Skin and
Wound Care
Dressings
Section 5 of 7
RN and LPN
Self-learning Module
DMC Adv Wound Care and Specialty Bed Committee
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
1
Acknowledgements
Original authors 1997:
Maria Teresa Palleschi, CNS-BC, CCRN
JoAnn Maklebust, MSN, APRN-BC, AOCN, FAAN
Kristin Szczepaniak, MSN, RN, CS, CWOCN
Karen Smith, MSN, RN, CRRN
The authors would like to acknowledge the efforts of the 1997 Critical Care Wounds Work
Group in providing the basis for this self-learning module. We thank the following
members for their expertise and dedication to the effort in formulating these
recommendations and the ongoing work required to communicate wound care
advances to our DMC staff :
Cloria Farris RN
Evelyn Lee, BSN, RN, CETN, CRNI
Mary Sieggreen MSN, RN, CS, CNP
Patricia Clark MSN, RN, CS, CCRN
Bernice Huck, RN, CETN
James Tyburski, MD
Michael Buscuito, MD
In 2000 the authors acknowledge the following staff for assisting with reviewing and revising this learning module:
Mary Gerlach MSN, RN, CWOCN, CS
Carole Bauer BSN, RN, OCN, CWOCN
Debra Gignac MSN, RN, CS
Sue Sirianni MSN, RN, CCRN
Toni Renaud-Tessier MSN, RN, CS
Evelyn Lee BSN, RN, CETN, CRNI
Mary Sieggreen MSN, RN, CS, CNP
Patricia Clark MSN, RN, CS, CCRN
Bernice Huck RN, CETN
In 2005, the authors acknowledge the following staff for assisting with reviewing and revising this learning module:
Donna Bednarski, MSN, APRN,BC, CNN, CNP
Carole Bauer BSN, RN, OCN, CWOCN
Sue Sirianni MSN, RN, CCRN
Evelyn Lee MSN, RN, CWOCN
Mary Sieggreen MSN, RN, CS, CNP
Bernice Huck RN, BSN, CPN, WOCN
Carolyn J. Stockwell, MSN, RN, ANP, CCM
In 2009 the DMC module was revised by the following staff:
Maria Teresa Palleschi ACNS-BC CCRN
Laura Harmon ACNP-BC, CCRN, CWOCN
Evelyn Lee MSN, RN, CWOCN
Diana LaBumbard ACNP-BC, CCRN
Bernice Huck BSN, CWOCN
Carolyn J. Stockwell, ANP-BC, CNP, CCM
Mary Sieggreen ACNS-BC, CNP CVN
Pauline Kulwicki ACNS-BC CNP CNRN
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
2
Purposes
and Objectives
Purposes:
•
To communicate DMC standards and policies in skin and wound care practice.
•
To provide a study module and source of reference.
•
To prepare RN and LPN orientees for clinical validation of skin and wound care.
Directions:
• All staff are responsible to read the content of these modules
and pass the tests.
• If you are unable to finish reviewing the content of this course in
one sitting, click the Bookmark option found on the left-hand
side of the screen, and the system will mark the slide you are
currently viewing. When you are able to return to the course,
click on the title of the course and you will have button choices
to either:
–
–
Review the Course Material which will take you to the beginning of the
course OR
Jump to My Bookmark which will take you to where you left off on
your previous review of this module.
Objectives:
By completing this module, the RN and LPN will:
1. Recognize the professional responsibility of licensed health care providers.
• RNs will utilize the knowledge to make clinical decisions and
enter EMR orders based on DMC evidenced based
flowcharts found in Tier 2 Skin and Wound Policies.
2. Review basic skin and wound care concepts.
3. Apply DMC standard skin and wound management principles.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
3
Dressings
Basic wound care is provided using DMC Wound and Skin Care Flow
Charts as guidelines for the RN to independently make decisions and
initiate orders for wound care.
•
•
Dressings are selected by RN staff based on wound characteristics.
Ensure continuity by entering EMR orders for all wound care
The following dressing changes may not be delegated to the unlicensed
personnel:
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–
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Wet-to-Dry. Dressings that are ordered wet to dry but are changed at a
frequency that does not allow the dressing to dry in the wound bed and
debride the wound are considered continuously moist.
Weep No More (WNM) Suction Dressing.
Silver.
Complex wounds that require filling or packing.
The RN may delegate dressing changes to the PCA:
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After each wound assessment.
After determining dressing type and frequency.
The following dressings may be delegated to unlicensed personnel:
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Alginate.
