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DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 1 Skin and Wound Care EMR Section 7 of 7 RN and LPN Self-learning Module DMC Adv Wound Care and Specialty Bed Committee
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 2 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 Acknowledgements
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 3 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. Purposes and Objectives Purposes and Objectives
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 4 When a patient is admitted or develops a pressure ulcer, remember to document in the following forms: Histories- did the patient have a pressure ulcer in the past? Document location and current characteristics e.g., Stage Adult Admission Assessment – on the Braden Scale form, answer question about pressure ulcer present on admission –Document ulcer(s) in Integumentary Detailed. Complete pressure ulcer grid in its entirety. Ongoing Assessment – document all the characteristics of the pressure ulcer on the grid including size upon admission and every Monday –RN staff is responsible to assess wounds that PCA staff change Pressure Ulcer Order Set – RN initiated orders for either Prevention or Management based on DMC Skin and Wound Care policies Plan of Care – document altered tissue integrity including repositioning every 2 hours and if on specialty surface Wound Care Education Form - select Ad hoc form and complete type of education patient received and need for further education Enter all pressure ulcers, community or hospital acquired into SRM Variance Reporting system Pressure Ulcer Documentation
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 5 “ Go to Pressure Ulcer Prevention Order Set” The following data points will send an EMR notification informing RN staff to activate / enter orders: Braden Score of less than or equal to 18 Braden Subset Scores 2 or less: –Activity Braden equal to Bedrest –Mobility Braden equal to Completely Limited –Moisture Braden equal to Constantly Moist –Sensory Perception Braden equal to Completely Limited –Friction & Shear Braden equal to Problem –Nutrition Braden equal to Very Poor Generalized edema or anasarca present Incontinence in the Genitourinary or GI system assessment Impaired Nutritional Intake Intake < 50% of normal in last 3 days Skin Breakdown/Pressure Ulcer Level of consciousness: lethargic, obtunded or comatose Weight loss greater than or equal to 10 pounds Whenever the activate or “Go to” notification is present, ensure orders are entered for prevention using the EMR Pressure Ulcer Prevention Order Set Pressure Ulcer Prevention Orders
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 6 “ Go to Pressure Ulcer Management Order Set” The following data points will send an EMR notification informing RN staff to activate / enter orders: Pressure Ulcer on Admission Assessment Yes response to “Does the Patient have a Pressure Ulcer” Redness, induration, bogginess, erythema, non- blanchable on the Abnormality Skin grid Any documentation entered for following locations: elbows, hips, coccyx, ankles or heels on the Abnormality Skin grid Whenever the activate or “Go to: notification is present, ensure orders are entered for prevention using the EMR Pressure Ulcer Management Order Set –Prevention interventions are incorporated into the Management Order Set Individual staff RN PI data is gathered for the pressure ulcer prevention and management process –Information in EMR for patients at risk / low Braden subscores is collected to track date / time / individual RN for the following: Assessment entry Prevention and management task completion Pressure ulcer prevention and / or management order set entry Information collected is used by management to improve individual RN documentation and patient care Pressure Ulcer Management Orders
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 7 These are some of the cues that signal further assessment / documentation is required New configuration on tool bar! Integumentary has been split up into Ongoing, Pressure Ulcer Care, Incision / Wound Care and Skin Abnormalities. Ensure that data is entered into the correct grid based on patient assessment. Assessment Integumentary System If pressure ulcer, skin abnormality, or incision / wound is present, always complete the corresponding grid. Skin abnormalities are not pressure ulcers. Do not document pressure ulcers in this section.
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 8 Document surface especially for patients at risk for or with a pressure ulcer Assessment Integumentary, Ongoing This page contains key assessment points to document. Scroll down to view entire assessment form.
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 9 Assessment Pressure Ulcer Care Select Pressure Ulcer Care Measure all pressure ulcers whenever discovered, upon admission and every Monday Complete all of the columns in the Pressure Ulcer Care Grid with each assessment Describe periwound area since deterioration may lead to ulcer enlargement Dressings must match EMR order entered. Use comments for details not included in grid options.
