Title: Skin and Wound Care
1Skin and Wound Care Dressings Section 5 of 7
RN and LPN Self-learning Module
DMC Adv Wound Care and Specialty Bed Committee
2Acknowledgements
- 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
3Purposes 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.
4Dressings
- 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
characteristics. - 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
moist. - 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.
5 Dressings
- Protective Barrier Wipe
- Protective barrier wipe provide a protective
coating on unbroken skin after they dry - Provide some degree of protection from mechanical
injury - Most liquid film barriers contain alcohol and
cause stinging on contact with denuded/fragile
skin - Transparent Adhesive Dressings 2 PC 5213
- Semi permeable, sterile thin film
- Maintains a moist environment
- Non-absorptive
- Assists in promoting autolysis of devitalized
tissue - Creates a second skin and protects against
friction - 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
tunneling - Blisters that are growing in size. Site will
leak and require removal causing more tissue
damage. - Heels, especially those with eschar
-
- Hydrocolloid Dressings 2 PC 5211
6Dressings
- Hydrogels and hydrogel impregnated gauze 2 PC
5212 - 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
tissue - 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
hemostasis
7Dressings
- Silver Dressings Ordered by Wound Care
Specialists - 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
moisture - 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
8Dressings/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.
9See 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
10See 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
11Weep-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
gauze. - 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
12-
-
- Tegaderm
- Gauze Suction
Site most vulnerable to leaking
catheter - 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
application. - 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
hours. - 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
13Management 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
wipe. - 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
removal. - 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.
14 Peri-wound Skin Flow Chart
RN to ASSESS and DOCUMENT periwound skin
Skin Intact
Skin Broken
Protect and reassess
REDDENED or BLISTERED PERI WOUNDSKIN
RASH
WARM TENDER INDURATED SKIN
MACERATED SKIN
DENUDED SKIN
FUNGAL / YEAST INFECTION
Do not cover with an occlusive dressing
CONSULT
Consult
Stomahesive wafer
Moisture Barrier Hydrocolloid
Consult to R/O Infection AVOID Tape Prevent
Trauma
CONSULT
Antifungal Agent
These flow sheets do not represent the full scope
of care Refer to APN / CWOCN / Wound Care
Specialist when in doubt.
15Management 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.
16Dressing 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
Trunk
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.
17Definitions
- DEFINITIONS
- The following definitions apply to the Skin and
Wound Care Flow Charts - A
- Abscess a circumscribed collection of pus that
forms in tissue as a result of acute or chronic
localized infection. It is associated with
tissue destruction and frequently swelling. - Acute wounds those likely to heal in the
expected time frame, with no local or general
factor delaying healing. Includes burns,
split-skin donor grafts, skin graft donor site,
sacrococcygeal cysts, bites, frostbites, deep
dermabrasions, and postoperative-guided tissue
regeneration. - B
- Bariatric Term applying to care, prevention,
control and treatment of obesity. - Basic Wound Care RN identifies and orders
treatment plan based on DMC Skin and Wound Care
Flowcharts. - Blister elevated fluid filled lesions caused by
pressure, frictions, and viral, fungal, or
bacterial infections. A blister greater than 1
cm in diameter is a bulla and blisters less than
1 cm is a vesicle. - Bottoming Out determined by the caregiver
placing an outstretched hand (palm up) under a
mattress overlay, below the part of the body at
risk for ulcer formation. If the caregiver can
feel less than one inch of support material
between the caregivers hand and the patients
body at this site, the patient has bottomed
out. Reinflation of the mattress overlay is
required. - C
- Cellulitis inflammation of cellular or
connective tissue. Inflammation may be
diminished or absent in immunosuppressed
individuals. - Chronic wounds those expected to take more than
4 to 6 weeks to heal because of 1 or more factors
delaying healing, including venous leg ulcers,
pressure ulcers, diabetic foot ulcers, extended
burns, and amputation wounds. - Colonized presence of bacteria that causes no
local or systemic signs or symptoms. - Community Acquired Pressure Ulcer Any pressure
ulcer that is identified on admission and
documented in the Adult or Pediatric Admission
Assessment as being present on admission (POA). - Contaminated containing bacteria, other
microorganisms, or foreign material. Term
usually refers to bacterial contamination.