Continuous moist.
Dry sterile.
Foam.
Hydrocolloid.
Hydrogel, hydrogel impregnated gauze.
Superficial wounds.
Transparent film.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
4
Dressings
Protective Barrier Wipe
–
–
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Protective barrier wipe provide a protective coating on unbroken skin after they dry
Provide some degree of protection from mechanical injury
Most liquid film barriers contain alcohol and cause stinging on contact with
denuded/fragile skin
Transparent Adhesive Dressings 2 PC 5213
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–
–
–
–
–
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Semi permeable, sterile thin film
Maintains a moist environment
Non-absorptive
Assists in promoting autolysis of devitalized tissue
Creates a “second skin” and protects against friction
Allows for visualization of wound
Not used over the following wounds / areas:
• Wounds with heavy drainage, depth > 0.5cm, clinical signs of infection, sinus
tracts or tunneling
• Blisters that are growing in size. Site will leak and require removal causing
more tissue damage.
• Heels, especially those with eschar
Hydrocolloid Dressings 2 PC 5211
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–
–
–
–
–
–
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Thick or thin wafer made of gelatin and pectin absorptive particles which interact with
wound exudate to form a gelatinous mass.
Maintains a moist environment.
Minimal to moderate absorption of exudate. Apply thick wafer over areas with
exudate. Apply thin wafer over sites with minimal or no exudate. Thin wafers may
conform more easily to irregular surfaces.
Assists in promoting autolysis of devitalized tissue.
May be left on for 3-5 days.
Used to cover wound entirely with a 1.5 inch border attached to the surrounding skin.
Does not require a secondary dressing.
Do not remove immediately upon external soiling. Cover a hydrocolloid wafer with
transparent film if it is at risk for external soiling. Removing adherent products strips
the epidermis and increases the risk for skin breakdown.
Not used over the following wounds / areas
• Where anaerobic infection is suspected.
• Presence of rash.
• Over pressure areas that will cause dressing to roll, requiring replacement and
causing damage to periwound tissue.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
5
Dressings
Hydrogels and hydrogel impregnated gauze 2 PC 5212
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Clear viscous wound gel that is water based and contains glycerin.
Available in a tube, impregnated in a gauze dressing, or as a sheet
Maintains a moist environment
Absorbs minimal exudate
May donate moisture to the wound.
Assists in promoting autolysis of devitalized tissue
Requires a secondary dressing
Usually requires fewer dressing changes than saline moistened gauze
Not used over the following wounds / areas
• copious drainage or maceration.
• Where anaerobic infection is suspected.
Alginate Dressings: 2 PC 5207
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–
–
–
–
–
–
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Heavy fiber dressing made from seaweed
Maintains a moist environment
Absorbs moderate to heavy exudate
May be used to fill wound cavities
May be used in bleeding wounds / sites for hemostasis
Assists in promoting autolysis of devitalized tissue
Usual amount needed: 1 sheet or 6 inches of rope changed daily
Do not moisten dressing before application
Irrigate with normal saline before removal
Not used over the following wounds / areas
• dry or minimally draining wounds
• Third-degree burns
Foam Dressings: 2 PC 5210
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Soft polyurethane dressing sheets
Maintains a moist environment
Absorbs moderate exudate.
Useful for managing exudate under compression.
Not recommended for non-draining wounds, sinuses or tunneling
Dressing may be changed up to 3X per week except for fillers which may be daily.
May be used for tracheostomy, drain sites, or open wounds with exudate
Mepilex is used over small to moderate drainage with a pink / red wound base
–
Not used over the following wounds / areas
•
•
Contraindicated for third degree burns
Wounds that require fill
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
6
Dressings
Silver Dressings: Ordered by Wound Care Specialists
Useful for colonized wounds or those at risk of infection and decreases
wound’s bacterial load. Wound drainage activates antimicrobial
activity in foam and hydrofiber. Drainage not necessary for textile
InterDry Ag
•
Mepilex Ag Silver foam, good for up to 7 days.
• Used in exudating colonized wounds
• Easy to remove, cleanse wound, replace
•
Aquacel Ag Hydrofiber dressing with silver, 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
• Difficult to remove, cleanse wound and replace due to
gelatinous consistency.
•
InterDry Ag
• Used for Intertrigo and other skin to skin surfaces with
rash
Not used over the following wounds / areas
• Sensitivity to silver
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
7
Dressings/Topical
Agent Grid
Tegaderm HP; Manufacturer 3M Available sizes: 4X4, 8X8 Product
Classification Transparent Film
Description: A clear, adherent non-absorbent dressing that is permeable to oxygen
and water vapor.
