Download Diabetic Foot, Rashes, and IAD

Skin and
Wound Care
Diabetic Foot, Rashes, IAD
Section 4 of 7
RN and LPN
Self-learning Module
DMC Adv Wound Care and Specialty Bed Committee
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
Diabetic Foot Ulcer
World Health Organization definition
“The foot of a diabetic that has the potential risk of pathologic
consequences, including infection, ulceration, and/or destruction of
deep tissues associated with neurologic abnormalities, various
degrees of peripheral vascular disease, and/or metabolic
complications in the lower limb.”
Patients most likely to have a foot ulcer:
•Long standing diabetes
•Insulin dependant
•Smokers
•Common complication
•15% develop foot ulcers
•Prevalence 4-10%
•ALOS infected/ischemic
•59% longer than diabetic patients without ulcers
•14%-20% require amputation
•Precursor to 85% amputation in diabetic patients
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
4
Diabetic Foot
Risk Factors
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Peripheral Neuropathy
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Primary factor
Autonomic neuropathy
Structural abnormality
Limited joint mobility
Foot deformities
Abnormal pressures
Minor trauma
Peripheral Vascular Disease
Previous ulcers
Previous amputations
Assessment and Treatment
•
Ensure podiatry consult
Charcot Joint
•
Assess for pedal pulse or Doppler signal
•
Blood glucose in target range
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Educate patient regarding prevention strategies
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Avoid all pressure to the ulcer. Obtain off loading devices
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Check feet daily (use mirror) – lesions, redness, blisters
Wash daily, dry well – no hot water
Avoid heating pads, hot water bottles
Moisturize, except between toes
Always wear shoes
Get professional nail and callous care
Avoid chemicals
Report problems early
Total non weight bearing: crutches, bed, wheel chair, cane
Total contact cast, brace, or specialty boots or shoes
Document in EMR
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Detailed, Integumentary
Incision / Wound Grid
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
5
Leg Ulcers
•
80-90% of all leg ulcers are vascular in nature with the largest number arising
from venous insufficiency.
•
Cleanse leg ulcer with normal saline to remove wound debris before assessing
ulcer.
•
Assess leg for venous versus arterial ulcers:
VENOUS characteristics
ARTERIAL characteristics
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Warm foot, edema
Brawny discoloration
Some pain when foot dependent
Pain relieved with elevation
May be large size
Usually above ankle on medial side
May be granulating
Ulcer base moist
•
Palpate foot and leg pulses. If pulses are absent or an arterial
ulcer is suspected, consult physician.
•
If necrotic tissue present, consult Wound Care Specialist.
•
Compression dressings are used for treating non-infected venous ulcers, usually
on an outpatient basis.
•
Leg ulcer dressings should maintain moisture, absorb excessive drainage and
protect the wound bed.
•
Deep ulcers may require three layers of dressings: a contact layer touching
wound bed; a loose fill layer; and a cover layer which holds the dressing in
place.
•
Shallow ulcers may require only one layer of dressing.
•
Venous ulcers require leg elevation when not ambulating.
DMC Advanced Wound Care and Specialty Bed Committee
•
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Foot cool or cold
Shiny, dry, pale skin, nail deformities
Pain with elevation
Absence of leg hair
Usually small size
May be below ankle, on toes or
pressure area(s)
• Elevation pallor, dependent rubor
• Slow capillary refill
• Ulcer base dry
©DMC 2009
6
Leg Ulcer Dressing
Flow Chart
RN TO ASSESS
Foot and Leg
PULSES / Doppler Signals
Pulse /
Doppler Signal
Present
Pulse /
Doppler Signal
Absent
INTACT SKIN or
HEALED ULCER
BROKEN SKIN
CLEANSING
Normal Hygiene
Soap & Warm H20
CLEANSING
Normal Saline
ASSESS
Ulcer Color, Size,
Depth, Necrosis
PROTECTION
Prevent trauma
Refer to Skin Care
Flow Chart
Clean No Necrotic
Tissue
Consult physician
NECROTIC TISSUE
Present
Consult APN /
CWOCN or
Physician
ASSESS
Periulcer skin
Refer to Peri-wound
Skin Flow Chart
CHOOSE method
to Attach
Cover Dressing
Avoid Tape
CHOOSE Dressing
Shallow Ulcer
DRAINAGE
HEAVY
Dry Gauze,Alginate
CONSULT APN / CWOCN
MODERATE
Moist Saline Gauze,
Hydrogel Gauze
NONE TO MINIMAL
Hydrocolloid,
Hydrogel Gauze,
Moist Saline Gauze
Deep Ulcer
Consult APN / CWOCN
DRAINAGE
HEAVY
Dry Gauze, Alginate
Cover with Gauze
or ABD
MODERATE
Moist Saline Gauze,
Hydrogel Gauze
Cover with dry gauze
or ABD
NONE TO MINIMAL
Moist Saline Gauze,
Hydrogel Gauze
These flow sheets do not represent the full scope of care
For evaluation of Compression therapy, consult APN / CWOCN / Wound Care Specialist .
