Skin Champion Education - Mid-America Wound Healing Society

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Skin Champion
Education
Robert J. Dole VAMC
SKIN/Wound care education
Objectives
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Describe the pathophysiology of wound healing
Explain the difference between acute and chronic wounds
Identify factors that impair wound healing
Describe the benefits of moist wound healing
State the principles of wound management
Explain pressure ulcer risk, skin, and wound assessment
documentation requirements.
• Discuss the importance of pressure ulcer prevention
• Describe how a pressure ulcer develops
• Describe the key elements in pressure ulcer assessment and
staging
Anatomy of the Skin
Epidermis
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Outermost layer (epi- means upon)
Thickness from 0.1mm to 1.0mm
Slightly acidic – avg. pH 5.5
“ACID MEMBRANE”
Contains melanocytes – pigment
Made up of 4 to 5 layers depending on
location
Layers of the epidermis
• Stratum corneum - horny layer - dead skin
cells (keratinized epithelium) -environment
• Acid mantle protects from some fungi and
bacteria
• Shed and replaced every 4 to 6 weeks
• Stratum lucidum - clear layer – single cell
layer found where thickest – soles of feet
• Intense enzyme activity prepares cells for
stratum corneum even though lacks nuclei
• Stratum granulosum - granular layer – 1
to 5 cells – flat cells with nuclei – aids
keratin formation -
Layers of the epidermis
• Stratum spinosum – cells begin to flatten
as they migrate – protein precursor of
keratinized skin cells synthesized
• Stratum basale / stratum germinativum
• One cell thick
• Only layer that undergoes mitosis
• Forms dermoepidermal junction – protrusions
known as rete ridges or epidermal ridges extend
into dermis and are surrounded by vascularized
dermal papillae
• Support and exchange of fluid and cells
Dermis - deeper layer of skin
• Collagen (strength) and elastin (elasticity)
fibers produced by fibroblasts
• Extracellular matrix – gives skin its
physical characteristics
• Blood and lymphatic vessels – transport O2,
nutrients and remove wastes
• Nerve fibers, hair follicles, sweat glands –
contribute to sensation, temperature
regulation, excretion and absorption
• Sebaceous glands – sebum lubricates and
softens the skin
Dermis
Two layers of connective tissue
• Papillary dermis - outermost layer
• Composed of collagen and reticular fibers
important in wound healing
• Capillaries transport nourishment
• Reticular dermis – innermost
• Thick network of collagen bundles anchor it to
subcutaneous tissue, fasciae, muscle and bone
Subcutaneous tissue
(Hypodermis)
• Layer of loose connective tissue that
contains major blood and lymph vessels and
nerves
• High proportion of fat cells
• Fewer small blood vessels than dermis
• Provides insulation, absorbs shocks to the
skeletal system
Effects of Aging
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50% reduction in cell turnover rate of stratum corneum
20% reduction in dermal thickness
Reduction in vascularization and blood flow to the skin
Redistribution of subcutaneous tissues to stomach and
thighs
Reduced adhesion between layers
Reduced number of Langerhan’s cells – macrophages that
attack invading bacteria
50% decrease in fibroblasts and mast cells involved in
inflammatory process
Decrease number of sweat glands
Decreased absorption
Reduced ability to sense pressure, heat and cold
Phases of Wound Healing
• Hemostasis - vasoconstriction and
coagulation
• collagen fibers in the damaged vessels wall
activate platelets
• Inflammation – defense and healing
• Neutrophils engulf debris and bacteria
• Monocytes converted to macrophages
• Macrophages produce growth factors that
attract cells needed for new vessel growth,
collagen for granulation and epithelialization
Phases of Wound Healing
• Proliferation
• granulation tissue (connective tissue) fills the
wound
• Wound edges retract/contract