Indications for Usage: Superficial, partial-thickness wounds, with small amount of
slough to enhance autolytic debridement. Used in wounds with little or no exudate
Disadvantages: No ability to absorb drainage so dressing may cause maceration
of periwound tissue.
Change Frequency: Weekly and PRN for trapped fluid.
Duoderm: Signal & Thin Manufacturer Convatec Available sizes: 4X4, 8X8
Product Classification Hydrocolloid
Description: Occlusive, adhesive wafer contains hydroactive particle to maintain
moist environment & promote autolysis
Indications for Usage: Superficial or Stage II over areas that are not weight
bearing. Not for use on sacrum / coccyx Shallow-full thickness wounds with
necrosis or slough and light to moderate exudate. Thin duoderm appropriate for
wounds with little to no exudate
Disadvantages: Not recommended for wounds with heavy exudate, sinus tracts, or
infections. Wafer may curl and require frequent changes resulting in tearing fragile
periwound skin Dressing edges may require tape to decrease curling / rolling. Thin
duoderm will not contain large amounts of exudate.
Change Frequency: Every 3-5 days and PRN for drainage / curling
Hydrosorb Manufacturer Convatec Available sizes: 4X4
Product Classification Foam
Description: Absorptive, non adherent, sponge like polymer dressing
Indications for Usage: Partial and full-thickness wounds with minimal to moderate
exudate and as a secondary dressing for wounds with packing
Disadvantages: Not recommended for dry wounds. May macerate peri-wound
skin.
Change Frequency: Daily & PRN for drainage.
Kaltostat: Manufacturer Convatec Available sizes: 4X4, rope Product
Classification Calcium Alginate
Description: Alginate dressing that helps reduce bleeding and manages exudate in
low to moderately exuding wounds.
Indications for Usage: Superficial, partial-thickness wounds, with small amount of
slough to enhance autolytic debridement. Used in wounds with moderate exudate
Disadvantages: Able to absorb drainage, monitor periwound for maceration.
Change Frequency: Daily and PRN.
Duoderm Hydroactive, gel : Manufacturer Convatec Available sizes: 15gm and
30gm Product Classification Hydrogel
Description: Water-based gel with some absorptive properties.
Indications for Usage: For use in large and tunneled wounds.
Disadvantages: None. .
Change Frequency: Reapply every 12 -24 hours.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
8
See Dressings/Topical
Agent Grid
Skintegrity: Manufacturer Medline Available sizes: 4X4
Product Classification Hydrogel Impregnated Gauze
Description: Gauze dressing that is coated with hydrogel
Indications for Usage: Partial-thickness and full thickness wounds, that require
moisture and filling. Abrasions, Burns, radiation skin damage. Ulcers with small
amount of slough to enhance autolytic debridement, e.g., sacral ulcers
Disadvantages: Limited moisture retention, may adhere to wound bed if allowed to
dry. Requires a secondary dressing. Can cause maceration of periwound tissue.
Change Frequency: Reapply every 12 -24 hours.
Mepilex Border with Safetac Technology Manufacturer MÖLNLYCKE
Available sizes: 4X4 and 6X6
Product Classification: Hydrophilic Foam
Description: sponge like polymer dressing that may or may not be adherent,
Effectively absorbs exudate and maintains a moist wound environment. The
Safetac layer seals the wound edges, preventing the exudate to leak onto the
surrounding skin, thus minimizing the risk for maceration. The Safetac layer
ensures that the dressing can be changed without damaging the wound or skin.
Indications for Usage: Shallow areas with minimal amount of exudate and little or
no slough / eschar, e.g., Sacral Pressure Ulcers.
Disadvantages: None
Change Frequency: Every 3-5 days. Peel back dressing and assess wound with
assessment.
Xeroform: Manufacturer Kendall Available sizes: 4X4, Roll
Product Classification: Petrolatum
Description: Sterile dressing composed of 3% Bismuth tribromophenate in a
petrolatum blend on fine mesh gauze
Indications for Usage: Superficial partial –thickness wounds, burns, skin graft
sites.
Disadvantages: May become dry and adherent to wound bed. Allergic reaction to
bismuth.
Change Frequency: Every 12 -24 hours.
