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THE DIFFERENT
TYPES OF WOUNDS
Contents
The Different Types of Wounds . . . . . . . . . . . . . . . . . . . 2
Acute Versus Chronic Wounds. . . . . . . . . . . . . . . . . . . . 2
Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Lower Extremity Wounds. . . . . . . . . . . . . . . . . . . . . . . . 4
Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Suspected Deep Tissue Injury . . . . . . . . . . . . . . . . . . . 11
Kennedy Terminal Ulcers . . . . . . . . . . . . . . . . . . . . . . . 13
Surgical Site Incision . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Skin Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1
The Different Types of Wounds
In the past, standard practice did not differentiate between the
various types of wounds and consider how multiple factors
might affect wound healing. In fact, we frequently spent more
time worrying about the “hole” in the patient (the wound)
than assessing the “whole” patient. Current research, however,
illustrates how important it is to carefully assess the wound
and identify the correct treatment so we do not cause further
harm; in other words, to work smart from the beginning.
A wound will most likely require different treatments as it
progresses. As the drainage slows, for example, the dressing
choice will no longer be one that absorbs exudate, but
possibly one that donates or retains moisture.
Worth
remembering ...
Any patient that
spends a good
deal of time
sitting in a chair,
wheelchair, or
lying in bed is at
risk for developing
pressure ulcers.
When assessing the wound and the patient, the best step
to make first is determining the etiology of the wound.
Recognizing factors that affect the patient’s ability to heal
can mean the difference between a slow-healing wound
and a completely closed wound.
Acute Versus Chronic Wounds
Acute wounds heal uneventfully and within an expected
time frame. However, complications can develop quickly
in some instances such as surgical incisions, gunshot
wounds or abrasions and must be acted upon promptly.
Chronic wounds do not heal in the standard time frame and
may linger for weeks, months or even years. There are relatively few real complications, other than slow healing. Some
chronic wounds are venous leg ulcers, arterial leg ulcers and
neuropathic or diabetic ulcers and those caused by mechanical
injury such as pressure ulcers. Usually, chronic wounds occur
in an individual with an underlying pathology that prevents
normal wound healing.
Pressure Ulcers
Pressure ulcers, also known as pressure wounds,
bedsores, or decubiti are described as a localized area
of tissue necrosis (death) that results from the compression
2
of soft tissue between a bony area and a surface. Blood
supply to the tissue is decreased, which leads to vascular
compromise, tissue anoxia (lack of oxygen), and eventually
cell death that presents as a wound.
TIPS!
Patients with just
one risk factor can
develop pressure
ulcers; therefore,
every time you
change, dress,
bathe, transfer, or
turn a patient,
check the skin.
Two forces that lead to skin breakdown are friction and
shear. Friction injuries occur when the skin moves across a
coarse surface. Most of these injuries can be avoided by using
appropriate techniques when moving patients. Voluntary and
involuntary movement by the patient can also lead to friction
injuries, especially to elbows and heels. Shear injury occurs
when the skin remains stationary and the underlying tissue
shifts. The shift reduces the blood supply to the skin that soon
results in ischemia and tissue damage. Most shear injuries can
be eliminated by proper turning and positioning.
According to the Centers for Medicare & Medicaid Services
(CMS) guidelines, “A resident at risk can develop a pressure
ulcer within two to six hours of the onset of pressure.”
Watch for a change in the temperature, feel or look of skin.
Pay attention to areas that appear different from surrounding
tissue. On darkly pigmented skin, damaged areas might look
darker or lighter, and could be red, blue or purple in color.
Look for redness that is “non-blanchable.” Healthy red areas
turn white when pressed and released, while damaged areas
are non-blanchable and remain red. Gently feel for changes
in skin temperature and be suspicious of areas that feel
spongy or harder than surrounding tissue. Check patients
from head to toe, paying special attention to bony prominences like the back of the head, ears, shoulder blades,
coccyx, elbows and heels.
Patients must be well nourished if pressure ulcer prevention
is a goal. Assist patients who are unable to feed themselves
and encourage or assist other patients to eat and drink. Keep
patients moving. Turn and reposition them at least every
two hours and encourage them to make slight adjustments
often. For individuals who cannot move by themselves,
schedule position changes and use pillows for support, if
needed. Avoid shear and friction by using the appropriate
bed linen. Do not use a blue underpad, or “chux,” to move
patients. If the patient can use their upper body to help with
movement, use a trapeze and keep their knees bent to prevent
sliding. Also use a skin lubricant, liquid skin barrier or powder.
Ensure proper elevation by maintaining the head of the bed
3
at no more than a 30-degree angle. Keep heels elevated by
placing pillows under the legs and to prevent knees and heels
from rubbing together.
Lower Extremity Wounds
Lower extremity wounds are generally divided into venous
ulcers, arterial ulcers and neuropathic/diabetic wounds.
Before treatment of any lower extremity wound begins,
circulation must be assessed.
•
•
•
•
•
•
•
Is there sufficient blood perfusion to close the wound?
Measure the ankle-brachial index (ABI) and check
the pedal pulses, color, temperature, location,
muscle wasting and the patient’s lower extremity
hair-growth pattern.
Determine if the patient has diabetes and, if so,
check the blood sugars and A1C levels.
Is there any swelling that is affected by elevation?
Are there other skin changes such as staining in
the lower part of the leg or microvaricosities?
Is there a previous history of deep venous thrombosis
(DVT) or ulcers?
Is there pain? If so, have the patient describe the pain.
Answering these questions helps determine if this wound is
a neuropathic/diabetic foot ulcer, a venous stasis problem
requiring some form of compression, or an arterial ulcer that
may need to be referred to a surgeon for evaluation.
Arterial Leg Ulcers
Arterial ulcers are also called ischemic ulcers. They are
the result of tissue ischemia due to arterial insufficiency.
These ulcers account for 5 percent to 20 percent of all leg
ulcers, and they occur at the distal (remote) end of the
arterial system. They are often seen on the tips of the toes.
When arterial blood flow is interrupted by an obstruction
or narrowing of an artery, it causes arterial insufficiency,
which can lead to arterial ulcers. Another cause of occlusion
is artherosclerosis. Arterial perfusion of the lower extremity
should be assessed with Doppler ABI, flow studies or color
scans before aggressive treatment is initiated.
4
The Different
Types of Wounds
5
Arterial
Neuropathic/Diabetic
Definition
Wounds caused by ischemia,
which is related to the presence of arterial occlusive
disease.
Neuropathy is often associated
with diabetes. Wounds result from
damage to the autonomic, sensory
or motor nerves and have an arterial perfusion deficit.
Location
The distal aspect of arterial
circulation can be anywhere
on the leg, including the toes
and feet.
Can be anywhere on the lower
extremity, usually located on the
foot.
Wound
Margin
“Punched out,” well-defined
borders
Similar to arterial wounds, usually
with a calloused edge
Wound Bed
Pale wound bed, little or no
granulation, necrotic tissue is
common
Similar to arterial wounds, usually
with a calloused edge
Wound Size
Can be small, but often increases due to lack of arterial
perfusion
Often small
Exudate
Minimal to no exudate
Similar to arterial wounds
Edema
If present, localized
Similar to arterial wounds
Limb Staining
Usually not present
Similar to arterial wounds
Ankle-Brachial
Index (ABI)
< 0.8
< 0.5 (indicates inability
to heal)
Not reliable, sometimes falsely
evaluated due to calcification
Pedal Pulses
Usually reduced or absent
Not reliable
Pain
Occurs at rest, at night, or
when the extremity is elevated
Due to neuropathy, the pain
may be absent or severe
Best Practice
• If perfusion is not adequate,
consider vascular consult
• If perfusion is adequate,
follow protocol based on
wound assessment and
characteristics
• If dry and stable, leave
eschar intact
Maintain optimal moisture
• Control diabetes, if appropriate
• Repetitive removal of callous
• Bioburden control and
prevention of systemic infection
• Remove pressure with
appropriate off-loading shoe or
other appliance
The Different
Types of Wounds
Pressure
Venous
Definition
Damage to the skin or
underlying structures as a
result of tissue compression
and inadequate perfusion.
Failure of the venous valve
function to return blood from the
lower extremities to the heart.
This causes venous congestion
and leads to venous hypertension.
Location
Usually over a bony
prominence.
Located in the gaiter area (ankle to
mid calf), it is often medial malleolus and may be circumferential.
Wound
Margin
Usually circular
Irregular shaped
Wound Bed
Can have viable or necrotic
tissue
Usually shallow, can have
viable or necrotic tissue
Wound Size
Can be very large or
very small
Usually large
Exudate
Can vary from none
to heavy
Can vary from none to heavy to
generalized weeping
Edema
Can be localized, usually not
seen
Generalized edema to lower
extremity
Limb Staining
Usually not present
Usually seen
Ankle-Brachial
Index (ABI)
N/A
> 0.8
Pedal Pulses
N/A
Usually normal or
undetectable due to edema.
Pain
Usually present, but often
undertreated
Often occurs in a dependent
position along with edema.
Best Practice
• Remove necrotic tissue
• Maintain optimal moisture
• Protect periwound skin
• Control bioburden
• Remove pressure
• Compression
• Remove necrotic tissue
• Maintain optimal moisture
• Protect periwound skin
• Control bioburden
• Ensure lower extremity
moisturization
6
Venous Leg Ulcers
Any ulcer caused by stagnation of blood due to venous
congestion or venous hypertension is known as a venous
leg ulcer. Venous ulcers require both an optimal moist
wound healing environment and edema-control measures,
typically with compression. The limb must have sufficient
arterial flow and be free from acute cellulitis or uncontrolled
congestive heart failure. Therefore, determining perfusion is
a key factor prior to applying any compression. Applying
compression inappropriately can cause significant
negative outcomes.
