Skin and Wound Care

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Skin and Wound Care Dressings Section 5 of 7
RN and LPN Self-learning Module

DMC Adv Wound Care and Specialty Bed Committee

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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

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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.
• 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.

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Dressings

• Basic wound care is provided using DMC Wound and
  Skin Care Flow
• Charts as guidelines for the RN to independently
  make decisions and
• initiate orders for wound care.
• Dressings are selected by RN staff based on wound
  characteristics.
• Ensure continuity by entering EMR orders for all
  wound care
• The following dressing changes may not be
  delegated to the unlicensed
• personnel
• Wet-to-Dry. Dressings that are ordered wet to
  dry but are changed at a frequency that does not
  allow the dressing to dry in the wound bed and
  debride the wound are considered continuously
  moist.
• Weep No More (WNM) Suction Dressing.
• Silver.
• Complex wounds that require filling or packing.
• The RN may delegate dressing changes to the PCA
• After each wound assessment.
• After determining dressing type and frequency.
• The following dressings may be delegated to
  unlicensed personnel
• Alginate.

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Dressings

• Protective Barrier Wipe
• Protective barrier wipe provide a protective
  coating on unbroken skin after they dry
• Provide some degree of protection from mechanical
  injury
• Most liquid film barriers contain alcohol and
  cause stinging on contact with denuded/fragile
  skin
• Transparent Adhesive Dressings 2 PC 5213
• Semi permeable, sterile thin film
• Maintains a moist environment
• Non-absorptive
• Assists in promoting autolysis of devitalized
  tissue
• Creates a second skin and protects against
  friction
• Allows for visualization of wound
• Not used over the following wounds / areas
• Wounds with heavy drainage, depth gt 0.5cm,
  clinical signs of infection, sinus tracts or
  tunneling
• Blisters that are growing in size. Site will
  leak and require removal causing more tissue
  damage.
• Heels, especially those with eschar
• Hydrocolloid Dressings 2 PC 5211

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Dressings

• Hydrogels and hydrogel impregnated gauze 2 PC
  5212
• Clear viscous wound gel that is water based and
  contains glycerin.
• Available in a tube, impregnated in a gauze
  dressing, or as a sheet
• Maintains a moist environment
• Absorbs minimal exudate
• May donate moisture to the wound.
• Assists in promoting autolysis of devitalized
  tissue
• Requires a secondary dressing
• Usually requires fewer dressing changes than
  saline moistened gauze
• Not used over the following wounds / areas
• copious drainage or maceration.
• Where anaerobic infection is suspected.
• Alginate Dressings 2 PC 5207
• Heavy fiber dressing made from seaweed
• Maintains a moist environment
• Absorbs moderate to heavy exudate
• May be used to fill wound cavities
• May be used in bleeding wounds / sites for
  hemostasis

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Dressings

• Silver Dressings Ordered by Wound Care
  Specialists
• Useful for colonized wounds or those at risk of
  infection and decreases wounds bacterial load.
  Wound drainage activates antimicrobial activity
  in foam and hydrofiber. Drainage not necessary
  for textile InterDry Ag
• Mepilex Ag Silver foam, good for up to 7 days.
• Used in exudating colonized wounds
• Easy to remove, cleanse wound, replace
• Aquacel Ag Hydrofiber dressing with silver,
  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
• Difficult to remove, cleanse wound and replace
  due to gelatinous consistency.
• InterDry Ag
• Used for Intertrigo and other skin to skin
  surfaces with rash
• Not used over the following wounds / areas
• Sensitivity to silver

