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

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DMC Advanced Wound Care and Specialty Bed Committee

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

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DMC Advanced Wound Care and Specialty Bed Committee

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.

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DMC Advanced Wound Care and Specialty Bed Committee

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

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Braden Schema

Pressure Ulcer Development

Mobility Activity Sensory Perception Extrinsic Factors Moisture Friction Shear Intrinsic Factors Nutrition Arteriolar pressure Age Other Hypothetical factors: Interstitial fluid flow Emotional stress Smoking Skin temperature Pressure Tissue Tolerance Pressure Ulcer Development

Braden, B., Bergstrom, N. (1987).

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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 = Very high risk 10 - 12 13 - 14 = High risk = Moderate risk 15 - 18 19 - 23 = 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. •L

ow 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

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DMC Advanced Wound Care and Specialty Bed Committee

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

.

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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.

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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

.

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DMC Advanced Wound Care and Specialty Bed Committee

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

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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.

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Prevention Flow Chart

RN TO ASSESS PATIENT FOR PRESSURE ULCERS AND PRESSURE ULCER RISK

If patient has a Braden Score of < 18 If patient has a history of pressure ulcers or an actual pressure ulcer Assess for nutritional deficits Assess for incontinence, moisture problems Assess mobility deficits, activity deficits and sensory perception Institute prevention flow chart, enter EMR Pressure Ulcer Prevention / Management Order Set

and

If Braden score for nutrition is < 2 Protect skin from fecal and urinary drainage If patient is bedbound, chairbound, or unable/ unwilling to reposition self Refer to DMC Skin / Wound Care Flowchart If Serum Albumin < 3.5

or

Refer to Skin Care Flowchart If weight change of 10% within 3 month period

or

Protect from effects of Pressure / shear Determine potential for rehabilitation If patient has chronic disease Consult Dietitian for complete nutritional assessment Reposition frequently to decrease pressure duration Provide pressure redistribution to decrease pressure intensity Place in 30 degree lateral sidelying position. Avoid the trochanter Order Static Air Mattress and Q shift handchecks* Provide foam positioner wedge to maintain body position Avoid prolonged HOB elevation > 30 degrees Protect bony prominences Suspend heels off bed with pillow or Heel Lift Boot Protect from tubes and equipment Have patient use trapeze to move Order Chair Cushion for sitting Monitor effectiveness of plan Consult APN / CWOCN for alternative pressure relieving surfaces and further evaluation If participates in therapy

and

Tolerates 15 minutes of activity

and

Patient has potential for carryover** 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.

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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.

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DMC Advanced Wound Care and Specialty Bed Committee

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 charge.  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 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.

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DMC Advanced Wound Care and Specialty Bed Committee

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 Dynamic Aire (

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 air fluidized 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 DMC Advanced Wound Care and Specialty Bed Committee

patient.

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Specialty Beds

Specialty Surface Description Classification Indications Contraindications Weight Limit mobility

FOAM

RIM Only

-Provides comfort & pressure redistribution when 4 inch GeoMatt used. Provides adequate depth, density and indentation load deformations Foam overlay Comfort Facilitates bed -Unstable spinal cord injuries -Cervical traction 250-300lbs and / or does not bottom out* RN

SofCare

Comfort & pressure redistribution

® Mattress

Static Air Mattress

Hill ROM Acucair ® & SizeWise Alternate Mattress Replacement

Comfort & pressure redistribution, shear & moisture reduction Continuous air flow overlay -Prevention in pts at risk for pressure ulcer -Pt able to turn in 2 or more positions without placement on existing pressure area -Unstable spinal cord injuries -Cervical traction 300lbs and / or does not bottom out* RN -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 -Unstable spinal cord injuries -Cervical traction 300lbs and / or does not bottom out* APN / CWOCN Ordering Personnel Special Concerns

Discontinuation Obtain From:

Requires use of turning schedule & incontinence cover to prevent soiling RIM Only -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 CPD Dynamic Air Therapy or Isoflex mattresses preclude use of this product APN / CWOCN -DMC Ordering Process Dynamic Air Therapy in CHM & DRH precludes use of this product

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Specialty Beds

Specialty Surface Description Classification Indications Contraindications Weight Limit Ordering Personnel Special Concerns Add

Hill ROM Flexicair ® Eclipse

-Comfort & pressure redistribution, shear & moisture reduction Low Air Loss Bed Prevention in patients > 250lbs -Treatment in pts with breakdown -Unstable spinal cord injuries 300lbs and / or does not bottom out* APN / CWOCN

Hill ROM Clinitron ®

-Comfort & pressure redistribution, shear & moisture reduction Air Fluidized therapy bed -Treatment in pts with breakdown, posterior burns on bedrest, flaps, & grafts -Provides more moisture / friction / shear control -Unstable spinal cord injuries -Cervical traction -Not recommended for pts at risk for pulmonary complications or those getting OOB 250-300lbs