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 10 EMR Pressure Ulcer Prevention and Management Order Entry Nicholson, Jack Select Prevention Order Set for patients at risk and Management Order Set for patients with pressure ulcers Pressure Ulcer Order Sets
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 11 Enter ordering name as healthcare provider and communication type as RN Plan of Care or Per Protocol Nicholson, Jack Pressure Ulcer Order Sets
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 12 Nutrition Consult is entered for all patients at risk for or with a pressure ulcer This may not generate a consult APN / CWOCN. A separate order is required for patients with complex or deteriorating wounds. Pressure Ulcer Order Sets
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 13 In the Pressure Ulcer Management Order Set, double click Wound Care Basic to enter dressing orders Pressure Ulcer Order Sets Select the primary dressing for the ulcer based on the DMC Flowcharts
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 14 Pressure Ulcer Order Sets Select secondary dressing. If primary dressing does not require a cover e.g., hydrocolloid / Duoderm, select “None” for secondary dressing Select everything that covers the primary dressing and the attachment system e.g., barrier wafer (stomahesive)
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 15 Pressure Ulcer Order Sets Select Debridement Type. Autolytic debridement occurs with hydrogel impreg gauze, hydrogel, and hydrocolloid / Duoderm Mechanical debridement occurs with true wet to dry dressings when they are allowed to dry in the wound bed and ripped out debriding healthy and dead tissue.
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 16 Pressure Ulcer Order Sets Enter special instructions as needed that will clarify orders Add frequency of dressing change to the special instructions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 17 Pressure Ulcer Order Sets Orders from the Pressure Ulcer Prevention or Management Order Set appear in the Activity and Vitals/ Patient Care section
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 18 Document repositioning frequency in Comments for patients at risk / actual pressure ulcer Plan of Care Initiate an Integumentary Plan of Care for patients at risk or with an actual pressure ulcer
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 19 Nicholson, Jack Document in Ad Hoc Charting. Select EMR Forms, Education Wound Care Form ; Patient Education Documentation Use the Education Wound Care Form to document patient / family education regarding prevention or treatment of pressure ulcers.
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 20 Patient Education Documentation Select individuals taught, teaching method and barriers to learning Document concepts taught and patient / family future needs for teaching. Add Comments as needed.
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 21 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. 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. 5 Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 22 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. Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 23 D Dressings, hydrogel or hydrogel impregnated gauze: primary dressing. A water- based non-adherent dressing primarily designed to hydrate the wound, may absorb small amount of exudate e.g., Skintegrity. Indicated for dry to minimally exudative wounds with or without clean granular wound base. Donates moisture to the wound and is used to facilitate autolysis. May be used to provide moisture to wound bed without macerating surrounding tissue. Requires a secondary dressing. Dressings: Primary : dressing placed directly on the wound bed. Dressings: Secondary: dressing used to cover primary dressing. Dressings, silver: Useful for colonized wounds or those at risk of infection and decreases wound’s bacterial load. good for up to 5 - 7 days. –Alginate e.g., Aquacel Ag - Highly absorbent interacts with wound exudate and forms a soft gel to maintain moist environment. May be used in dry wounds covered with saline moistened gauze as secondary dressing to maintain moisture –Foam e.g., Mepilex Ag - Used for colonized wounds or those at risk of infection and decreases wound’s bacterial load. Used in exudating colonized wounds –Textile e.g., InterDry Ag - Used for Intertrigo and other skin to skin surfaces with rash. May remain in place for 5 days. Dressings, transparent: primary or secondary dressing. A clear, adherent non- absorptive dressing that is permeable to oxygen and water vapor e.g., Tegaderm. Creates a moist environment that assists in promoting autolysis of devitalized tissue. Protects against friction. Allows for visualization of wounds. Indicated for superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with little or no exudate Dressings, wet-to-dry: a debridement technique in which gauze moistened with normal saline is applied to the wound and removed once the gauze becomes dry and adheres to the wound bed. Indicated for debridement of necrotic tissue from the wound as the dressing is removed, however method is not selective and removes healthy tissue as well. Other methods of debridement are considered more effective. Wet to dry dressing orders that are changed at a frequency that does not allow drying are considered continuously moist dressings. Dressing, xeroform: primary dressing. Impregnated gauze with petrolatum and 3% bismuth. Indicated for skin donor sites and other areas to protect from contamination while allowing fluid to pass to secondary dressing. Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 24 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. Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 25 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 sub- atmospheric pressure (negative pressure) suction dressing that promotes moist wound healing. Controlled sub-atmospheric pressure improves tissue perfusion, stimulates granulation tissue, reduces edema and excessive wound fluid, and reduces overall wound size. Some indications for use include pressure ulcers, venous ulcers, diabetic foot ulcers, dehisced surgical incisions, partial thickness burns, grafts, split thickness skin grafts, traumatic wounds, fasciotomy, myocutaneous flaps, and temporary closure for abdominal compartment syndrome (V.A.C. ACS). No Touch Technique: Dressing change technique where only the outer layer of dressing is touched with clean gloves. The dressing surface against the wound bed is never touched. O P Periwound: area surrounding a wound. Assessed for signs of inflammation or maceration. Pressure Ulcer: localized injury to the skin and/or underlying tissue usually over a bony prominence or beneath a medical device, as a result of pressure, or pressure in combination with shear and/or friction. Pressure ulcers are staged according to extent of tissue damage or classified as DTI or unstageable. Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 26 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 blood- filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. *Bruising indicates suspected deep tissue injury. These lesions may herald the subsequent development of a Stage 3 or Stage 4 Pressure Ulcer even with optimal management. Treatment: protect, reposition off area at all times, contact APN CWOCN, assess frequently for deterioration. Although useful during initial assessment, the staging classification system cannot be used to monitor progress over time. Pressure ulcer staging is not reversible. Ulcers do not heal in reverse order from a higher number to a lower number and are not be described s such e.g., “the ulcer was a Stage II but now looks like a Stage I”). Wounds with slough or eschar cannot be staged. The full extent or wound depth is hidden by slough or eschar. Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 27 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. Definitions
DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 28 Ayello, E.A.; Braden, B.J. (2001). Why is pressure ulcer risk assessment so important? Nursing 2001 31(11): 75-79. Ayello, E.A; Lyder, C. (2007) Protecting patients from harm: preventing pressure ulcers. Nursing 2007 Lippincott, Williams & Wilkins: New York. 36-40 Baharestani,M. (2007). An Ovedrview of neonatal and pediatric wound care knowledge and considerations. OstomyWoundManagement 53(6) 34-55. Baranoski, S & Ayello,E. (2003) Wound Care Essentials Practice Principles Lippincott, Williams & Wilkins:New York Bates-Jensen BM, Ovington LG. (2007). Management of exudate and infection. In Sussman C, & Bates-Jensen BM,(Eds.), Wound Care: A Collaborative Practice Manual for Health Professionals. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins. Bergstrom N, Bennett MA, Carlson CE, et al. (1994) Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 95-0652. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E (1998). Predicting pressure ulcer risk : a multisite study of the predictive validity of the Braden Scale. Nursing Research 47 (5): 261-9. Bergstrom N, Braden B, Laguzza A, Holman V (1987) The Braden Scale for Predicting Pressure Sore Risk. Nursing Research, 36, 205-210. Bergstrom N, Demuth P & Braden B, (1987) A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nursing Clinics of North America, 22 (2) 417-422. Braden, B. & Maklebust, J. (2005). Preventing pressure ulcers with the Braden Scale: An update on this easy-to-use tool that assesses a patient’s risk. American Journal of Nursing,6, 70-72. Bryant, R.A. & Nix,D.P. (2007) Acute & chronic wounds: Current management concepts. 3 rd ed. St. Louis, MO, Mosby. Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians; Proposed Rule. Federal Register. 2008;73(84):23552–59. Available at: http://edocket.access. gpo.gov/2008/pdf/08-1135.pdf.http://edocket.access Centers for Medicare & Medicaid Services. Proposed Fiscal Year 2009 Payment, Policy Changes for Inpatient Stays in General Acute Care Hospitals. Available at: http://www.cms.hhs.gov/ Accessed May 13, 2008.http://www.cms.hhs.gov/ Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Cochrane Collaboration, 2008 Support surfaces for pressure ulcer prevention (Review). JohnWiley & Sons, Ltd. Hospitals and Physicians; Proposed Rule. Federal Register. 2008;73(84):23550. Available at: ttp://edocket.access.gpo. gov/2008/pdf/08-1135.pdf.ttp://edocket.access.gpo Centers for Medicare & Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. Federal Register. 2007;72(162):47130–48175. Consortium for Spinal Cord Medicine. (2000) Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health care professionals. Available at www.pva.org. Washington, D.C.: Paralyzed Veterans of America.www.pva.org Doughty D. (2000) Urinary and fecal incontinence: nursing management. 2 nd ed. St. Louis, MO. Mosby Gray, M. (2004). Preventing and managing perineal dermatitis: A shared goal for wound and continence care. Journal of Wound Ostomy & Continence Nursing 31(1)Suppl. Hess CT (2008) Skin & wound care: Clinical guide. 6 th ed. Ambler,PA: Lippincott Williams & Wilkins. Bibliography
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