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Skin and Wound Care


Dressings Section 5 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 ... – PowerPoint PPT presentation

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Title: Skin and Wound Care


Skin and Wound Care Dressings Section 5 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.

  • Basic wound care is provided using DMC Wound and
    Skin Care Flow
  • Charts as guidelines for the RN to independently
    make decisions and
  • initiate orders for wound care.
  • Dressings are selected by RN staff based on wound
  • Ensure continuity by entering EMR orders for all
    wound care
  • The following dressing changes may not be
    delegated to the unlicensed
  • personnel
  • Wet-to-Dry. Dressings that are ordered wet to
    dry but are changed at a frequency that does not
    allow the dressing to dry in the wound bed and
    debride the wound are considered continuously
  • Weep No More (WNM) Suction Dressing.
  • Silver.
  • Complex wounds that require filling or packing.
  • The RN may delegate dressing changes to the PCA
  • After each wound assessment.
  • After determining dressing type and frequency.
  • The following dressings may be delegated to
    unlicensed personnel
  • Alginate.


  • Protective Barrier Wipe
  • Protective barrier wipe provide a protective
    coating on unbroken skin after they dry
  • Provide some degree of protection from mechanical
  • Most liquid film barriers contain alcohol and
    cause stinging on contact with denuded/fragile
  • Transparent Adhesive Dressings 2 PC 5213
  • Semi permeable, sterile thin film
  • Maintains a moist environment
  • Non-absorptive
  • Assists in promoting autolysis of devitalized
  • Creates a second skin and protects against
  • Allows for visualization of wound
  • Not used over the following wounds / areas
  • Wounds with heavy drainage, depth gt 0.5cm,
    clinical signs of infection, sinus tracts or
  • Blisters that are growing in size. Site will
    leak and require removal causing more tissue
  • Heels, especially those with eschar
  • Hydrocolloid Dressings 2 PC 5211

  • Hydrogels and hydrogel impregnated gauze 2 PC
  • Clear viscous wound gel that is water based and
    contains glycerin.
  • Available in a tube, impregnated in a gauze
    dressing, or as a sheet
  • Maintains a moist environment
  • Absorbs minimal exudate
  • May donate moisture to the wound.
  • Assists in promoting autolysis of devitalized
  • Requires a secondary dressing
  • Usually requires fewer dressing changes than
    saline moistened gauze
  • Not used over the following wounds / areas
  • copious drainage or maceration.
  • Where anaerobic infection is suspected.
  • Alginate Dressings 2 PC 5207
  • Heavy fiber dressing made from seaweed
  • Maintains a moist environment
  • Absorbs moderate to heavy exudate
  • May be used to fill wound cavities
  • May be used in bleeding wounds / sites for

  • Silver Dressings Ordered by Wound Care
  • Useful for colonized wounds or those at risk of
    infection and decreases wounds bacterial load.
    Wound drainage activates antimicrobial activity
    in foam and hydrofiber. Drainage not necessary
    for textile InterDry Ag
  • Mepilex Ag Silver foam, good for up to 7 days.
  • Used in exudating colonized wounds
  • Easy to remove, cleanse wound, replace
  • Aquacel Ag Hydrofiber dressing with silver,
    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
  • Difficult to remove, cleanse wound and replace
    due to gelatinous consistency.
  • InterDry Ag
  • Used for Intertrigo and other skin to skin
    surfaces with rash
  • Not used over the following wounds / areas
  • Sensitivity to silver

