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Skin and Wound Care

Braden Scale & Prevention Section 2 of 7 RN and LPN


Self-learning Module

DMC Adv Wound Care and Specialty Bed Committee

DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

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

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.

2. Review basic skin and wound care concepts.

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.

3. Apply DMC standard skin and wound management principles.

DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

Pressure Ulcer Risk Assessment


Epidemiology and Economics
The National Pressure Ulcer Advisory Panel (NPUAP) reported that in 2003 there were 455,000 hospital stays during which pressure ulcers were noted-a 63 percent increase from 11 years earlier.

Patients 65 years and older accounted for 72.3 percent of all those hospitalizations. LOS for primary diagnosis of pressure sores lasted nearly 13 days and varied by patients age. The average charge for hospital stay for pressure ulcers was $37,800.

Reference: Statistical Brief #3, April 2006. Agency for Healthcare Research and Quality.

Timely, accurate identification of patients at risk for pressure ulcers provides opportunity for early preventive interventions. Pressure ulcer risk assessment is the basis for planning patient treatment, evaluating its effects, and communicating with others.
The Braden Scale for Predicting Pressure Sore Risk is a formal, valid, internationally recognized tool for predicting patient risk for pressure ulcers.

Identifying patients at risk using the Braden Scale involves assessing six subscales:
Sensory perception Moisture Activity Mobility Nutrition Friction and shear
DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

Braden Schema
Pressure Ulcer Development

Mobility

Activity

Pressure
Sensory Perception

Extrinsic Factors

Moisture Friction Shear


Intrinsic Factors Nutrition Arteriolar pressure Age Other Hypothetical factors: Interstitial fluid flow Emotional stress Smoking Skin temperature

Pressure Ulcer Development

Tissue Tolerance

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

DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

Braden Scale
Predicting Pressure Sore Risk
The Braden Scale score ranks patients according to their level of risk for pressure ulceration. Lower scores indicate a lower functional status and, therefore, a higher level of risk:
9 or less 10 - 12 13 - 14 15 - 18 19 - 23 = = = = = Very high risk High risk Moderate risk Mild risk Generally not at risk

A total Braden Scale score of 18 or below in an adult patient is predictive for the development of a pressure ulcer unless preventive measures are taken. If the total Braden scale score is < 18, the patient must have preventive interventions. Preventative measures must focus on those Braden subscales in which a patient has a low score. 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 Set

PREVENTION-PREVENTION-PREVENTION
DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

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.

DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

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.

DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

Pressure Ulcer Prevention


Basic tenets of pressure ulcer prevention are managing nutrition, pressure (friction/shear) and incontinence / excessive moisture.
If nutrition deficits exist, RN may enter an EMR Healthcare Provider order to consult a dietitian. Protect skin from excessive moisture and fecal / urinary drainage. Be proactive, start with petrolatum or other barrier creams immediately.

To manage pressure, control both the intensity and duration. Pressure duration is time spent in one position. Manage by repositioning frequently. Pressure intensity is the amount of pressure. Manage by using a special pressure redistribution support surface e.g., SofCare, Isoflex, Acucair.
Avoid massaging bony prominences. Massage does not increase circulation or prevent pressure ulcers. It may cause more damage to compromised tissue Use a lift pad to move patients up in the bed to avoid friction and shear

While reclining - use the rule of 30


Unless medically contraindicated, the HOB is kept at a 30 angle or lower to reduce shear force. When the HOB bed is elevated, shear force results in the skin and superficial fascia remaining fixed against the bed linen while the deep fascia and skeleton slide down toward the foot of the bed over bony prominences. This can stretch the blood vessels and result in sacral shear ulcers. Use of an overhead trapeze is helpful if a patient has enough upper body strength to lift self off the bed.

DMC Advanced Wound Care and Specialty Bed Committee

DMC 2009

Preventing Heel Ulcers


HEELS UP!
No support surface provides adequate pressure relief for heels.
Diabetic patients with normal Braden scale score are at increased risk for foot / heel ulcers due to peripheral neuropathy.

Elevate or float heels off sleep surface to prevent pressure ulcers.

Effect of pressure on heels

Elevate heels off the bed

All you need is one hand to fit between heels and the sleep surface. Use Heel Lift Boots for patients who will not keep heels off surface
HUH/ HWH/ KCH PU COMMITTEE, 5-05 rev DMC Adv Wound Care and Spec Bed Comm 9/08

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Reducing the Duration of Pressure


While reclining - use the rule of 30
Patients are repositioned minimally every 2 hours. Teach able patients to shift their body weight while in bed. In addition, the patient is repositioned alternately from a right 30 degree lateral side-lying position to a left 30 degree lateral side-lying position. This will keep pressure off of the sacrum and the trochanter at the same time. Use a foam positioning device to support the body in this position. Avoid positioning patients at a ninety degree angle. Placing them in 90 which is the degree side-lying positions places them on the trochanter most vulnerable bony prominence.