• Epithelium migrates across the wound
• Maturation
• Shrinking and strengthening of the scar
• Continues for months and even years – 80%
Hemostasis phase
Inflammatory phase
Proliferation phase
Maturation phase
Non-healing wound
Acute wounds
• Occur by intension or trauma
• Begins with a sudden, single insult
• Proceeds to heal in an orderly manner
• Surgical wounds
• Traumatic wounds: unplanned injury to the
skin
• Burns
• Skin grafting
Acute wound
Chronic wounds
• Caused by underlying pathology that
produces repeated and prolonged insults to
the tissues
• Frequently complicated by ischemia,
necrotic tissue and heavy bacterial loads
• High levels of inflammatory proteases and
low levels of growth factors
Chronic wound
Factors that affect healing
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Nutrition
Oxygenation
Infection
Age
Chronic health conditions
Medications
Smoking
Nutrition
• Malnutrition increases the risk of developing
pressure ulcers and delays healing
• Protein is crucial for proper healing (0.8 to 1.6g/kg/day)
• Collagen formation is reduced or delayed without
adequate protein
• Fatty acids (lipids) used in cell structures and
inflammatory processes
• Vitamins C, B-complex, A, and E and minerals iron,
copper, zinc, and calcium are important
• Zinc deficiency slows epithelialization and decreases
tensile strength
Oxygenation
• Wound healing depends on a regular supply of oxygen
• Critical for leukocytes to destroy bacteria and
fibroblasts for collagen synthesis
• Impaired blood flow to the wound or the patients
inability to take in adequate O2
• Causes of inadequate blood flow to the wound
• Pressure, arterial occlusion, prolonged vasoconstriction,
PVD and atherosclerosis
• Compromised perfusion more likely to impair healing
• Causes of inadequate systemic blood oxygenation
• Acute and chronic conditions such as COPD,
hypothermia hypotension, hypovolemia, cardiac
insufficiency
Infection
• Systemic infections (pneumonia, TB) increase
metabolism and depletes the fluids, nutrients and O2 the
body needs for healing
• Localized from the injury or develops secondary
• Inflammatory phase lingers delaying wound healing
• Metabolic by-products of bacterial ingestion
accumulate in the wound and interferes with formation
of new blood vessels and collagen synthesis
• Signs: new or increased pain, exudate, redness, heat,
induration, edema, malodor
Aging
• Slower turnover rate in epidermal cells
• Decreased O2 at the wound – increasingly fragile
capillaries and reduction in skin vascularization
• Altered nutrition and hydration
• Impaired function of immune or respiratory
systems
• Reduced dermal and subcutaneous mass
• Healed wounds lack tensile strength and are
subject to reinjury
• Chronic health conditions
Chronic health conditions
• Pulmonary disease, atherosclerosis, diabetes and
malignancies increase risk and interfere with
wound healing
• Impaired circulation common in diabetes and
conditions that cause hypoxia
• Neuropathy associated with diabetes increases risk
and can impair leukocyte function
• Dehydration, ESKD, thyroid disease, heart failure,
PVD, vasculitis, and other collagen vascular
disorders can delay healing
Medications
• Any medication that reduces movement,
circulation, or metabolic function
• Sedatives
• tranquilizers
• Medications that reduce the body’s ability
to mount an appropriate inflammatory
response
• Steroids
• Chemotherapeutic agents
Smoking
• Carbon dioxide binds to the hemoglobin in
blood in place of oxygen
• Reduces the amount of circulating oxygen
• Occurs with exposure to second hand
smoke as well
• Nicotine causes vasoconstriction and
increased coagulability
Wounds/Ulcers
Principles of Wound Healing
Prevention
12
12
10
Left
Back
Right
10
Left
Left
4
Right
Left
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6
PUPPI on Patrol
PUPPI on Patrol
The Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a
“War on Wounds!”
The Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a
“War on Wounds!”