Wounds with bacterial counts of 105 or fewer
organisms per gram of tissue are generally
considered contaminated those with higher counts
are generally considered infected. - Cytotoxic Agents solutions with destructive
action on all cells, including healthy ones. May
be used by APN / CWOCN to cleanse wounds for
defined periods of time. Examples of cytotoxic
agents include Betadine, Dakins Peroxide, and
CaraKlenz. - D
- Debridement, autolytic disintegration or
liquefaction of tissue or cells self-digestion
of necrotic tissue.
5
18Definitions
- 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
19Definitions
- 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.
20Definitions
- 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.
21Definitions
- 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
22Definitions
- 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.
23Definitions
- 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.
24Bibliography
- Ayello, E.A. Braden, B.J. (2001). Why is
pressure ulcer risk assessment so important?
Nursing 2001 31(11) 75-79. - Ayello, E.A Lyder, C. (2007) Protecting
patients from harm preventing pressure ulcers.
Nursing 2007 Lippincott, Williams Wilkins New
York. 36-40 - Baharestani,M. (2007). An Ovedrview of neonatal
and pediatric wound care knowledge and
considerations. OstomyWoundManagement 53(6)
34-55. - Baranoski, S Ayello,E. (2003) Wound Care
Essentials Practice Principles Lippincott,
Williams WilkinsNew York - Bates-Jensen BM, Ovington LG. (2007). Management
of exudate and infection. In Sussman C,
Bates-Jensen BM,(Eds.), Wound Care A
Collaborative Practice Manual for Health
Professionals. 3rd ed. Baltimore, MD Lippincott
Williams Wilkins. -
- Bergstrom N, Bennett MA, Carlson CE, et al.
(1994) Treatment of Pressure Ulcers. Clinical
Practice Guideline, No. 15. Rockville MD U.S.
Department of Health and Human Services. Public
Health Service, Agency for Health Care Policy
and Research. AHCPR Pub. No. 95-0652. - Bergstrom N, Braden B, Kemp M, Champagne M , Ruby
E (1998). Predicting pressure ulcer risk a
multisite study of the predictive validity of the
Braden Scale. Nursing Research 47 (5) 261-9. - Bergstrom N, Braden B, Laguzza A, Holman V (1987)
The Braden Scale for Predicting Pressure Sore
Risk. Nursing Research, 36, 205-210.
25Bibliography
- Kinetic Concepts Inc. (2007). V.A.C. therapy
clinical guidelines A reference for
clinicians.San Antonio,Texas. - Kinetic Concepts Inc.(2006) Info V.A.C. User
manual. San Antonio, Texas - Krasner, DL Rodeheaver, GT Sibbald, RG. (eds).
(2001). Chronic wound care a clinical source
book for healthcare professionals (3rd ed.).
Wayne, PA HMP Communications. - Maklebust, J. Sieggreen, M. (2001). Pressure
ulcers guidelines for prevention and management,
(3rd ed.). Springhouse PA Springhouse
Corporation. - Maklebust, J. (2005). Pressure ulcers The great
insult. In M. Lorusso (Ed.), Nursing Clinics of
North America,40(2) (365-89).Pennsylvania W.B.
Saunders. - Maklebust, J.,Sieggreen, M., Sidor, D., Gerlach,
M., Bauer, C., Anderson, C. (2005)
Computer-based testing of the Braden Scale for
Predicting Pressure Sore Risk. Ostomy Wound
Management, 51(4) 40-42,44,46. - Panel for the Prediction and Prevention of
Pressure Ulcers in Adults (1992). Pressure
Ulcers in Adults Prediction and Prevention.
Clinical Practice Guideline, No. 3. AHCPR
Publication No. 92-0047. Rockville, MD Agency
for Health Care Policy and Research, Public
Health Service, US Department of Health and Human
Services. - Sussman, C. Bates-Jensen, B. (2007). Wound
care a collaborative practice manual for
healthcare professionals. 3rd ed. Baltimore,MD
Lippincott Williams Wilkins. -
- Van Rijswijk, L., Braden, B.J. (1999). Pressure
ulcer patient and wound asssessment an AHCPR
clinical practice guideline update. Ostomy Wound
Management, 45 (1A Suppl) 56s-67s.