While chair sitting


Shear also occurs over the ischial tuberosities when chair sitting patients slide forward in the chair. Teach able patients to shift their body weight every 15-30 minutes while chair sitting. Patients who cannot shift themselves are repositioned / shifted by caregivers at least every hour and more often if breakdown exists. Patients sitting in a chair require a pressure redistribution surface e.g., SofCare cushion, ROHO cushion. They need to be repositioned at 30-60 minute intervals to change pressure points.
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Prevention Flow Chart


RN TO ASSESS PATIENT FOR PRESSURE ULCERS AND PRESSURE ULCER RISK

If patient has a Braden Score of < 18

If patient has a history of pressure ulcers or an actual pressure ulcer

Assess for nutritional deficits

Assess for incontinence, moisture problems

Assess mobility deficits, activity deficits and sensory perception

Institute prevention flow chart, enter EMR Pressure Ulcer Prevention / Management Order Set and

If Braden score for nutrition is < 2


If Serum Albumin < 3.5 or If weight change of 10% within 3 month period or

Protect skin from fecal and urinary drainage

If patient is bedbound, chairbound, or unable/ unwilling to reposition self

Refer to DMC Skin / Wound Care Flowchart

Refer to Skin Care Flowchart Protect from effects of Pressure / shear Determine potential for rehabilitation

If patient has chronic disease

Reposition frequently to decrease pressure duration

Provide pressure redistribution to decrease pressure intensity Order Static Air Mattress and Q shift handchecks* Protect bony prominences Suspend heels off bed with pillow or Heel Lift Boot Protect from tubes and equipment Order Chair Cushion for sitting

Monitor effectiveness of plan Consult APN / CWOCN for alternative pressure relieving surfaces and further evaluation

If participates in therapy and

Consult Dietitian for complete nutritional assessment

Place in 30 degree lateral sidelying position. Avoid the trochanter Provide foam positioner wedge to maintain body position Avoid prolonged HOB elevation > 30 degrees

Tolerates 15 minutes of activity and Patient has potential for carryover**

Recommend PT/OT consult to maximize mobility *Static Air Mattress not in use at CHM RIM. **Observed capacity to learn and follow through with motor skills necessary for increased functional independence.

Have patient use trapeze to move

These flow sheets do not represent the full scope of care Refer to APN / CWOCN / Wound Care Specialist when in doubt.
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Reducing Intensity of Pressure


To be effective, support surfaces must mold to the body to maximize contact, then redistribute the patients weight as uniformly as possible pressure redistribution. Surfaces are designed so that body weight floating on a fluid system is evenly distributed over the entire surface. As pressure is increasingly distributed over more body surface area, the intensity of pressure decreases over all body areas. Support surfaces also use the principle of deformation, meaning they must be capable of deforming enough to permit prominent areas of the body to sink into the support. The surfaces also must be able to transmit pressure forces from one body area to another. The degree of head elevation can affect the clinical effectiveness of a support surface. When the head of the bed is elevated, pressure is shifted to the sacral and ischial areas of the body. The patient may bottom out if the seating area of the support surface flattens and loses volume. If bottoming out occurs, the support surface no longer provides therapeutic benefit. Whether patients at risk for pressure ulcers are in bed or a chair, pressure points must be protected. Today, many types of special beds, mattresses, and cushions are available to reduce the intensity of pressure. Pressure redistribution surfaces include special foam and static air mattresses; low air loss, air-fluidized, and oscillating beds. There is no scientific evidence that one support surface consistently works better than all others. The best way to match a support surface to a particular patients needs is to learn the special characteristics of each type of surface. See the following pages for the DMC Decision Guidelines for Specialty Beds and Overlay Mattresses.

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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 patients body weight does not fully compress the overlay.
If the overlay is compressed enough for the patient to rest on the underlying mattress, the patient is bottoming out. To check for proper mattress overlay inflation, place an outstretched hand (palm up) under the overlay, below the part of the body at risk for a pressure ulcer. If the caregiver feels less than one inch of uncompressed support surface, the patient has bottomed out. To combat bottoming out, either increase inflation or move the patient to a mattress with more depth (Bergstrom, et. al, 1994). Sof-Care mattresses need to be checked daily for bottoming out even when using the Gaymar continuous inflation pump.

