Download Specialty Beds - Detroit Medical Center

Skin and
Wound Care
Braden Scale & Prevention
Section 2 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 are responsible to read the content of these modules
and pass the tests.
• If you are unable to finish reviewing the content of this course in
one sitting, click the Bookmark option found on the left-hand
side of the screen, and the system will mark the slide you are
currently viewing. When you are able to return to the course,
click on the title of the course and you will have button choices
to either:
–
–
Review the Course Material which will take you to the beginning of the
course OR
Jump to My Bookmark which will take you to where you left off on
your previous review of this module.
Objectives:
By completing this module, the RN and LPN will:
1. Recognize the professional responsibility of licensed health care providers.
• RNs will utilize the knowledge to make clinical decisions and
enter EMR orders based on DMC evidenced based
flowcharts found in Tier 2 Skin and Wound Policies.
2. Review basic skin and wound care concepts.
3. Apply DMC standard skin and wound management principles.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
3
Pressure Ulcer
Risk Assessment
Epidemiology and Economics
The National Pressure Ulcer Advisory Panel (NPUAP)
reported that in 2003 there were 455,000 hospital
stays during which pressure ulcers were noted-a 63
percent increase from 11 years earlier.
•
•
•
Patients 65 years and older accounted for 72.3
percent of all those hospitalizations.
LOS for primary diagnosis of pressure sores lasted
nearly 13 days and varied by patients age.
The average charge for hospital stay for pressure
ulcers was $37,800.
Reference: Statistical Brief #3, April 2006. Agency for Healthcare Research and
Quality.
Timely, accurate identification of patients at risk for
pressure ulcers provides opportunity for early
preventive interventions. Pressure ulcer risk
assessment is the basis for planning patient treatment,
evaluating its effects, and communicating with others.
The Braden Scale for Predicting Pressure Sore Risk is a formal,
valid, internationally recognized tool for predicting patient risk
for pressure ulcers.
Identifying patients at risk using the Braden Scale involves
assessing six subscales:
•
•
•
•
•
•
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
4
Braden Schema
Pressure Ulcer Development
Mobility
Activity
Pressure
Sensory
Perception
Extrinsic Factors
Moisture
Friction
Shear
Intrinsic Factors
Nutrition
Arteriolar pressure
Pressure Ulcer
Development
Tissue Tolerance
Age
Other Hypothetical
factors:
Interstitial fluid flow
Emotional stress
Smoking
Skin temperature
Braden, B., Bergstrom, N. (1987).
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
5
Braden Scale
Predicting Pressure
Sore Risk
•The Braden Scale score ranks patients according to their level of risk for
pressure ulceration. Lower scores indicate a lower functional status
and, therefore, a higher level of risk:
9 or less
10 - 12
13 - 14
15 - 18
19 - 23
=
=
=
=
=
Very high risk
High risk
Moderate risk
Mild risk
Generally not at risk
• A total Braden Scale score of 18 or below in an adult patient is
predictive for the development of a pressure ulcer unless preventive
measures are taken. If the total Braden scale score is < 18, the patient
must have preventive interventions.
•Preventative measures must focus on those Braden subscales in which a
patient has a low score.
•Low subscales indicate risk even if total score >18.
•The intensity of interventions is based on the level of risk.
•Target the reason the scale is low in the interventions you select for
your patient.
• All patients who have a Braden Score of 18 or below must have
interventions initiated that will lower the risk for pressure ulcer
development.
•Initiate a Plan of Care for Risk for Impaired tissue Integrity and
corresponding EMR Pressure Ulcer Prevention Order Set
PREVENTION-PREVENTION-PREVENTION
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
6
Braden Scale
Predicting Pressure
Sore Risk
Successful use of the Braden Scale for Predicting Pressure Sore Risk
has been shown to improve patient outcomes by reducing the number of
hospital acquired pressure ulcers.
•
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
7
Braden Q Scale
Predicting Pressure
Sore Risk
The Braden Q scale is a modification of the original Braden Scale used in
adult populations. This modification of the Braden was developed by two
nurses, Dr. Martha Curley and Dr. Sandy Quigley. Braden Q is very reliable
in predicting pressure ulcer risk in children < 5 years old.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
8
Pressure Ulcer
Prevention
Basic tenets of pressure ulcer prevention are managing nutrition, pressure
(friction/shear) and incontinence / excessive moisture.