A venous leg ulcer is usually located mid-calf to the heel,
is medial or lateral, and can be circumferential. It is poorly
defined and often has jagged edges. The wound bed has ruddy
red granulation tissue that is usually superficial and includes
the presence of yellow fibrin. The drainage is moderate to
heavy, and edema is usually generalized to the lower extremity.
The pulse may be difficult to assess secondary to the edema.
The wound may be moderately painful, which will often
improve with a decrease in edema. Venous ulcers can occur
in patients with superficial or perforator vein disease in
addition to patients with deep vein disease. These wounds
are most common in older adults; however, they account
for 70 to 90 percent of all leg ulcers.
Neuropathic/Diabetic
DID YOU KNOW
Lymphedema is one
of the most underdiagnosed and
under-treated
conditions affecting
wound healing.
7
Neuropathy is a nerve disorder that results in lost or impaired
function in the tissues of the affected nerve fibers. It is often
associated with diabetes. Neuropathic/diabetic wounds result
from damage to the autonomic, sensory or motor nerves and
have an arterial perfusion deficit. They can be anywhere on
the lower extremity, usually located on the foot, and are called
diabetic foot ulcers.
Lymphedema
Lymphedema is one of the most under-diagnosed and
under-treated conditions affecting wound healing. There
is no known cure, but like many chronic diseases, it can be
managed successfully by patients if they are knowledgeable
of the disease and its treatment. It is estimated that up to 250
million patients worldwide currently suffer with lymphedema.
The functioning lymphatic system is comprised of lymphatic
vessels filled with lymphatic fluid, lymph nodes and organs.
Think of the lymphatics as the “back up” system to remove
fluid from the interstitial tissue when the venous system is
overwhelmed. The lymphatic vessels closely mirror the
vascular system. Its structure is similar to the venous
system, consisting of one-way intraluminal valves to
prevent reflux of lymph fluid.
The Progression of Lymphedema
® Serum proteins and water leak into the interstitial space.
® The lymphatic vessels absorb the excess fluid, now called
lymphatic fluid.
® The lymphatic fluid re-enters the blood stream through the
lymph system, the spleen, and the vena cava.
® Nearby sketetal muscles contract, placing external pressure
on the lymph channels, which propels the lymph forward.
Lymphatic dysfunction occurs from primary or secondary
causes. Primary lymphedema is caused by a structural
congenital abnormality present at birth. While many
patients show clinical signs of lymphedema when they
are young, some cases do not appear until middle age.
Secondary lymphedema has a readily identifiable source
from structural damage to the lymphatic system. This
can occur from radiation, surgery, node dissection,
obesity and burns.
Much like venous insufficiency, when there is structural
damage to the lymph channels, valvular incompetence
ensues. Subsequent fibrosis of the lymphatic vessel wall
occurs and lymph channels become clogged with protein,
thus blocking flow of fluid. This leads to lymph flow into
the dermal plexus, causing edema and marked inflammation
due to macrophage infiltration. Clinical evidence of
lymphedema is categorized in four stages.
8
Stages of Lymphedema
•
•
•
•
Stage 0: This stage is subclinical. Impaired lymph
flow exists without clinical signs.
Stage I: Soft edema that usually resolves on its own.
The patient often reports that their legs are “puffy”
after being upright for several hours, but the symptom
disappears when they lie down.
Stage II: Pitting, brawny edema. The skin tissue is
firm and no longer soft, but not yet fibrotic.
Stage III: Skin texture changes and displays “peau d’
orange.” This type of skin has the look and texture of
an orange peel with prominent, indented pores. The
epidermis forms thick scaly areas with cracks or deposits
that may eventually develop a fibrotic warty-like tissue.
Cracks and deep creases harbor bacteria and predispose
the patient to infection.
Stage III Lymphedema
Patients in lymphedema Stage II and III often have repeated
episodes of cellulitis, as the lymph system is unable to clear
bacteria from the interstitium to the lymph nodes and
spleen for their destruction. Often, the clinical hallmark of
undiagnosed lymphedema is numerous bouts of infection
or non-healing wounds in the affected area. Interstitial
fluid accumulation impairs wound healing by pressing on
the vascular system, cutting off the delivery of oxygenation
and nutrients. Local ischemia and resulting cellular waste
products cannot be removed. Should the area develop
weepy drainage, known as lymphorrhea, the proteins become
irritating to the epidermis and subsequently contribute to
a secondary infection. Other sequela associated with lymphedema includes complex regional pain syndrome, decreased
sensation, limited range of motion and deconditioning.
9
Diagnosis is made on clinical examination. A thorough history
should be taken because heart failure, DVT and other causes
of edema should be considered in the differential diagnosis.
Many patients with lower extremity lymphedema have
concomitant venous hypertension with resultant venous
insufficiency. Malignancy associated with quick onset or
rapidly progressive lymphedema should always be suspected
with unilateral lymphedema.
A physical exam focuses on palpation of the soft tissue
involved. Comparison to unaffected contralateral or adjacent
areas is important. Hard fibrotic tissue is described as lipodermatasclerosis for documentation purposes. Skin color, temperature, and the presence of weepy exudate with or without
wounds are essential to assess, document and treat.
Treatment is focused on reducing protein accumulation
and attempting to restore the flow of lymph through the
lymphatic channels. As in many chronic diseases, treatment
is ongoing and requires active participation by the patient for
self-management. It consists of two phases.
•
Phase one involves manual lymph drainage (MLD) and
short-stretch compression bandaging until maximal
fluid reduction has been achieved. MLD is a skin
stretching/massage action to direct lymph flow in a
certain direction to bypass any sclerotic or obstructed
lymph channels. A thorough understanding of lymph
channels is necessary to perform this procedure. A certified MLD therapist is essential to achieving these goals.
This process usually takes three to eight weeks. During
this time, the patient is taught skin hygiene to reduce
infection and exercises to facilitate lymph drainage.
•
Phase two of the treatment is often referred to as the
maintenance stage. During this time, compression
garments are used instead of short-stretch bandages to
maintain the limb or body part girth achieved through
MLD and bandaging. Skin and nail hygiene, exercise
and the importance of weight control are emphasized.
Skin should be moisturized daily with a non-irritating
emollient after bathing.
10
Even though research is not conclusive, some patients
have benefited from pneumatic intermittent compression pumps.
Suspected Deep Tissue Injury
What is deep tissue injury and where does it come from? Is
it a “purple pressure ulcer”? Is it a pressure ulcer at all since
the skin is intact?
In an attempt to formally define this phenomenon, in 2007
the National Pressure Ulcer Advisory Panel (NPUAP) proposed
the following definition:
“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.”
Worth
remembering ...
A small amount
of pressure over a
long period of time
can do as much
damage as a large
amount of pressure
over a short period
of time.
11
The wounds appear ischemic, and deterioration occurs in the
metabolically active muscle bed. Ischemia may be due to direct
pressure or shearing injury to nutrient vessels. While these
deep-tissue injuries clearly involve occlusion or infarction of
the nutrient-rich arterial supply, the pathogenetic mechanisms
of deep-tissue injury remain elusive. There is no discernable
mass of blood, yet a DTI is described as, and often feels like, a
hematoma. The role of shearing forces that stretch, kink, or
tear the perforating blood vessels from underlying muscle or
fascia has not been systematically studied, but shearing forces
should be avoided. Direct pressure that occludes nutrient
vessels could also be pathogenic.
How much time and how much pressure did it take to
compromise the deeper tissues? Remember, a small amount
of pressure over a long period of time can do as much damage
as a large amount of pressure over a short period of time.
Cells need oxygen and nutrients in order to divide and
migrate. Without both components cell death and necrosis
occur. Also, friction, shear and increased torque on deeper
tissues and vessels increase the likelihood of deep tissue
injury and pressure ulcer formation.
Deep tissue injury occurs either in the muscle bed or
subcutaneous fat. The damage is not quickly evident
because it presents itself slowly as the tissue deteriorates
from the inside out, taking on the appearance of a bruised
or discolored area prior to surface skin opening (see the
DTI diagram). The skin is usually intact at the time of initial
assessment and is sometimes incorrectly described as a Stage
I pressure ulcer. However, its rapid deterioration to a full-thickness injury is unlike a true Stage I pressure ulcer, which is a resolvable lesion. Areas of superficial blistering or broken blisters
appear within 24 hours, similar to those seen with fractures or
ischemic flaps. The surface tissue may be hard (indurated), or
soft and mushy to the touch. It may be either warm or cold to
the touch depending on how much circulatory compromise
has taken place. The tissues evolve into full-thickness ulcers
despite the best of care.
Differential Diagnosis of Deep Tissue Injury
Bruise: To injure the underlying soft tissue or bone
of part of the body without breaking the skin. A
bruise usually heals in about two weeks under
normal conditions. History of trauma is common.
Calciphylaxis: An adaptive response following induced
systemic hypersensitivity to a calcifying factor such as
vitamin D and an agent such as a metallic salt, usually
resulting in localized inflammation and calcification of
tissues. Lesions may have a violet hue and be excruciatingly tender and extremely firm. Lesions are most
commonly seen on the lower extremities, not bony
prominences. The incidence of these lesions is very low
12
in the general patient population, but often seen in
those with end-stage renal disease.
Fournier gangrene: An intensely painful streptococcus
infection that affects the perineum. It may present
initially as cellulitis.
Hematoma: A deep-seated purple nodule from clotted
blood that is usually associated with trauma.
Perirectal abscess: This injury commonly presents as a
dull, aching or throbbing pain in the perianal area.