Hill ROM Clinitron® Rite Hite

-Comfort & pressure redistribution, shear & moisture reduction -Has bed scale & X-ray window Air Fluidized therapy bed & low air loss surface -Pts who qualify for Clinitron Therapy but require period of high head elevation e.g., mechanical ventilation -Unstable spinal cord injuries -Cervical traction -if pt requires OOB, consider other therapy 350lbs and / or does not APN / CWOCN APN / CWOCN

Discontinuation Obtain From:

-Evidence of wound healing, increase in activity -DMC Ordering Process -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 convert to Acucair -Evidence of wound healing, increase in activity -Pt able to repos with needed frequency -DMC Ordering Process -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 convert to Acucair -Evidence of wound healing, increase in activity -Pt able to repos with needed frequency -DMC Ordering Process

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Specialty Beds

Specialty Surface Description Classification Indications

Hill ROM Total Care Bariatric

Wide bed to facilitate movement of pts Pressure reduction, Low Air Loss Pressure redistribution -Facilitates pt movement in bed, ambulation, pulmonary toilet, egress from foot • Turn-assist -Percussion / vibration -Wide bed to facilitate pt movement Foam

KCI BariKare KCI Bari Air ®

-Wide bed to facilitate pt movement -Comfort & pressure redistribution, shear & moisture reduction Low Air Loss -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 Weight Limit -Unstable spinal cord injuries 465 lbs Up to 850lbs -Unstable spinal cord injuries -Cervical traction Up to 850lbs Ordering Personnel Special Concerns

Discontinuation Obtain From:

APN / CWOCN Front exit facilitates patient ambulation and egress.

Cardiac chair positioning enhances pulm function X-ray cassette holder -Elevate heels -meets weight and ambulation requirements -DMC Ordering Process APN / CWOCN Front exit facilitates patient ambulation and egress.

Cardiac chair positioning enhances pulm function X-ray cassette holder -meets weight and ambulation requirements -DMC Ordering Process APN / CWOCN Front exit facilitates patient ambulation and egress.

Cardiac chair positioning enhances pulm function X-ray cassette holder -Elevate heels -Turn for pulm hygiene -May convert to Acucair -Evidence of wound healing, increase in activity -Pt able to repos with needed frequency -DMC Ordering Process

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DMC Advanced Wound Care and Specialty Bed Committee

Specialty Beds

Specialty Surface Description Classification Indications Contraindications Weight Limit

Sizewise Platform

- -Wide bed to facilitate movement of pts Up to 1000Lbs expandable deck allowing for widths of 39” or 48

Sizewise Mighty Air

-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 Low Air Loss Foam --Comfort device -Facilitates pt movement, in bed Up to 1000lbs Low air loss therapy 2 therapy modes – Static & Alternating -Unstable spinal cord injuries -Cervical traction Up to 1000lbs

Sizewise Big Turn

-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 Low Air Loss. -Lateral rotation up to 40 degrees -Percussion/ Vibration -Side wall bolster supports -Unstable spinal cord injuries -Cervical traction -if pt requires OOB, consider other therapy Up to 1000lbs Ordering Personnel Special Concerns APN / CWOCN -Requires use of turning schedule -48 inch surface must be broken down to transfer pt room to room APN / CWOCN -Elevate heels 48 inch surface must be broken down to transfer pt room to room APN / CWOCN -Elevate heels 48 inch surface must be broken down to transfer pt room to room

Discontinuation Obtain From:

-meets weight and ambulation requirements -DMC Ordering Process -meets weight and ambulation requirements -DMC Ordering Process -meets weight and ambulation requirements -DMC Ordering Process

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DMC Advanced Wound Care and Specialty Bed Committee

Specialty Beds

Specialty Surface Description Classification Indications Contraindications

Hill ROM Zoneaire - CHM

•Provides pressure redistribution, shear and moisture reduction.

•Self adjusts with weight shifts Integrated 6 zone low air loss.

Prevention or identified as at risk for breakdown

Stryker XPRT

•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. non-integrated support surface meets critical pulmonary therapy needs and pressure redistribution Pulmonary complications: percussion, vibration, rotation to 40% Pressure redistribution •Unstable spinal cord injuries -Cervical traction •Unstable spinal cord injuries -Cervical traction Weight Limit Ordering Personnel Special Concerns 300 lbs therapeutic weight limit 500 Lbs CHM RN staff HUH / HWH Critical Care RN staff •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

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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

(POA). : 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

Contaminated

: containing bacteria, other microorganisms, or foreign material. Term usually refers to bacterial contamination. Wounds with bacterial counts of 10 considered infected.