Dressings/Topical Agent Grid
Tegaderm HP Manufacturer 3M Available sizes 4X4, 8X8 Product Classification Transparent Film Description A clear, adherent non-absorbent dressing that is permeable to oxygen and water vapor. Indications for Usage Superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with little or no exudate Disadvantages No ability to absorb drainage so dressing may cause maceration of periwound tissue. Change Frequency Weekly and PRN for trapped fluid.
Duoderm Signal Thin Manufacturer Convatec Available sizes 4X4, 8X8 Product Classification Hydrocolloid Description Occlusive, adhesive wafer contains hydroactive particle to maintain moist environment promote autolysis Indications for Usage Superficial or Stage II over areas that are not weight bearing. Not for use on sacrum / coccyx Shallow-full thickness wounds with necrosis or slough and light to moderate exudate. Thin duoderm appropriate for wounds with little to no exudate Disadvantages Not recommended for wounds with heavy exudate, sinus tracts, or infections. Wafer may curl and require frequent changes resulting in tearing fragile periwound skin Dressing edges may require tape to decrease curling / rolling. Thin duoderm will not contain large amounts of exudate. Change Frequency Every 3-5 days and PRN for drainage / curling
Hydrosorb Manufacturer Convatec Available sizes 4X4 Product Classification Foam Description Absorptive, non adherent, sponge like polymer dressing Indications for Usage Partial and full-thickness wounds with minimal to moderate exudate and as a secondary dressing for wounds with packing Disadvantages Not recommended for dry wounds. May macerate peri-wound skin. Change Frequency Daily PRN for drainage.
Kaltostat Manufacturer Convatec Available sizes 4X4, rope Product Classification Calcium Alginate Description Alginate dressing that helps reduce bleeding and manages exudate in low to moderately exuding wounds. Indications for Usage Superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with moderate exudate Disadvantages Able to absorb drainage, monitor periwound for maceration. Change Frequency Daily and PRN.
Duoderm Hydroactive, gel Manufacturer Convatec Available sizes 15gm and 30gm Product Classification Hydrogel Description Water-based gel with some absorptive properties. Indications for Usage For use in large and tunneled wounds. Disadvantages None. . Change Frequency Reapply every 12 -24 hours.
See Dressings/Topical Agent Grid
Skintegrity Manufacturer Medline Available sizes 4X4 Product Classification Hydrogel Impregnated Gauze Description Gauze dressing that is coated with hydrogel Indications for Usage Partial-thickness and full thickness wounds, that require moisture and filling. Abrasions, Burns, radiation skin damage. Ulcers with small amount of slough to enhance autolytic debridement, e.g., sacral ulcers Disadvantages Limited moisture retention, may adhere to wound bed if allowed to dry. Requires a secondary dressing. Can cause maceration of periwound tissue. Change Frequency Reapply every 12 -24 hours.
Mepilex Border with Safetac Technology Manufacturer MÖLNLYCKE Available sizes 4X4 and 6X6 Product Classification Hydrophilic Foam Description sponge like polymer dressing that may or may not be adherent, Effectively absorbs exudate and maintains a moist wound environment. The Safetac layer seals the wound edges, preventing the exudate to leak onto the surrounding skin, thus minimizing the risk for maceration. The Safetac layer ensures that the dressing can be changed without damaging the wound or skin. Indications for Usage Shallow areas with minimal amount of exudate and little or no slough / eschar, e.g., Sacral Pressure Ulcers. Disadvantages None Change Frequency Every 3-5 days. Peel back dressing and assess wound with assessment.
Xeroform Manufacturer Kendall Available sizes 4X4, Roll Product Classification Petrolatum Description Sterile dressing composed of 3 Bismuth tribromophenate in a petrolatum blend on fine mesh gauze Indications for Usage Superficial partial thickness wounds, burns, skin graft sites. Disadvantages May become dry and adherent to wound bed. Allergic reaction to bismuth. Change Frequency Every 12 -24 hours.
Antifungal InterDry AG Manufacturer Coloplast Available sizes Roll Product Classification Antifungal ordered by APN / CWOCN Description A skin fold management system designed to manage moisture, odor and inflammation in skin folds and other skin-to-skin contact areas. A polyester textile impregnated with silver complex, InterDry Ag provides effective antimicrobial action for up to five days and improves the symptoms associated with intertrigo maceration, denudement, inflammation, and satellite lesions. Product works by wicking moisture away to keep skin dry and provides a friction reducing surface to reduce the risk of skin tears and pressure ulcers. Indications for Usage Superficial partial thickness wounds, burns, skin graft sites. Disadvantages May be dislodged during ambulation. Change Frequency 5 days
See Dressings/Topical Agent Grid
Mepilex Ag Manufacturer MÖLNLYCKE Available sizes APN / CWOCN order Product Classification Antimicrobial Description combines the unique features of Safetac technology with the bacteria reducing power of silver. Works quickly, inactivating wound pathogens within 30 minutes and for up to 7 days. At dressing removal, does not stick to the wound or strip surrounding skin, minimizing patient pain and wound trauma. Indications for use An antimicrobial soft silicone foam dressing designed for management of low to moderately colonized exuding wounds such as leg and foot ulcers, pressure ulcers and partial thickness burns. Disadvantages Do not use on patients with a known sensitivity to silver or during radiation treatment or radiologic examinations e.g. X-ray, ultrasound, diathermy or Magnetic Resonance Imaging. Do not use together with oxidising agents such as hypochlorite solutions or hydrogen peroxide.
AQUACEL Ag Manufacturer ConvaTec Available sizes APN / CWOCN order Product Classification Antimicrobial Description incorporates silver into Hydrofiber Technology resulting in gelling of the dressing with the broad-spectrum antimicrobial properties of ionic silver (Ag). Indications for Usage a primary dressing indicated for use on moderately and highly exuding chronic and acute wounds where there is an infection or an increased risk of infection. Supports wound healing by providing a moist wound healing environment provides sustained antimicrobial activity for up to 7 days. Disadvantages Do not use on patients with a known sensitivity to silver. Gelatinous in wound and under secondary dressing.
AllKare Protective Barrier Wipe Manufacturer Convatec Available sizes 1x1 wipe Product Classification Skin sealant Description Non water soluble clear, co-polymer protective barrier wipe Indications for Usage Protects periwound tissue from injury and maceration. Can be used under tape or adhesive products to increase adherence and protect skin Disadvantages Pain if tissue is denuded. Change Frequency Daily or with dressing changes.
Stomahesive wafers Manufacturer ConvaTec Available sizes 4X4 and 8 x 8 Product Classification Skin Barrier Wafer Description a pectin based wafer. Indications for Usage Skin protection from wound ostomy and eflfuent drainage. As a periwound skin barrier / window on which to apply tape or Montgomery straps to protect against skin stripping. Disadvantages May accelerate skin yeast if present due to occlusive nature. Change Frequency Weekly and PRN barrier erosion or yeast development.
Petrolatum and SensiCare Protective Barrier Manufacturer ConvaTec Product Classification Moisture barrier Description Moisture barrier Indications for Usage repels stool/ urine, assists in preventing breakdown, soothes and protects skin. After cleansing, place thin layer over exposed perineal area. Remove excess Disadvantages Product not to be completely scrubbed off skin. Change Frequency PRN incontinence
Weep-No-More Suction Dressing
2 PC 5214
  • General Information A Weep-No-More (WNM) suction
    dressing may be applied to adult patients with
    weeping or draining sites to facilitate
    measurement of drainage and/or prevent skin
    maceration from excessive drainage.
  • Weep-No-More dressings may be placed over wounds,
    incisions, puncture sites, and around drains or
    sites that cannot be adequately managed with
    conventional dressings.
  • Other sterile tubes may be used for drainage
    instead of suction catheters
  • A physician order is required for WNM suction
    dressings over a surgical incision and/or wound.
    Dressings over these sites are changed every
    24 hours in order to assess surgical
    incision/wound characteristics.
  • WNM dressings over non-surgical sites are changed
    every 72 hours and PRN.
  • Sterile dressings and catheters are used for each
    WNM dressing change.
  • Cleanse the weeping/draining site as indicated
    and prep skin surrounding weeping site with
    liquid film barrier wipe.
  • Using aseptic technique
  • Cover weeping site with a 4x4 folded sterile
  • Place a sterile 14 FR suction catheter or tube
    between folded gauze with the gauze always placed
    closest to the wound/ draining site.
  • The suction catheter or tube lays on top of the
    gauze to prevent direct suction being applied to
    the site.
  • Cover with Tegaderm Transparent Film Larger
    areas may require more than one gauze or
    Tegaderm. Smaller areas, such as a puncture
    site, may require 2x2 size gauze.

