have a continuous
    inflation pump available to all DMC sites, free
    of charge.
  • With pressure reducing mattress overlays /
    surfaces, it is important to ensure that the
    patients body weight does not fully compress the
  • If the overlay is compressed enough for the
    patient to rest on the underlying mattress, the
    patient is bottoming out.
  • To check for proper mattress overlay inflation,
    place an outstretched hand (palm up) under the
    overlay, below the part of the body at risk for a
    pressure ulcer. If the caregiver feels less than
    one inch of uncompressed support surface, the
    patient has bottomed out.
  • To combat bottoming out, either increase
    inflation or move the patient to a mattress with
    more depth (Bergstrom, et. al, 1994).
  • Sof-Care? mattresses need to be checked daily for
    bottoming out even when using the Gaymar
    continuous inflation pump.

Specialty Beds
  • Specialty beds and surfaces are selected based on
    the patients status, size and therapeutic
    benefit associated with the bed. Specialty beds
    require patient evaluation and order processing
    by an APN or CWOCN.
  • If the goal is pressure ulcer prevention,
    pressure redistribution surfaces or mattresses
    such as low air loss, static air / Sof-Care? and
    Hill Rom Dynamic-Aire (available at DRH ) may
    meet patient requirements.
  • Patients with pressure ulcers (II through IV) or
    open wounds on dependent body surfaces or flaps,
    grafts or burns may require low-air loss surfaces
    or air-fluidized beds.
  • Patients who are at risk for pulmonary
    complications and pressure ulcers may require a
    rotation surface with low air loss such as
    Stryker XPRT or SizeWise Big Turn.
  • Patients in Critical Care with moderate to severe
    pulmonary complications such as atelectasis,
    pneumonia, and ARDS may require continuous
    lateral rotation therapy as well as a
    redistribution surface, e.g., XPRT, Total Care
    Sport ?
  • While the use of pressure-redistribution surfaces
    on beds or chairs may allow caregivers to
    lengthen repositioning intervals, they may also
    give a false sense of security.
  • Patients require individual turning schedules
    regardless of pressure-redistribution devices or
    specialty support surfaces.
  • Even though every 2 hours is the routine turning
    interval, patients may require more frequent
  • Heels must be elevated even when specialty
    support surfaces are in place.
  • Specific indications and contraindications for
    use are listed on the following Specialty Bed
  • Excessive moisture on intact skin may cause
    maceration and skin breakdown. A support surface
    that provides air flow such as low air loss or
    air fluidized can aid in keeping the skin dry.
  • Bariatric Products
  • Wider, more durable bariatric beds such as the
    Total Care Bariatric, BariAir, and Mighty Air are
    available for patients weighing greater than 250
    lbs who cannot be repositioned therapeutically.
    Bariatric room environments provide a whole room
    set-up (commode, walker, lift) to meet the needs
    of the bariatric patient.

Specialty Beds
Specialty Beds
Specialty Beds
Specialty Beds
Specialty Beds

  • 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
  • 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
  • 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
  • C
  • Cellulitis inflammation of cellular or
    connective tissue. Inflammation may be
    diminished or absent in immunosuppressed
  • 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
  • D
  • Debridement, autolytic disintegration or
    liquefaction of tissue or cells self-digestion
    of necrotic tissue.

  • 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
  • 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.,
  • 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
  • Does not require a secondary dressing

  • 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.

  • 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
  • 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
  • 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.

  • 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
  • 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

  • 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
  • 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
  • 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
  • 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
  • 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
  • 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.

  • 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?
  • 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.

  • 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)
  • 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.


  • 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
  • Maklebust, J. (2005). Pressure ulcers The great
    insult. In M. Lorusso (Ed.), Nursing Clinics of
    North America,40(2) (365-89).Pennsylvania W.B.
  • 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
  • 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.