You are on page 1of 23

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

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 1
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
Debra Gignac MSN, RN, CS
Sue Sirianni MSN, RN, CCRN
Toni Renaud-Tessier MSN, RN, CS
Evelyn Lee BSN, RN, CETN, CRNI
Mary Sieggreen MSN, RN, CS, CNP
Patricia Clark MSN, RN, CS, CCRN
Bernice Huck RN, CETN

In 2005, the authors acknowledge the following staff for assisting with reviewing and revising this learning module:
Donna Bednarski, MSN, APRN,BC, CNN, CNP
Carole Bauer BSN, RN, OCN, CWOCN
Sue Sirianni MSN, RN, CCRN
Evelyn Lee MSN, RN, CWOCN
Mary Sieggreen MSN, RN, CS, CNP
Bernice Huck RN, BSN, CPN, WOCN
Carolyn J. Stockwell, MSN, RN, ANP, CCM

In 2009 the DMC module was revised by the following staff:


Maria Teresa Palleschi ACNS-BC CCRN
Laura Harmon ACNP-BC, CCRN, CWOCN
Evelyn Lee MSN, RN, CWOCN
Diana LaBumbard ACNP-BC, CCRN
Bernice Huck BSN, CWOCN
Carolyn J. Stockwell, ANP-BC, CNP, CCM
Mary Sieggreen ACNS-BC, CNP CVN
Pauline Kulwicki ACNS-BC CNP CNRN

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 2
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.

3. Apply DMC standard skin and wound management


principles.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 3
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.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 4
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.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 5
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.

Avoid multiple layers of linen on specialty beds and surfaces


because they interfere with the reduction / redistribution of
pressure.

Consult APN / CWOCN or dermatology for rashes.


DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 6
Skin Care
Flow Chart
RN TO
ASSESS SKIN

Trunk and Weeping Skin Perineal/ Perianal Care


Extremity or Rash

Irritated
Dry or Fragile Consult
Normal Intact Normal Intact Skin Unbroken Skin Denuded / IAD*
Skin

CLEANSING CLEANSING CLEANSING


CLEANSING CLEANSING
Normal Hygiene Normal Hygiene Normal Saline
Water Only Normal Saline
Soap and Water Soap and Water or Cleanser

MOISTURIZING MOISTURIZING
MOISTURIZING MOISTURIZING MOISTURIZING
Lotion or Lotion or
Unnecessary Unnecessary Unnecessary
Petrolatum Petrolatum

PROTECTION PROTECTION PROTECTION PROTECTION PROTECTION


Prevent Trauma Prevent Trauma Prevent Trauma Petrolatum Barrier Paste
Avoid Massage Barrier Paste Zinc Oxide
Avoid Tape/
Adhesive Agents
*Incontinence Associated Dermatitis

These flow sheets do not represent the full scope of care


Refer to APN / CWOCN / Wound Care Specialist when in doubt.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 7
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.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 8
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

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 9
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

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 10
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
normalDMCsaline solution
Advanced Wound after
Care and Specialty 24 hours.
Bed Committee DMC 2009 11
Wound Assessment
and Documentation

SIZE AND DEPTH SURROUNDING SKIN


Measure or trace Assess for color, moisture, suppleness
wound area. WOUND BED
Measure depth Assess for
WOUND necrotic and
granulation
WOUND EDGES
ASSESSMENT tissue,
fibrin slough,
Assess for undermining
exudate
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).

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 12
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.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 13
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.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 14
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.
5
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 10 5 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.
Debridement, chemical: topical application of biologic enzymes to break down devitalized tissue,
e.g., Accuzyme, Santyl (Collagenase).The following definitions apply to the Skin and Wound Care
Flow Charts:
Debridement, mechanical: removal of foreign material and devitalized or contaminated tissue
from a wound by physical forces rather than by chemical (enzymatic) or natural (autolytic) forces.
Examples are scrubbing, wet-to-dry dressings, wound irrigation, and whirlpool.
Debridement, sharp: removal of foreign matter or devitalized tissue by a sharp instrument such
as a scalpel. Laser debridement is also considered a type of sharp debridement.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 15
Definitions

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
Contraindicated for third-degree burns and not recommended for infected wounds.
MayDMCbeAdvanced
used byWound Carecare
wound and Specialty Bed Committee
consultants DMC 2009
to promote autolysis in some patients with eschar. 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.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 17
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, H&P or
consultative form.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 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
P
Periwound: area surrounding a wound. Assessed for signs of inflammation or maceration.

