Skin and Wound Care

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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

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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

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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.

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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.

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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.

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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.

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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.
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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.

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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

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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

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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.

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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).

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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.

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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.

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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.

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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

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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.

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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
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