Antifungal: InterDry™ AG Manufacturer: Coloplast Available sizes: Roll
Product Classification: Antifungal ordered by APN / CWOCN
Description: A skin fold management system designed to manage moisture, odor
and inflammation in skin folds and other skin-to-skin contact areas. A polyester
textile impregnated with silver complex, InterDry ™ Ag provides effective
antimicrobial action for up to five days and improves the symptoms associated with
intertrigo: maceration, denudement, inflammation, and satellite lesions. Product
works by wicking moisture away to keep skin dry and provides a friction reducing
surface to reduce the risk of skin tears and pressure ulcers.
Indications for Usage: Superficial partial –thickness wounds, burns, skin graft
sites.
Disadvantages: May be dislodged during ambulation.
Change Frequency: 5 days
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
9
See Dressings/Topical
Agent Grid
Mepilex® Ag Manufacturer: MÖLNLYCKE Available sizes: APN / CWOCN
order Product Classification: Antimicrobial
Description: combines the unique features of Safetac technology with the bacteria
reducing power of silver. Works quickly, inactivating wound pathogens within 30
minutes and for up to 7 days. At dressing removal, does not stick to the wound or
strip surrounding skin, minimizing patient pain and wound trauma.
Indications for use: An antimicrobial soft silicone foam dressing designed for
management of low to moderately colonized exuding wounds such as leg and foot
ulcers, pressure ulcers and partial thickness burns.
Disadvantages: Do not use on patients with a known sensitivity to silver or during
radiation treatment or radiologic examinations e.g. X-ray, ultrasound, diathermy or
Magnetic Resonance Imaging. Do not use together with oxidising agents such as
hypochlorite solutions or hydrogen peroxide.
AQUACEL® Ag Manufacturer: ConvaTec Available sizes: APN / CWOCN
order Product Classification: Antimicrobial
Description: incorporates silver into Hydrofiber® Technology resulting in gelling
of the dressing with the broad-spectrum antimicrobial properties of ionic silver
(Ag+).
Indications for Usage: a primary dressing indicated for use on moderately and
highly exuding chronic and acute wounds where there is an infection* or an
increased risk of infection. Supports wound healing by providing a moist wound
healing environment provides sustained antimicrobial activity for up to 7 days.
Disadvantages: Do not use on patients with a known sensitivity to silver.
Gelatinous in wound and under secondary dressing.
AllKare Protective Barrier Wipe Manufacturer Convatec Available sizes: 1x1
wipe Product Classification Skin sealant
Description: Non water soluble clear, co-polymer protective barrier wipe
Indications for Usage: Protects periwound tissue from injury and maceration. Can
be used under tape or adhesive products to increase adherence and protect skin
Disadvantages: Pain if tissue is denuded.
Change Frequency: Daily or with dressing changes.
Stomahesive wafers: Manufacturer ConvaTec Available sizes: 4X4 and 8 x 8
Product Classification: Skin Barrier Wafer
Description: a pectin based wafer.
Indications for Usage: Skin protection from wound ostomy and eflfuent drainage.
As a periwound skin barrier / window on which to apply tape or Montgomery straps
to protect against skin stripping.
Disadvantages: May accelerate skin yeast if present due to occlusive nature.
Change Frequency: Weekly and PRN barrier erosion or yeast development.
Petrolatum and SensiCare Protective Barrier : Manufacturer ConvaTec
Product Classification Moisture barrier
Description: Moisture barrier
Indications for Usage: repels stool/ urine, assists in preventing breakdown,
soothes and protects skin. After cleansing, place thin layer over exposed perineal
area. Remove excess
Disadvantages: Product not to be completely scrubbed off skin.
Change Frequency: PRN incontinence
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
10
Weep-No-More
Suction Dressing
2 PC 5214
•
General Information: A Weep-No-More (WNM) suction dressing may be applied
to adult patients with weeping or draining sites to facilitate measurement of
drainage and/or prevent skin maceration from excessive drainage.
– Weep-No-More dressings may be placed over wounds, incisions, puncture
sites, and around drains or sites that cannot be adequately managed with
conventional dressings.
– Other sterile tubes may be used for drainage instead of suction catheters
– A physician order is required for WNM suction dressings over a surgical
incision and/or wound. Dressings over these sites are changed every
24 hours in order to assess surgical incision/wound characteristics.
– WNM dressings over non-surgical sites are changed every 72 hours and
PRN.
– Sterile dressings and catheters are used for each WNM dressing change.
•
Cleanse the weeping/draining site as indicated and prep skin surrounding
weeping site with liquid film barrier wipe.
•
Using aseptic technique:
– Cover weeping site with a 4x4 folded sterile gauze.