Suction catheter or tubing
Folded 4 x4 gauze
  • Tegaderm
  • Gauze Suction
    Site most vulnerable to leaking
  • Place Tegaderm film dressing over gauze and
    suction catheter. A gauze layer rests between the
    suction catheter and the Tegaderm dressing.
  • Wipe Tegaderm edges with protective film barrier
    wipe to improve dressing adherence. The site most
    vulnerable to leaking is the area where the
    suction catheter exits the dressing. Prep this
    area well with protective film barrier wipe and
    patch with Tegaderm PRN.
  • Connect suction catheter to wall suction. Only a
    very small amount of wall suction pressure is
    required to facilitate WNM dressing drainage. Set
    suction on lowest setting necessary to drain
    dressing. Dressing should contract with suction
  • If no contraction is noted, an air leak is
    present in the dressing. Assess for adhesion
    around suction catheter and for edges not covered
    well by Tegaderm. WNM dressing will not drain
    until gauze is saturated with drainage.
  • Reassess need for continuing WNM dressings over
    sites that have not drained for approximately 12
  • To prevent skin breakdown from daily Tegaderm
    dressing removal or long-term WNM use, window
    with Stomahesive hydrocolloid dressing.
    Stomahesive is less expensive to use than
    Duoderm and transparent film pulls off easily
    from the Stomahesive surface
  • Stomahesive
  • Tegaderm

