DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 1 Skin and Wound Care Dressings Section 5 of 7 RN and LPN Self-learning Module DMC Adv Wound

DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 1

Skin and Wound Care

DressingsSection 5 of 7

RN and LPNSelf-learning Module

DMC Adv Wound Care and Specialty Bed Committee


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 RNEvelyn Lee, BSN, RN, CETN, CRNIMary Sieggreen MSN, RN, CS, CNPPatricia Clark MSN, RN, CS, CCRN Bernice Huck, RN, CETNJames Tyburski, MDMichael Buscuito, MD

In 2000 the authors acknowledge the following staff for assisting with reviewing and revising this learning module:Mary Gerlach MSN, RN, CWOCN, CSCarole Bauer BSN, RN, OCN, CWOCNDebra Gignac MSN, RN, CS Sue Sirianni MSN, RN, CCRNToni Renaud-Tessier MSN, RN, CSEvelyn Lee BSN, RN, CETN, CRNIMary Sieggreen MSN, RN, CS, CNPPatricia 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, CNPCarole Bauer BSN, RN, OCN, CWOCNSue Sirianni MSN, RN, CCRN Evelyn Lee MSN, RN, CWOCNMary Sieggreen MSN, RN, CS, CNPBernice Huck RN, BSN, CPN, WOCNCarolyn J. Stockwell, MSN, RN, ANP, CCM

In 2009 the DMC module was revised by the following staff: Maria Teresa Palleschi ACNS-BC CCRNLaura Harmon ACNP-BC, CCRN, CWOCNEvelyn Lee MSN, RN, CWOCNDiana LaBumbard ACNP-BC, CCRN Bernice Huck BSN, CWOCNCarolyn J. Stockwell, ANP-BC, CNP, CCM Mary Sieggreen ACNS-BC, CNP CVNPauline Kulwicki ACNS-BC CNP CNRN

AcknowledgementsAcknowledgements


Purposes:• To communicate DMC standards and policies in skin and wound care

practice.

• To provide a study module and source of reference.

• To prepare RN and LPN orientees for clinical validation of skin and wound care.

Directions:• All staff are responsible to read the content of these modules and

pass the tests.• If you are unable to finish reviewing the content of this course in

one sitting, click the Bookmark option found on the left-hand side of the screen, and the system will mark the slide you are currently viewing. When you are able to return to the course, click on the title of the course and you will have button choices to either:

– Review the Course Material which will take you to the beginning of the course OR

– Jump to My Bookmark which will take you to where you left off on your previous review of this module.

Objectives: By completing this module, the RN and LPN will:

1. Recognize the professional responsibility of licensed health care providers.

• RNs will utilize the knowledge to make clinical decisions and enter EMR orders based on DMC evidenced based flowcharts found in Tier 2 Skin and Wound Policies.

2. Review basic skin and wound care concepts.

3. Apply DMC standard skin and wound management principles.

Purposes and Objectives

Purposes and Objectives


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.– Continuous moist. – Dry sterile.– Foam.– Hydrocolloid. – Hydrogel, hydrogel impregnated gauze.– Superficial wounds.– Transparent film.

DressingsDressings


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 > 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

– Thick or thin wafer made of gelatin and pectin absorptive particles which interact with wound exudate to form a gelatinous mass.

– Maintains a moist environment.– Minimal to moderate absorption of exudate. Apply thick wafer over areas with

exudate. Apply thin wafer over sites with minimal or no exudate. Thin wafers may conform more easily to irregular surfaces.

– Assists in promoting autolysis of devitalized tissue.– May be left on for 3-5 days.– Used to cover wound entirely with a 1.5 inch border attached to the surrounding skin.– Does not require a secondary dressing.– Do not remove immediately upon external soiling. Cover a hydrocolloid wafer with

transparent film if it is at risk for external soiling. Removing adherent products strips the epidermis and increases the risk for skin breakdown.

– Not used over the following wounds / areas• Where anaerobic infection is suspected.• Presence of rash.• Over pressure areas that will cause dressing to roll, requiring replacement and

causing damage to periwound tissue.