The pain worsens when sitting and immediately before
defecation. The pain abates after defecation. A tender
fluctuant mass may be felt at the anal edge. These
abscesses can open to reveal large cavities that can be
confused with deep pressure ulcers.
We have to touch our patients as we assess them. If we are
not diligent in our assessment we can miss the early stages of
deep tissue injury. Education is a key factor for all healthcare
providers. It will enable you to conduct thorough skin assessments and understand how to use precise terms to describe
the deep tissue injury.
Kennedy Terminal Ulcers
The Kennedy Terminal Ulcer has a sudden onset and
usually appears about two weeks before death. It is superficial
but progresses quickly in size and depth. It is generally pearshaped; located at the base of the spine; and can be red, yellow
and black. The borders of the ulcer are usually irregular. It is
not a cause of a patient's death, but it can appear as the dying
process begins. Residents on tube feedings or intravenous
therapy can develop the ulcers four to six weeks before death.
It may be related to an overall breakdown in tissue due to
a decline in circulation; pressure, or other causes yet to
be determined.
Treatment for Kennedy Terminal Ulcers is the same as for other
pressure ulcers based on clinical research. The use of dressings,
adjunctive treatment modalities, support surfaces and other
offloading devices are determined after a comprehensive
13
assessment has been completed. Debridement will also be
determined based on clinical assessment results.
The exact cause of Kennedy Terminal Ulcers is unknown, but
the skin is an organ and, as with other organ systems, organ
failure is a possibility. One theory is that as people approach
death, the internal organs may begin to slow down and go
into what is known as multi-organ failure. No particular set of
symptoms may be identified except that the skin over bony
prominences starts to show the effects of pressure in a very
short period of time. Turning a patient every two hours is
standard; however, now it may cause superficial tissue damage.
If a Kennedy Terminal Ulcer surfaces, it may be time to address
end-of-life issues. Educate the patient as well as family members about a living will, power of attorney and organizing the
patient’s personal affairs. Ensure that the patient’s wishes and
needs are clearly known.
Kennedy Terminal Ulcers tend to be more prominent in the
geriatric population and are frequently seen in hospice patients. Following are examples of Kennedy Terminal Ulcers.
Kennedy Terminal Ulcer: Note variation in presentation.
Photos courtesy of Karen Lou Kennedy-Evans
14
Surgical Site Incision
When a surgical incision results in a full-thickness opening
through the skin, there are a few options for closure. In a
clean, surgically-created wound the edges are typically
brought together and sutured, stapled or secured in some
manner. The term for this process is primary intention.
As a result, periwound redness is a standard element of the
healing process. As the redness fades, the wound will continue
to heal at maximum strength for up to 18 months.
When a surgical wound is grossly contaminated and the
possibility of infection is great; or if the defect is too large,
the wound is left to close through secondary intention. In
this situation the wound edges are left open, and the wound
heals as any other chronic wound. The wound will fill with
granulation and epithelialization, proceed through the
maturation phase, and heal from the “bottom up.”
Another option is to surgically close the wound. This option
is used when there is an initial suspicion of infection, but after
24 to 28 hours there is no evidence of an actual infection. This
is referred to as tertiary closure or delayed primary closure.
Surgical wounds that open or dehisce (split) can be the
result of infection or various immunocompromised states
of the host, such as diabetes or malnutrition. When a surgical
wound dehisces or is non-healing, the patient must be assessed
and stabilized if necessary. Often a systemic antibiotic or
antimicrobial is ordered, and then the wound is treated.
Following the principles of wound healing, you will need
to address the optimal moist environment. Managing
draining wounds with absorptive dressing or a closed suction
system may be necessary. If the wound has stopped draining,
a dressing that donates moisture and maintains the moist
wound bed is necessary.
Assess the depth of the wound and evaluate it for fistula
formation. A fistula is an abnormal passage between two
areas, such as the small bowel and the skin, called an
enterocutaneous fistula.
15
Ideally, the tissue in the wound bed is clean and granulating.
However, in a chronic wound or dehisced surgical incision,
there may be necrotic tissue, slough and eschar, which are
known to harbor bacteria and delay wound healing. Debridement may be necessary and should be achieved by the most
effective and efficient method for the patient. In many cases
this is often achieved surgically.
A topical antimicrobial may also be necessary to treat an
overload of bacteria. Many products that contain silver
are able to address this bioburden.
Skin Tears
DID YOU KNOW
The incidence of
skin tears is directly
related to a lack of
internal hydration
and topical
moisturization.
A skin tear is a wound that results from either a separation
of the epidermis and dermis, or both the epidermis and
dermis from the underlying structures. There are different
degrees of skin involvement and damage. Causes include but
are not limited to trauma caused by bumping into equipment
and furniture, or transfer injuries that occur while getting in
and out of motor vehicles and hitting the car door. Other
traumas include skin stripping from tape or device removal
and lacerations from falls or foreign objects. Handling of
patients with fragile skin may also result in tearing of the
skin if a twisting motion is used on the forearm instead of
employing a grab and release method. The most frequent
injuries occur on the upper extremities, with the legs and
feet reported as the next highest. Over half of the skin
tears reported have undetermined causes. Patients that are
dependent upon caregivers for their activities of daily living
(ADLs) are most at risk as they are “handled” the most often.
The incidence of skin tears is directly related to a lack of
internal hydration and topical moisturization. Topical
moisturization using pH balanced cleansers and moisturizers
are essential to maintaining skin health. Encourage fluids
unless the patient is on a fluid restriction. Patients that
are on steroid therapy may be at greater risk for impaired
skin integrity and skin tears.
When assessing a skin tear, identify the causative factor.
Does the patient have dry skin, requiring better moisturization
internally and externally? What soaps, lotions and creams
are being used, and what is the pH of these products? Is the
16
patient on medications that affect the integrity of the skin?
Do the patient and caregivers need instructions about how to
protect the patient’s delicate skin and not cause further trauma
to the area? If these issues are addressed while the skin tear is
being treated, further skin damage is less likely to occur.
Payne-Martin Classification System for Skin Tears
The Payne-Martin Classification for Skin Tears further defines
and describes wounds that tend to occur more frequently in
older adults.
Risk factors include age, hydration status, medications,
nutrition, immobility, increased caregiver handling injuries,
edema and ecchymosis. Immature skin of infants and elderly
skin are at risk for tearing because of the fragility of the
dermal-epidermal junction.
In 1990 Regina Payne and Marie-Lynn Martin developed a
classification tool for skin tears that groups characteristics
and degrees of damage exhibited by these injuries into
three categories.
N
N
N
Category I: A skin tear without tissue loss.
• Characteristics are based on whether the damage is
a linear tear or a skin-flap type tear. Both tears can
be fully approximated.
Category II: A skin tear with partial tissue loss.
• Tears will have a partial-thickness epidermal tissue
loss. The tears are further classified as scant versus
moderate to large tissue loss.
Category III: A skin tear with complete tissue loss,
• where the epidermal flap is absent.
These are wounds with complete tissue loss.
The tool should be used to quantify data, discover and
decrease causes of injury and plan treatment protocols.
17
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Black J. Deep tissue injury. Wounds: A compendium of clinical research and
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Centers for Medicare & Medicaid Services. CMS manual system page. Available at: http://www.cms.hhs.gov. Accessed January 23, 2007.
Creager MA, Libby P, eds. Peripheral arterial diseases. Braunwald's Heart
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Daniel RK, Kerrigan CL, ed. Principles and physiology of skin flap surgery.
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http://www.emedicine.com/med/topic2722.htm. Accessed November 21, 2006.
Ford D. Pressure ulcer named after byron nurse who discovered it.
People Northwest, Fort Wayne News Sentinal. October 8, 1992.
Giordano CP, Scott D, Koval KJ, et al. Fracture blister formation: a laboratory
study. Journal of Trauma. 1995;38(6):907-9.
Groth KE. Clinical observations and experimental studies on the origin of
decubiti. Acta Clin Scand. 1942;87(Suppl 76):S1-S209.
Husain T. An experimental study of some pressure effects on tissues, with
reference to the bedsore problem. Journal of Pathology and Bacteria.
1953:66,347-358.
Kennedy KL. Gaymar Pictorial Guide to Pressure Ulcer Assessment.
Gaymar Industries, Inc.; 1997.
Kennedy KL. Strategies for the extended care professional; ask Mabel:
What is a kennedy terminal ulcer? ECPN. 2002;81(3):36-38.
Kennedy KL. The prevalence of pressure ulcers in an intermediate care facility.
Decubitus. 1989;2(2):44-45.
Kozier B, Erb G, Olivieri. Fundamentals of Nursing. 4th ed. Addison–Wesley;
1991.
18
lymphnet.org. Available at: http://www.lymphnet.org.
Accessed November 21, 2006.
MacDonald JM. Wound healing and lymphedema: a new look at an old problem.
Ostomy-Wound Management. 2001;47(4):52-57.
Mayer M, eds. Wound, Ostomy, Continence Nursing Secrets. Philadelphia, Pa:
Hanley and Belfus, Inc.; 2003.
McCann S, Gruen G. Fracture blisters: a review of the literature. Orthopaedic
Nursing. 1997;16(2):17-22.
National Pressure Ulcer Advisory Panel. Deep Tissue Injury Task Force.
Reston, Va. 2002.
Paget J. Clinical lecture on bed-sores. Student Journal and Hospital Gazette.
1873:144-146.
Parks DS, Granger DN. Ischemia-reperfusion injury: a radical view. Hepatology.
1988;8(3):680-682.
Payne RL, Martin ML. The epidemiology and management of skin tears in older
adults. Ostomy Wound Management. 1990;26:26-37.
Payne RL, Martin ML. Defining and classifying skin tears: need for a common
language. Ostomy Wound Management. 1993;39(5):16-20,22-4,26.