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Specialty Beds
Specialty beds and surfaces are selected based on the patient`s status, size and therapeutic benefit associated with the bed. Specialty beds require patient evaluation and order processing by an APN or CWOCN. If the goal is pressure ulcer prevention, pressure redistribution surfaces or mattresses such as low air loss, static air / Sof-Care and Hill Rom DynamicAire (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 airfluidized beds. Patients who are at risk for pulmonary complications and pressure ulcers may require a rotation surface with low air loss such as Stryker XPRT or SizeWise Big Turn. Patients in Critical Care with moderate to severe pulmonary complications such as atelectasis, pneumonia, and ARDS may require continuous lateral rotation therapy as well as a redistribution surface, e.g., XPRT, Total Care Sport While the use of pressure-redistribution surfaces on beds or chairs may allow caregivers to lengthen repositioning intervals, they may also give a false sense of security.
Patients require individual turning schedules regardless of pressure-redistribution devices or specialty support surfaces. Even though every 2 hours is the routine turning interval, patients may require more frequent repositioning.

Heels must be elevated even when specialty support surfaces are in place.

Specific indications and contraindications for use are listed on the following Specialty Bed Table.

Excessive moisture on intact skin may cause maceration and skin breakdown. A support surface that provides air flow such as low air loss or air fluidized can aid in keeping the skin dry.

Bariatric Products Wider, more durable bariatric beds such as the Total Care Bariatric, BariAir, and Mighty Air are available for patients weighing greater than 250 lbs who cannot be repositioned therapeutically. Bariatric room environments provide a whole room set-up (commode, walker, lift) to meet the needs of the bariatric patient.
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Specialty Beds
Specialty Surface FOAM
RIM Only

SofCare Mattress

Hill ROM Acucair &


SizeWise Alternate Mattress Replacement

Description

-Provides comfort & pressure redistribution when 4 inch GeoMatt used. Provides adequate depth, density and indentation load deformations Foam overlay Comfort Facilitates bed mobility

Comfort & pressure redistribution

Comfort & pressure redistribution, shear & moisture reduction

Classification Indications

Static Air Mattress -Prevention in pts at risk for pressure ulcer -Pt able to turn in 2 or more positions without placement on existing pressure area

Continuous air flow overlay -Prevention in pts at risk for pressure ulcer -For pts who develop pressure ulcers while on SofCare -Pt able to turn in 2 or more positions without placement on existing pressure area AND requires moisture management -Unstable spinal cord injuries -Cervical traction 300lbs and / or does not bottom out* APN / CWOCN -Requires use of turning schedule

Contraindications

-Unstable spinal cord injuries -Cervical traction 250-300lbs and / or does not bottom out* RN Requires use of turning schedule & incontinence cover to prevent soiling

-Unstable spinal cord injuries -Cervical traction 300lbs and / or does not bottom out* RN -Requires use of turning schedule -Unstable surface for transfers in & OOB -Use Gaymar pump to maintain inflation -Check for bottoming out Plastic may cause perspiration

Weight Limit Ordering Personnel Special Concerns

Discontinuation

APN / CWOCN

Obtain From:

RIM Only

CPD Dynamic Air Therapy or Isoflex mattresses preclude use of this product

-DMC Ordering Process Dynamic Air Therapy in CHM & DRH precludes use of this product DMC 2009
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DMC Advanced Wound Care and Specialty Bed Committee

Specialty Beds
Specialty Surface
Description

Hill ROM Flexicair Eclipse


-Comfort & pressure redistribution, shear & moisture reduction

Hill ROM Clinitron


-Comfort & pressure redistribution, shear & moisture reduction

Hill ROM Clinitron Rite Hite


-Comfort & pressure redistribution, shear & moisture reduction -Has bed scale & X-ray window Air Fluidized therapy bed & low air loss surface -Pts who qualify for Clinitron Therapy but require period of high head elevation e.g., mechanical ventilation -Unstable spinal cord injuries -Cervical traction -if pt requires OOB, consider other therapy

Classification Indications

Low Air Loss Bed Prevention in patients > 250lbs -Treatment in pts with breakdown -Unstable spinal cord injuries

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

Contraindications

Weight Limit
Ordering Personnel Special Concerns

300lbs and / or does not bottom out*


APN / CWOCN Add

250-300lbs
APN / CWOCN -May cause dehydration motion sickness, wound desiccation -Company rep may be contacted to move bed -Consider a private room -Use MaxiFlo incontinence pads (available from Cardinal) -Elevate heels -Turn for pulm hygiene -May convert to Acucair -Evidence of wound healing, increase in activity -Pt able to repos with needed frequency -DMC Ordering Process