12
10
Right
12
Back
Back
2
10
Back
Back
Back
Right
Right
Left
4
8
6
2
Left
Back
Left
2
Left
6
8
Right
Right
Right
Back
8
2
6
PUPPI on Patrol
PUPPI on Patrol
The Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a
“War on Wounds!”
The Pressure Ulcer Prevention Performance Improvement (PUPPI)
team is launching a
“War on Wounds!”
4
4
BRADEN INTERVENTIONS
4. No Impairment (Provide routine skin care).
Sensory
Perception
Able to
respond
meaningfully
to pressurerelated
discomfort.
3. Slightly limited
a. Encourage turning and reposition q 2 hours when in bed. Utilize
pillows to separate pressure areas. When in W/C assist with position
changes to alter pressure points at least every hour. Instruct and
encourage active patient/family participation as able.
b. Consider elevation of heels off of the bed surface with longitudinal
pillows.
c. Consider keeping HOB at or below 30 degrees. HOB may be
elevated for meals then lowered within one hour p.c. (unless
contraindicated).
d. When elevating HOB, gatch the knee area (elevate 10-20 degrees)
e. Consider wheelchair cushion (esp. if existing skin breakdown)
2. Very limited
a. Provide above.
b. Limit W/C to 1-2 hour intervals.
c. Instruct to shift weight in W/C q 15 minutes.
d. Use a turn sheet to lift up in bed or turn.
1. Completely limited
a. Provide all of above as needed.
Moisture
4. Rarely moist
a. Instruct resident to request care as needed
b. Assess and provide routine skin care as needed to keep skin clean and dry.
Degree to
which skin
3. Occasionally moist
is exposed a. Provide above with use of incontinent care products as needed (No Rinse pH
to moisture. balanced cleanser, protective ointment, absorbent briefs with protective liner to
prevent trapping of moisture against skin.)
b. Consider keeping HOB at or below 30 degrees. HOB may be elevated for
meals then lowered within one hour p.c. (unless contraindicated).
c. When elevating HOB, gatch the knee area (elevate 10-20 degrees)
2. Very moist.
a. Provide all of above as needed.
b. Assess and address cause for fecal/urinary incontinence
c. Consider fecal/urinary incontinence containment device (esp. if existing skin
breakdown)
1. Constantly moist
a. Provide all of above
b. Apply fecal/urinary incontinence device, as able.
Activity
Degree of
physical
activity.
4. Walks frequently
a. Encourage activity as tolerated
3. Walks occasionally
a. Provide above.
b. Teach patient/family the importance of changing positions for prevention of
pressure ulcers. Encourage small frequent position changes.
c. Consider wheelchair cushion (esp. if existing skin breakdown)
2. Chair fast
a. Provide all of above
b. Obtain wheelchair cushion.
c. Limit W/C to 1-2 hour intervals. Instruct to shift weight in W/C q 15 minutes.
d. Assist as needed with turning and reposition q 2 hours when in bed. Utilize
pillows to separate pressure areas.
e. Consider elevation of heels off of the bed surface with longitudinal pillows.
1. Bedfast
a. Provide all above, as needed.
b. Consider WOCN consult for higher level support surface (esp. if existing skin
breakdown)
4. No Limitation(Provide routine skin care).
Mobility
Ability to
change and
control
body
position.
3. Slightly limited
a. Assist as needed with turning and reposition q 2 hours when in bed.
Utilize pillows to separate pressure areas.
b. Instruct to shift weight in W/C q 15 minutes. Consider W/C cushion
(esp. if existing skin breakdown).
c. Consider elevation of heels off of the bed surface with longitudinal
pillows.
d. Consider use of foam wedges to help maintain positioning.
e. Consider keeping HOB at or below 30 degrees. HOB may be
elevated for meals then lowered within one hour p.c. (unless
contraindicated).
f. When elevating HOB, gatch the knee area (elevate 10-20 degrees)
2. Very Limited
a. Provide above
b. Limit W/C to 1-2 hour intervals
1. Completely immobile
a. Provide above.
b. Consider Wound Care Nurse consult for higher level support surface
(esp. if there is existing skin breakdown).