Russell, L. Pressure ulcer classification: defining early skin damage.
British Journal of Nursing. 2002;11(16): 33-41.
Shea JD. Pressure sores: classification and management. Clinical Orthopedics.
1875:89-100,112.
Willms-Kretschmer K, Majno G. Ischemia of the skin. American Journal of
Pathology. 1969;54(5):327-341.
19
ASSESSMENT AND
DOCUMENTATION
Contents
Wound Assessment Parameters . . . . . . . . . . . . . . . . . . . 2
Measuring the Wound . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pressure Ulcer Staging . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Pain Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Example of an Assessment Form . . . . . . . . . . . . . . . . . 18
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Photography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1
Wound Assessment Parameters
Thorough assessment of any wound is necessary before a
plan of care can be developed for the patient and the wound.
Several specific wound and overall patient parameters should
be included.
Worth
remembering ...
Wound Assessment
Parameters:
Etiology
Pathogen
confirmation
Wound Bed
Location
Size
Depth of
Tissue Damage
Periwound
Skin
Drainage
Pain
Odor
Etiology
Understanding the etiology or cause of a wound is the first
step in developing a care plan. For example, a patient may
present with typical characteristics of venous disease such as
a full-thickness wound located in the gaiter area and also show
signs of an arterial component like minimal hair growth on
the toes and muscle wasting. This patient would need further
evaluation with a minimum of an ankle brachial index (ABI)
and a Duplex Scan. Compression therapy is appropriate for the
venous leg, but contraindicated in arterial insufficiency. There
is also the possibility of what is referred to as “mixed etiology,”
or a combination of both arterial insufficiency and venous
hypertension. Compression may be appropriate, but not on
the same level as for a venous diagnosis alone. If the patient
also has diabetes, these tests may prove inconclusive and
further studies are warranted. A pressure ulcer may appear
obvious; however, part of this complete and accurate
assessment includes ruling out other etiologies. There are
dermatological conditions or even carcinomas that can
present as wounds and should be considered, especially
if the wound does not appear “normal” to you.
Pathogen Confirmation
Does the patient have signs and symptoms of systemic
infection? Has the patient had a fever or an elevated white
blood cell count? Are there signs or symptoms of bacteremia,
and does a blood culture show evidence of bacteria in the
bloodstream? Is there evidence of cellulitis? You would expect
to see redness, edema, local heat and pain. However, if there
is advancing cellulitis, the symptoms may be traveling in one
direction away from the wound. In these scenarios, a systemic
antibiotic may be necessary. Are there signs of clinical wound
infection? You may see a delay in wound healing, increased
edema, purulent drainage, and intensified or new onset of
pain and odor. This is a sign that there is an overabundance
of pathogens and wound healing is usually impaired. If so,
consider topical antimicrobial therapy such as ionic silver
2
dressings. If there is no indication of clinical infection, provide
for an optimal moist environment.
Wound Bed
This assessment parameter will be imperative to the selection
of dressing treatment choices. Look at the wound and ask
yourself what type of tissue is in the wound bed. If the tissue
is viable (living), it usually presents as beefy red (granular),
pale red or pink (non-granular). If the wound bed is filled
with necrotic (dead) tissue, it will present with slough,
eschar or a combination of both. Slough is usually described
as yellow, tan or gray and is often “slimy” or moist. Eschar is
typically described as the hard leathery “lid” of dark brown
or black dead tissue on the wound. Be sure to describe the
type of tissue and document the amount of each in a
percentage. This percentage must equal 100 percent. For
example, the wound bed is covered with 50 percent
eschar and 50 percent granulation.
Location
Even though the location of a wound should seem obvious,
it is imperative that the location be properly communicated.
Simply ask yourself, “where is the wound?” Be sure to use
anatomical marks. A pressure ulcer, for example, should be
identified by its bony prominence. A pressure ulcer that is on
the buttocks is best referred to as an ischial wound. If the
wound is on the lower extremity, orienting with terms such
as medial or lateral are suggested. Another seemingly obvious
parameter, the designation of either “left” or “right,” should
be included in all documentation where applicable.
Size
Length, width and depth are important descriptors when
documenting one aspect of the healing process. You will
enhance the care you provide to your patient if you are
able to determine the parameter of the wound with
correct measurements using a consistent approach.
Measuring the length, width and depth in centimeters is the
most common method used in wound care. The length and
width of any wound is measured from one edge of the
wound to the other. There are at least two recognized
methods for measuring the length and width of a wound:
3
•
Head to Toe: This method measures from “head to
toe” (length) and “arm to arm” (width). This is the
recommended measurement of pressure ulcers per the
National Pressure Ulcer advisory Panel (NPUAP).
•
Longest Aspect: This method measures the length as
the longest aspect of the wound. The width is measured
perpendicular to the length.
The depth, or third measurement of size, is performed by
placing a device, such as a cotton-tipped applicator, into the
wound bed perpendicular to the length and width. Essentially,
this means placing the device straight down into the wound.
•
Undermining and tunneling should be evaluated using
the face of a clock and a cotton-tipped applicator. If
present, they are measurements that are recorded as
supplements to the depth. Use the face of a clock as a
reference for placement and size. For example, “there is
tunneling at 2 o’clock for 3 cm,” or “there is undermining in the wound from 1 o’clock to 5 o’clock for 2 cm.”
Measuring in centimeters is consistent and generally more
accurate than inches. It will also help with reimbursement
issues, as most often centimeter measurements are required,
not inches. Probably the most important concept to remember
is to measure according to your facility’s policy. Both methods
of “head to toe” or “longest aspect” are acceptable, as long as
there is consistency from clinician to clinician. Standards of
practice suggest that wounds should be measured weekly
and as needed (prn).
Depth of Tissue Damage
The depth of tissue damage is also described as the “stage
of the wound” if the wound is a pressure ulcer, or by either
“partial-thickness” or “full-thickness” if the would is any
etiology other than pressure.
Partial-thickness refers to a wound that shows damage of the
epidermis or dermis, but not through the dermis. If the
wound is pressure related, it would be called a Stage II
pressure ulcer. Full-thickness, on the other hand, is a
wound that is through the dermis and into or through
the underlying structures. If it is a pressure ulcer it
would be a Stage III or IV.
4
Measuring the Wound
1
2
3
4
5
6
Wound Measuring Ruler
7
8
(Discard after single use)
Patient Name ________________________________________
Date ______________________________________________
9
10
11
12
13
CENTIMETERS
14
15
Wound Size
Length ____________________________
Width ____________________________
Depth ____________________________
1-888-701-SKIN
Head
12
9
The tools shown below may help you consistently
measure a wound. When measuring length, width and
depth, use a disposable ruler with centimeters. Imagine
that the wound is the face of a clock. The top of the
wound is toward the patient’s head, or 12 o’clock.
Conversely, the bottom of the wound is in the direction
of the patient’s feet, or 6 o’clock.
Head to Toe Method
Length is measured in centimeters from 12
3
6
length = 6.0 cm
width = 4.5 cm
o’clock to 6 o’clock at the longest point.
Width is measured in centimeters perpendicular
to the length at the widest point, or 9 o’clock
to 3 o’clock.
Longest Aspect Method
Head
6.4 cm
4.1 cm
Another acceptable way to measure length and
width is to use the longest plane, regardless of its
orientation to the patient or a clock. The width is
perpendicular. This method of measuring is most
useful when a computerized system is used or when
there is an unusual shape to the wound. Above all,
measurement consistency is key.
Depth is always measured using the deepest part of the
wound, perpendicular to the skin surface. Depth is not a
measurement of undermining or tunneling.
Feet
Depth is measured in
centimeters by inserting
a cotton-tipped applicator
into the deepest site of the
wound bed.
Grasp the applicator with the
thumb and forefinger, sliding
the finger down the applicator
until the finger meets the
wound’s edge.
Withdraw the applicator and
measure against a centimeter
ruler and record.
If the depth of the wound is “superficial,” where the wound bed is exposed, but it cannot be measured with a cotton-tipped applicator, the depth would be documented as < 0.1 cm. You should be
able to accurately assess depth for wounds greater than 0.1 cm with a cotton-tipped applicator.
5
Pressure Ulcer Staging
Worth
remembering ...
Proper staging
is vital for creating
accurate documentation, developing
care plans, delivering optimal wound
treatment, and
receiving
appropriate
reimbursement.
Pressure ulcer staging continues to elude many clinicians and
cause confusion when it comes to accurate assessment and
documentation. Staging can vary greatly from one clinician to
another depending on their knowledge of the skin, comfort
with the staging definitions, and the information available.
However, proper staging is vital for creating accurate documentation, developing care plans, delivering optimal wound treatment, and receiving appropriate reimbursement.
The National Pressure Ulcer Advisory Panel (NPUAP) categorizes pressure ulcers by stages. These stages should be used only
for pressure ulcers, while other wounds should be described as
partial- or full-thickness wounds. A pressure ulcer should be
staged at the time of initial assessment and if the ulcer deteriorates. The highest stage defines the wound, so if the ulcer is
improving, label it with the original stage as healing, such as a
healing Stage III ulcer.
In February 2007 the National Pressure Ulcer Advisory Panel
(NPUAP) redefined the definition of a pressure ulcer and the
stages of pressure ulcers, including the original 4 stages.
NPUAP also added 2 stages, one on deep tissue injury and one
on unstageable pressure ulcers. This release is the culmination
of more than 5 years of work, beginning with the identification of deep tissue injury in 2001.
Pressure Ulcer Definition
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
A number of contributing or confounding factors are also associated
with pressure ulcers; the significance of these factors is yet to
be elucidated.