350lbs and / or does not


APN / CWOCN -May cause dehydration motion sickness, wound desiccation -Company rep may be contacted to move bed -Consider a private room -Use MaxiFlo incontinence pads (available from Cardinal) -Elevate heels -Turn for pulm hygiene -May convert to Acucair -Evidence of wound healing, increase in activity -Pt able to repos with needed frequency -DMC Ordering Process

Discontinuation

-Evidence of wound healing, increase in activity

Obtain From:

-DMC Ordering Process

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Specialty Beds
Specialty Surface
Description

Hill ROM Total Care Bariatric


Wide bed to facilitate movement of pts Pressure reduction,

KCI BariKare
-Wide bed to facilitate pt movement

KCI Bari Air


-Wide bed to facilitate pt movement -Comfort & pressure redistribution, shear & moisture reduction Low Air Loss -Pressure redistribution -Facilitates pt movement in bed, ambulation, pulmonary toilet, egress from foot Turn-assist Stabilization handles

Classification Indications

Low Air Loss Pressure redistribution -Facilitates pt movement in bed, ambulation, pulmonary toilet, egress from foot Turn-assist -Percussion / vibration -Unstable spinal cord injuries

Foam -Comfort device -Facilitates bed movement, ambulation, pulmonary toilet

Contraindications

-Unstable spinal cord injuries -Cervical traction Up to 850lbs APN / CWOCN Front exit facilitates patient ambulation and egress. Cardiac chair positioning enhances pulm function X-ray cassette holder Up to 850lbs APN / CWOCN Front exit facilitates patient ambulation and egress. Cardiac chair positioning enhances pulm function X-ray cassette holder -Elevate heels -Turn for pulm hygiene -May convert to Acucair -Evidence of wound healing, increase in activity -Pt able to repos with needed frequency -DMC Ordering Process

Weight Limit Ordering Personnel Special Concerns

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

Discontinuation

-meets weight and ambulation requirements

Obtain From:

-DMC Ordering Process

-DMC Ordering Process

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Specialty Beds
Specialty Surface
Description

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

Sizewise Mighty Air


-Wide bed to facilitate movement of pts Up to 1000Lbs expandable deck allowing for widths of 39 or 48 -Comfort & pressure redistribution, shear & moisture reduction -Has bed scale, HOB elevation scale Turning Low Air Loss Low air loss therapy 2 therapy modes Static & Alternating

Sizewise Big Turn


-Wide bed to facilitate movement of pts Up to 1000Lbs expandable deck allowing for widths of 39 or 48 -Comfort & pressure redistribution, shear & moisture reduction -Has bed scale, HOB elevation scale Low Air Loss. -Lateral rotation up to 40 degrees -Percussion/ Vibration -Side wall bolster supports -Unstable spinal cord injuries -Cervical traction -if pt requires OOB, consider other therapy Up to 1000lbs APN / CWOCN -Elevate heels 48 inch surface must be broken down to transfer pt room to room

Classification Indications

Foam --Comfort device -Facilitates pt movement, in bed

Contraindications

-Unstable spinal cord injuries -Cervical traction

Weight Limit Ordering Personnel Special Concerns

Up to 1000lbs APN / CWOCN -Requires use of turning schedule -48 inch surface must be broken down to transfer pt room to room -meets weight and ambulation requirements -DMC Ordering Process

Up to 1000lbs APN / CWOCN -Elevate heels 48 inch surface must be broken down to transfer pt room to room

Discontinuation

-meets weight and ambulation requirements -DMC Ordering Process

-meets weight and ambulation requirements -DMC Ordering Process

Obtain From:

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Specialty Beds
Specialty Surface
Description

Hill ROM Zoneaire - CHM


Provides pressure redistribution, shear and moisture reduction.

Stryker XPRT
provides full rotation, percussion and vibration therapy in an all-in-one support surface. Low air loss and powered pressure redistribution provide advanced pressure ulcer prevention and treatment. non-integrated support surface meets critical pulmonary therapy needs and pressure redistribution

Self adjusts with weight shifts

Classification

Integrated 6 zone low air loss.