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Dressings/Topical Agent Grid
Tegaderm HP Manufacturer 3M Available sizes 4X4, 8X8 Product Classification Transparent Film Description A clear, adherent non-absorbent dressing that is permeable to oxygen and water vapor. Indications for Usage Superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with little or no exudate Disadvantages No ability to absorb drainage so dressing may cause maceration of periwound tissue. Change Frequency Weekly and PRN for trapped fluid.
Duoderm Signal Thin Manufacturer Convatec Available sizes 4X4, 8X8 Product Classification Hydrocolloid Description Occlusive, adhesive wafer contains hydroactive particle to maintain moist environment promote autolysis Indications for Usage Superficial or Stage II over areas that are not weight bearing. Not for use on sacrum / coccyx Shallow-full thickness wounds with necrosis or slough and light to moderate exudate. Thin duoderm appropriate for wounds with little to no exudate Disadvantages Not recommended for wounds with heavy exudate, sinus tracts, or infections. Wafer may curl and require frequent changes resulting in tearing fragile periwound skin Dressing edges may require tape to decrease curling / rolling. Thin duoderm will not contain large amounts of exudate. Change Frequency Every 3-5 days and PRN for drainage / curling
Hydrosorb Manufacturer Convatec Available sizes 4X4 Product Classification Foam Description Absorptive, non adherent, sponge like polymer dressing Indications for Usage Partial and full-thickness wounds with minimal to moderate exudate and as a secondary dressing for wounds with packing Disadvantages Not recommended for dry wounds. May macerate peri-wound skin. Change Frequency Daily PRN for drainage.
Kaltostat Manufacturer Convatec Available sizes 4X4, rope Product Classification Calcium Alginate Description Alginate dressing that helps reduce bleeding and manages exudate in low to moderately exuding wounds. Indications for Usage Superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with moderate exudate Disadvantages Able to absorb drainage, monitor periwound for maceration. Change Frequency Daily and PRN.
Duoderm Hydroactive, gel Manufacturer Convatec Available sizes 15gm and 30gm Product Classification Hydrogel Description Water-based gel with some absorptive properties. Indications for Usage For use in large and tunneled wounds. Disadvantages None. . Change Frequency Reapply every 12 -24 hours.
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See Dressings/Topical Agent Grid
Skintegrity Manufacturer Medline Available sizes 4X4 Product Classification Hydrogel Impregnated Gauze Description Gauze dressing that is coated with hydrogel Indications for Usage Partial-thickness and full thickness wounds, that require moisture and filling. Abrasions, Burns, radiation skin damage. Ulcers with small amount of slough to enhance autolytic debridement, e.g., sacral ulcers Disadvantages Limited moisture retention, may adhere to wound bed if allowed to dry. Requires a secondary dressing. Can cause maceration of periwound tissue. Change Frequency Reapply every 12 -24 hours.
Mepilex Border with Safetac Technology Manufacturer MÖLNLYCKE Available sizes 4X4 and 6X6 Product Classification Hydrophilic Foam Description sponge like polymer dressing that may or may not be adherent, Effectively absorbs exudate and maintains a moist wound environment. The Safetac layer seals the wound edges, preventing the exudate to leak onto the surrounding skin, thus minimizing the risk for maceration. The Safetac layer ensures that the dressing can be changed without damaging the wound or skin. Indications for Usage Shallow areas with minimal amount of exudate and little or no slough / eschar, e.g., Sacral Pressure Ulcers. Disadvantages None Change Frequency Every 3-5 days. Peel back dressing and assess wound with assessment.
Xeroform Manufacturer Kendall Available sizes 4X4, Roll Product Classification Petrolatum Description Sterile dressing composed of 3 Bismuth tribromophenate in a petrolatum blend on fine mesh gauze Indications for Usage Superficial partial thickness wounds, burns, skin graft sites. Disadvantages May become dry and adherent to wound bed. Allergic reaction to bismuth. Change Frequency Every 12 -24 hours.
Antifungal InterDry AG Manufacturer Coloplast Available sizes Roll Product Classification Antifungal ordered by APN / CWOCN Description A skin fold management system designed to manage moisture, odor and inflammation in skin folds and other skin-to-skin contact areas. A polyester textile impregnated with silver complex, InterDry Ag provides effective antimicrobial action for up to five days and improves the symptoms associated with intertrigo maceration, denudement, inflammation, and satellite lesions. Product works by wicking moisture away to keep skin dry and provides a friction reducing surface to reduce the risk of skin tears and pressure ulcers. Indications for Usage Superficial partial thickness wounds, burns, skin graft sites. Disadvantages May be dislodged during ambulation. Change Frequency 5 days
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See Dressings/Topical Agent Grid
Mepilex Ag Manufacturer MÖLNLYCKE Available sizes APN / CWOCN order Product Classification Antimicrobial Description combines the unique features of Safetac technology with the bacteria reducing power of silver. Works quickly, inactivating wound pathogens within 30 minutes and for up to 7 days. At dressing removal, does not stick to the wound or strip surrounding skin, minimizing patient pain and wound trauma. Indications for use An antimicrobial soft silicone foam dressing designed for management of low to moderately colonized exuding wounds such as leg and foot ulcers, pressure ulcers and partial thickness burns. Disadvantages Do not use on patients with a known sensitivity to silver or during radiation treatment or radiologic examinations e.g. X-ray, ultrasound, diathermy or Magnetic Resonance Imaging. Do not use together with oxidising agents such as hypochlorite solutions or hydrogen peroxide.
AQUACEL Ag Manufacturer ConvaTec Available sizes APN / CWOCN order Product Classification Antimicrobial Description incorporates silver into Hydrofiber Technology resulting in gelling of the dressing with the broad-spectrum antimicrobial properties of ionic silver (Ag). Indications for Usage a primary dressing indicated for use on moderately and highly exuding chronic and acute wounds where there is an infection or an increased risk of infection. Supports wound healing by providing a moist wound healing environment provides sustained antimicrobial activity for up to 7 days. Disadvantages Do not use on patients with a known sensitivity to silver. Gelatinous in wound and under secondary dressing.
AllKare Protective Barrier Wipe Manufacturer Convatec Available sizes 1x1 wipe Product Classification Skin sealant Description Non water soluble clear, co-polymer protective barrier wipe Indications for Usage Protects periwound tissue from injury and maceration. Can be used under tape or adhesive products to increase adherence and protect skin Disadvantages Pain if tissue is denuded. Change Frequency Daily or with dressing changes.
Stomahesive wafers Manufacturer ConvaTec Available sizes 4X4 and 8 x 8 Product Classification Skin Barrier Wafer Description a pectin based wafer. Indications for Usage Skin protection from wound ostomy and eflfuent drainage. As a periwound skin barrier / window on which to apply tape or Montgomery straps to protect against skin stripping. Disadvantages May accelerate skin yeast if present due to occlusive nature. Change Frequency Weekly and PRN barrier erosion or yeast development.
Petrolatum and SensiCare Protective Barrier Manufacturer ConvaTec Product Classification Moisture barrier Description Moisture barrier Indications for Usage repels stool/ urine, assists in preventing breakdown, soothes and protects skin. After cleansing, place thin layer over exposed perineal area. Remove excess Disadvantages Product not to be completely scrubbed off skin. Change Frequency PRN incontinence
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Weep-No-More Suction Dressing
2 PC 5214