Pressure Ulcer Stages
Suspected Deep Tissue Injury
A suspected deep tissue injury is:
Purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue
6
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.
Further description:
Deep tissue injury may be difficult to detect in individuals
with dark skin tones. Evolution may include a thin blister
over a dark wound bed. The wound may further evolve and
become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Stage I
A Stage I pressure ulcer is:
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.
Further description:
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).
The ulcer appears as a defined area of persistent redness in
lightly pigmented skin, whereas in darker skin tones, the
ulcer may appear with persistent red, blue or purple hues.
To detect a Stage I pressure ulcer, inspect the patient’s
bony prominences (hips, sacrum, coccyx, heel) at
each repositioning.
Stage I pressure ulcer: The focus is to prevent further breakdown.
7
Stage II
A Stage II pressure ulcer is:
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.
Further description:
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.
*Bruising indicates suspected deep tissue injury
To detect a Stage II pressure ulcer, inspect the skin for shallow
wounds or shiny areas of skin loss. Do not classify skin tears,
erosion from urine or feces, and wounds covered with slough
or eschar as Stage II.
Hints to help you distinguish a Stage II from a Stage III or IV
pressure ulcer follow:
•
•
•
•
A Stage II pressure ulcer cannot have, or ever have had,
necrotic tissue.
Stage II pressure ulcers heal by regenerating the dermis and
epidermis. They do not fill with granulation tissue.
There is a flat edge, as opposed to a deep crater appearance.
There is no undermining or tunneling.
Stage II pressure ulcers: The focus is to prevent further breakdown
and protect the wound.
8
Stage III
A Stage III pressure ulcer is:
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.
Further description:
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.
To detect a Stage III pressure ulcer, inspect all skin for wounds.
Do not label deep wounds covered with nonviable tissue as
Stage III. Label them as unstageable. Look for evidence of
infection in the ulcer as well as redness, swelling, pain,
warmth and exudate.
Stage III pressure ulcers: The focus is to maintain a moist wound
healing environment.
9
Stage IV
A Stage IV pressure ulcer is:
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.
Further description:
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.
To detect a Stage IV pressure ulcer, inspect all skin for wounds.
Palpate or gently probe the ulcer with a sterile applicator to
feel for the bone. Do not label ulcers with necrotic tissue
(eschar or slough) as Stage IV. Label them as unstageable.
Hints to help you distinguish a Stage III or IV from a Stage II
pressure ulcer follow:
•
•
•
•
These wounds may have slough or eschar.
They heal through granulation, epithelialization and
contraction.
There is no regeneration of the epidermis or dermis.
Undermining or tunneling may be present.
Stage IV pressure ulcers: The focus is to maintain a moist wound
healing environment and prevent infection.
10
Unstageable
A wound that is Unstageable is:
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.
Further description:
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.
Also, consider that there may be wounds under casts that
cannot be staged until they are completely visible. This stage
is also known as nonstageable. Regardless of how the ulcer
is referenced, you will not be able to properly stage this type
of wound in its current condition.
Unstageable
11
Periwound skin condition
Again, using the face of a clock, assess and document the
condition of the periwound skin. The condition of the skin
around the wound can be a good indicator of wound healing.
Is it red, macerated, hard or hot? Is it denuded, raw, or is the
periwound skin intact? Be sure to assess for color, sensation,
induration and edema. If the periwound skin is red or dark
purple it may indicate additional Stage I damage or signify
early signs of necrosis. Dry periwound skin could divert
energy from wound healing to repair the dry skin. Macerated
periwound skin or skin that is too moist not only diverts
energy from healing, it can lead to further wound damage.
There are some typical parameters that you will want to be
aware of, including normal conditions as well as pathologic
conditions that must be addressed. During the inflammatory
phase of healing, normal inflammation occurs that should
disappear in the first five days. If that inflammation continues
beyond the fifth day, but is less than 3 to 5 cm, it may be
erythema, which is just a physiologic response. When the
erythema is greater than 3 to 5 cm, it is considered cellulitis, a
pathologic response and may need further investigation. If the
cellulitis travels in one direction away from the wound, called
advancing cellulitis, systemic infection should be considered.
Drainage
Wound drainage is made up of dead cells from the wound,
necrotic tissue that has liquefied and white blood cells as well
as natural growth factors. When assessing the wound, be sure
to evaluate the amount and type of drainage or exudate that
is produced by the wound. Use descriptive terms so that it is a
realistic representation of the wound. Make sure to use
descriptors such as color and consistency. In describing
the amount, some clinicians will use subjective terms such as
small, moderate or heavy amounts. Another way is to describe
the amount of drainage on a dressing. This method can be
accurate; however, remember to document how long that
dressing had been in place. If a dressing is saturated after 12
hours or 5 days, the dressing is still saturated, but the drainage
level is very different given those time frames.
12
Pain
If clinicians and patients were asked to rank concerns in
regard to wound care, their answers would be quite different.
Wound debridement and infection control might top the
list for clinicians but pain and odor are chief worries for the
patient. Patients with chronic wounds view pain as the worst
aspect of their wounds. Surprisingly, they rank pain control
as more important than healing. Additionally, pain has been
shown to be a primary reason why patients responsible for
their own care fail to attend clinic visits.
What Causes Pain
It is safe to assume that every wound is painful and every
patient who has a wound experiences pain. Szor and Bourguignon reported that 87.5 percent of patients with wounds
reported pain at dressing change and 84.5 percent of patients
with wounds reported pain at rest.
Patients frequently experience pain during dressing changes
from dried dressings stuck to the wound tissue. Some dressings
have strong adhesives that pull at sensitive periwound skin.
Dressing changes that include debridement can be extremely
uncomfortable.
Edema, swelling and inflammation can cause or contribute to
the pain experience. Infection and inflammation alone can
be painful. In these situations, wound pain can serve as an
important indicator of inadequate wound management,
untreated underlying cause or infection.
Superficial infection may cause local pain or discomfort due
to the release of mediators by the bacteria and the host. The
exudate of chronic wounds has abnormally high concentrations of proteases, particularly matrix metalloproteinases
(MMPs). These increased proteases shift the wound healing
balance into a continuing chronic inflammatory phase.
13
How Dressing Choice Affects Pain
The following tips will help reduce the patient’s pain during
dressing changes.
1.
Use products designed to be non-traumatic. Gauze will
cause pain and should be avoided. Avoid wet-to-dry regimens. If a dressing gets dry, moisten it with wound cleanser
or normal saline to soak it prior to removal. Try to use
non-adherent products.
2.
Consider innovative alternatives, such as polyacrylate
debriding. Used properly, polyacrylate debridement products
provide similar effectiveness to enzymatic debriding products
without the stinging sensation at the wound site that can be
associated with enzymatic debriders.
3.
Practice moist wound healing. It is the current standard of
practice, results in less pain, faster healing and less scarring.
Select dressings such as hydrogels (sheet, strands/cavity and
amorphous) to maintain optimal moisture in the wound
bed of drier wounds.
4.
Reduce pain by reducing the frequency of dressing changes.
Use dressings that can remain in place for longer periods of
time, minimizing wound-bed manipulation. Soft dressings
with silicone-facing and adhesives are typically repositionable on the wound site.
5.
Another way to reduce the frequency of dressing changes
is by matching exudate levels with product absorbency. If
profuse drainage is controlled by a superabsorbent dressing,
fewer changes are necessary and the pain cycle is reduced.
6.
Do not neglect pain management during wound cleansing.
Appropriate non-cytotoxic wound cleansers used at body
temperature (~100ºF) at 4 to 15 pounds per square inch (psi)
are best to keep discomfort at bay. Avoid cytotoxic solutions
such as povidone iodine or hydrogen peroxide when
cleaning the wound.
7.
Use a copolymer skin prep, especially the non-stinging
varieties, to help strengthen and prepare the skin for
adhesive application. Think of skin preps as an extra
layer of the epidermis that can help reduce trauma to
tender periwound skin.
8.
Consider tape alternatives such as netting, tubular dressings,
Velcro® wraps and montgomery straps to secure dressings.
14
Pain Scales
There are several pain scales that can be used to determine the
level of a patient’s pain. Document the scale used and always
use the same scale for each follow up assessment.
Wong-Baker FACES Pain Rating Scale
0
No Hurt
1
Hurts
Litttle Bit
2
3
Hurts
Hurts
Litttle More Even More
4
Hurts
Whole Lot
5
Hurts
Worst
From Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of
Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission.
Copyright, Mosby.
This scale has traditionally been used in the pediatric market.
It is also very appropriate in the acute care setting and, more
importantly, it is easy to use. First, ask the patient to point
to the face on the scale that represents their pain, or how
they feel. Then document the number corresponding to
the chosen face.
Visual Analog Scale (VAS)*
No Pain
Pain as bad as it
could possibly be
*A 10-cm baseline is recommended for VAS scales.
From: Acute Pain Management: Operative or Medical Procedures and Trauma,
Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032; February
1992. Agency for Healthcare Research & Quality, Rockville, MD; pages
116-117.
Directions: Ask the patient to indicate on the line where
the pain is in relation to the two extremes. Measure the
level of pain from the left-hand side to the mark, usually
in centimeters.
15
Numerical Rating Scale (NRS)
0
No
Pain
1
2
3
4
5
6
Moderate
Pain
7
8
From McCaffery, M. Pasero C; Pain: Clinical manual, p. 63.
1999 Copyrighted by Mosby, Inc.
9
10
Worst
possible
Pain
The patient is asked to point to the number on the scale that
represents their pain. That number is then documented.