 If nutrition deficits exist, RN may enter an EMR Healthcare Provider order to
consult a dietitian.
 Protect skin from excessive moisture and fecal / urinary drainage.
Be proactive, start with petrolatum or other barrier creams immediately.
 To manage pressure, control both the intensity and duration.
– Pressure duration is time spent in one position. Manage by repositioning
frequently.
– Pressure intensity is the amount of pressure. Manage by using a special
pressure redistribution support surface e.g., SofCare, Isoflex, Acucair.
 Avoid massaging bony prominences. Massage does not increase circulation or
prevent pressure ulcers. It may cause more damage to compromised tissue
 Use a lift pad to move patients up in the bed to avoid friction and shear
While reclining - use the rule of 30
Unless medically contraindicated, the HOB is kept at a 30 angle or lower to
reduce shear force. When the HOB bed is elevated, shear force results in the
skin and superficial fascia remaining fixed against the bed linen while the deep
fascia and skeleton slide down toward the foot of the bed over bony prominences.
This can stretch the blood vessels and result in sacral shear ulcers. Use of an
overhead trapeze is helpful if a patient has enough upper body strength to lift self
off the bed.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
9
Preventing Heel
Ulcers
HEELS UP!
No support surface provides adequate pressure relief for heels.
–
Diabetic patients with normal Braden scale score are at increased risk for foot / heel
ulcers due to peripheral neuropathy.
Elevate or float heels off sleep surface to prevent pressure ulcers.
Effect of pressure on heels
Elevate heels off the bed
All you need is one hand to fit between heels and the sleep surface.
Use Heel Lift Boots for patients who will not keep heels off surface
HUH/ HWH/ KCH PU COMMITTEE, 5-05 rev DMC Adv Wound Care and Spec Bed Comm 9/08
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
10
Reducing the
Duration of Pressure
While reclining - use the rule of 30
•
•
Patients are repositioned minimally every 2 hours. Teach able patients to shift
their body weight while in bed.
In addition, the patient is repositioned alternately from a right 30 degree lateral
side-lying position to a left 30 degree lateral side-lying position. This will
keep pressure off of the sacrum and the trochanter at the same time. Use a
foam positioning device to support the body in this position.
Avoid positioning patients at a ninety degree angle. Placing them in 90 which is
the degree side-lying positions places them on the trochanter most vulnerable
bony prominence.
While chair sitting

Shear also occurs over the ischial tuberosities when chair sitting patients slide
forward in the chair.

Teach able patients to shift their body weight every 15-30 minutes while chair
sitting. Patients who cannot shift themselves are repositioned / shifted by
caregivers at least every hour and more often if breakdown exists.

Patients sitting in a chair require a pressure redistribution surface e.g., SofCare
cushion, ROHO cushion. They need to be repositioned at 30-60 minute
intervals to change pressure points.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
11
Prevention
Flow Chart
RN TO ASSESS PATIENT
FOR PRESSURE ULCERS AND
PRESSURE ULCER RISK
If patient has a history
of pressure ulcers or
an actual pressure ulcer
If patient has a
Braden Score of < 18
Assess for nutritional
deficits
Assess for
incontinence,
moisture problems
If Braden score for
nutrition is < 2
Protect skin from fecal
and urinary drainage
If Serum Albumin
< 3.5 or
Refer to Skin Care
Flowchart
Consult Dietitian for
complete nutritional
assessment
If patient is bedbound,
chairbound, or unable/
unwilling to reposition self
Protect from effects of
Pressure / shear
If weight change of
10% within 3 month
period or
If patient has chronic
disease
Assess mobility deficits,
activity deficits
and sensory perception
Reposition frequently
to decrease
pressure duration
Place in 30 degree
lateral sidelying
position. Avoid the
trochanter
Provide foam
positioner wedge to
maintain body position
Avoid prolonged
HOB elevation > 30
degrees
Have patient use
trapeze to move
Institute prevention flow chart,
enter EMR Pressure
Ulcer Prevention / Management
Order Set and
Refer to DMC Skin / Wound
Care Flowchart
Determine potential
for rehabilitation
Provide pressure
redistribution to
decrease pressure
intensity
Monitor
effectiveness of
plan
If participates in
therapy and
Order Static Air
Mattress and
Q shift handchecks*
Consult APN / CWOCN
for alternative pressure
relieving surfaces and
further evaluation
Tolerates
15 minutes
of activity and
Patient has
potential
for carryover**
Protect bony
prominences
Suspend heels
off bed with pillow
or Heel Lift Boot
Protect from tubes
and equipment
Order Chair
Cushion for sitting
Recommend
PT/OT
consult to
maximize mobility
*Static Air Mattress – not in use at CHM RIM.