4. Excellent(Provide tray set up and other routine assistance as
Nutrition needed).
Usual food 3. Adequate
intake
a. Encourage meals and assist with meals as needed.
pattern.
b. Offer ordered supplements.
c. Assess needs for oral care, assist PRN
2. Probably inadequate
a. Provide above
b. Consult dietician
1. Very poor
a. Provide above
b. Consider WOCN consult for higher level support surface
(esp. if existing skin breakdown)
3. No apparent problem (Provide routine skin care)
Friction
2. Potential problem
&
a. Use a turn sheet to lift up in bed or turn.
Shear
b. When elevating HOB, gatch the knee area (elevate 10-20
degrees)
c. Consider keeping HOB at or below 30 degrees. HOB may
be elevated for meals then lowered within one hour p.c. (unless
contraindicated).
d. Consider heel/elbow pads or socks.
1. Problem
a. Provide above
b. Consider use of assisting devices (i.e. trapeze)
Types of Wounds
• Treat Based on Drainage
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Pressure Ulcers
Diabetic Ulcers
Venous Insufficiency Ulcers
Arterial Ulcers
• Specific Treatments
• Incontinence Dermatitis
• Perineal Candidiasis
• Skin Tears
Types of Wounds
Diabetic/Neuropathic Ulcers
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Found in diabetic patients
with peripheral
neuropathy; usually on the
ball of the foot or tops of
toes; prone to infection
• Approximately 15% of
patients with diabetes
develop foot ulcers.
• 23% of this group
develop osteomyelitis
• Incidence of vascular
disease is at least four
times higher in
patients with diabetes
and increases with age
and disease duration
Diabetic/Neuropathic UlcersCauses
• Pressure, secondary to
peripheral neuropathy
and/or arterial insufficiency
• Plantar aspect of foot
• Over metatarsal heads
• Under heel
• Poor microvascular
circulation
• Poor blood sugar control
• Lack of sensation
Diabetic/Neuropathic
Ulcer Characteristics
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Below the ankle
Poor circulation
Neuropathy
Sites of pressure,
friction, shear
• Sites of trauma
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Even wound margins
Peri-wound callous
Round
Hemorrhagic callous
Increased potential for
infection
Types of Wounds
Venous Insufficiency Ulcers
Usually due to minor
trauma; pretibial area of
shin or above the medial
ankle; superficial but
difficult to heal
Venous Ulcers - Causes
• Problems with venous
blood return to heart
• Non-functioning or
inadequate calf muscle
pump
• Incompetent perforator
valve
• Incompetent valves in the
vein
• All lead to venous
hypertension
• Venous blood pools in
lower extremity and foot
Characteristics of
Venous Insufficiency Ulcers
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Edema
Hyperpigmentation
Gaiter distribution
Ankle flare
Atrophy of skin
Eczema
Lipodermatosclerosis
Palpable pulses
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Irregular borders
Usually shallow
Weepy
Located on medial lower
leg and malleolus
• can be circumferential
• Pain relieved by elevation
• Heavily contaminated
Types of Wounds
Arterial Ulcers
Due to arterial occlusive disease which
results in tissue necrosis; usually occur on
the ankle or bony areas of the foot; painful,
dry, and pale; pedal pulses diminished or
absent
Characteristics of
Arterial Ulcers
• Absence of hair
• Atrophy below level
of occlusion
• Pain upon elevation
• Absence of palpable
pulse
• Sites of trauma
• Often bright red
granulation tissue
• Well defined
borders/punched out
appearance
• Minimal drainage
• Usually full thickness
• Usually lateral foot, can
be anywhere
• Dependent rubor
• Tendon exposure
Types of Wounds
Incontinence Dermatitis
 Injury to the skin caused by
exposure to excessive
moisture, urine, and/or stool
 Characterized by
inflammation, rash, and
possibly denuded skin
 Anywhere in the
sacral/coccyx, buttock, or
perineal area
Types of Wounds
Perineal Candidiasis
• Fungal/Candida infection
characterized by
erythematous papules and
satellite lesions, and/or
scaly borders
Types of Wounds
Skin Tears
 Traumatic wound occurring principally
on the extremities of older adults as a result of friction and/or
shearing forces which separate the epidermis from the dermis, or
separate both the epidermis and the dermis from underlying
structures
 Incision-like skin lesion
 Classified based on the presence and amount of the skin flap
Stage I Pressure Ulcers
• Intact skin with nonblanchable 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.