– Place a sterile 14 FR suction catheter or tube between folded gauze with
the gauze always placed closest to the wound/ draining site.
– The suction catheter or tube lays on top of the gauze to prevent direct
suction being applied to the site.
– Cover with Tegaderm® Transparent Film Larger areas may require more
than one gauze or Tegaderm®. Smaller areas, such as a puncture site,
may require 2x2 size gauze.
Suction catheter or
tubing
Folded 4 x4 gauze
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
11
Weep-No-More
Suction Dressing
2 PC 5214
Tegaderm®
Gauze
Site most vulnerable to leaking
Suction
catheter
•
Place Tegaderm® film dressing over gauze and suction catheter. A gauze layer rests between
the suction catheter and the Tegaderm® dressing.
•
Wipe Tegaderm® edges with protective film barrier wipe to improve dressing adherence. The
site most vulnerable to leaking is the area where the suction catheter exits the dressing. Prep
this area well with protective film barrier wipe and patch with Tegaderm® PRN.
•
Connect suction catheter to wall suction. Only a very small amount of wall suction pressure is
required to facilitate WNM dressing drainage. Set suction on lowest setting necessary to drain
dressing. Dressing should contract with suction application.
•
If no contraction is noted, an air leak is present in the dressing. Assess for adhesion around
suction catheter and for edges not covered well by Tegaderm®. WNM dressing will not drain
until gauze is saturated with drainage.
•
Reassess need for continuing WNM dressings over sites that have not drained for
approximately 12 hours.
•
To prevent skin breakdown from daily Tegaderm® dressing removal or long-term WNM use,
window with Stomahesive® hydrocolloid dressing. Stomahesive® is less expensive to use
than Duoderm® and transparent film pulls off easily from the Stomahesive® surface
Stomahesive®
Tegaderm®
•
•
Overlap Tegaderm onto Stomahesive®. Change Stomahesive® PRN.
For multiple areas of weeping, WNM sites may be joined with a Y connector to one suction
canister. Use 18 inch suction tubing to connect multiple sites. Due to the tubing required for
multiple WNM sites, a higher suction setting may be necessary for the system to drain
effectively.
Remember that this area is considered a wound! Document the following:
amount of output, dressing change, site appearance, appearance of tissue in/near WNM, and
expected outcomes related to wound or site.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
12
Management of Skin
Surrounding Wounds
•
The skin and tissue surrounding a wound is called peri-wound skin.
•
The goals of treating peri-wound skin are to:
– Maintain skin integrity
– Prevent further breakdown of irritated skin.
– Promote healing of denuded areas.
•
Assess and document peri-wound skin condition with each dressing
change.
•
Select dressing material that will keep the wound bed moist and the
surrounding intact skin dry. Protect periwound tissue with protective
barrier wipe.
•
Rashes and induration are abnormal findings and necessitate a
consult to the APN/ CWOCN / Wound Care Specialist. Never cover
a rash with an occlusive dressing e.g. Duoderm, or
Stomahesive.
•
Intact reddened or painful peri-wound skin indicates possible cellulitis
or trauma from tape removal.
– Consult APN / CWOCN / Wound Specialist for further
assessment
– Avoid adhesive tape, excessive heat or enzymatic product
contact with periwound area.
– Protect skin. Consider use of products such as protective barrier
wipe, transparent film, or Stomahesive and Montgomery straps.
•
Treat broken peri-wound skin as an open wound.
–
–
Cleanse with saline
Gently dry
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
13
Peri-wound
Skin Flow Chart
RN to ASSESS
and DOCUMENT
periwound skin
Skin Intact
REDDENED
or
BLISTERED
PERI WOUND
SKIN
Consult to
R/O
Infection
AVOID Tape
Prevent
Trauma
RASH
Do not cover
with an
occlusive
dressing
Protect and
reassess
Skin Broken
WARM
TENDER
INDURATED
SKIN
MACERATED
SKIN
DENUDED
SKIN
FUNGAL /
YEAST
INFECTION
CONSULT
Moisture
Barrier
Hydrocolloid
Stomahesive
wafer
Consult
Antifungal
Agent
CONSULT
These flow sheets do not represent the full scope of care
Refer to APN / CWOCN / Wound Care Specialist when in doubt.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
14
Management of
Dressing Attachment
•
The goal of attaching a dressing is to maintain healthy skin, stabilize
the dressing, and/ or protect skin from further deterioration.
•
Adherent dressings
– Tape removal is the major cause of peri-wound trauma. Avoid
tape usage whenever possible. If tape is used, protect skin
beneath tape with a protective barrier wipe (not alcohol wipe).