DressingsDressings


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– Assists in promoting autolysis of devitalized tissue– Usual amount needed: 1 sheet or 6 inches of rope changed daily– Do not moisten dressing before application– Irrigate with normal saline before removal– Not used over the following wounds / areas

• dry or minimally draining wounds• Third-degree burns

Foam Dressings: 2 PC 5210– Soft polyurethane dressing sheets – Maintains a moist environment– Absorbs moderate exudate.– Useful for managing exudate under compression.– Not recommended for non-draining wounds, sinuses or tunneling– Dressing may be changed up to 3X per week except for fillers which may be daily. – May be used for tracheostomy, drain sites, or open wounds with exudate– Mepilex is used over small to moderate drainage with a pink / red wound base – Not used over the following wounds / areas

• Contraindicated for third degree burns• Wounds that require fill

DressingsDressings


Silver Dressings: Ordered by Wound Care Specialists

Useful for colonized wounds or those at risk of infection and decreases wound’s 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

DressingsDressings


Dressings/Topical Agent Grid

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.


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




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


• 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.

Weep-No-More Suction Dressing


Suction catheter or tubing

Folded 4 x4 gauze

2 PC 5214


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®

• Overlap Tegaderm onto Stomahesive®. Change Stomahesive® PRN.• For multiple areas of weeping, WNM sites may be joined with a Y connector to one suction canister. Use 18 inch

suction tubing to connect multiple sites. Due to the tubing required for multiple WNM sites, a higher suction setting may be necessary for the system to drain effectively.

Remember that this area is considered a wound! Document the following: amount of output, dressing change, site appearance, appearance of tissue in/near WNM, and expected outcomes related to wound or site.



2 PC 5214


• 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.

• Treat broken peri-wound skin as an open wound. – Cleanse with saline– Gently dry

Management of Skin Surrounding WoundsManagement of Skin

Surrounding Wounds


RN to ASSESS and DOCUMENTperiwound skin

Skin Intact Skin Broken

REDDENED or

BLISTERED PERI WOUND

SKIN

RASH

WARM TENDER

INDURATEDSKIN

MACERATEDSKIN

DENUDED SKIN

FUNGAL / YEAST

INFECTION

Consult to R/O

Infection AVOID Tape

Prevent Trauma

Do not cover with an

occlusive dressing

CONSULT

Antifungal Agent

Consult Stomahesive

wafer

Moisture Barrier

Hydrocolloid

These flow sheets do not represent the full scope of care

Refer to APN / CWOCN / Wound Care Specialist when in doubt.

Peri-woundSkin Flow Chart

Peri-woundSkin Flow Chart

CONSULT

Protect and reassess


• 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.

Management of Dressing Attachment

Management of Dressing Attachment


RN TO ASSESS:skin condition around wound

Non-adherentDressing

Adherent dressing

Intact Skin

Assess body location

Non-intact Skin

Head,arm, foot, or leg

TrunkGroin, perineal,

suprapubic areas

Net panties

Kerlix/ Kling gauzeStretch netting,

Mepilex, Tubular Stockinette

Stomahesive barrierwafer

Protective Barrier Wipe

Paper tapeClear tapeSilk tape

Montgomery Straps

Stretch nettingTubular

Stockinette

Dressing Attachment Flow Chart

Dressing Attachment Flow Chart

These flow sheets do not represent the full scope of care

Refer to APN / CWOCN / Wound Care Specialist when in doubt.


DEFINITIONSThe following definitions apply to the Skin and Wound Care Flow ChartsA• Abscess: a circumscribed collection of pus that forms in tissue as a result of acute or chronic

localized infection. It is associated with tissue destruction and frequently swelling.• Acute wounds: those likely to heal in the expected time frame, with no local or general factor

delaying healing. Includes burns, split-skin donor grafts, skin graft donor site, sacrococcygeal cysts, bites, frostbites, deep dermabrasions, and postoperative-guided tissue regeneration.

B• Bariatric: Term applying to care, prevention, control and treatment of obesity.• Basic Wound Care: RN identifies and orders treatment plan based on DMC Skin and Wound Care

Flowcharts. • Blister: elevated fluid filled lesions caused by pressure, frictions, and viral, fungal, or bacterial

infections. A blister greater than 1 cm in diameter is a bulla and blisters less than 1 cm is a vesicle.