• General Information A Weep-No-More (WNM) suction
  dressing may be applied to adult patients with
  weeping or draining sites to facilitate
  measurement of drainage and/or prevent skin
  maceration from excessive drainage.
• Weep-No-More dressings may be placed over wounds,
  incisions, puncture sites, and around drains or
  sites that cannot be adequately managed with
  conventional dressings.
• Other sterile tubes may be used for drainage
  instead of suction catheters
• A physician order is required for WNM suction
  dressings over a surgical incision and/or wound.
  Dressings over these sites are changed every
  24 hours in order to assess surgical
  incision/wound characteristics.
• WNM dressings over non-surgical sites are changed
  every 72 hours and PRN.
• Sterile dressings and catheters are used for each
  WNM dressing change.
• Cleanse the weeping/draining site as indicated
  and prep skin surrounding weeping site with
  liquid film barrier wipe.
• Using aseptic technique
• Cover weeping site with a 4x4 folded sterile
  gauze.
• Place a sterile 14 FR suction catheter or tube
  between folded gauze with the gauze always placed
  closest to the wound/ draining site.
• The suction catheter or tube lays on top of the
  gauze to prevent direct suction being applied to
  the site.
• Cover with Tegaderm Transparent Film Larger
  areas may require more than one gauze or
  Tegaderm. Smaller areas, such as a puncture
  site, may require 2x2 size gauze.

Suction catheter or tubing
Folded 4 x4 gauze
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• Tegaderm
• Gauze Suction
  Site most vulnerable to leaking
  catheter
• Place Tegaderm film dressing over gauze and
  suction catheter. A gauze layer rests between the
  suction catheter and the Tegaderm dressing.
  