– For non-intact skin, use a barrier wafer (Stomahesive) under
tape.
– Use Stomahesive wafer under Montgomery straps to avoid
repeated tape removal/skin stripping.
•
Non-adherent dressings
– For body sites that do not tolerate adherent dressings, use roll
gauze, stretch netting, tubular stockinette, Mepilex or stretch net
panties depending on body location of the wound.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
15
Dressing Attachment
Flow Chart
RN TO ASSESS:
skin condition
around wound
Adherent dressing
Non-adherent
Dressing
Assess body
location
Intact Skin
Protective
Barrier
Wipe
Non-intact Skin
Stomahesive
barrier
wafer
Paper tape
Clear tape
Silk tape
Montgomery Straps
Head,arm, foot,
or leg
Kerlix/ Kling gauze
Stretch netting,
Mepilex, Tubular
Stockinette
Groin, perineal,
suprapubic areas
Trunk
Stretch netting
Tubular
Stockinette
Net panties
These flow sheets do not represent the full scope of care
Refer to APN / CWOCN / Wound Care Specialist when in doubt.
DMC Advanced Wound Care and Specialty Bed Committee
©DMC 2009
16
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
17
Definitions
D
•
Denuded: Loss of superficial skin / epidermis.
•
Drainage: wound exudate, fluid that may contain serum, cellular debris, bacteria,
leukocytes, pus, or blood.
•
Dressings, primary: dressings placed directly on the wound bed.
•
Dressings, secondary: dressings used to cover primary dressing.
•
Dressings, alginate: primary dressing. A non-woven highly absorptive dressing
manufactured from seaweed. Absorbs serous fluid or exudate in moderately to heavily
exudative wounds to form a hydrophilic gel that conforms to the shape of the wound. May
be used for hemorrhagic wounds. Non adhesive, nonocclusive primary dressing.
Promotes granulation, epithelization, and autolysis.
•
Dressings, foam: primary or secondary dressing. Low adherence sponge-like polymer
dressing that may or may not be adherent to wound bed or periwound tissue e.g.,
Mepilex. Indicated for moderately to heavily exudative wounds with or without a clean
granular wound bed, capable of holding exudate away from the wound bed. Not
indicated for wounds with slough or eschar. Foam and low-adherence dressings are
used in wounds for granulation and epithelialization stages as well as over fragile skin.
•
Dressings, continuously moist saline: primary dressing. A dressing technique in
which gauze moistened with normal saline is applied to the wound bed. The dressing is
changed often enough to keep the wound bed moist and is remoistened when the
dressing is removed. The goal is to maintain a continuously moist wound environment.
Indicated for dry wounds or those with slough that require autolytic therapy.
•
Dressings, gauze: primary or secondary dressing. a woven or non-woven cotton or
synthetic fabric dressing that is absorptive and permeable to water, water vapor, and
oxygen. May be impregnated with petrolatum, antiseptics, or other agents. Indicated for
surgical and draining wounds.
•
Dressings, hydrocolloid: primary dressing. Two kinds of wafer, thick and thin. Wafers
contain hydroactive/absorptive particles that interact with wound exudate to form a
gelatinous mass. Moldable adhesive wafers are made of carbohydrate with a
semiocclusive film layer backing e.g., DuoDerm®.
–
–
–
–
–
–
–
–
–
–
–
Thick wafers are applied over areas with exudate while thin wafers are used over sites with minimal
or no exudate.
Thin wafers may conform to sites easier than thick wafers. Contraindicated where anaerobic
infection is suspected.
Dressing is not removed upon external soiling. Removing any intact product that adheres to skin
strips the epidermis, causes damage and increases the risk for breakdown.
Cover hydrocolloid with a transparent film to decrease friction from repositioning patient or if
dressing is at risk for soiling.
May be used for intact skin that requires protection against friction.
Hydrocydrocolloid and low-adherence dressings are for wounds in the epithelialization stage.
Used to cover a wound entirely, leaving approximately a 1.5 inch border around the wound margins.
Does not require a secondary dressing
Contraindicated for third-degree burns and not recommended for infected wounds.
May be used by wound care consultants to promote autolysis in some patients with eschar.
Not recommended for wounds with depth or friable periwound tissue or those that require monitoring
more often than once or twice a week. May be left on for 3-5 days.