**Observed capacity to learn and follow
through with motor skills necessary for
increased functional independence.
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
12
Reducing Intensity
of Pressure
To be effective, support surfaces must mold to the body to maximize
contact, then redistribute the patient’s weight as uniformly as possible
– pressure redistribution.
• Surfaces are designed so that body weight floating on a fluid
system is evenly distributed over the entire surface.
• As pressure is increasingly distributed over more body
surface area, the intensity of pressure decreases over all
body areas.
Support surfaces also use the principle of deformation, meaning they
must be capable of deforming enough to permit prominent areas of the
body to sink into the support. The surfaces also must be able to transmit
pressure forces from one body area to another.
The degree of head elevation can affect the clinical effectiveness of a
support surface.
– When the head of the bed is elevated, pressure is shifted to the
sacral and ischial areas of the body.
– The patient may “bottom out” if the seating area of the support
surface flattens and loses volume. If bottoming out occurs, the
support surface no longer provides therapeutic benefit.
Whether patients at risk for pressure ulcers are in bed or a chair, pressure
points must be protected. Today, many types of special beds,
mattresses, and cushions are available to reduce the intensity of
pressure. Pressure redistribution surfaces include special foam and
static air mattresses; low air loss, air-fluidized, and oscillating beds.
There is no scientific evidence that one support surface consistently works
better than all others. The best way to match a support surface to a
particular patient’s needs is to learn the special characteristics of each
type of surface. See the following pages for the DMC Decision
Guidelines for Specialty Beds and Overlay Mattresses.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
13
Mattress Overlays
/ Surfaces
Mattress overlays raise the level of the bed surface making
getting in and out of bed more difficult. There is also less
space between the mattress and the top of the side rail.
Ensure patient safety when using these types of overlays.
Foam and air products are used for pressure ulcer prevention. For
patients at risk for pressure ulcers who have excessive moisture
against the skin from incontinence, wound drainage, or
perspiration, a support surface that flows air across the skin is
recommended.
Two inch foam mattress overlays are comfort items only and not
suitable for pressure reduction (Bergstrom, et. al, 1994).
Geo-Matt foam overlays, 3.5 inch thick, high density fire-retardant
foam with contoured, cross-cut cells. Utilized occasionally at RIM,
inexpensive, portable, pressure reducing, and facilitates patient
self-movement from bed to chair.
Gaymar Sof-Care air mattresses are static air mattresses used for
patients at risk for pressure ulcers. Sof-Care mattresses have a
continuous inflation pump available to all DMC sites, free of
charge.
With pressure reducing mattress overlays / surfaces, it is important to
ensure that the patient’s body weight does not fully compress the
overlay.
–
–
–
–
If the overlay is compressed enough for the patient to rest on the
underlying mattress, the patient is “bottoming out”.
To check for proper mattress overlay inflation, place an outstretched
hand (palm up) under the overlay, below the part of the body at risk for
a pressure ulcer. If the caregiver feels less than one inch of
uncompressed support surface, the patient has bottomed out.
To combat “bottoming out”, either increase inflation or move the patient
to a mattress with more depth (Bergstrom, et. al, 1994).
Sof-Care mattresses need to be checked daily for bottoming out
even when using the Gaymar continuous inflation pump.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
14
Specialty Beds
•
Specialty beds and surfaces are selected based on the patient`s status, size and
therapeutic benefit associated with the bed. Specialty beds require patient
evaluation and order processing by an APN or CWOCN.