• Wipe Tegaderm edges with protective film barrier
  wipe to improve dressing adherence. The site most
  vulnerable to leaking is the area where the
  suction catheter exits the dressing. Prep this
  area well with protective film barrier wipe and
  patch with Tegaderm PRN.
• Connect suction catheter to wall suction. Only a
  very small amount of wall suction pressure is
  required to facilitate WNM dressing drainage. Set
  suction on lowest setting necessary to drain
  dressing. Dressing should contract with suction
  application.
• If no contraction is noted, an air leak is
  present in the dressing. Assess for adhesion
  around suction catheter and for edges not covered
  well by Tegaderm. WNM dressing will not drain
  until gauze is saturated with drainage.
• Reassess need for continuing WNM dressings over
  sites that have not drained for approximately 12
  hours.
• To prevent skin breakdown from daily Tegaderm
  dressing removal or long-term WNM use, window
  with Stomahesive hydrocolloid dressing.
  Stomahesive is less expensive to use than
  Duoderm and transparent film pulls off easily
  from the Stomahesive surface
• Stomahesive
• Tegaderm

Weep-No-More Suction Dressing
2 PC 5214
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Management of Skin Surrounding Wounds

• The skin and tissue surrounding a wound is called
  peri-wound skin.
• The goals of treating peri-wound skin are to
• Maintain skin integrity
• Prevent further breakdown of irritated skin.
• Promote healing of denuded areas.
• Assess and document peri-wound skin condition
  with each dressing change.
• Select dressing material that will keep the wound
  bed moist and the surrounding intact skin dry.
  Protect periwound tissue with protective barrier
  wipe.
• Rashes and induration are abnormal findings and
  necessitate a consult to the APN/ CWOCN / Wound
  Care Specialist. Never cover a rash with an
  occlusive dressing e.g. Duoderm, or Stomahesive.
• Intact reddened or painful peri-wound skin
  indicates possible cellulitis or trauma from tape
  removal.
• Consult APN / CWOCN / Wound Specialist for
  further assessment
• Avoid adhesive tape, excessive heat or enzymatic
  product contact with periwound area.
• Protect skin. Consider use of products such as
  protective barrier wipe, transparent film, or
  Stomahesive and Montgomery straps.

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Peri-wound Skin Flow Chart
RN to ASSESS and DOCUMENT periwound skin
Skin Intact
Skin Broken
Protect and reassess
REDDENED or BLISTERED PERI WOUNDSKIN
RASH
WARM TENDER INDURATED SKIN
MACERATED SKIN
DENUDED SKIN
FUNGAL / YEAST INFECTION
Do not cover with an occlusive dressing
CONSULT
Consult
Stomahesive wafer
Moisture Barrier Hydrocolloid
Consult to R/O Infection AVOID Tape Prevent
Trauma
CONSULT
Antifungal Agent
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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Management of Dressing Attachment

• The goal of attaching a dressing is to maintain
  healthy skin, stabilize the dressing, and/ or
  protect skin from further deterioration.
• Adherent dressings
• Tape removal is the major cause of peri-wound
  trauma. Avoid tape usage whenever possible. If
  tape is used, protect skin beneath tape with a
  protective barrier wipe (not alcohol wipe).
• For non-intact skin, use a barrier wafer
  (Stomahesive) under tape.
• Use Stomahesive wafer under Montgomery straps to
  avoid repeated tape removal/skin stripping.
• Non-adherent dressings
• For body sites that do not tolerate adherent
  dressings, use roll gauze, stretch netting,
  tubular stockinette, Mepilex or stretch net
  panties depending on body location of the wound.

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Dressing Attachment Flow Chart
RN TO ASSESS skin condition around wound
Non-adherent Dressing
Adherent dressing
Assess body location
Intact Skin
Non-intact Skin
Head,arm, foot, or leg
Trunk
Groin, perineal, suprapubic areas
Stomahesive barrier wafer
Protective Barrier Wipe
Paper tape Clear tape Silk tape Montgomery Straps
Net panties
Kerlix/ Kling gauze Stretch netting, Mepilex,
Tubular Stockinette
Stretch netting Tubular Stockinette
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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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.
• 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 105 or fewer
  organisms per gram of tissue are generally
  considered contaminated those with higher counts
  are generally considered infected.
• Cytotoxic Agents solutions with destructive
  action on all cells, including healthy ones. May
  be used by APN / CWOCN to cleanse wounds for
  defined periods of time. Examples of cytotoxic
  agents include Betadine, Dakins Peroxide, and
  CaraKlenz.
• D
• Debridement, autolytic disintegration or
  liquefaction of tissue or cells self-digestion
  of necrotic tissue.

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18
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

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Definitions

• 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 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
• 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.
• 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, HP or consultative form.

21
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).
• 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

22
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.

23
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, HP 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 gt 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.

24
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