DMC Advanced Wound Care and Specialty Bed Committee
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Definitions
D
•
Dressings, hydrogel or hydrogel impregnated gauze: primary dressing. A waterbased non-adherent dressing primarily designed to hydrate the wound, may absorb
small amount of exudate e.g., Skintegrity. Indicated for dry to minimally exudative
wounds with or without clean granular wound base. Donates moisture to the wound and
is used to facilitate autolysis. May be used to provide moisture to wound bed without
macerating surrounding tissue. Requires a secondary dressing.
•
Dressings: Primary : dressing placed directly on the wound bed.
•
Dressings: Secondary: dressing used to cover primary dressing.
•
Dressings, silver: Useful for colonized wounds or those at risk of infection and
decreases wound’s bacterial load. good for up to 5 - 7 days.
– Alginate e.g., Aquacel Ag - Highly absorbent interacts with wound exudate and
forms a soft gel to maintain moist environment. May be used in dry wounds
covered with saline moistened gauze as secondary dressing to maintain moisture
– Foam e.g., Mepilex Ag - Used for colonized wounds or those at risk of infection
and decreases wound’s bacterial load. Used in exudating colonized wounds
– Textile e.g., InterDry Ag - Used for Intertrigo and other skin to skin surfaces with
rash. May remain in place for 5 days.
•
Dressings, transparent: primary or secondary dressing. A clear, adherent nonabsorptive dressing that is permeable to oxygen and water vapor e.g., Tegaderm.
Creates a moist environment that assists in promoting autolysis of devitalized tissue.
Protects against friction. Allows for visualization of wounds. Indicated for superficial,
partial-thickness wounds, with small amount of slough to enhance autolytic
debridement. Used in wounds with little or no exudate
•
Dressings, wet-to-dry: a debridement technique in which gauze moistened with normal
saline is applied to the wound and removed once the gauze becomes dry and adheres
to the wound bed. Indicated for debridement of necrotic tissue from the wound as the
dressing is removed, however method is not selective and removes healthy tissue as
well. Other methods of debridement are considered more effective. Wet to dry dressing
orders that are changed at a frequency that does not allow drying are considered
continuously moist dressings.
•
Dressing, xeroform: primary dressing. Impregnated gauze with petrolatum and 3%
bismuth. Indicated for skin donor sites and other areas to protect from contamination
while allowing fluid to pass to secondary dressing.
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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.
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Definitions
I
•
Incontinence-related dermatitis: an inflammation of the skin in the genital, buttock, or upper
leg areas that is often associated with changes in the skin barrier. Presents as redness, a
rash, or vesiculation, with symptoms such as pain or itching. Associated with fecal or urinary
incontinence.
•
Infection: overgrowth of microorganisms causing clinical signs/ symptoms of infection:
warmth, edema, redness, and pain.
•
Induration: an abnormal hardening of the tissue surrounding wound margins, detected by
palpation. It occurs following reactive hyperemia or chronic venous congestion.
J
K
L
M
•
Maceration: excessive tissue softening by wetting or soaking (waterlogged).
N
•
Negative pressure wound therapy (NPWT) provides an occlusive controlled subatmospheric pressure (negative pressure) suction dressing that promotes moist wound
healing. Controlled sub-atmospheric pressure improves tissue perfusion, stimulates
granulation tissue, reduces edema and excessive wound fluid, and reduces overall wound
size. Some indications for use include pressure ulcers, venous ulcers, diabetic foot ulcers,
dehisced surgical incisions, partial thickness burns, grafts, split thickness skin grafts,
traumatic wounds, fasciotomy, myocutaneous flaps, and temporary closure for abdominal
compartment syndrome (V.A.C. ACS).
•
No Touch Technique: Dressing change technique where only the outer layer of dressing is
touched with clean gloves. The dressing surface against the wound bed is never touched.
O
P
•
Periwound: area surrounding a wound. Assessed for signs of inflammation or maceration.
•
Pressure Ulcer: localized injury to the skin and/or underlying tissue usually over a bony
prominence or beneath a medical device, as a result of pressure, or pressure in combination
with shear and/or friction. Pressure ulcers are staged according to extent of tissue damage or
classified as DTI or unstageable.
DMC Advanced Wound Care and Specialty Bed Committee
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Definitions
P
•
Pressure Ulcer Staging: One of the most commonly used systems to classify pressure
ulcers. This staging system was developed by the National Pressure Ulcer Advisory Panel
(NPUAP) and is recommended by the AHCPR Guidelines for pressure ulcers.
– Stage I: Intact skin with non-blanchable redness of a localized area usually over a
bony prominence. Darkly pigmented skin may not have visible blanching; its color
may differ from the surrounding area. The area may be painful, firm, soft, warmer or
cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals
with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).