•
If the goal is pressure ulcer prevention, pressure redistribution surfaces or
mattresses such as low air loss, static air / Sof-Care and Hill Rom DynamicAire (available at DRH ) may meet patient requirements.
•
Patients with pressure ulcers (II through IV) or open wounds on dependent body
surfaces or flaps, grafts or burns may require low-air loss surfaces or airfluidized beds.
•
Patients who are at risk for pulmonary complications and pressure ulcers may
require a rotation surface with low air loss such as Stryker XPRT or SizeWise
Big Turn.
•
Patients in Critical Care with moderate to severe pulmonary complications such
as atelectasis, pneumonia, and ARDS may require continuous lateral rotation
therapy as well as a redistribution surface, e.g., XPRT, Total Care Sport 
•
While the use of pressure-redistribution surfaces on beds or chairs may allow
caregivers to lengthen repositioning intervals, they may also give a false sense
of security.
–
Patients require individual turning schedules regardless of pressure-redistribution
devices or specialty support surfaces.
•
–
Even though every 2 hours is the routine turning interval, patients may require
more frequent repositioning.
Heels must be elevated even when specialty support surfaces are in place.
•
Specific indications and contraindications for use are listed on the following
Specialty Bed Table.
•
Excessive moisture on intact skin may cause maceration and skin breakdown. A
support surface that provides air flow such as low air loss or air fluidized can aid
in keeping the skin dry.
Bariatric Products
•
Wider, more durable bariatric beds such as the Total Care Bariatric, BariAir, and
Mighty Air are available for patients weighing greater than 250 lbs who cannot
be repositioned therapeutically. Bariatric room environments provide a whole
room set-up (commode, walker, lift) to meet the needs of the bariatric patient.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
15
Specialty Beds
Specialty Surface
FOAM
SofCare® Mattress
RIM Only
Hill ROM Acucair® &
SizeWise Alternate Mattress
Replacement
Description
-Provides comfort &
pressure
redistribution when 4
inch GeoMatt used. Provides adequate
depth, density and
indentation load
deformations
Comfort & pressure
redistribution
Comfort & pressure
redistribution, shear &
moisture reduction
Classification
Foam overlay
Static Air Mattress
Continuous air flow overlay
Indications
Comfort
Facilitates bed
mobility
-Prevention in pts at risk for
pressure ulcer
-Pt able to turn in 2 or more
positions without placement
on existing pressure area
-Prevention in pts at risk for
pressure ulcer
-For pts who develop
pressure ulcers while on
SofCare
-Pt able to turn in 2 or more
positions without
placement on existing
pressure area AND
requires moisture
management
Contraindications
-Unstable spinal cord
injuries
-Cervical traction
-Unstable spinal cord
injuries
-Cervical traction
-Unstable spinal cord
injuries
-Cervical traction
Weight Limit
250-300lbs and / or
does not bottom out*
300lbs and / or does not
bottom out*
300lbs and / or does not
bottom out*
Ordering
Personnel
RN
RN
APN / CWOCN
Special Concerns
Requires use of
turning schedule &
incontinence cover to
prevent soiling
-Requires use of turning
schedule
-Unstable surface for
transfers in & OOB
-Use Gaymar pump to
maintain inflation
-Check for bottoming out
Plastic may cause
↑perspiration
-Requires use of turning
schedule
Discontinuation
Obtain From:
APN / CWOCN
RIM Only
CPD
Dynamic Air Therapy or
Isoflex mattresses preclude
use of this product
DMC Advanced Wound Care and Specialty Bed Committee
-DMC Ordering Process
Dynamic Air Therapy in
CHM & DRH precludes use
of this product
©DMC 2009
16
Specialty Beds
Specialty Surface
Hill ROM
Flexicair® Eclipse
Hill ROM
Clinitron ®
Hill ROM
Clinitron® Rite Hite
Description
-Comfort & pressure
redistribution, shear
& moisture reduction
-Comfort & pressure
redistribution, shear &
moisture reduction
-Comfort & pressure
redistribution, shear &
moisture reduction
-Has bed scale & X-ray
window
Classification
Low Air Loss Bed