Stage I Pressure Ulcers
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).
Stage II Pressure Ulcer
Partial thickness loss
of dermis presenting
as a shallow open
ulcer with a red pink
wound bed, without
slough.
May present as an
intact or
open/ruptured serum
filled blister or a
shiny or dry shallow
ulcer without slough
or bruising
Stage II Pressure Ulcer
Presents as a shiny or
dry shallow ulcer
without slough or
bruising.* This stage
should not be used to
describe skin tears,
tape burns, perineal
dermatitis, maceration
or excoriation.
*Bruising indicates
suspected deep tissue
injury
Stage III Pressure Ulcer
• 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.
Stage III Pressure Ulcer
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.
Stage IV Pressure Ulcer
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.
Stage IV Pressure Ulcer
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.
Unstageable Pressure Ulcer
Full thickness 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.
Unstageable Pressure Ulcer
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 heels serves as
“the body’s natural
(biological) cover” and
should not be removed.
Suspected 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.
Suspected Deep Tissue Injury
Deep tissue injury may be
difficult to detect in
individuals with dark skin
tones. Evolution may include
a thin blister over a dark
wound bed. The wound may
further evolve and become
covered by a thin eschar.
Evolution may be rapid
exposing additional layers of
tissue even with optimal
treatment.
Definitions
• Eschar: wound is covered with
thick, dry, black necrotic tissue.
Eschar may be allowed to
slough off naturally, or it may
require surgical removal
(debridement)
• Slough: a mass or layer of dead
tissue separated from the
surrounding or underlying
tissue, usually cream or yellow
in color
• Granulation Tissue: new
connective tissue and tiny blood
vessels that form on the
surfaces of a wound during the
healing process
Definitions
• Undermining: The wound
extends under the visible
opening; a hollow between the
skin surface and the wound bed
that occurs when necrosis
destroys the underlying tissue
• Tunneling: A narrow opening
or passageway underneath the
skin that can extend in any
direction through soft tissue and
results in dead space with
potential for abscess formation
• Maceration: The softening and
eventual breakdown of tissue
due to excess moisture, making
the wound prone to infection
Pressure Ulcers—Understanding
and Staging Pressure Ulcers
Treatment
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Goals:
 MOIST wound healing
 Protect from trauma
 Moisture balance
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Dressings serve to protect the wound from trauma and
contamination, and facilitate healing by absorption of
exudate and protection of healing surfaces
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Select dressings based on wound drainage:
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Dry wound (Dessicated): Wet it
•
Moist wound: Maintain it, prevent maceration
•
Mod-High draining wound (Heavy Exudate): contain
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Use skin prep to protect skin from skin tears.
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Cleanse ALL wounds with NS or Wound Cleanser
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Date all dressings
Treatment
• Heavy Exudate
• An absorptive dressing should be employed to avoid
build up of chronic wound fluid that can lead to wound
maceration and inhibition of cell proliferation and
healing.
• An appropriate wound dressing can remove excess
wound exudate while maintaining a moist environment
to accelerate wound healing
• Dressings with absorptive qualities include alginates,
foams, and hydrofibers
Treatment
• Dessicated
• Dessicated ulcers lack wound fluids, which provide
tissue growth factors to facilitate re-epithelialization.