Indications

Prevention or identified as at risk for breakdown

Pulmonary complications: percussion, vibration, rotation to 40% Pressure redistribution Unstable spinal cord injuries -Cervical traction

Contraindications

Unstable spinal cord injuries -Cervical traction

Weight Limit Ordering Personnel Special Concerns

300 lbs therapeutic weight limit CHM RN staff Needs to be turned on in Prevention Mode Requires use of turning schedule Cycle for 10 minutes to be sure it is working properly before placing patient on it

500 Lbs HUH / HWH Critical Care RN staff

Discontinuation Obtain From: CHM only Call CHM Environmental Service for bed delivery Available on HUH / HWH Critical Care units

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Definitions
DEFINITIONS The following definitions apply to the Skin and Wound Care Flow Charts A Abscess: a circumscribed collection of pus that forms in tissue as a result of acute or chronic localized infection. It is associated with tissue destruction and frequently swelling. Acute wounds: those likely to heal in the expected time frame, with no local or general factor delaying healing. Includes burns, split-skin donor grafts, skin graft donor site, sacrococcygeal cysts, bites, frostbites, deep dermabrasions, and postoperative-guided tissue regeneration. B Bariatric: Term applying to care, prevention, control and treatment of obesity. Basic Wound Care: RN identifies and orders treatment plan based on DMC Skin and Wound Care Flowcharts. Blister: elevated fluid filled lesions caused by pressure, frictions, and viral, fungal, or bacterial infections. A blister greater than 1 cm in diameter is a bulla and blisters less than 1 cm is a vesicle. 5 Bottoming Out: determined by the caregiver placing an outstretched hand (palm up) under a mattress overlay, below the part of the body at risk for ulcer formation. If the caregiver can feel less than one inch of support material between the caregivers hand and the patients 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, Dakins 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.
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Definitions
D
Denuded: Loss of superficial skin / epidermis. Drainage: wound exudate, fluid that may contain serum, cellular debris, bacteria, leukocytes, pus, or blood. Dressings, primary: dressings placed directly on the wound bed. Dressings, secondary: dressings used to cover primary dressing. Dressings, alginate: primary dressing. A non-woven highly absorptive dressing manufactured from seaweed. Absorbs serous fluid or exudate in moderately to heavily exudative wounds to form a hydrophilic gel that conforms to the shape of the wound. May be used for hemorrhagic wounds. Non adhesive, nonocclusive primary dressing. Promotes granulation, epithelization, and autolysis. Dressings, foam: primary or secondary dressing. Low adherence sponge-like polymer dressing that may or may not be adherent to wound bed or periwound tissue e.g., Mepilex. Indicated for moderately to heavily exudative wounds with or without a clean granular wound bed, capable of holding exudate away from the wound bed. Not indicated for wounds with slough or eschar. Foam and low-adherence dressings are used in wounds for granulation and epithelialization stages as well as over fragile skin. Dressings, continuously moist saline: primary dressing. A dressing technique in which gauze moistened with normal saline is applied to the wound bed. The dressing is changed often enough to keep the wound bed moist and is remoistened when the dressing is removed. The goal is to maintain a continuously moist wound environment. Indicated for dry wounds or those with slough that require autolytic therapy. Dressings, gauze: primary or secondary dressing. a woven or non-woven cotton or synthetic fabric dressing that is absorptive and permeable to water, water vapor, and oxygen. May be impregnated with petrolatum, antiseptics, or other agents. Indicated for surgical and draining wounds. Dressings, hydrocolloid: primary dressing. Two kinds of wafer, thick and thin. Wafers contain hydroactive/absorptive particles that interact with wound exudate to form a gelatinous mass. Moldable adhesive wafers are made of carbohydrate with a semiocclusive film layer backing e.g., DuoDerm.
Thick wafers are applied over areas with exudate while thin wafers are used over sites with minimal or no exudate. Thin wafers may conform to sites easier than thick wafers. Contraindicated where anaerobic infection is suspected. Dressing is not removed upon external soiling. Removing any intact product that adheres to skin strips the epidermis, causes damage and increases the risk for breakdown. Cover hydrocolloid with a transparent film to decrease friction from repositioning patient or if dressing is at risk for soiling. May be used for intact skin that requires protection against friction. Hydrocydrocolloid and low-adherence dressings are for wounds in the epithelialization stage. Used to cover a wound entirely, leaving approximately a 1.5 inch border around the wound margins. Does not require a secondary dressing Contraindicated for third-degree burns and not recommended for infected wounds. May be used by wound care consultants to promote autolysis in some patients with eschar. Not recommended for wounds with depth or friable periwound tissue or those that require monitoring more often than once or twice a week. May be left on for 3-5 days.
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Definitions
D
Dressings, hydrogel or hydrogel impregnated gauze: primary dressing. A 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 wounds 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 wounds 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 wounds 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. 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. 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). 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.

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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.
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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 physicians 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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Bibliography
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Bibliography

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