World Health Organization (WHO) Analgesic Ladder
The WHO endorses the use of an analgesic ladder for the
assessment and administration of analgesics. Pain management is categorized in three phases, or steps. The first step
begins with pain, providing nonopioid therapy plus or
minus the inclusion of an adjuvant therapy. The second step
is represented as persisting or increased pain that leads the
clinician to the second tier of pain management, which is
opioid therapy for mild to moderate pain with or without
the additional inclusion of nonopioids or adjuvant therapy.
When pain persists or increases, this leads to the top step of
pain management therapy which is an opioid for moderate
to severe pain, with or without the additional inclusion of
nonopioids or adjuvant therapy. The goal always leads to
freedom from pain.
The 3-step analgesic ladder
developed by the World Health
Organization. Reproduced by
permission of WHO. Cancer Pain Relief.
Geneva: WHO; 1986.
16
Odor
Odor is another sensitive issue important to patients and clinicians. Advanced wound care products have taken quantum
leaps since the early days of "cover and conceal" philosophies.
Today’s woundcare professionals have many good choices to
provide for moist wound healing as well as addressing odor.
Odor Control
Research has shown that wounds most commonly associated
with odor include leg ulcers, fungating and cancerous lesions,
and wounds with necrotic tissue. Strategies include identifying
the cause of the odor and working to eliminate it. One way is
to cleanse the wound with antimicrobial wound cleansers
containing safe ingredients like benzalkonium chloride (BZK),
a universal antimicrobial. Another approach is choosing
dressings that use pain-free antimicrobials to kill bacteria
and odors in wounds. Both options are cost-effective and
over-the-counter solutions that kill a wide range of pathogens
and do not contribute to antibiotic resistance. Finally, other
dressings with charcoal or cyclodextrins that actively absorb
the unpleasant odor from wounds may be used.
Make sure that your assessment and documentation includes
all of these parameters, including the patient’s pain level and
what you did to help alleviate it.
17
Example of an Assessment Form
There are many examples of assessment forms used in the
industry. One example is provided here for your reference.
Wound Assessment Summary
TIPS!
This is just one of
many woundassessment forms.
Make sure you
are as thorough
as possible
when assessing
the wound.
Facility Name
Assessment Date
Patient Name (Last, First, MI) or (ID #)
Clinician Contact Number
TYPE: (Circle)
PRESSURE
VENOUS/STASIS
ARTERIAL
COCCYX
RIGHT ISCHIAL TUBEROSCITY
Pain Score
__________
SURGICAL
SKIN TEAR
LEFT SACRAL
FISTULA
SITE/LOCATION: (Circle)
Clinician Name
Measures taken
___________________
TRAUMA
DIABETIC
OTHER (DESCRIBE):____________________________
RIGHT SACRAL
LEFT ISCHIAL TUBEROSCITY
LEFT TROCHANTER
RIGHT TROCHANTER
LEFT HEEL
RIGHT HEEL
OTHER (indicate site / location) __________
DEBRIDEMENT: NO
YES
SURGICAL
TYPE:
Lab Values / Tests
Albumin / Prealbumin
Results________ Date_____
II
III
CHEMICAL
AUTOLYTIC
MECHANICAL POLYACRYLATE
Dimensions (in centimeters)
Diagnosis: (Circle all that apply)
Alzheimer’s Disease
Comatose
Crohn's Disease
Dementia
Diabetes
Hemiparesis
Hemiplegia
Neurological Disorder
Paraplegia/Quadriplegia
Peripheral Vascular Disease
Systemic Lupus
Ulcerative Colitis
Norton Plus / Braden
Risk Assessment Score_________
Status/ Depth of Tissue
Destruction(Not Pressure Ulcer)
TYPE
& COLOR:
IV
MAGGOT THERAPY
Scoring System Used (circle one)
L:______W:______ D: _______
Onset (Choose one, date)
Admitted With_____________
Acquired _________________
EXUDATE
AMOUNT:
Serum Lymphocyte Count
Results________ Date______
Initial Stage
(Pressure Ulcer Only)
I
DATE:________________
SHARP
Partial-Thickness
Full-Thickness
ODOR:
AFTER_______ HRS, DRESSINGS ARE SATURATED:
ODOR: (circle one)
NONE
MILD
(circle all that apply if exudate present)
WOUND BED
TISSUE:
(Must equal 100%
between viable/living tissue,
slough/eschar. Circle as
many perimeters that
describe the wound bed)
NONE
SMALL
MODERATE
LARGE
FOUL
Serous
Serosanguineous
Tan
Whitish
Sanguineous
Creamy
Gel-like
% Slough: (Dead tissue inside wound)
(circle one)
Yellow White
Foreign Body: (circle one)
No
Sutures
Staples
0
Gray
Beige
25
Blue
75
100
50
75
100
Tunnel/Undermining: ___NONE ____TUNNEL ____UNDERMINING
Macerated
Surrounding Skin Temperature: (check one)
Dry
Denuded
Edema
In Darkly Pigmented Skin: Deepening or Darkening of Normal Color
Support Surface:
50
Rusty
Adherent: stringy, loose-hanging
___Loosely adherent: debris, clumps that are attached to the wound tissue
Surrounding Skin: (circle one)
Purple
Beige
____Non
% Eschar: (Dead tissue that covers the wound “like a lid)
0
25
(circle one) Black
Brown
(check one) ___Adherent soft eschar ___Firmly adherent hard eschar
Red
Green
% Viable/Living Tissue:
0
25
50
75
100
(circle one) Granulating Tissue (“cobblestone”) OR Smooth, Non-Granulating Tissue (No tissue growth)
(circle color)
Dusky Pink Red Beefy Red
(check one)
Clear
Yellow
OTHER___________________
Indurated (Hard)
_____Consistent with Body Temperature
______Warmer than the Surrounding Skin
Nutritional Status: Include type of diet, percent consumed and other food information.
Treatment Plan: Include products and frequency of use.
Additional Wound Description / Comments
Template Compliments of Medline Industries, Inc.
18
Documentation
Documentation of the wound assessment provides information for the direct care provider regarding the wound
condition and appearance. This information is helpful when
determining the best course of care and allows a measurement
for the response to the care provided. Therefore, information
in written documentation form provides justification for the
recommended therapy or treatment.
The written/photographic record also serves as a communication tool between disciplines. Make sure the information is
accessible to all members of the healthcare team; not hidden
away where few can access or even know it exists.
Another purpose for documentation is for a legal record of
assessment, interventions and outcomes. Information in
the medical record should accurately reflect the findings and
report interventions taken. The information needs to be timely
when entered and factual without excessive wordiness. Staff
should be instructed to “paint a picture” with words, which
can help the reader to visualize the wound without navigating
through a long novel.
In simple terms, measure what can be measured and describe
what cannot be measured. Quantify the wound size in agreedupon dimensions. Be consistent with the method you choose.
Choose the greatest depth and measure undermining. Do not
forget to describe the wound edge as well.
Measure the periwound erythema, induration or crepitus
(crackling sound) and document this information. For persons
with edema in the lower extremity, a measurement of the
ankle and calf circumference can also be quantified.
A description of the wound base, drainage and odor may be
best handled qualitatively. There are a number of scales that
have attempted to quantify drainage and odor; however,
inter-rater reliability is not consistent and a simple qualitative
description may be best.
Finally, it is helpful to describe the person, especially with
respect to weight; position, hydration and other factors that
may impair wound repair or predispose the patient to further
skin breakdown.
19
Review your facility’s policies and procedures for the frequency
of measurements recommended for wound assessment and
documentation. In the acute care setting, the frequency of
assessment may be more often than in long-term care, homecare or outpatient settings. At a minimum, the wound should
be completely assessed on admission for care, at discharge, and
weekly (or at the next visit) during care. This frequency allows
for a series of measurements to compare the care and the
outcomes to interventions.
There is not a definitive location to place wound documentation in the medical record. It is important that the documentation be located where all members of the healthcare team can
have ready access to it. Ideally, the location for documentation
will be capable of storing photos if your facility requires
wound photography.
Documentation needs to be written in a timely, concise and
accurate way. Your goal is for anyone who reads the information to understand the patient’s situation and the plan of care
going forward. Individuals reading the documentation may
be colleagues, other healthcare team members, the patient or
members of the legal community. Write so that anyone reading the document understands the language and the terms
used. Be sensitive to regional expressions.
Photography
Whether or not to photograph is a controversial and difficult
to manage task. Photographing the wound involves identifying when and how the picture should be taken, how the image
will be stored, and who will be responsible for the process. The
rigors of medical record storage are not something most clinicians are equipped to manage. It is ideal for the photographic
image to be linked to the written description of the wound so
the image and written word complement one another.
Good basic photography requires a consistent process and
equipment for taking the photo. Use a consistent background
and include a metric ruler in the photograph. A variety of
rulers or color dots are available to assist with standardization.
The photo should be taken as close as possible to “fill the
frame,” minimizing background clutter. If possible, subsequent
photos should be taken with the patient in the same position
as the original photo.
20
There is a great deal of discussion in the literature regarding
when and if photos should be taken. The guiding principle
is that if an institution elects to include photography, there
should be a policy and procedure to direct the clinician.
Photography should have a purpose and be used to
supplement the written description, not replace it.
Once the decision has been made to include photography
in the wound care practice, storage of the data needs to be
planned with the medical records department and with the
computer support service. Again, if you have the ability to
prospectively develop an electronic medical record, work
with the team to develop the program. Develop a system to
allow easy transfer of an image into the written note. This
would allow the best of both worlds for photo storage and
merging the written text.
21
Guidelines for Digital Photography
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Ì
Digital photos are always preferred.
Avoid using grid film or a disposable camera when possible.
Camera movement is the most common cause of blurry
pictures. Stand firm with your feet shoulder width apart and
tuck your elbows tight to prevent any shaking.