Treatment: Do not cover, assess frequently for progression.
– Stage II: partial thickness loss of dermis presenting as a shallow open ulcer with a
red pink wound bed, without slough. May also present as an intact or open/ruptured
serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or
bruising.* This stage should not be used to describe skin tears, tape burns, perineal
dermatitis, maceration or excoriation. Treatment: Hydrogel / hydrogel impregnated
gauze, or foam / Mepilex dependent on location.
– Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle are not exposed. Slough may be present but does not obscure the
depth of tissue loss. May include undermining and tunneling. The depth of a stage III
pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and
malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In
contrast, areas of significant adiposity can develop extremely deep stage III pressure
ulcers. Bone/tendon is not visible or directly palpable. Treatment: Hydrogel / hydrogel
impregnated gauze or continuously moist dressings.
– Stage IV: full thickness tissue loss with exposed bone, tendon or muscle. Slough or
eschar may be present on some parts of the wound bed. Often include undermining
and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location.
The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue
and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or
supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis
possible. Exposed bone/tendon is visible or directly palpable. Treatment: Hydrogel /
hydrogel impregnated gauze, continuously moist dressings.
– Unstageable: full thickness tissue loss in which the base of the ulcer is covered by
slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the
wound bed. Until enough slough and/or eschar is removed to expose the base of the
wound, the true depth, and therefore stage, cannot be determined. Stable (dry,
adherent, intact without erythema or fluctuance) eschar on the heels serves as "the
body's natural (biological) cover" and should not be removed. Treatment: contact APN
/ CWOCN for enzymatic agent for areas outside of the heels.
– Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or shear. The
area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler
as compared to adjacent tissue. *Bruising indicates suspected deep tissue injury.
These lesions may herald the subsequent development of a Stage 3 or Stage 4
Pressure Ulcer even with optimal management. Treatment: protect, reposition off area
at all times, contact APN CWOCN, assess frequently for deterioration.
Although useful during initial assessment, the staging classification system cannot be used to
monitor progress over time. Pressure ulcer staging is not reversible. Ulcers do not heal in
reverse order from a higher number to a lower number and are not be described s such e.g.,
“the ulcer was a Stage II but now looks like a Stage I”). Wounds with slough or eschar cannot
be staged. The full extent or wound depth is hidden by slough or eschar.
DMC Advanced Wound Care and Specialty Bed Committee
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Definitions
P
•
Present on Admission (POA): Any alteration in tissue integrity that is identified on
admission is defined as community-acquired and documented in the Adult Admission
History as present on admission (POA).
– Acceptable documentation of ulcer assessment for community acquired
conditions / pressure ulcers includes a detailed description within any
assessment record e.g., EMR Adult Admission History, Progress Note, H&P or
consultative form.
•
Protective barrier film: Clear liquid that seals and protects the skin from mechanical
injury e.g., AllKare wipes (contains alcohol), Medical Adhesive Spray (alcohol free).
Some contain alcohol and require vigorous fanning after application to avoid burning on
contact.
•
Pustule: Elevated superficial filled with purulent fluid.
•
Purulent: forming or containing pus.
Q
R
•
Rash: term applied to any eruption of the skin. Usually shade of red.
•
Shear: friction plus pressure causing muscle to slide across bone and obstructing
blood flow e.g., sitting with head of the bed (HOB) at > 30 angle.
•
Skin Sealant: clear liquid that seals and protects the skin.
•
Tissue Biopsy: use of a sharp instrument to obtain a sample of skin, muscle, or bone.
•
Tissue: Eschar: dry, thick, leathery, dead tissue
•
Tissue: Necrotic: devitalized or dead tissue
•
Tissue: Slough: moist, dead tissue.
•
Weep-No-More (WNM) Suction Dressing: an occlusive suction dressing using a
folded gauze dressing which covers a catheter or tubing enclosed within a transparent
film. May be placed over wounds and incisions with a physician’s order and changed
at least every 24 hours. May also be ordered by the RN over non-surgical sites, e.g.,
puncture sites and changed at least every 72 hours. May be used over sites that
cannot be adequately managed with conventional dressings..
•
Wound Care as Ordered: refers to RN generated orders for treatment based on DMC
Skin and Wound Care Flowcharts.
•
Wound irrigation: cleansing the wound by flushing with fluid e.g., 250 mL sterile
normal saline under pressure.
DMC Advanced Wound Care and Specialty Bed Committee
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