• Bottoming Out: determined by the caregiver placing an outstretched hand (palm up) under a mattress overlay, below the part of the body at risk for ulcer formation. If the caregiver can feel less than one inch of support material between the caregiver’s hand and the patient’s body at this site, the patient has “bottomed out”. Reinflation of the mattress overlay is required.

C • Cellulitis: inflammation of cellular or connective tissue. Inflammation may be diminished or

absent in immunosuppressed individuals.• Chronic wounds: those expected to take more than 4 to 6 weeks to heal because of 1 or more

factors delaying healing, including venous leg ulcers, pressure ulcers, diabetic foot ulcers, extended burns, and amputation wounds.

• Colonized: presence of bacteria that causes no local or systemic signs or symptoms.• Community Acquired Pressure Ulcer: Any pressure ulcer that is identified on admission and

documented in the Adult or Pediatric Admission Assessment as being present on admission (POA).

• Contaminated: containing bacteria, other microorganisms, or foreign material. Term usually refers to bacterial contamination. Wounds with bacterial counts of 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, Dakin’s Peroxide, and CaraKlenz.

D• Debridement, autolytic: disintegration or liquefaction of tissue or cells; self-digestion of necrotic

tissue. • Debridement, chemical: topical application of biologic enzymes to break down devitalized tissue,

e.g., Accuzyme, Santyl (Collagenase).The following definitions apply to the Skin and Wound Care Flow Charts:

• Debridement, mechanical: removal of foreign material and devitalized or contaminated tissue from a wound by physical forces rather than by chemical (enzymatic) or natural (autolytic) forces. Examples are scrubbing, wet-to-dry dressings, wound irrigation, and whirlpool.

• Debridement, sharp: removal of foreign matter or devitalized tissue by a sharp instrument such as a scalpel. Laser debridement is also considered a type of sharp debridement.

5

DefinitionsDefinitions


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.



D• Dressings, hydrogel or hydrogel impregnated gauze: primary dressing. A water-

based non-adherent dressing primarily designed to hydrate the wound, may absorb small amount of exudate e.g., Skintegrity. Indicated for dry to minimally exudative wounds with or without clean granular wound base. Donates moisture to the wound and is used to facilitate autolysis. May be used to provide moisture to wound bed without macerating surrounding tissue. Requires a secondary dressing.

• Dressings: Primary : dressing placed directly on the wound bed.

• Dressings: Secondary: dressing used to cover primary dressing.

• Dressings, silver: Useful for colonized wounds or those at risk of infection and decreases wound’s bacterial load. good for up to 5 - 7 days.

– Alginate e.g., Aquacel Ag - Highly absorbent interacts with wound exudate and forms a soft gel to maintain moist environment. May be used in dry wounds covered with saline moistened gauze as secondary dressing to maintain moisture

– Foam e.g., Mepilex Ag - Used for colonized wounds or those at risk of infection and decreases wound’s bacterial load. Used in exudating colonized wounds

– Textile e.g., InterDry Ag - Used for Intertrigo and other skin to skin surfaces with rash. May remain in place for 5 days.

• Dressings, transparent: primary or secondary dressing. A clear, adherent non-absorptive dressing that is permeable to oxygen and water vapor e.g., Tegaderm. Creates a moist environment that assists in promoting autolysis of devitalized tissue. Protects against friction. Allows for visualization of wounds. Indicated for superficial, partial-thickness wounds, with small amount of slough to enhance autolytic debridement. Used in wounds with little or no exudate

• Dressings, wet-to-dry: a debridement technique in which gauze moistened with normal saline is applied to the wound and removed once the gauze becomes dry and adheres to the wound bed. Indicated for debridement of necrotic tissue from the wound as the dressing is removed, however method is not selective and removes healthy tissue as well. Other methods of debridement are considered more effective. Wet to dry dressing orders that are changed at a frequency that does not allow drying are considered continuously moist dressings.

• Dressing, xeroform: primary dressing. Impregnated gauze with petrolatum and 3% bismuth. Indicated for skin donor sites and other areas to protect from contamination while allowing fluid to pass to secondary dressing.