• Pressure ulcer healing is promoted by dressings that
maintain a moist wound environment while keeping the
surrounding intact skin dry.
• Choices for a dry wound include saline moistened
gauze, transparent films, hydrocolloids, hydrogels, and
Tenderwet
Incontinence Dermatitis
Aloe Vesta Barrier Cream
Carrington moisture barrier
Butt paste
• Moisturizing
• Water-repellent protective
barrier
• Apply BID, PRN
Xenaderm Ointment (Castor
Oil/Balsam Peru/Trypsin)
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Use: Incontinence and
Radiation Dermatitis;
Superficial skin breakdown
causing pain
Creates moist wound
environment by stimulating
capillary bed, promotes
epithelium, assists in pain
control.
Does not require secondary
dressing
Apply BID & PRN
Wound Dressings
• Wound Gel
• Hydrogel (Carrington/Carasyn)
• Santyl Collagenase
• Foam
• Mepitel and
Lyofoam
• Non-adherent Dressing
• Petrolatum Gauze
• Oil/Emulsion Dressing (Adaptic)
Wound Gel
Wound-specific
• Adds moisture
• Autolytic debridement
• Softens eschar
Foam Dressing
Mepilex Border
Lyofoam(special rx)
 Uses: dry, moist, minimalmod drainage
 Stage II, Shallow III, skin
tears, abrasions, venous
stasis ulcers,
 Change qd, PRN
Non-adherent Dressing
Petrolatum Gauze
Oil/Emulsion (Adaptic)
 Uses: Prevent adherence of
dressing to wound bed; Keeps
wounds/meds moist; Maintains
placement of skin grafts;
Decreases pain
 May be used in conjunction with
wound vac to prevent adherence
of foam to wound
 Oil based products can cause too
much moisture creating
macerated tissue over rims
 Requires secondary dressing
 Usually change Daily
 Others: Telfa – lifts no/minimal
debris from wound base
Enzymatic Debridement
Collagenase ointment
• Uses: Stage III-IV
Pressure Ulcers
• Debrides mixed viable
tissue
• Must be kept moist
• Change daily
Moist to Low Draining Wounds
• Wound Gel
• Hydrogel (Carrasyn)
• Foam
• Mepilex Border
• Hydrocolloid
• Restore Hydrocolloid 4x4
• Restore Extra Thin 4x4 (caution!)
• Antimicrobial Gel/Ointment
• Bacitracin/Bactroban
• Iodosorb Gel
• Silvadene Cream
Hydrocolloid Dressings
Restore Hydrocolloid 4x4
Restore Extra Thin 4x4
 Uses: dry, moist,
minimal drainage
 Stage I & II, shallow III
 Primary/secondary
dressing
 Change q 3-7 days and
PRN soiled/loose
 May be cut to fit
 Do not use on infected
wounds; caution
w/diabetic wounds
Antimicrobial Gels/Ointments
Iodosorb Gel
 Uses: Diabetic Foot
ulcers, infected woundshigh drainage
 Cadexamer Iodide based
gel, provides sustained
antimicrobial coverage
to wounds without
causing toxicity, absorbs
drainage but does not
allow wound to dry out
 Requires secondary
dressing
 Change daily; potent to
72hours
Antimicrobial Gels/Ointments
Silvadene Cream –
antibiotic gel
 Provides silver with
significant
antimicrobial
properties
 Can not be used on
patients allergic to
sulfa drugs
 Requires secondary
dressing
 Change daily
Antimicrobial Gels/Ointments
Silvasorb gel
For wounds with dry
to moderate exudate.
Use SilvaSorb Gel for a
three-day (72hr)
antimicrobial barrier,
plus the moisture
donating benefits of
hydrogel.
• (we do not have this at
RJD, at this time.)