Weep-No-More Suction Dressing
2 PC 5214

Management of Skin Surrounding Wounds
  • The skin and tissue surrounding a wound is called
    peri-wound skin.
  • The goals of treating peri-wound skin are to
  • Maintain skin integrity
  • Prevent further breakdown of irritated skin.
  • Promote healing of denuded areas.
  • Assess and document peri-wound skin condition
    with each dressing change.
  • Select dressing material that will keep the wound
    bed moist and the surrounding intact skin dry.
    Protect periwound tissue with protective barrier
  • Rashes and induration are abnormal findings and
    necessitate a consult to the APN/ CWOCN / Wound
    Care Specialist. Never cover a rash with an
    occlusive dressing e.g. Duoderm, or Stomahesive.
  • Intact reddened or painful peri-wound skin
    indicates possible cellulitis or trauma from tape
  • Consult APN / CWOCN / Wound Specialist for
    further assessment
  • Avoid adhesive tape, excessive heat or enzymatic
    product contact with periwound area.
  • Protect skin. Consider use of products such as
    protective barrier wipe, transparent film, or
    Stomahesive and Montgomery straps.


Peri-wound Skin Flow Chart
RN to ASSESS and DOCUMENT periwound skin
Skin Intact
Skin Broken
Protect and reassess
Do not cover with an occlusive dressing
Stomahesive wafer
Moisture Barrier Hydrocolloid
Consult to R/O Infection AVOID Tape Prevent
Antifungal Agent
These flow sheets do not represent the full scope
of care Refer to APN / CWOCN / Wound Care
Specialist when in doubt.

Management of Dressing Attachment
  • The goal of attaching a dressing is to maintain
    healthy skin, stabilize the dressing, and/ or
    protect skin from further deterioration.
  • Adherent dressings
  • Tape removal is the major cause of peri-wound
    trauma. Avoid tape usage whenever possible. If
    tape is used, protect skin beneath tape with a
    protective barrier wipe (not alcohol wipe).
  • For non-intact skin, use a barrier wafer
    (Stomahesive) under tape.
  • Use Stomahesive wafer under Montgomery straps to
    avoid repeated tape removal/skin stripping.
  • Non-adherent dressings
  • For body sites that do not tolerate adherent
    dressings, use roll gauze, stretch netting,
    tubular stockinette, Mepilex or stretch net
    panties depending on body location of the wound.


Dressing Attachment Flow Chart
RN TO ASSESS skin condition around wound
Non-adherent Dressing
Adherent dressing
Assess body location
Intact Skin
Non-intact Skin
Head,arm, foot, or leg
Groin, perineal, suprapubic areas
Stomahesive barrier wafer
Protective Barrier Wipe
Paper tape Clear tape Silk tape Montgomery Straps
Net panties
Kerlix/ Kling gauze Stretch netting, Mepilex,
Tubular Stockinette
Stretch netting Tubular Stockinette
These flow sheets do not represent the full scope
of care Refer to APN / CWOCN / Wound Care
Specialist when in doubt.

  • 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.