E• Enzymes: protein catalyst that induces chemical changes in cells to digest specific tissue.

Indicated for partial and full thickness wounds with eschar or necrotic tissue. Gauze is used as a secondary dressing, e.g.., Santyl and polysporin.

•

• Epithelialization: regeneration of epidermis across a wound’s surface.

• Erythema: Blanchable (Reactive Hyperemia): reddened area of skin that turns white or pale when pressure is applied with a fingertip and then demonstrates immediate capillary refill. Blanchable erythema over a pressure site is usually due to a normal reactive hyperemic response.

• Erythema: Non-blanchable: redness that persists when fingertip pressure is applied. Non-blanchable erythema over a pressure site is a sign of a Stage I pressure ulcer.

• Excoriation: loss of epidermis; linear or hollowed-out crusted area; dermis is exposed Examples: Abrasion; scratch. Not the same as denuded of skin.

• Exudate: any fluid that has been extruded from a tissue or its capillaries, more specifically because of injury or inflammation. It is characteristically high in protein and white blood cells but varies according to individual health and healing stages.

G • Gangrene: Gangrene is ischemic tissue that initially appears pale, then blue gray, followed

by purple, and finally black. Pain occurs at the line of demarcation between dead and viable tissue. Consists of 3 types: Dry, Wet, and Gas

– Dry gangrene is tissue with decreased perfusion and cellular respiration. Tissue becomes dark and loses fluid. Area becomes shriveled / mummified. Not considered harmful and is not painful. Area requires protection, kept dry, avoid maceration. Alcohol pads may be used between gangrenous toes to dry tissue out.

– Wet gangrene is dead moist tissue that is a medium for bacterial growth. Area requires protection, kept dry, do not use a wet to dry dressing. Monitor for erythema and signs of infection in adjacent tissue.

– Gas gangrene is tissue infected with an anaerobic organism e.g., clostridium. Systemic antibiotics are required and tissue must be removed by physician in the OR. Keep moist tissue moist and dry tissue dry. Monitor adjacent tissue for signs of infection progressing

• Granulation Tissue: pink/red, moist tissue that contains new blood vessels, collagen, fibroblasts, and inflammatory cells, which fills an open, previously deep wound when it starts to heal.

H• Hospital acquired condition (HAC) – condition that occurs during current hospitalization.

Formerly known as nosocomial. Ulcers without assessment documentation in the patient medical record within 24 hours of admission are classified as hospital acquired even though they were present on admission (POA). Acceptable documentation of ulcer assessment for hospital acquired conditions / pressure ulcers includes a detailed description within any assessment record e.g., EMR Adult Ongoing Assessment, Progress Note, H&P or consultative form.



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.

JKLM• 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.

OP

• 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.



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.



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.QR

• Rash: term applied to any eruption of the skin. Usually shade of red.

• Shear: friction plus pressure causing muscle to slide across bone and obstructing blood flow e.g., sitting with head of the bed (HOB) at > 30 angle.

• Skin Sealant: clear liquid that seals and protects the skin.

• Tissue Biopsy: use of a sharp instrument to obtain a sample of skin, muscle, or bone.

• Tissue: Eschar: dry, thick, leathery, dead tissue

• Tissue: Necrotic: devitalized or dead tissue

• Tissue: Slough: moist, dead tissue.

• Weep-No-More (WNM) Suction Dressing: an occlusive suction dressing using a folded gauze dressing which covers a catheter or tubing enclosed within a transparent film. May be placed over wounds and incisions with a physician’s order and changed at least every 24 hours. May also be ordered by the RN over non-surgical sites, e.g., puncture sites and changed at least every 72 hours. May be used over sites that cannot be adequately managed with conventional dressings..

• Wound Care as Ordered: refers to RN generated orders for treatment based on DMC Skin and Wound Care Flowcharts.

• Wound irrigation: cleansing the wound by flushing with fluid e.g., 250 mL sterile normal saline under pressure.



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Documents

DMC Advanced Wound Care and Specialty Bed Committee ©DMC 2009 1 Skin and Wound Care Dressings Section 5 of 7 RN and LPN Self-learning Module DMC Adv Wound