Presentation on theme: "Braden Scale & Prevention"— Presentation transcript:
1 Braden Scale & Prevention Skin and Wound CareBraden Scale & PreventionSection 2 of 7RN and LPNSelf-learning ModuleDMC Adv Wound Care and Specialty Bed Committee
2 AcknowledgementsOriginal authors 1997:Maria Teresa Palleschi, CNS-BC, CCRNJoAnn Maklebust, MSN, APRN-BC, AOCN, FAANKristin Szczepaniak, MSN, RN, CS, CWOCNKaren Smith, MSN, RN, CRRNThe 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 RNEvelyn Lee, BSN, RN, CETN, CRNIMary Sieggreen MSN, RN, CS, CNPPatricia Clark MSN, RN, CS, CCRNBernice Huck, RN, CETNJames Tyburski, MDMichael Buscuito, MDIn 2000 the authors acknowledge the following staff for assisting with reviewing and revising this learning module:Mary Gerlach MSN, RN, CWOCN, CSCarole Bauer BSN, RN, OCN, CWOCNDebra Gignac MSN, RN, CSSue Sirianni MSN, RN, CCRNToni Renaud-Tessier MSN, RN, CSEvelyn Lee BSN, RN, CETN, CRNIBernice Huck RN, CETNIn 2005, the authors acknowledge the following staff for assisting with reviewing and revising this learning module:Donna Bednarski, MSN, APRN,BC, CNN, CNPEvelyn Lee MSN, RN, CWOCNBernice Huck RN, BSN, CPN, WOCNCarolyn J. Stockwell, MSN, RN, ANP, CCMIn 2009 the DMC module was revised by the following staff:Maria Teresa Palleschi ACNS-BC CCRNLaura Harmon ACNP-BC, CCRN, CWOCNDiana LaBumbard ACNP-BC, CCRNBernice Huck BSN, CWOCNCarolyn J. Stockwell, ANP-BC, CNP, CCMMary Sieggreen ACNS-BC, CNP CVNPauline Kulwicki ACNS-BC CNP CNRN
3 Purposes and Objectives 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 ORJump 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.
4 Pressure Ulcer Risk Assessment Epidemiology and EconomicsThe 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 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 perceptionMoistureActivityMobilityNutritionFriction and shear
6 PREVENTION-PREVENTION-PREVENTION Braden ScalePredicting PressureSore RiskThe 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 = High risk = Moderate risk = Mild risk = Generally not at riskA 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.Low 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 SetPREVENTION-PREVENTION-PREVENTION
7 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.
8 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.
9 Pressure Ulcer Prevention While reclining - use the rule of 30 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 tissueUse a lift pad to move patients up in the bed to avoid friction and shearWhile reclining - use the rule of 30Unless 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.
10 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 heelsElevate heels off the bedAll 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 surfaceHUH/ HWH/ KCH PU COMMITTEE, 5-05 rev DMC Adv Wound Care and Spec Bed Comm 9/08
11 Reducing the Duration of Pressure While reclining - use the rule of 30Patients 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 sittingShear also occurs over the ischial tuberosities when chair sitting patients slide forward in the chair.Teach able patients to shift their body weight every 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 minute intervals to change pressure points.