Air Fluidized therapy bed
Air Fluidized therapy bed &
low air loss surface
Indications
Prevention in patients
> 250lbs
-Treatment in pts with
breakdown
-Treatment in pts with
breakdown, posterior burns
on bedrest, flaps, & grafts
-Provides more moisture /
friction / shear control
-Pts who qualify for
Clinitron Therapy but
require period of high head
elevation e.g., mechanical
ventilation
Contraindications
-Unstable spinal cord
injuries
-Unstable spinal cord
injuries
-Cervical traction
-Not recommended for pts
at risk for pulmonary
complications or those
getting OOB
-Unstable spinal cord
injuries
-Cervical traction
-if pt requires OOB,
consider other therapy
Weight Limit
300lbs and / or does
not bottom out*
250-300lbs
350lbs and / or does not
Ordering
Personnel
APN / CWOCN
APN / CWOCN
APN / CWOCN
Special Concerns
Add
-May cause dehydration
motion sickness, wound
desiccation
-Company rep may be
contacted to move bed
-Consider a private room
-Use MaxiFlo incontinence
pads (available from
Cardinal)
-Elevate heels
-Turn for pulm hygiene
-May cause dehydration
motion sickness, wound
desiccation
-Company rep may be
contacted to move bed
-Consider a private room
-Use MaxiFlo incontinence
pads (available from
Cardinal)
-Elevate heels
-Turn for pulm hygiene
Discontinuation
-Evidence of wound
healing, increase in
activity
-May convert to Acucair
-Evidence of wound
healing, increase in activity
-Pt able to repos with
needed frequency
-May convert to Acucair
-Evidence of wound
healing, increase in activity
-Pt able to repos with
needed frequency
Obtain From:
-DMC Ordering
Process
-DMC Ordering Process
-DMC Ordering Process
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
17
Specialty Beds
Specialty Surface
Hill ROM
Total Care Bariatric
KCI
BariKare
KCI
Bari Air®
Description
Wide bed to facilitate
movement of pts
Pressure reduction,
-Wide bed to facilitate pt
movement
-Wide bed to facilitate pt
movement
-Comfort & pressure
redistribution, shear &
moisture reduction
Classification
Low Air Loss
Foam
Low Air Loss
Indications
Pressure
redistribution
-Facilitates pt
movement in bed,
ambulation,
pulmonary toilet,
egress from foot
• Turn-assist
-Percussion /
vibration
-Comfort device
-Facilitates bed movement,
ambulation, pulmonary
toilet
-Pressure redistribution
-Facilitates pt movement in
bed, ambulation,
pulmonary toilet, egress
from foot
• Turn-assist
• Stabilization handles
Contraindications
-Unstable spinal cord
injuries
Weight Limit
465 lbs
Up to 850lbs
Up to 850lbs
Ordering
Personnel
APN / CWOCN
APN / CWOCN
APN / CWOCN
Special Concerns
Front exit facilitates
patient ambulation
and egress.
Cardiac chair
positioning enhances
pulm function
X-ray cassette holder
-Elevate heels
Front exit facilitates patient
ambulation and egress.
Cardiac chair positioning
enhances pulm function
X-ray cassette holder
Front exit facilitates patient
ambulation and egress.
Cardiac chair positioning
enhances pulm function
X-ray cassette holder
-Elevate heels
-Turn for pulm hygiene
Discontinuation
-meets weight and
ambulation
requirements
-meets weight and
ambulation requirements
-May convert to Acucair
-Evidence of wound
healing, increase in activity
-Pt able to repos with
needed frequency
Obtain From:
-DMC Ordering
Process
-DMC Ordering Process
-DMC Ordering Process
-Unstable spinal cord
injuries
-Cervical traction
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
18
Specialty Beds
Specialty Surface
Sizewise
Platform
Sizewise
Mighty Air
Sizewise
Big Turn
Description
- -Wide bed to
facilitate movement
of pts
Up to 1000Lbs
expandable deck
allowing for widths of
39” or 48
-Wide bed to facilitate
movement of pts
Up to 1000Lbs
expandable deck allowing
for widths of 39” or 48
-Comfort & pressure
redistribution, shear &
moisture reduction
-Has bed scale, HOB
elevation scale
Turning
-Wide bed to facilitate
movement of pts
Up to 1000Lbs
expandable deck allowing
for widths of 39” or 48
-Comfort & pressure
redistribution, shear &
moisture reduction
-Has bed scale, HOB
elevation scale
Classification
Foam
Low Air Loss
Low Air Loss.