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
7
Surgical Wounds
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Cleanse wounds with normal saline with each dressing change.
Assess wound for color, size, depth, drainage, necrosis, edges and
peri-wound skin.
Necrotic tissue is nonviable and needs to be removed. Consult for
debridement options.
Deep surgical wounds may require three layers of dressings. See
Dressing Section of module for details.
• Contact layer: Dressings in contact with the wound bed should
maintain tissue moisture.
• Fill layer: Additional dressing materials are placed on top of the
contact layer to loosely fill dead space.
• Cover layer: Covering is dependent on wound location and amount
of wound drainage.
•
Shallow wounds may require only one layer of dressing that
maintains moisture and covers the wound.
•
Cardiothoracic patients with sternal incisions:
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Cover until healed.
Cover while patient remains mechanically ventilated and/or has a
tracheostomy.
Do not change dressing for 48 hours postoperatively.
Cleanse with sterile normal saline.
Bariatric surgery patients are educated:
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Not to shower for 48 hours to prevent surgical glue from being disrupted
e.g., Dermabond.
To wash with fragrance free soap and water over incisions.
To avoid stretching / bending / twisting to prevent tearing incision.
To wear an abdominal binder while ambulating.
•
•
Patients post bariatric surgery that require an open approach must wear their
binders at all times for 4-6 weeks.
Consult APN / CWOCN when uncertain about wound care.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Surgical Wound
Flow Chart
RN TO ASSESS
SURGICAL WOUND
Drains in Place
Open Incision
Closed Incision*
Cleanse with Normal
Saline
Consult
Open to Air After
Initial Dressing
Removed
Assess Wound Color,
Size, Depth, Drainage,
Necrosis and Peri-wound Tissue
Necrotic Tissue
Consult
Use Normal Hygiene
for Cleansing
Non-necrotic Tissue
Monitor for Redness,
Pain, Swelling, Drainage
Choose Dressing to
loosely fill wound
Choose Dressing to
Cover Wound
1.
2.
Deep Wound
Shallow Wound
3.
4.
DRAINAGE
DRAINAGE
HEAVY
Dry Gauze, Alginate
Wound Pouch
HEAVY
Unlikely
Gauze or ABD, Consult
HEAVY
Gauze or ABD
Consult
MODERATE
Damp Saline Gauze,
Hydrogel Gauze
MODERATE
Gauze or ABD
MODERATE
Damp Saline Gauze,
Hydrogel Gauze
Plain NuGauze Strips
NONE TO MINIMAL
Damp Saline Gauze
Hydrogel Gauze
NONE TO MINIMAL
Damp Saline Gauze,
Hydrogel Gauze
Hydrocolloid
Transparent Film
*For Cardiothoracic
sternal incisions:
Cover until healed
Cover while mechanically
ventilated and/or while
pt has a tracheostomy
Do not change for 48 hrs stop.
Cleanse with sterile normal
saline at each drsing change.
DRAINAGE
NONE TO MINIMAL
Gauze, Transparent
Film
These flow sheets do not represent the full scope of care.
Refer to APN / CWOCN Wound Care Specialist when in doubt.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Herpes Simplex
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Uniform grouped dome-shaped pustule rapidly form on a
erythematous base, umbilicate, subsequently erode,and
crust
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More numerous and scattered with initial infection.
•
May resemble pressure ulcers when pustule merge.
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Immunocompromised are at increased risk.
•
Do not cover with hydrocolloid dressings or any
dressing / cream that retains moisture.
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Area is left open to air.