12 PreventionFlow ChartRN TO ASSESS PATIENTFOR PRESSURE ULCERS ANDPRESSURE ULCER RISKIf patient has aBraden Score of < 18If patient has a historyof pressure ulcers oran actual pressure ulcerInstitute prevention flow chart,enter EMR PressureUlcer Prevention / ManagementOrder Set andAssess for nutritionaldeficitsAssess forincontinence,moisture problemsAssess mobility deficits,activity deficitsand sensory perceptionIf Braden score fornutrition is < 2Protect skin from fecaland urinary drainageIf patient is bedbound,chairbound, or unable/unwilling to reposition selfRefer to DMC Skin / WoundCare FlowchartIf Serum Albumin< 3.5 orRefer to Skin CareFlowchartProtect from effects ofPressure / shearDetermine potentialfor rehabilitationIf weight change of10% within 3 monthperiod orReposition frequentlyto decreasepressure durationProvide pressureredistribution todecrease pressureintensityMonitoreffectiveness ofplanIf participates intherapy andIf patient has chronicdiseaseConsult APN / CWOCNfor alternative pressurerelieving surfaces andfurther evaluationPlace in 30 degreelateral sidelyingposition. Avoid thetrochanterTolerates15 minutesof activity andOrder Static AirMattress andQ shift handchecks*Consult Dietitian forcomplete nutritionalassessmentPatient haspotentialfor carryover**Protect bonyprominencesProvide foampositioner wedge tomaintain body positionSuspend heelsoff bed with pillowor Heel Lift BootAvoid prolongedHOB elevation > 30degreesRecommendPT/OTconsult tomaximize mobilityProtect from tubesand equipment*Static Air Mattress – not in use at CHM RIM.**Observed capacity to learn and follow through with motor skills necessary for increased functional independence.Have patient usetrapeze to moveOrder ChairCushion for sittingThese flow sheets do not represent the full scope of careRefer to APN / CWOCN / Wound Care Specialist when in doubt.
13 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 theymust be capable of deforming enough to permit prominent areas of thebody to sink into the support. The surfaces also must be able to transmitpressure forces from one body area to another.The degree of head elevation can affect the clinical effectiveness of asupport 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.
14 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 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 charge.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.
15 Specialty BedsSpecialty 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 ProductsWider, 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 patient.
16 SizeWise Alternate Mattress Replacement Specialty BedsSpecialty SurfaceFOAMRIM OnlySofCare® MattressHill ROM Acucair® &SizeWise Alternate Mattress ReplacementDescription-Provides comfort & pressure redistribution when 4 inch GeoMatt used. -Provides adequate depth, density and indentation load deformationsComfort & pressure redistributionComfort & pressure redistribution, shear & moisture reductionClassificationFoam overlayStatic Air MattressContinuous air flow overlayIndicationsComfortFacilitates bed mobility-Prevention in pts at risk for pressure ulcer-Pt able to turn in 2 or more positions without placement on existing pressure area-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 managementContraindications-Unstable spinal cord injuries-Cervical tractionWeight Limitlbs and / or does not bottom out*300lbs and / or does not bottom out*Ordering PersonnelRNAPN / CWOCNSpecial ConcernsRequires use of turning schedule & incontinence cover to prevent soiling-Requires use of turning schedule-Unstable surface for transfers in & OOB-Use Gaymar pump to maintain inflation-Check for bottoming outPlastic may cause ↑perspirationDiscontinuationObtain From:CPDDynamic Air Therapy or Isoflex mattresses preclude use of this product-DMC Ordering ProcessDynamic Air Therapy in CHM & DRH precludes use of this product
17 Specialty Beds Specialty Surface Hill ROM Flexicair® Eclipse Clinitron ®Clinitron® Rite HiteDescription-Comfort & pressure redistribution, shear & moisture reduction-Comfort & pressure redistribution, shear & moisture reduction-Has bed scale & X-ray windowClassificationLow Air Loss BedAir Fluidized therapy bedAir Fluidized therapy bed & low air loss surfaceIndicationsPrevention in patients > 250lbs-Treatment in pts with breakdown-Treatment in pts with breakdown, posterior burns on bedrest, flaps, & grafts-Provides more moisture / friction / shear control-Pts who qualify for Clinitron Therapy but require period of high head elevation e.g., mechanical ventilationContraindications-Unstable spinal cord injuries-Cervical traction-Not recommended for pts at risk for pulmonary complications or those getting OOB-if pt requires OOB, consider other therapyWeight Limit300lbs and / or does not bottom out*lbs350lbs and / or does notOrdering PersonnelAPN / CWOCNSpecial ConcernsAdd-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 hygieneDiscontinuation-Evidence of wound healing, increase in activity-May convert to Acucair-Pt able to repos with needed frequencyObtain From:-DMC Ordering Process
