Skin and Wound Care

1

Skin and Wound Care Diabetic Foot, Rashes,
IAD Section 4 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 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
  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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Diabetic Foot Ulcer

• World Health Organization definition
• The foot of a diabetic that has the potential
  risk of pathologic consequences, including
  infection, ulceration, and/or destruction of deep
  tissues associated with neurologic abnormalities,
  various degrees of peripheral vascular disease,
  and/or metabolic complications in the lower
  limb.
• Patients most likely to have a foot ulcer
• Long standing diabetes
• Insulin dependant
• Smokers
• Common complication
• 15 develop foot ulcers
• Prevalence 4-10
• ALOS infected/ischemic
• 59 longer than diabetic patients without ulcers
  
• 14-20 require amputation
• Precursor to 85 amputation in diabetic patients

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Diabetic Foot

• Risk Factors
• Peripheral Neuropathy
• Primary factor
• Autonomic neuropathy
• Structural abnormality
• Limited joint mobility
• Foot deformities
• Abnormal pressures
• Minor trauma
• Peripheral Vascular Disease
• Previous ulcers
• Previous amputations
• Assessment and Treatment
• Ensure podiatry consult
• Assess for pedal pulse or Doppler signal
• Blood glucose in target range
• Educate patient regarding prevention strategies
• Check feet daily (use mirror) lesions, redness,
  blisters

Charcot Joint
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Leg Ulcers

• 80-90 of all leg ulcers are vascular in nature
  with the largest number arising from venous
  insufficiency.
• Cleanse leg ulcer with normal saline to remove
  wound debris before assessing ulcer.
• Assess leg for venous versus arterial ulcers
• VENOUS characteristics ARTERIAL
  characteristics
• Warm foot, edema Foot cool or cold
• Brawny discoloration Shiny, dry, pale skin,
  nail deformities
• Some pain when foot dependent Pain with
  elevation
• Pain relieved with elevation Absence of leg
  hair
• May be large size Usually small size
• Usually above ankle on medial side May be
  below ankle, on toes or
• May be granulating pressure area(s)
• Ulcer base moist Elevation pallor,
  dependent rubor
• Slow
  capillary refill Ulcer base dry
• Palpate foot and leg pulses. If pulses are
  absent or an arterial ulcer is suspected, consult
  physician.

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Leg Ulcer Dressing Flow Chart
RN TO ASSESS Foot and Leg PULSES / Doppler
Signals
Pulse / Doppler Signal Present
Pulse / Doppler Signal Absent
INTACT SKIN or HEALED ULCER
BROKEN SKIN
Consult physician
CLEANSING Normal Hygiene Soap Warm H20
CLEANSING Normal Saline
PROTECTION Prevent trauma Refer to Skin Care Flow
Chart
ASSESS Ulcer Color, Size, Depth, Necrosis
NECROTIC TISSUE Present
ASSESS Periulcer skin Refer to Peri-wound Skin
Flow Chart
Clean No Necrotic Tissue
CHOOSE method to Attach Cover Dressing Avoid
Tape
Consult APN / CWOCN or Physician
CHOOSE Dressing
Consult APN / CWOCN
Shallow Ulcer
Deep Ulcer
DRAINAGE
DRAINAGE
HEAVY Dry Gauze,Alginate CONSULT APN / CWOCN
HEAVY Dry Gauze, Alginate Cover with Gauze or
ABD
MODERATE Moist Saline Gauze, Hydrogel Gauze
MODERATE Moist Saline Gauze, Hydrogel Gauze Cover
with dry gauze or ABD
NONE TO MINIMAL Hydrocolloid, Hydrogel
Gauze, Moist Saline Gauze
NONE TO MINIMAL Moist Saline Gauze, Hydrogel
Gauze
These flow sheets do not represent the full scope
of care For evaluation of Compression therapy,
consult APN / CWOCN / Wound Care Specialist .
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Surgical Wounds

• Cleanse wounds with normal saline with each
  dressing change.
• Assess wound for color, size, depth, drainage,
  necrosis, edges and peri-wound skin.
• Necrotic tissue is nonviable and needs to be
  removed. Consult for debridement options.
• Deep surgical wounds may require three layers of
  dressings. See Dressing Section of module for
  details.
• Contact layer Dressings in contact with the
  wound bed should maintain tissue moisture.
• Fill layer Additional dressing materials are
  placed on top of the contact layer to loosely
  fill dead space.
• Cover layer Covering is dependent on wound
  location and amount
• of wound drainage.
• Shallow wounds may require only one layer of
  dressing that maintains moisture and covers the
  wound.
• Cardiothoracic patients with sternal incisions
• Cover until healed.
• Cover while patient remains mechanically
  ventilated and/or has a tracheostomy.
• Do not change dressing for 48 hours
  postoperatively.
• Cleanse with sterile normal saline.
• Bariatric surgery patients are educated

