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Rebecca Roberts RN MSN CWOCN

Gayle Moore-
Moore-Lisa RN MSN CWOCN
Garth Ireland RN MSN MPA CWOCN
 Obj 

þ ëy the end of the presentation the

participant will be able to
ƛ accurately assess and document patient
wounds
ƛ list basic wound care principles
ƛ identify wound care products available at
UHCMS
 Assessment
Wound Measurement

LengthΠhead to foot

Width: perpendicular
to length
Depth
Undermining:Clock
face
Tunnel: tract in the
wound
  
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þ Wound drawing

þ Photography
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þ Wound bed:
ƛ Color: red, black (eschar), yellow (slough)
þ Exudate:
ƛ Color
ƛ Odor
ƛ Quantity
þ Periwound skin
ƛ Erythma, Maceration, denuded
ƛ Palpate for induration, warmth, fluctuation
 |

þ Pressure Ulcers
ƛ Tissue damage due to pressure
ƛ Staged 1 to 4 based on depth of tissue involved
þ Only staged if wound bed visible otherwise Ơunstageableơ
or deep tissue injury
ƛ Usually over pressure points
þ Occiput
þ Elbow
þ Scapula
þ Sacrum
þ Ischium
þ Malleolus
þ Hip
þ ëraces, casts or tubing


  

þ A pressure ulcer is a localized injury to

skin and/or underlying tissue usually over
a bony prominence a result of pressure, or
pressure in combination with shear and/or
friction.




—he National Pressure Ulcer Advisory

Panel has divided pressure ulcers into
4 stages based on anatomical tissue
loss and has included two additional
categories of suspected deep tissue
injury and unstageable pressure
ulcers.
  

University Hospital Case Medical Center is

committed to the prevention of all
nosocomial pressure ulcers. —he goal is
zero incidence of pressure ulcers acquired
during hospitalization.

  

þ CMS is asking that a pressure ulcer be

properly documented by the physician
upon admission. A pressure ulcer
documented by the physician after the
admission will be counted as a
nosocomial pressure ulcer. —his is
even if there is admission
documentation in the chart by other
services such as nursing or dietary
that the ulcer existed.

  
þ ºor the admission assessment the
physician must view the patient from head
to toe. Dressings must be removed, if
possible, and the patient turned to view
pressure points such as the heels, sacrum,
occiput , elbows and scapula
þ Pressure ulcers present on admission need
to be documented as such and properly
staged in the record.
 | 
þ —he Center for Medicare and Medicaid
Service (CMS) has stated that effective
October 1, 2008, hospitals will not be paid
for the care of nosocomial pressure ulcers.
þ Since many private insurances follow
Medicare guidelines, these private plans
may also institute similar restrictions.

 
!
þ Recent replacement of all patient beds
with pressure reduction surfaces on
Medical surgical floors.
þ Evaluation of replacement beds for
intensive care units and operating
suites.
þ Extensive nursing in-
in-service on
assessment, prevention and treatment
of pressure related skin problems.
 !

þ Intact skin with non-

non-
blanchable redness of a
localized area usually over a
bony prominence.
þ Pigmented skin may not
have visable blanching. Its
color may be different from
the surrounding area.
þ —he area may be painful,
firm, soft, warmer or cooler
than adjacent tissue.
!
!
!!

þ Partial thickness loss of dermis presenting

as a shallow open ulcer with a red or pink
wound bed. May also present as an intact
or open/ruptured serum-
serum-filled blister.
þ A shiny or dry shallow ulcer without slough
or bruising (indicative of suspected deep
tissue injury).
þ Does not include: skin tears, tape burns,
perineal dermatitis, maceration or
excoriation.
!!


!!


!!


!!!

þ ºull thickness tissue loss.

Subcutaneous fat may be visible but
not bone, tendon or muscle are not
exposed.
þ —he depth of a stage III pressure
varies by anatomical location. —he
bridge of the nose, occiput and
malleolus do not have subcutaneous
tissue and stage III ulcer can be
shallow.
!!!


!"

þ ºull thickness tissue loss with exposed

bone, tendon and/or muscle.
þ Slough or eschar may be present in
some parts of the wound.
þ Often includes undermining or
tunneling.
!"


  b



þ ºull thickness tissue loss in which the base
of the ulcer is covered by slough (yellow,
tan, brown) and/or eschar (tan, brown or
black) in the wound bed.
þ Until enough slough and/or eschar is
removed to expose the base of the wound,
the true depth and therefore stage can not
be determined.
þ Stable (dry, adherent, intact without
erythema or fluctuance) eschar on the heels
serves as the bodys natural cover and
should not be removed.
 b



 b



 b






!j

þ Purple or maroon localized area
discolored intact skin or blood-
blood-filled
blister due to damage of underlying
soft tissue from pressure and/or shear
þ —he area may be preceded by tissue
that is firm, mushy, boggy, warmer or
cooler as compared to adjacent tissue.
þ —he area may evolve rapidly to expose
additional layers of tissue injury.