Ideally, each case study should have at least a beginning,
middle and end photo.
Lighting can make the difference between a poor photo
and a great photo. Natural light is best; however, in dark
environments use a flash.
If you are unsure of the flash issue, take several pictures both
with and without the flash. The more you use your camera,
the more comfortable you will be with lighting.
If the light source is behind you, make sure your body does
not create a shadow.
Pay attention to your background. A solid color background
is always preferred to a pattern or printed one. Avoid clutter
in the photo.
Avoid shiny blue under pads, as they can reflect the flash.
Take the photo from the same angle each time. Always
take the photo at a slight angle, as this will avoid “wash out”
of the subject.
Position the patient in the same manner for each set of
photos so that progress may be seen.
Include information regarding the wound size and date
on a ruler IN the photo. This ruler should be in centimeters.
Take a minimum of three photos at each visit per wound site:
A location shot approximately four feet away from
the wound.
A two foot “close-up” that includes 90 percent patient
and 10 percent background.
A two foot with zoom that highlights tissue texture
and drainage.
Be sure to clean your lens. A small amount of particulate
matter can distort or completely ruin your photo.
Obtain photo permit, as required by your agency or facility.
22
References:
Agency for Healthcare Research & Quality. Acute Pain Management: Operative
or Medical Procedures and Trauma, Clinical Practice Guideline No. 1.
AHCPR Publication. 1992:116-117.
Alvarez OM, et al. Chronic wounds: palliative management for the frail
population. Wounds. 2002;14(Suppl 8):S5–S27.
Bruggisser R. Bacterial and fungal absorption properties of a hydrogel dressing
with a superabsorbent polymer core. Journal of Wound Care. 2005;14(9):1–5.
Dow G. Ostomy/Wound Management. May 2003;49(5A):8–13.
Eager C. Wound care practices survey presented at the Symposium on Advanced
Wound Care. 2003.
European Wound Management Society (EWMA) Position Document. Pain at
Wound Dressing Changes. Medical Education Partnership, Ltd. 2002. Available
at: http://www.aawcone.org.
Fleck CE, Paustian C. The use of silver containing dressings: the new “silver
bullet” in wound management? ECPN. 2003;80:22–25.
Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric
Nursing. 7th ed. St. Louis, 2005:1259. Used with permission. Copyright, Mosby.
Hollinworth H. Less pain, more gain. Nursing Times. 1997;93(46):89-91.
Kalinski C, et al. Effectiveness of a topical formulation containing metronidazole for wound odor and exudate control. Wounds. 2005;17(4):84–90.
Kannon GA, Garrett AB. Moist wound healing with occlusive dressings:
a clinical review. Dermatol Surg. 1995;21:583–90.
Konig M, Vanscheidt W, Augustin M, Kapp H. Enzymatic versus autolytic
debridement of chronic leg ulcers: a prospective randomized trial. Journal
of Wound Care. 2005;14(7):320–323.
Lipman RDA. Avery Dennison Medical: Odor absorbing hydrocolloid dressing
for direct wound contact [poster number 82]. Chicago, Ill. Wound Healing
Society (WHS) 15th Annual Meeting. May 18–21, 2005.
Mast BA, Shulz GS. Interactions of cytokines, growth factors and proteases
in acute and chronic wounds. Wound Repair Regen. 1996;4:411–20.
McCaffery M, Pasero C. Pain: Clinical manual. Copyrighted by Mosby, Inc.;
1999:63.
23
Numerical Rating Scale. Available at:
http://www.mdanderson.org/pdf/pted_painscale_numeric.pdf.
Accessed January 29, 2007.
Ovington L. Hanging wet to dry dressings out to dry. Home Health Nurse.
2001;19(8):477.
Paustian C. Debridement rates with activated polyacrylate dressings.
Ostomy Wound Management. 2003;49(Suppl 1):S2.
Paustian C, Stegman MR. Preparing the wound for healing: the effect of
activated polyacrylate dressings on debridement. Ostomy Wound Management.
2003;49:9:34–42.
Percival SL, Percival PG, Bowler PG, et al. Bacterial resistance to silver in
wound care. Journal of Hospital Infection. 2005;60:1–7.
Pieper B, DiNardo E. Reasons for non-attendance for the treatment of venous
ulcer in an inner-city clinic. JWOCN. 1998;25:180–6.
Pressure Ulcer Basics, Educational CD’s [computer program]. © NPUAP. 2004.
Price E. Wound care: the stigma of smell. Nursing Times. 1996;88(20):71–72.
Reddy M. Chronic wound pain in older adults. Geriatrics & Aging.
2004;7(3):16.
Rodeheaver GT. Wound cleansing, wound irrigation, wound disinfection.
In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care:
A Clinical Sourcebook for Healthcare Professionals. Third Edition.
Malvern, Pa: HMP Communications. 2001:369-83.
Szor JK, Bourguignon C. Description of pressure ulcer pain at rest and at dressing change. Journal of Wound Ostomy Continence Nursing. 1999;26:115–120.
Thomas S, Fisher B, Fram PJ, Waring MJ. Odor absorbing dressings. Journal of
Wound Care. 1998;7(5):246–250.
van Rijswijk L, Braden BJ. Pressure ulcer patient and wound assessment: An
AHCPR clinical practice guideline update. Ost Wound Manag. 1999;45
(Suppl 1A):S56.
Visual Analog Scale. Available at: http://www.partnersagainstpain.com/
printouts/A7012AS1.pdf. Accessed January 29, 2007.
Wong-Baker FACES Pain Rating Scale. Available at: http://www.mdanderson.
org /pdf /pted_painscale_faces.pdf. Accessed January 29, 2007.
World Health Organization (WHO) Pain Relief Ladder. Available at:
http://www.who.int/cancer/palliative/painladder/en/. Accessed January 24, 2007.
24
DEBRIDEMENT
Contents
Necrotic Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Eschar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Slough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Types of Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . 3
When Not to Debride. . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1
Debridement is the removal of dead or devitalized tissue from
the wound bed until healthy tissue is exposed. Nonviable or
necrotic tissue can either be eschar or slough. Eschar and
slough are both implicated in poor healing and increased
bacterial load in the wound.
Necrotic Tissue
Worth
remembering ...
A scab is dried
blood and
exudate, not
dead tissue.
A wound bed cannot be assessed when it is filled with necrotic
tissue. Necrotic tissue harbors large numbers of bacteria,
increases the threat of infection and delays healing.
A scab is dried blood and exudate, not dead tissue. A scab
does not imply tissue loss; in fact, it is usually related to a
partial-thickness wound. The term scab is not interchangeable
with eschar.
Removal of devitalized tissue is necessary for wound healing.
The wound can appear larger as the debridement progresses.
Weekly wound assessments must include information on the
percentage of necrotic tissue versus viable tissue present in the
wound bed in order to monitor progress. When a pressure
ulcer involves necrotic tissue, staging cannot be confirmed
until the wound base is visible.
Arterial blood flow, or perfusion, of the lower extremity
should be assessed before the wound is debrided. If perfusion is inadequate, restoration of blood supply should be
performed. If this is not an option, the eschar should be
managed with dry dressings, pressure relief and nutritional
support. Assessment should include frequent observation
for signs of infection.
Eschar
Eschar is a form of necrotic tissue. Eschar is skin, subcutaneous
tissue, and possibly muscle that has died and dried in layers.
It is the “leathery” cover on the wound at the skin surface. It
looks like a “lid,” and can be black, brown or tan, and can be
either hard or pliable.
2
DID YOU KNOW
AHRQ guidelines do
not recommend
debridement for
heel ulcers with
dry eschar if they
do not have
edema, erythema,
fluctulance (sponginess) or drainage.
The Agency for Healthcare Research and Quality (AHRQ)
guidelines do not recommend debridement for heel ulcers
with dry eschar if they do not have edema, erythema, fluctulance (sponginess) or drainage. Assess these wounds daily to
monitor for pressure ulcer complications that would require
debridement (e.g., edema, erythema, fluctulance, drainage).
Elevating or off-loading heels is the standard of treatment
and can be done with pillows.
Slough
Slough is a moist combination of fibrin, bacteria, cell debris,
leukocytes and exudate. Essentially, it is necrotic or dead tissue
inside the wound bed. Slough is not an organized tissue; it is
a group of wound cells that the body cannot eliminate on its
own. It can be white, beige, yellow or rust colored. Slough
consistency can be dry, crusty, slimy, rubbery or moist. The
wound should be reevaluated during the debridement
process at each dressing change to ensure the chosen
treatment is still appropriate.
Types of Debridement
3
Type of
Debridement
Description
Surgical
Sharp
Debridement
The most rapid of all debridement methods, surgical debridement converts the chronic wound to an acute wound.
This method in particular should be employed when there
are signs of advancing cellulitis or sepsis, extensive, thick or
adherent eschar. However, this method requires an operating room or special procedure room and the expertise of a
surgeon. This method can be quite costly and is not recommended if the patient is not a surgical candidate.
Conservative
Sharp
Debridement
This method can be performed by a physician or advanced
practice clinician (check your state’s practice act), and
can routinely be done at the bedside. Conservative sharp
debridement removes only devitalized or dead material.
Insufficient perfusion and increased bleeding risks are some
of the disadvantages of this method.
Type of
Debridement
Description
Autolytic
Debridement
Lysozymes, the body’s own white blood cells and autolytic
enzymes, break down necrotic tissue through liquification
and rehydration. Any dressing that keeps the wound
optimally moist will facilitate autolytic debridement.
This method is selective and noninvasive. It is inexpensive,
produces minimal discomfort, and requires minimal expertise. Autolytic debridement, however, can take longer than
other methods. It is not recommended for patients with a
decreased white blood cell (WBC) count. This method
should not be used on infected or heavily draining wounds.