Pressure Ulcer: localized injury to the skin and/or underlying tissue usually over a bony
prominence or beneath a medical device, as a result of pressure, or pressure in combination
with shear and/or friction. Pressure ulcers are staged according to extent of tissue damage or
classified as DTI or unstageable.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 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.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 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, H&P 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 > 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.

Tissue: Eschar: dry, thick, leathery, dead tissue

Tissue: Necrotic: devitalized or dead tissue


Tissue: Slough: moist, dead tissue.

Weep-No-More (WNM) Suction Dressing: an occlusive suction dressing using a


folded gauze dressing which covers a catheter or tubing enclosed within a transparent
film. May be placed over wounds and incisions with a physicians order and changed
at least every 24 hours. May also be ordered by the RN over non-surgical sites, e.g.,
puncture sites and changed at least every 72 hours. May be used over sites that
cannot be adequately managed with conventional dressings..

Wound Care as Ordered: refers to RN generated orders for treatment based on DMC
Skin and Wound Care Flowcharts.

Wound irrigation: cleansing the wound by flushing with fluid e.g., 250 mL sterile
normal saline under pressure.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 21
Bibliography

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 & Wilkins:New 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.
Bergstrom N, Demuth P & Braden B, (1987) A clinical trial of the Braden Scale for Predicting Pressure Sore Risk.
Nursing Clinics of North America , 22 (2) 417-422.
Braden, B. & Maklebust, J. (2005). Preventing pressure ulcers with the Braden Scale: An update on this easy-to-use
tool that assesses a patients risk. American Journal of Nursing,6, 70-72.
Bryant, R.A. & Nix,D.P. (2007) Acute & chronic wounds: Current management concepts. 3rd ed. St. Louis, MO,
Mosby.
Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes to the Hospital Inpatient
Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician
Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding
Financial Relationships Between Hospitals and Physicians; Proposed Rule. Federal Register.
2008;73(84):2355259. Available at: http://edocket.access. gpo.gov/2008/pdf/08-1135.pdf.
Centers for Medicare & Medicaid Services. Proposed Fiscal Year 2009 Payment, Policy Changes for Inpatient Stays in
General Acute Care Hospitals. Available at: http://www.cms.hhs.gov/ Accessed May 13, 2008.
Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes to the Hospital Inpatient
Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician
Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding
Financial Relationships Between
Cochrane Collaboration, 2008 Support surfaces for pressure ulcer prevention (Review). JohnWiley & Sons, Ltd.

Hospitals and Physicians; Proposed Rule. Federal Register. 2008;73(84):23550. Available at: ttp://edocket.access.gpo.
gov/2008/pdf/08-1135.pdf.

Centers for Medicare & Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):4713048175.

Consortium for Spinal Cord Medicine. (2000) Pressure ulcer prevention and treatment following spinal cord injury: a
clinical practice guideline for health care professionals. Available at www.pva.org. Washington, D.C.: Paralyzed
Veterans of America.
Doughty D. (2000) Urinary and fecal incontinence: nursing management. 2nd ed. St. Louis, MO. Mosby

Gray, M. (2004). Preventing and managing perineal dermatitis: A shared goal for wound and continence care. Journal of
Wound Ostomy & Continence Nursing 31(1)Suppl.
Hess CT (2008) Skin & wound care: Clinical guide. 6th ed. Ambler,PA: Lippincott Williams & Wilkins.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 22
Bibliography

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.

Whittington, K., & Briones, R.(2004). National prevalence and incidence study: 6-year sequential acute care data.
Advances in Skin &
Wound Care, 17, 4904.

Wound,Ostomy and Continence Nurses Society.(2002) Guidelines for Management of Wounds in Patients
with Lower-Extremity Arterial Disease. Glenview,IL.
.

DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 23