18 Specialty Beds Specialty Surface Hill ROM Total Care Bariatric KCI BariKareBari Air®DescriptionWide bed to facilitate movement of pts Pressure reduction,-Wide bed to facilitate pt movement-Comfort & pressure redistribution, shear & moisture reductionClassificationLow Air LossFoamIndicationsPressure redistribution-Facilitates pt movement in bed, ambulation, pulmonary toilet, egress from foot• Turn-assist-Percussion / vibration-Comfort device-Facilitates bed movement, ambulation, pulmonary toilet-Pressure redistribution• Stabilization handlesContraindications-Unstable spinal cord injuries-Cervical tractionWeight Limit465 lbsUp to 850lbsOrdering PersonnelAPN / CWOCNSpecial ConcernsFront exit facilitates patient ambulation and egress.Cardiac chair positioning enhances pulm functionX-ray cassette holder-Elevate heels-Turn for pulm hygieneDiscontinuation-meets weight and ambulation requirements-May convert to Acucair-Evidence of wound healing, increase in activity-Pt able to repos with needed frequencyObtain From:-DMC Ordering Process
19 Specialty Beds Specialty Surface Sizewise Platform Mighty Air Big Turn Description- -Wide bed to facilitate movement of ptsUp to 1000Lbsexpandable deck allowing for widths of 39” or 48-Wide bed to facilitate movement of pts-Comfort & pressure redistribution, shear & moisture reduction-Has bed scale, HOB elevation scaleTurningClassificationFoamLow Air LossLow Air Loss.Indications--Comfort device-Facilitates pt movement, in bedLow air loss therapy2 therapy modes – Static & Alternating-Lateral rotation up to40 degrees-Percussion/ Vibration-Side wall bolster supportsContraindications-Unstable spinal cord injuries-Cervical traction-if pt requires OOB, consider other therapyWeight LimitUp to 1000lbsOrdering PersonnelAPN / CWOCNSpecial Concerns-Requires use of turning schedule-48 inch surface must be broken down to transfer pt room to room-Elevate heels48 inch surface must be broken down to transfer pt room to roomDiscontinuation-meets weight and ambulation requirementsObtain From:-DMC Ordering Process
20 Specialty Beds Specialty Surface Hill ROM Zoneaire - CHM Stryker XPRT DescriptionProvides pressure redistribution, shear and moisture reduction.Self adjusts with weight shiftsprovides 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.ClassificationIntegrated 6 zone low air loss.non-integrated support surface meets critical pulmonary therapy needs and pressure redistributionIndicationsPrevention or identified as at risk for breakdownPulmonary complications: percussion, vibration, rotation to 40%Pressure redistributionContraindicationsUnstable spinal cord injuries-Cervical tractionWeight Limit300 lbs therapeutic weight limit500 LbsOrdering PersonnelCHM RN staffHUH / HWH Critical Care RN staffSpecial ConcernsNeeds to be turned on in Prevention ModeRequires use of turning scheduleCycle for 10 minutes to be sure it is working properly before placing patient on itDiscontinuationObtain From:CHM onlyCall CHM Environmental Service for bed deliveryAvailable on HUH / HWH Critical Care units
21 Definitions DEFINITIONS The following definitions apply to the Skin and Wound Care Flow ChartsAAbscess: 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.BBariatric: 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.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.CCellulitis: 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 105 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.DDebridement, 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.5
22 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 dressingContraindicated 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.
23 DefinitionsDDressings, 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 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 moistureFoam e.g., Mepilex Ag - Used for colonized wounds or those at risk of infection and decreases wound’s bacterial load. Used in exudating colonized woundsTextile 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 exudateDressings, 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.
24 DefinitionsEEnzymes: 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.GGangrene: 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 GasDry 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 progressingGranulation 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.HHospital 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.
25 DefinitionsIIncontinence-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.JKLMMaceration: excessive tissue softening by wetting or soaking (waterlogged).NNegative 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.OPPeriwound: 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.
26 DefinitionsPPressure 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 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 tomonitor progress over time. Pressure ulcer staging is not reversible. Ulcers do not heal inreverse 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 cannotbe staged. The full extent or wound depth is hidden by slough or eschar.
27 DefinitionsPPresent 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.QRRash: 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 tissueTissue: Necrotic: devitalized or dead tissueTissue: 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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