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Culture is the most definitive method
Sample lesions in the vesicular or early ulcerative stage
Vesicles are punctured and a swab is then rubbed onto the base of the
lesion
Treatment is dependent upon size and dissemination of lesions
•
•
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Topical antiviral
IV antiviral
Progression from pustules to umbilicated pustules to crusts
Pustule
Umbilicated Pustules
DMC Advanced Wound Care and Specialty Bed Committee
Crusts
©DMC 2009
10
Fungal Rash
Fungal rash presents as a pruritic area of solid discoloration, associated with:
•Redness or darker pigmentation
•Extrafollicular red pustules
•Maceration with white satellite lesions in the periphery
•Burning sensation
Rash is frequently caused by candida albicans, a skin flora that proliferates in a warm,
moist dark environment. Predisposing factors include:
•Diabetes
•Incontinence
•Damp dressings
•Antibiotic therapy
•Steroids
•Immunosuppression
•Use of oral contraceptives
Fungal infection is typically seen under
pendulous breasts, overhanging abdominal folds,
axilla, between toes, and in the perineal area.
Actions:
•Establish a toilet program
•Reduce effects of moisture / incontinence
•Cleanse perineal area with perineal cleanser or normal saline with each incidence
of incontinence.
•Gently pat area dry. Avoid excessive friction and scrubbing, which may cause
further trauma to the skin.
•Do not use closed diapers on patients with fungal rash.
•Consider using a fecal collector, rectal trumpet or Flexiseal®, condom or retracted
penis pouch.
•Consult APN for:
•Low air loss surface
•Interdry Ag ®
•Consider obtaining orders for:
•Ova and parasites, Clostridium difficile
•Miconazole powder
•Lactobillus granules in feedings to restore the bacterial flora in patients without GI
complications
•IV antifungal agents for severe fungal infections
•Educate caregivers
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
11
Incontinence
Associated
Dermatitis
Incontinence associated dermatitis (IAD) is inflammation of the surface of
the skin with redness edema and in some cases bullae or vesicles.
Eroded or denuded areas of superficial skin layers are generally
associated with severe cases. Fungal rash is a common complication.
Three principles areas contributing to IAD: tissue tolerance, perineal
environment, and toileting ability. Aging skin is particularly vulnerable to
damage from long term exposure to urine and stool.
The use of diapers has been identified as a primary cause of IAD.
Diapers alter the microflora by increasing the number of coagulase
negative staphlococci. Skin covered by a diaper has a higher pH than
one exposed to air thereby increasing the possibility for IAD. Do not use
closed diapers on patients with IAD.
Actions:
•Routine use of skin protectants such as barrier creams and ointments e.g.,
Petrolatum, Sensicare, Xenaderm.
•Cleanse denuded skin with saline.
•Establish a toileting program when feasible.
•Avoid scrubbing and using rough towels / washcloths over at risk areas.
•Avoid using diapers in patients
•Educate caregivers
•Begin aggressive treatment for underlying incontinence.
•Treat fungal rash when present.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
12
Intertrigo
Intertrigo occurs in between opposed skin surfaces.
Characterized by erythema, maceration, burning, itching,
and sometimes erosions, fissures, exudate, and
secondary infection. Risk factors are thought to be obesity
and poor hygiene. Diabetes may be associated with its
development.
• Treatment:
– Ordered by APN
– InterDry Ag is a fabric with Antimicrobial Silver Complex that
is placed between skin folds and other skin to skin areas. It
is designed to manage moisture, odor and inflammation.
– Positioned between folds with at least 1 inch exposed at
either end to allow for moisture evaporation.
– Left in place for up to 5 days unless grossly soiled.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
13
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
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Bariatric: Term applying to care, prevention, control and treatment of obesity.
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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
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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
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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
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Debridement, autolytic: disintegration or liquefaction of tissue or cells; self-digestion of
necrotic tissue.
•
Debridement, chemical: topical application of biologic enzymes to break down devitalized
tissue, e.g., Accuzyme, Santyl (Collagenase).The following definitions apply to the Skin and
Wound Care Flow Charts:
•
Debridement, mechanical: removal of foreign material and devitalized or contaminated
tissue from a wound by physical forces rather than by chemical (enzymatic) or natural
(autolytic) forces. Examples are scrubbing, wet-to-dry dressings, wound irrigation, and
whirlpool.
•
Debridement, sharp: removal of foreign matter or devitalized tissue by a sharp instrument
such as a scalpel. Laser debridement is also considered a type of sharp debridement.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
14
Definitions
D
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Denuded: Loss of superficial skin / epidermis.
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Drainage: wound exudate, fluid that may contain serum, cellular debris, bacteria,
leukocytes, pus, or blood.
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Dressings, primary: dressings placed directly on the wound bed.
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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®.
–
–
–
–
–
–
–
–
–
–
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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
©DMC 2009
15
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
©DMC 2009
16
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
©DMC 2009
17
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.
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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.
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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
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