Moderate to Heavy Draining
Wounds
• Calcium Alginate (heavy drainage)
• Calcium Alginate – silver/AG ca+ alginate
• 7 day potency products
• Antimicrobial Gel/Ointments (moderate
drainage)
• Iodosorb Gel – 72hr potency
• Silvadene Cream – 24hr potency
Calcium Alginate/Hydrofibers
Calcium Alginate (Restore)
 Use: mod-large drainage
 Stage II, III, IV, skin tears,
venous stasis ulcers, surgical
wounds, Dehisced wounds
 Change daily , QOD, or PRN
strikethrough drainage
 May be cut to fit
 Needs secondary dressing
 Contraindicated for dry
wounds and third degree
burns - adheres easily
Others: Aquacel Ag
Tape
• 1 or 2 inch Paper Tape
• General purpose
• Hypoallergenic and
latex-free
• Preferred choice for
wound care to prevent
skin stripping
• Vital use skin prep to
protect skin pre-tape
Wound Cleanser
 Cara Klenz
 Gentle
 No rinse
Normal Saline Syringe
 Used to irrigate the
wound
 Non-antibacterial
soap
Skin Cleansing
Aloe vesta foam cleanser
• No-rinse, gentle
cleanser
• Moisturizes and
conditions skin
Skin Prep
Hollister prep wipes
• Protects Skin from
additional breakdown from
tape or moisture with
plastic, copolymer layer on
skin
• This layer lifted off with
tape removal, not repeat liftoff top skin layer.
Moisturizers
• Aloe Vesta Protective
Ointment
• Provides an effective
barrier that seals out
moisture, contains
emollients to
moisturize and is nonsensitizing and
fragrance free
• A&D Ointment
• Helps heal, protects,
smoothes/soothes
• Carmol Urea 20%
• Carmol Urea 40%
• Exfoliates as it
moisturizes
• May sting
• Primary use by our
podiatrist.
Ace Bandages, Gauze, & Packing
 Ace Bandages
 2”, 3”, 4”, and 6”
 Gauze





4x4 Sterile
2x2 Sterile
ABD (abdominal pad)
Kling- elastic, 3”
Kerlix- 4.5” sterile bandage
 Packing (emphasis ‘filling’)
 Plain Packing – ¼”, ½”, 1” – nu-gauze
 Silver alginate
Wound Care Reference Guide
Pressure Ulcer Policy
guidelines for choices
and application
Consulting Wound Care Nurse
When to call for help:
• Notify of ALL new admissions with
pressure ulcers
• New onset pressure ulcers
• Other wound development, from Stage I
• And/or partial, full-thickness wounds
Documentation
Requirements
• Braden Skin assessments are due:
•
•
•
•
•
•
On admission
On transfer (both sending and receiving wards)
On discharge
When there is a change in condition
Daily in acute care and ICU
Weekly in long-term care
Who Can Do Assessments?
• Only RN can do initial assessment in this
VAMC
• RN completes CPRS re-assessment with
Sometimes input requested of other nsg
staff members, LPNs, nurse technicians,
nurse assistants, & to add care plan
interventions
Which Template Do I Use?
• On admission, use initial skin assessment
that is embedded in the Initial Assessment
• Skin Re-Assessment per embedded re• Assessment template tool
• Inpatient wound dressing change:
• Wound assessment/size
• Applied care completed
Initial Skin Assessment Template
Part 1 – Braden Scale
Part 2 – Additional Risk Factors
Part 3 – Current Skin Assessment
Skin Problems
Skin Problems - Pressure Ulcer
Pressure Ulcer
Stage and Location
Pressure Ulcer - Size
102
Part 4 - Interventions
Interventions
CPRS Final Note
105
Skin Reassessment Template
Part 1 – Braden Scale
Part 2 - Skin Assessment
Skin Problems
Pressure Ulcer Information
from Previous Assessment
New Pressure Ulcer
Part 4 - Interventions
To update ALL current
interventions must be entered
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