!j



 #" 


þ It is important to distinguish between

pressure and possible vascular causes
of tissue injury.
þ Pressure related injuries occur over
bony prominences or areas of
shearing. Pressure injury can also be
related to equipment such as braces,
casts and tubing.
"

þ Medial lower leg
þ Champagne Glass
leg
þ Dependent edema
þ Hemosiderin
staining
þ Weeping wound
with irregular
borders
"


þ Cold, hairless leg
þ Lack of pulse
þ Pain on elevation
þ Relief on dependent
position
þ Wound with punched
out appearance and
pale or necrotic
wound bed

 j
 $b

þ Plantar surface of the foot
þ Round wound surrounded by callas
þ Lack of sensation
þ ºoot deformity: Charcot foot.

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þ iehiscence
þ Infection
þ ºistula
þ Necrosis
þ Altered wound healing

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þ
%
 
  %

 
ƛ Cover wound
ƛ ºill in wound cavity
ƛ Moisten dry wounds
ƛ Control excessive moisture

 
  

þ Wet to Moist NO— Wet to iry
ƛ New post operative wounds to monitor
bleeding
ƛ —wice a day dressing changes that
increase risk of contamination
ƛ Can reduce frequency of dressing change
by adding moisture (iuoderm Hydrogel)
ƛ Painful

 
  

þ Mepilex ëorder iressings
ƛ Silicone dressing of various sizes
ƛ Non occlusive to allow for air flow
ƛ Reduces pain and further trauma when
removed
ƛ Change every 3 to 5 days
ƛ ºor stage I and II PU, skin tears or for
cover dressings.

 
  

þ ‰enaderm Ointment
ƛ Protective barrier to skin
ƛ Perineal iermatitis
ƛ Skin —ears
ƛ Radiation iermatitis
ƛ Requires Mi order
ƛ Apply once to twice a day and after
incontinence

 
  

þ Hydrocolloid (iuoderm)
ƛ Wound cover and protection
ƛ Occlusive for minimal exudate
ƛ Change 2 to 3 times per week
ƛ Used in home care to reduce visits
ƛ Can cause trauma to area when removed

 
  

þ Mepilex —ransfer iressing
ƛ ºor heavily draining wounds such as
weeping venous wound or bullous lesions
ƛ Silicone foam dressing
ƛ Easy to remove with little trauma to
tissue
ƛ Wicks drainage. Requires absorbent
cover dressing
ƛ Change when saturated

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þ ºill wound cavity
ƛ Hydrofiber (Aquacel)
þ ºor moist and draining wounds
þ Easy to apply. Comes in rope and sheets

þ Change based on amount of drainage. iaily

to every 3 days.
þ —urns to gel. Easy and less painful to remove
and apply.

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þ Negative Pressure —herapy
þ KCI Wound VAC (Vacuum Assisted Closure)
ƛ Wound filled with sterile foam. Covered with
occlusive drape and attached to negative
pressure pump.
ƛ Removes exudate from wound
ƛ Promotes angiogenesis and wound contraction
ƛ Changed 3 times per week
ƛ Reduces exposure to contamination and pain
ƛ Expensive.
ƛ Can be used at home with insurance approval.
Not covered at home by Medicaid

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þ Promote a clean wound base free
from infection
ƛ Irrigate wound with each dressing change with
normal saline or wound cleaner to reduce
bioburden
ƛ Antimicrobial dressings
þ Aquacel AG
þ Mesalt (Hypertonic saline)
þ Wound VAC Silver iressing
ƛ Appropriate antibiotic therapy
 

þ Antibacterial fluids can be added to

wet gauze dressings:
ƛ Sulfamylon (mafenide)
ƛ iakins Solution (for short period for
infected, odorous wounds)
ƛ Same concerns as previously noted for
wet to moist dressings

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þ Remove nonviable tissue from the
wound to promote new growth
and reduce medium for infection
ƛ iebridement
þ Surgical:Sharps: immediate
ƛ ơExcisional iebridementơ removal of tissue and not
just loose tissue fragments.
þ Enzymatic: Collagenase/Santyl oint.
ƛ Apply once or twice a day.
ƛ Cover with dry dressing
ƛ Necrotic —issue needs to be scored with scalpel
ƛ Can be slow process

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þ Investigate and resolve underlying causes
ƛ Pressure Ulcers
þ Pressure relief
þ Reduce risk of shear
þ Incontinence care
ƛ Venous Insufficiency
þ Compression if arterial involvement ruled out
ƛ Arterial Ischemia
þ Revascularization
ƛ Neuopathic/iiabetic Ulcers
þ Glucose Control
þ Off loading footwear

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þ Collaboration
ƛ Physician: Plastics, Vascular, iermatology,
Infectious iisease
ƛ Nursing, WOCN
ƛ iietitian
ƛ iiabetic Educator
ƛ Physical —herapy
ƛ Social Service
ƛ Home Care
&'