Mechanical
Debridement
Wet-to-dry dressings
Wet-to-dry dressings are painful and sometimes result in
healthy tissue damage. The method is nonselective and
can be time-consuming. Generally, there is a low cost for
materials and it is easy to perform.
Whirlpool
Whirlpool is less painful than other methods; however,
this method does not impact dry eschar. A whirlpool can
dry out the skin and increase the risk of a nosocomial
infection (facility-acquired). There is also a risk of
increasing damage with some leg ulcers, especially
those with venous disease.
Irrigation or Wound Irrigation
Irrigation is cleansing a wound with sufficient pressure
to remove devitalized tissue. This can be achieved with
commercial wound cleansers where the pounds per square
inch (PSI) are between 4 and 15. Care should be taken in
products with too much pressure as they could contribute
to slower wound healing and possibly cause wound trauma.
4
Types of Debridement (continued)
5
Type of
Debridement
Description
Polyacrylate
Debridement
Dressings containing specific polymers, known as polyacrylates, attract and retain large-molecule proteins such as
slough and eschar, bacteria, and wound toxins. Polyacrylates
have demonstrated the ability to bind harmful proteins
such as matrix metalloproteases (MMPs) in the wound bed.
This method of debridement facilitates autolytic as well as
mechanical debridement, and has the ability to break up
bacterial biofilm.
Enzymatic
Debridement
The goal of enzymatic debridement is to liquefy necrotic
tissue or destroy the adhesion between necrotic tissue and
the underlying tissue with the use of enzymes. Enzymes
should be discontinued as soon as the wound is free of
necrotic tissue. Eschar must be cross-hatched (check your
state’s practice act) with a scalpel prior to enzyme application. This method is not indicated for infected wounds. It
may cause bleeding and can be painful. Enzymatic debriding agents are available through the pharmacy by prescription only.
Biological
Debridement
Medical-grade maggots are used to digest necrotic material.
Farm-grown sterile maggots are placed into the wound bed
and consume the necrotic material. Maggots are selective
in that they focus only on dead, not viable, tissue. Patients
report a moving or tingling sensation while the maggots
are in place, but the sensation appears to be well tolerated.
Furthermore, the enzymes secreted by the maggots may
enhance healing.
Ultrasound
Debridement
An emerging method of debridement is using ultrasound
waves. Low-frequency ultrasound creates cavitation by the
formation of mini gas bubbles. At certain amplitudes of
sound waves these bubbles implode, causing necrotic tissue
to liquefy. This method is selective because only viable tissue is destroyed at much higher levels than those required
for destruction of necrotic tissue.
When Not to Debride
According to the AHRQ guidelines, stable heel eschar, dry
gangrene, and lower extremities without adequate perfusion
should not be debrided. These wounds should be monitored
closely for signs and symptoms of infection or complications.
Protocols
ALGINATE
Used for:
•Eschar
•Moderate to Heavily-Draining Slough
1.
2.
3.
4.
5.
6.
7.
Clean the surface of the slough tissue with a wound
cleanser (Skintegrity®) at each dressing change.
Pat the periwound skin dry.
Apply a dimethicone barrier (Remedy® Nutrashield) to
the intact periwound skin. This protects the surrounding skin
from becoming macerated.
Apply an alginate dressing, sheet or rope (Maxorb®
Extra) and allow the dressing to overlap slightly onto
the intact skin.
Heavily draining: consider using a foam dressing to cover
the alginate for added absorbency. (Gentleheal® Standard,
Gentleheal Extra or Optifoam®).
Secure the dressing with a composite island
(Stratasorb®), bordered gauze (Bordered Gauze),
retention tape (Medfix Retention Dressing Sheet)
or net dressing (Elastic Net).
Change the dressing every 1 to 5 days, or as needed.
Note: All products shown in italics are distributed by Medline Industries, Inc.
and are used for example purposes only.
6
Protocols (continued)
ENZYMATIC DEBRIDEMENT
Used for:
•Eschar
•Slough
1.
Clean the surface of the eschar or slough with a wound
cleanser (Skintegrity) at each dressing change.
2.
3.
4.
5.
6.
Pat the periwound skin dry.
Eschar: Score or cross-hatch the eschar.
Apply an enzyme generously to the eschar or slough surface.
Cover and secure the surface with an appropriate secondary
dressing such as a composite island (Stratasorb),
bordered gauze (Bordered Gauze), retention tape
(Medfix Retention Dressing Sheet) or net dressing
(Elastic Net).
Change the dressing daily or more frequently according to
the enzyme instructions, if the enzyme dries out, or as
drainage requires.
Eschar Special Consideration:
Scoring or cross-hatching (check your state’s practice act) of eschar
MUST occur if the benefit of the enzyme is to be achieved. If this is
not possible, choose another debridement option.
Note: All products shown in italics are distributed by Medline Industries, Inc.
and are used for example purposes only.
7
HYDROGEL
HYDROGEL IMPREGNATED GAUZE
Used for:
•Eschar
•Dry-to-Moist Slough
1.
Clean the surface of the eschar or slough with a wound
cleanser (Skintegrity) with each dressing change.
2.
3.
Pat the periwound skin dry.
Apply a dimethicone barrier (Remedy Nutrashield), to
the periwound skin. This protects the periwound skin from
the effects of adhesives and picks up excess oils to promote
product adhesion.
Cover the eschar or slough with hydrogel impregnated
gauze (Skintegrity Hydrogel Impregnated Gauze), or a
hydrogel (Skintegrity Hydrogel).
Apply dampened gauze to the eschar or slough with a
wound cleanser (Skintegrity) or normal saline if necessary.
Eschar: Apply a transparent dressing (Suresite), allowing
at least a 1¼-inch overlap. The transparent dressing will hold
in more moisture and enhance softening of the eschar.
Slough: Secure the dressing with a composite island
(StrataSorb), bordered gauze (Bordered Gauze),
retention tape (Medfix Retention Dressing Sheet) or
net dressing (Elastic Net).
Change the dressing every 1 to 3 days.
4.
5.
6.
7.
8.
POLYACRYLATE DEBRIDER
Used for:
•Eschar
•Slough
1.
2.
3.
4.
Apply a dimethicone barrier (Remedy Nutrashield) to
the periwound skin.
Apply a super absorbent polymer pad (TenderWet®
Active).
Secure the dressing with a composite island (Stratasorb),
bordered gauze (Bordered Gauze), retention tape
(Medfix Retention Dressing Sheet) or net dressing
(Elastic Net).
Change the dressing daily.
Note: All products shown in italics are distributed by Medline Industries, Inc.
and are used for example purposes only.
8
Protocols (continued)
TRANSPARENT FILM
Used for:
•Eschar
1.
2.
3.
4.
5.
Clean the surface of the eschar tissue with a wound
cleanser (Skintegrity) at each dressing change.
Pat the periwound skin dry.
Apply a dimethicone barrier (Remedy Nutrashield) to
the periwound skin. This protects the periwound skin from
the effects of adhesives and picks up excess oils to promote
product adhesion.
Apply a transparent dressing (Suresite®), allowing at
least a 1¼-inch overlap. The transparent dressing will hold
more moisture and enhance softening of the eschar.
Change the dressing every 1 to 7 days. Frequency will depend
on the amount of fluid in the wound. Expect an increase in
drainage as necrotic tissue liquefies.
Special Considerations:
•Tunneling
1.
2.
3.
4.
Avoid occlusive dressings.
Without drainage: Loosely pack the tunneling loosely
with gauze saturated with normal saline or hydrogel.
With drainage: Loosely pack the tunneling loosely
with gauze packing.
Continue to dress the wound according to your
facility’s protocol.
Special Considerations:
•Undermining
1.
2.
3.
With drainage: Loosely fill the undermined area with
an alginate (Maxorb Extra) sheet or rope, or
gauze packing.
Without drainage: Loosely fill the undermined area
with gauze packing saturated with hydrogel.
Continue to dress the wound bed according to your
facility’s protocol.
Note: All products shown in italics are distributed by Medline Industries, Inc.
and are used for example purposes only.
9
References:
Bates Jensen B, eds. Management of necrotic tissue. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. 2nd ed. Gaithersburg,
Md: Aspen Publishers, Inc; 2001.
Bergstrom N, Bennet MA, Carlson CE, et al. Treatment of pressure ulcers in
adults. Clinical practice guideline, number 15. AHCPR Publication No. 950652. 1994.
Boynton P, Paustian C. Wound assessment and decision making options.
Critical Care Nursing Clinics of North America. 1996;8(2):125-139.
Dow G, Browne A, Sibbald RG. Infection in chronic wounds: controversies in
diagnosis and treatment. Ostomy Wound Management. 1999;45(8):23-7,29-40.
Fleck, CA. No pain no gain? Addressing pain in patients with wounds. ECPN.
2003;90:16-22.
Flemister B. The Use of a Superabsorbent Wound Dressing Pad for Interactive
Moist Wound Healing. Presented at the 13thAnnual Symposium on Advanced
Wound Care. Dallas, Texas. April 2000.
Morrison M, Moffatt C, Birdel-Nixon J, Bale S. Nursing Management of
Chronic Wounds. 2nd ed. Mosby International Limited; 1998.
Paustian C, Stegman MR. Preparing the wound for healing: the effect of
activated polyacrylate dressing for debridement. Ostomy Wound Management.
2003;49(9):34-42.
Robson M. Wound infection: a failure of wound healing caused by an imbalance
of bacteria. Surgical Clinics of North America. 1997;77(3):637-649.
Sibbald, Orsted, Schultz, Coutts, Keast. Preparing the wound bed 2003: focus on
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