Download Pressure Ulcer Documentation

Skin and
Wound Care
EMR
Section 7 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
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Pressure Ulcer
Documentation
When a patient is admitted or develops a pressure ulcer,
remember to document in the following forms:
• Histories- did the patient have a pressure ulcer in the past?
Document location and current characteristics e.g., Stage
•
Adult Admission Assessment – on the Braden Scale form,
answer question about pressure ulcer present on
admission
– Document ulcer(s) in Integumentary Detailed.
Complete pressure ulcer grid in its entirety.
•
Ongoing Assessment – document all the characteristics of
the pressure ulcer on the grid including size upon
admission and every Monday
– RN staff is responsible to assess wounds that PCA
staff change
•
Pressure Ulcer Order Set – RN initiated orders for either
Prevention or Management based on DMC Skin and Wound
Care policies
•
Plan of Care – document altered tissue integrity including
repositioning every 2 hours and if on specialty surface
•
Wound Care Education Form - select Ad hoc form and
complete type of education patient received and need for
further education
•
Enter all pressure ulcers, community or hospital acquired
into SRM Variance Reporting system
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Prevention Orders
“Go to Pressure Ulcer Prevention Order Set”
The following data points will send an EMR notification
informing RN staff to activate / enter orders:
• Braden Score of less than or equal to 18
• Braden Subset Scores 2 or less:
–
–
–
–
–
–
•
•
•
•
•
•
•
Activity Braden equal to Bedrest
Mobility Braden equal to Completely Limited
Moisture Braden equal to Constantly Moist
Sensory Perception Braden equal to Completely Limited
Friction & Shear Braden equal to Problem
Nutrition Braden equal to Very Poor
Generalized edema or anasarca present
Incontinence in the Genitourinary or GI system
assessment
Impaired Nutritional Intake
Intake < 50% of normal in last 3 days
Skin Breakdown/Pressure Ulcer
Level of consciousness: lethargic, obtunded or comatose
Weight loss greater than or equal to 10 pounds
Whenever the activate or “Go to” notification is present,
ensure orders are entered for prevention using the
EMR Pressure Ulcer Prevention Order Set
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Management Orders
“Go to Pressure Ulcer Management Order Set”
The following data points will send an EMR notification
informing RN staff to activate / enter orders:
• Pressure Ulcer on Admission Assessment
• Yes response to “Does the Patient have a Pressure
Ulcer”
• Redness, induration, bogginess, erythema, nonblanchable on the Abnormality Skin grid
• Any documentation entered for following locations:
elbows, hips, coccyx, ankles or heels on the Abnormality
Skin grid
Whenever the activate or “Go to: notification is present,
ensure orders are entered for prevention using the
EMR Pressure Ulcer Management Order Set
– Prevention interventions are incorporated into the
Management Order Set
Individual staff RN PI data is gathered for the pressure
ulcer prevention and management process
– Information in EMR for patients at risk / low Braden
subscores is collected to track date / time / individual
RN for the following:
• Assessment entry
• Prevention and management task completion
• Pressure ulcer prevention and / or management order set
entry
•
Information collected is used by management to
improve individual RN documentation and patient
care
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Assessment
Integumentary System
New configuration on tool bar!
Integumentary has been split up into
Ongoing, Pressure Ulcer Care, Incision /
Wound Care and Skin Abnormalities.
Ensure that data is entered into the correct
grid based on patient assessment.
If pressure ulcer, skin
abnormality, or incision /
wound is present, always
complete the corresponding
grid.
These are some of the cues
that signal further assessment
/ documentation is required
Skin abnormalities are not pressure
ulcers. Do not document pressure
ulcers in this section.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Assessment
Integumentary, Ongoing
This page contains key assessment points to document.
Scroll down to view entire assessment form.
Document surface especially
for patients at risk for or with
a pressure ulcer
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Assessment
Pressure Ulcer Care
Measure all pressure ulcers
whenever discovered, upon
admission and every Monday
Select Pressure Ulcer Care
Complete all of the
columns in the
Pressure Ulcer
Care Grid with
each assessment
Describe periwound area since
deterioration may lead to ulcer
enlargement
Dressings must match EMR order entered.
Use comments for details not included in
grid options.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
EMR Pressure Ulcer Prevention and
Management Order Entry
Nicholson, Jack
Select Prevention Order
Set for patients at risk
and Management Order
Set for patients with
pressure ulcers
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
Nicholson, Jack
Enter ordering name
as healthcare
provider and
communication type
as RN Plan of Care or
Per Protocol
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
This may not generate a consult
APN / CWOCN. A separate order is
required for patients with complex
or deteriorating wounds.
Nutrition Consult is
entered for all patients
at risk for or with a
pressure ulcer
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
In the Pressure Ulcer Management Order Set,
double click Wound Care Basic to enter dressing
orders
Select the primary dressing
for the ulcer based on the
DMC Flowcharts
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
Select secondary dressing. If primary dressing
does not require a cover e.g., hydrocolloid /
Duoderm, select “None” for secondary dressing
Select everything that covers the
primary dressing and the
attachment system e.g., barrier
wafer (stomahesive)
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
Select Debridement
Type.
Autolytic
debridement occurs
with hydrogel impreg
gauze, hydrogel, and
hydrocolloid /
Duoderm
Mechanical debridement occurs with true wet
to dry dressings when they are allowed to dry
in the wound bed and ripped out debriding
healthy and dead tissue.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
Enter special
instructions as
needed that will
clarify orders
Add frequency of dressing
change to the special
instructions
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Pressure Ulcer
Order Sets
Orders from the Pressure
Ulcer Prevention or
Management Order Set
appear in the Activity and
Vitals/ Patient Care section
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Plan of Care
Initiate an Integumentary Plan of Care for
patients at risk or with an actual pressure ulcer
Document repositioning
frequency in Comments for
patients at risk / actual
pressure ulcer
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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Patient Education
Documentation
Use the Education Wound Care Form to document
patient / family education regarding prevention or
treatment of pressure ulcers.
;
Nicholson, Jack
DMC Advanced Wound Care and Specialty Bed Committee
Document in Ad Hoc
Charting. Select EMR Forms,
Education Wound Care Form
©DMC 2009
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Patient Education
Documentation
Select individuals taught, teaching
method and barriers to learning
Document concepts taught and patient /
family future needs for teaching.
Add Comments as needed.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
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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
©DMC 2009
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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
©DMC 2009
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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
©DMC 2009
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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
©DMC 2009
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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
©DMC 2009
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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
26
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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27
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