5 or fewer organisms per gram of tissue are generally considered contaminated; those with higher counts are generally

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

whirlpool.

: 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

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.

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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.

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Definitions

• • • • • • •

D Dressings, hydrogel or hydrogel impregnated gauze

: primary dressing. A water based non-adherent dressing primarily designed to hydrate the wound, may absorb small amount of exudate e.g., Skintegrity. Indicated for dry to minimally exudative wounds with or without clean granular wound base. Donates moisture to the wound and is used to facilitate autolysis. May be used to provide moisture to wound bed without macerating surrounding tissue. Requires a secondary dressing.

Dressings: Primary :

dressing placed directly on the wound bed.

Dressings: Secondary:

dressing used to cover primary dressing.

Dressings, silver:

– Useful for colonized wounds or those at risk of infection and decreases 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 non absorptive dressing that is permeable to oxygen and water vapor e.g., Tegaderm. Creates a moist environment that assists in promoting autolysis of devitalized tissue. Protects against friction. Allows for visualization of wounds. Indicated for superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with little or no exudate

Dressings, wet-to-dry

: a debridement technique in which gauze moistened with normal saline is applied to the wound and removed once the gauze becomes dry and adheres to the wound bed. Indicated for debridement of necrotic tissue from the wound as the dressing is removed, however method is not selective and removes healthy tissue as well. Other methods of debridement are considered more effective. Wet to dry dressing orders that are changed at a frequency that does not allow drying are considered continuously moist dressings.

Dressing, xeroform

: primary dressing. Impregnated gauze with petrolatum and 3% bismuth. Indicated for skin donor sites and other areas to protect from contamination while allowing fluid to pass to secondary dressing.

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DMC Advanced Wound Care and Specialty Bed Committee

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):

normal reactive hyperemic response.

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

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

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 is tissue infected with an anaerobic organism e.g., clostridium.

Granulation Tissue:

fibroblasts, and inflammatory cells, which fills an open, previously deep wound when it starts to heal.

pink/red, moist tissue that contains new blood vessels, collagen, •

H Hospital acquired condition (HAC)

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.

–

condition that occurs during current hospitalization.

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DMC Advanced Wound Care and Specialty Bed Committee

Definitions

• • •

I

Incontinence-related dermatitis:

incontinence.

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

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

•

N

Maceration:

excessive tissue softening by wetting or soaking (waterlogged).

Negative pressure wound therapy (NPWT)

provides an occlusive controlled sub atmospheric pressure (negative pressure) suction dressing that promotes moist wound healing. Controlled sub-atmospheric pressure improves tissue perfusion, stimulates granulation tissue, reduces edema and excessive wound fluid, and reduces overall wound size. Some indications for use include pressure ulcers, venous ulcers, diabetic foot ulcers, dehisced surgical incisions, partial thickness burns, grafts, split thickness skin grafts, traumatic wounds, fasciotomy, myocutaneous flaps, and temporary closure for abdominal compartment syndrome (V.A.C. ACS).

No Touch Technique:

Dressing change technique where only the outer layer of dressing is touched with clean gloves. The dressing surface against the wound bed is never touched.

•

O P

Periwound:

area surrounding a wound. Assessed for signs of inflammation or maceration.

Pressure Ulcer

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

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DMC Advanced Wound Care and Specialty Bed Committee

Definitions

•

P Pressure Ulcer Staging

–

Stage I:

: 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. Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk). Treatment: Do not cover, assess frequently for progression. –

Stage II:

partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Treatment: Hydrogel / hydrogel impregnated gauze, or foam / Mepilex dependent on location. –

Stage III:

full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Treatment: Hydrogel / hydrogel impregnated gauze or continuously moist dressings. –

Stage IV:

full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Treatment: Hydrogel / hydrogel impregnated gauze, continuously moist dressings. –

Unstageable:

full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Treatment: contact APN / CWOCN for enzymatic agent for areas outside of the heels. –

Deep Tissue Injury:

Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. *Bruising indicates suspected deep tissue injury. These lesions may herald the subsequent development of a Stage 3 or Stage 4 Pressure Ulcer even with optimal management. Treatment: protect, reposition off area at all times, contact APN CWOCN, assess frequently for deterioration. Although useful during initial assessment, the staging classification system cannot be used to monitor progress over time. Pressure ulcer staging is not reversible. Ulcers do not heal in reverse order from a higher number to a lower number and are not be described s such e.g., “the ulcer was a Stage II but now looks like a Stage I”). Wounds with slough or eschar cannot be staged. The full extent or wound depth is hidden by slough or eschar.

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Definitions

• •

P Present on Admission (POA):

– consultative form. 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 • • • • • •

Q R

• • • • • •

Protective barrier film

contact . : 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

Pustule:

Elevated superficial filled with purulent fluid .

Purulent:

forming or containing pus.

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.

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