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Surgical Wound Flow Chart
RN TO ASSESS SURGICAL WOUND
Drains in Place
Open Incision
Closed Incision
Consult
Cleanse with Normal Saline
Open to Air After Initial Dressing Removed
Assess Wound Color, Size, Depth,
Drainage, Necrosis and Peri-wound Tissue
Use Normal Hygiene for Cleansing
Necrotic Tissue Consult
Non-necrotic Tissue
Monitor for Redness, Pain, Swelling, Drainage
Choose Dressing to loosely fill wound
Choose Dressing to Cover Wound
For Cardiothoracic sternal incisions 1.
Cover until healed 2. Cover while mechanically
ventilated and/or while
pt has a tracheostomy 3. Do not change for 48
hrs stop. 4. Cleanse with sterile normal
saline at each drsing change.
Deep Wound
Shallow Wound
DRAINAGE
DRAINAGE
DRAINAGE
HEAVY Dry Gauze, Alginate Wound Pouch
HEAVY Unlikely Gauze or ABD, Consult
HEAVY Gauze or ABD Consult
MODERATE Damp Saline Gauze, Hydrogel Gauze
MODERATE Damp Saline Gauze, Hydrogel Gauze Plain
NuGauze Strips
MODERATE Gauze or ABD
NONE TO MINIMAL Damp Saline Gauze, Hydrogel
Gauze Hydrocolloid Transparent Film
NONE TO MINIMAL Damp Saline Gauze Hydrogel Gauze
NONE TO MINIMAL Gauze, Transparent Film

• 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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Herpes Simplex

• Uniform grouped dome-shaped pustule rapidly form
  on a erythematous base, umbilicate, subsequently
  erode,and crust
• More numerous and scattered with initial
  infection.
• May resemble pressure ulcers when pustule merge.
  
• Immunocompromised are at increased risk.
• Do not cover with hydrocolloid dressings or any
  dressing / cream that retains moisture.
• Area is left open to air.
• Culture is the most definitive method
• Sample lesions in the vesicular or early
  ulcerative stage
• Vesicles are punctured and a swab is then rubbed
  onto the base of the lesion
• Treatment is dependent upon size and
  dissemination of lesions
• Topical antiviral
• IV antiviral
• Progression from pustules to umbilicated pustules
  to crusts

Pustule
Umbilicated Pustules
Crusts
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Fungal Rash

• Fungal rash presents as a pruritic area of solid
  discoloration, associated with
• Redness or darker pigmentation
• Extrafollicular red pustules
• Maceration with white satellite lesions in the
  periphery
• Burning sensation
• Rash is frequently caused by candida albicans, a
  skin flora that proliferates in a warm, moist
  dark environment. Predisposing factors include
• Diabetes
• Incontinence
• Damp dressings
• Antibiotic therapy
• Steroids
• Immunosuppression
• Use of oral contraceptives
• Fungal infection is typically seen under
  
  pendulous breasts,
  overhanging abdominal folds,
  
  axilla,
  between toes, and in the perineal area.
• Actions
• Establish a toilet program
• Reduce effects of moisture / incontinence
• Cleanse perineal area with perineal cleanser or
  normal saline with each incidence of
  incontinence.

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Incontinence Associated Dermatitis

• Incontinence associated dermatitis (IAD) is
  inflammation of the surface of the skin with
  redness edema and in some cases bullae or
  vesicles. Eroded or denuded areas of superficial
  skin layers are generally associated with severe
  cases. Fungal rash is a common complication.
• Three principles areas contributing to IAD
  tissue tolerance, perineal environment, and
  toileting ability. Aging skin is particularly
  vulnerable to damage from long term exposure to
  urine and stool.
• The use of diapers has been identified as a
  primary cause of IAD. Diapers alter the
  microflora by increasing the number of coagulase
  negative staphlococci. Skin covered by a diaper
  has a higher pH than one exposed to air thereby
  increasing the possibility for IAD. Do not use
  closed diapers on patients with IAD.
• Actions
• Routine use of skin protectants such as barrier
  creams and ointments e.g., Petrolatum,
  Sensicare, Xenaderm.
• Cleanse denuded skin with saline.
• Establish a toileting program when feasible.
• Avoid scrubbing and using rough towels /
  washcloths over at risk areas.
• Avoid using diapers in patients
• Educate caregivers
• Begin aggressive treatment for underlying
  incontinence.
• Treat fungal rash when present.

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Intertrigo

• Intertrigo occurs in between opposed skin
  surfaces. Characterized by erythema, maceration,
  burning, itching, and sometimes erosions,
  fissures, exudate, and secondary infection. Risk
  factors are thought to be obesity and poor
  hygiene. Diabetes may be associated with its
  development.
• Treatment
• Ordered by APN
• InterDry Ag is a fabric with Antimicrobial Silver
  Complex that is placed between skin folds and
  other skin to skin areas. It is designed to
  manage moisture, odor and inflammation.
• Positioned between folds with at least 1 inch
  exposed at either end to allow for moisture
  evaporation.
• Left in place for up to 5 days unless grossly
  soiled.

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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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15
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

16
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.

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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.

18
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

19
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.

20
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.

21
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22

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