Professional Documents
Culture Documents
Wound Care
Skin Care & Wound Healing
Section 1 of 7
RN and LPN
Self-learning Module
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 1
Acknowledgements
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
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 2
Purposes
and Objectives
Purposes:
To communicate DMC standards and policies in skin and wound care
practice.
To provide a study module and source of reference.
To prepare RN and LPN orientees for clinical validation of skin and
wound care.
Directions:
All staff members are responsible to read the content of each
module 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:
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 3
Key Points
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 4
More Key Points
Remember the old axiom Dont put anything in the wound you
wouldnt put in your own eye. Wound tissue is as sensitive as the
tissue in your eye.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 5
Skin Care
Aging skin loses its elasticity. The skin becomes thin, dry,
fragile and prone to tearing when handled roughly.
Avoid soap or chemical irritants on fragile skin.
Keep unbroken skin lubricated and protected from trauma.
Lotions or moisturizing creams are usually unnecessary for
intact perineal / perianal tissue.
Irritated
Dry or Fragile Consult
Normal Intact Normal Intact Skin Unbroken Skin Denuded / IAD*
Skin
MOISTURIZING MOISTURIZING
MOISTURIZING MOISTURIZING MOISTURIZING
Lotion or Lotion or
Unnecessary Unnecessary Unnecessary
Petrolatum Petrolatum
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 7
Goals of Care
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 8
Wound Healing
From Jones V, Bale S, Harding K Acute and Chronic Wound Healing in Wound Care
Essentials, Practice Principles S. Baranoski and E. Ayello (eds), Philadelphia:
Lippincott, Williams and Wilkins, 2004
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 9
Wound Healing
From Jones V, Bale S, Harding K Acute and Chronic Wound Healing in Wound Care
Essentials, Practice Principles S. Baranoski and E. Ayello (eds), Philadelphia:
Lippincott, Williams and Wilkins, 2004
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 10
Wound Irrigation
Label normal saline bottle with date and time. Discard opened
normalDMCsaline solution
Advanced Wound after
Care and Specialty 24 hours.
Bed Committee DMC 2009 11
Wound Assessment
and Documentation
1. Location
Anatomic location of the wound is important. The time required for
complete healing is affected by the blood supply to the region. For
this reason, wounds on the face generally heal faster than a similar
wound in a peripheral area where the blood supply is poorer. The rate
of healing is also affected by the extent to which the skin is tightly
adherent to the underlying fascia. For example, wounds on the shin
generally heal slower than comparable wounds anywhere else
because skin adherence is so tight over the shin (Baranoski,S., Ayello,
E.A., 2004).
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 12
Wound Assessment
and Documentation
2. Wound Dimensions
Size: the initial size of a wound is an important factor in noting the
rate of healing. Large deep wounds take longer to heal than small
deep wounds. By contrast, large shallow wounds, like skin-graft donor
sites, are covered with new epithelium at about the same rate as small
shallow wounds, especially when kept moist. Measure and document
the wound upon admission and every Monday using centimeters as
follows:
1. Length - longest point on wound, from head to toe.
2. Width - widest point on wound, from side to side.
3. Depth- the deepest point in the wound
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 13
Wound Assessment
and Documentation
6. Necrotic Tissue Dead devitalized avascular tissue and may impede
wound healing. It may be present in the wound as yellow, gray, brown
or black. Yellow or tan stringy tissue is referred to as slough. Black
devitalized tissue is eschar. Document color, type and percentage
of tissue in the wound bed. (Baranoski & Ayello, 2004)
7. Exudate Visual appraisal of the amount and character of wound
drainage is generally regarded as an important parameter in wound
assessment. One study showed the healing rate of wounds was
slowed by two-thirds when exudate was present at baseline. The
amount of exudate may be an important indicator of healing. (Xakellis
& Chrischilles, 1992). Document exudate color, consistency, odor
and amount.
8. Surrounding Skin Monitor and document wound margins for signs of
inflammation (erythema, swelling, pain) or maceration (waterlogged).
Inflammation may be caused by unrelieved pressure, infection or
adverse reactions to wound care treatments. Skin maceration,
caused by prolonged contact of wound fluid with the skin, may be a
sign that the topical wound treatment is inappropriate for the patient.
Document periwound condition.
9. Induration Induration is an area of hardened tissue that can be
palpated around a pressure ulcer or wound. Use fingertips to palpate
for induration on intact skin surrounding a pressure ulcer or wound.
Document induration and extent of wound margin.
10. Infection Occurs in viable tissue beneath the wound surface.
Clinical signs of wound infection are the presence of warmth, pain,
erythema, swelling, induration, and/or purulent drainage. Infection
occurs when the bacterial burden overwhelms the host. Assess the
peri-wound tissue for cellulitis. A tissue biopsy should be obtained to
confirm infection. Document signs of infection and contact APN /
CWOCN and/or physician.
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.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 15
Definitions
Drainage: wound exudate, fluid that may contain serum, cellular debris, bacteria,
leukocytes, pus, or blood.
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, 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 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
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 17
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.
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.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 18
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.
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.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 19
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 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.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 20
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.
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.
Wound Care as Ordered: refers to RN generated orders for treatment based on DMC
Skin and Wound Care Flowcharts.
Wound irrigation: cleansing the wound by flushing with fluid e.g., 250 mL sterile
normal saline under pressure.
DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 21
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DMC Advanced Wound Care and Specialty Bed Committee DMC 2009 23