Indications
--Comfort device
-Facilitates pt
movement, in bed
Low air loss therapy
2 therapy modes – Static &
Alternating
-Lateral rotation up to
40 degrees
-Percussion/ Vibration
-Side wall bolster supports
-Unstable spinal cord
injuries
-Cervical traction
-Unstable spinal cord
injuries
-Cervical traction
-if pt requires OOB,
consider other therapy
Contraindications
Weight Limit
Up to 1000lbs
Up to 1000lbs
Up to 1000lbs
Ordering
Personnel
APN / CWOCN
APN / CWOCN
APN / CWOCN
Special Concerns
-Requires use of
turning schedule
-48 inch surface must
be broken down to
transfer pt room to
room
-Elevate heels
48 inch surface must be
broken down to transfer pt
room to room
-Elevate heels
48 inch surface must be
broken down to transfer pt
room to room
Discontinuation
-meets weight and
ambulation
requirements
-meets weight and
ambulation requirements
-meets weight and
ambulation requirements
Obtain From:
-DMC Ordering
Process
-DMC Ordering Process
-DMC Ordering Process
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
19
Specialty Beds
Specialty Surface
Description
Hill ROM
Zoneaire - CHM
Stryker
XPRT
•Provides pressure
redistribution, shear
and moisture reduction.
•provides full rotation,
percussion and vibration
therapy in an all-in-one
support surface.
•Low air loss and powered
pressure redistribution provide
advanced pressure ulcer
prevention and treatment.
•Self adjusts with
weight shifts
Classification
Integrated 6 zone low
air loss.
non-integrated support
surface meets critical
pulmonary therapy needs and
pressure redistribution
Indications
Prevention or
identified as at risk
for breakdown
Pulmonary complications:
percussion, vibration,
rotation to 40%
Pressure redistribution
Contraindications
•Unstable spinal cord
injuries
-Cervical traction
•Unstable spinal cord
injuries
-Cervical traction
Weight Limit
300 lbs therapeutic
weight limit
500 Lbs
Ordering
Personnel
CHM RN staff
HUH / HWH Critical Care
RN staff
Special Concerns
•Needs to be turned
on in Prevention
Mode
•Requires use of
turning schedule
•Cycle for 10 minutes
to be sure it is
working properly
before placing patient
on it
Discontinuation
Obtain From:
•CHM only
•Call CHM
Environmental
Service for bed
delivery
Available on HUH / HWH
Critical Care units
DMC Advanced Wound Care and Specialty Bed Committee
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Definitions
DEFINITIONS
The following definitions apply to the Skin and Wound Care Flow Charts
A
•
Abscess: a circumscribed collection of pus that forms in tissue as a result of acute or chronic
localized infection. It is associated with tissue destruction and frequently swelling.
•
Acute wounds: those likely to heal in the expected time frame, with no local or general factor
delaying healing. Includes burns, split-skin donor grafts, skin graft donor site, sacrococcygeal
cysts, bites, frostbites, deep dermabrasions, and postoperative-guided tissue regeneration.
B
•
Bariatric: Term applying to care, prevention, control and treatment of obesity.
•
Basic Wound Care: RN identifies and orders treatment plan based on DMC Skin and Wound
Care Flowcharts.
•
Blister: elevated fluid filled lesions caused by pressure, frictions, and viral, fungal, or
bacterial infections. A blister greater than 1 cm in diameter is a bulla and blisters less than 1
cm is a vesicle.
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 caregiver’s hand and the patient’s
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, Dakin’s 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
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Definitions
D
•
Denuded: Loss of superficial skin / epidermis.
•
Drainage: wound exudate, fluid that may contain serum, cellular debris, bacteria,
leukocytes, pus, or blood.
•
Dressings, primary: dressings placed directly on the wound bed.
•
Dressings, secondary: dressings used to cover primary dressing.
•
Dressings, alginate: primary dressing. A non-woven highly absorptive dressing
manufactured from seaweed. Absorbs serous fluid or exudate in moderately to heavily
exudative wounds to form a hydrophilic gel that conforms to the shape of the wound. May
be used for hemorrhagic wounds. Non adhesive, nonocclusive primary dressing.
Promotes granulation, epithelization, and autolysis.
•
Dressings, foam: primary or secondary dressing. Low adherence sponge-like polymer
dressing that may or may not be adherent to wound bed or periwound tissue e.g.,
Mepilex. Indicated for moderately to heavily exudative wounds with or without a clean
granular wound bed, capable of holding exudate away from the wound bed. Not
indicated for wounds with slough or eschar. Foam and low-adherence dressings are
used in wounds for granulation and epithelialization stages as well as over fragile skin.
•
Dressings, continuously moist saline: primary dressing. A dressing technique in
which gauze moistened with normal saline is applied to the wound bed. The dressing is
changed often enough to keep the wound bed moist and is remoistened when the
dressing is removed. The goal is to maintain a continuously moist wound environment.
Indicated for dry wounds or those with slough that require autolytic therapy.
•
Dressings, gauze: primary or secondary dressing. a woven or non-woven cotton or
synthetic fabric dressing that is absorptive and permeable to water, water vapor, and
oxygen. May be impregnated with petrolatum, antiseptics, or other agents. Indicated for
surgical and draining wounds.
•
Dressings, hydrocolloid: primary dressing. Two kinds of wafer, thick and thin. Wafers
contain hydroactive/absorptive particles that interact with wound exudate to form a
gelatinous mass. Moldable adhesive wafers are made of carbohydrate with a
semiocclusive film layer backing e.g., DuoDerm®.
–
–
–
–
–
–
–
–
–
–
–
Thick wafers are applied over areas with exudate while thin wafers are used over sites with minimal
or no exudate.
Thin wafers may conform to sites easier than thick wafers. Contraindicated where anaerobic
infection is suspected.
Dressing is not removed upon external soiling. Removing any intact product that adheres to skin
strips the epidermis, causes damage and increases the risk for breakdown.
Cover hydrocolloid with a transparent film to decrease friction from repositioning patient or if
dressing is at risk for soiling.
May be used for intact skin that requires protection against friction.
Hydrocydrocolloid and low-adherence dressings are for wounds in the epithelialization stage.
Used to cover a wound entirely, leaving approximately a 1.5 inch border around the wound margins.
Does not require a secondary dressing
Contraindicated for third-degree burns and not recommended for infected wounds.
May be used by wound care consultants to promote autolysis in some patients with eschar.
Not recommended for wounds with depth or friable periwound tissue or those that require monitoring
more often than once or twice a week. May be left on for 3-5 days.
DMC Advanced Wound Care and Specialty Bed Committee
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Definitions
D
•
Dressings, hydrogel or hydrogel impregnated gauze: primary dressing. A waterbased 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 wound’s 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 wound’s 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 nonabsorptive 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
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Definitions
E
•
Enzymes: protein catalyst that induces chemical changes in cells to digest specific tissue.
Indicated for partial and full thickness wounds with eschar or necrotic tissue. Gauze is used
as a secondary dressing, e.g.., Santyl and polysporin.
•
•
Epithelialization: regeneration of epidermis across a wound’s 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
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Definitions
I
•
Incontinence-related dermatitis: an inflammation of the skin in the genital, buttock, or upper
leg areas that is often associated with changes in the skin barrier. Presents as redness, a
rash, or vesiculation, with symptoms such as pain or itching. Associated with fecal or urinary
incontinence.
•
Infection: overgrowth of microorganisms causing clinical signs/ symptoms of infection:
warmth, edema, redness, and pain.
•
Induration: an abnormal hardening of the tissue surrounding wound margins, detected by
palpation. It occurs following reactive hyperemia or chronic venous congestion.
J
K
L
M
•
Maceration: excessive tissue softening by wetting or soaking (waterlogged).
N
•
Negative pressure wound therapy (NPWT) provides an occlusive controlled subatmospheric 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
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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 bloodfilled 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
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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 physician’s 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
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