Multiple Choices A Wound Care Procedural Guide

Transcription

1 Multiple Choices A Wound Care Procedural Guide

2 A Wound Care Procedural Guide from Covidien There are many approaches to wound care, and selecting the appropriate therapy for your patients is not always easy. To develop an effective plan of care, you must first assess a patient s underlying physiologic status, which might include conditions such as autoimmune disease, peripheral vascular disease, incontinence, diabetes or cancer. You must also take into consideration patient s levels of proper nutrition as well as pressure, shear and friction forces.

3 The Multiple Choices program offers a systematic approach to wound care that will provide you with a plan for managing your patients wounds. As the optimal plan emerges, remember that holistic wound care is an interdisciplinary activity and you should be sure to consult other health-care professionals as your patients conditions warrant. In the end, a comprehensive patient analysis, combined with a cost-effective wound care strategy, will help ensure the best possible patient outcomes. Step 1. Assess Step 2. Prevent Step 3. Cleanse Step 4. Fill Step 5. Cover Step 6. Secure Step 7. Evaluate Procedures for Proper Wound Care Multiple Choices has been developed as a guide to facilitate treatment of acute and chronic wounds. Before any plan of care is initiated, you must be sure that the products and therapies selected are indicated, safe and effective in that situation, and that they meet your individual protocols.

4 Wound Assessment & Treatment Recommendations Least Adhesive Least Absorbent Curafil * Amorphous Gel/Impregnated Hydrogel Gauze Aquaflo Hydrogel Kendall Foam Dressings with Topsheet Kendall AMD Antimicrobial Foam Dressings with Topsheet Kendall Foam Dressings Telfa AMD Antimicrobial Non-Adherent Dressings Curity AMD Antimicrobial Dressings Kendall AMD Antimicrobial Foam Dressings Curasorb * /Curasorb * Zinc Calcium Alginate Most Absorbent

5 Curity AMD Antimicrobial Packing Strips Excilon AMD Antimicrobial Dressings Kerlix AMD Antimicrobial Dressings Most Adhesive Polyskin II Transparent Film Viasorb Transparent Dressing with Pad Telfa AMD Antimicrobial Island Non-Adherent Dressings with Adhesive Border Ultec Pro Hydrocolloid Copa Island Foam Dressings with Adhesive Border Kendall AMD Antimicrobial Foam Border Dressings Quick Reference Chart Do not use Kendall AMD antimicrobial products with Dakin s Solution cleanser. * For wounds with eschar, surgical/enzymatic debridement is recommended, followed by the use of Curity hypertonic dressing or Curafil * amorphous hydrogel dressing. Many dressing applications will also require the use of a secondary dressing. These can include thin film dressings such as Polyskin II transparent film dressings when protection from external moisture is needed; Telfa AMD antimicrobial dressing, Telfa AMD antimicrobial island dressing, Telfa island dressing, Telfa foam dressing with topsheet, or Viasorb dressings for areas where there is substantial intact skin around the wound margins; ABD pads, gauze or Telfa pads, secured with tape or a Kerlix AMD antimicrobial dressing, Kerlix or Kendall cohesive bandage roll, depending on the body part or skin condition surrounding the wound.

6 STEP 1: Assess Wound Assessment: Location Anatomical Terms Size (L x W x D) Depth (Partial/Full Thickness) Stage for pressure ulcers Occiput Exudate - Color - Amount - Odor - Consistency Tissue appearance/type Surrounding skin condition Sinus tracts, undermining or tunneling Clavicle Trochanter Thoracic vertebrae Lumbar vertebrae Acromion Process Scapula Olecranon (elbow) Sacrum Coccyx Infection - Erythema - Induration - Warmth - Fever - Edema - Non-healing - Odor - Deterioration Patella Iliac crest Ischial Tuberosity Wound Edges - Open - Intact - Epibole - Macerated Pain Metatarsals Medial Malleolus Lateral Malleolus Calcaneous

7 A. B. C. D. E. F. A. Suspected 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. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Stage I Pressure Ulcer 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 and may indicate at risk persons (a heralding sign of risk). C. Stage II Pressure Ulcer 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. *Bruising indicates suspected deep tissue injury. D. Stage III Pressure Ulcer 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. E. Stage IV Pressure Ulcer 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. F. 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. Suspected Deep Tissue Injury and Unstageable photos courtesy of Kim Stallo, BS, RN, CWOCN; Pressure Ulcer Stage I and II photos courtesy of Cynthia Fernandez, MS, BSN, RN, CWOCN; Stage III and IV photos courtesy of Judy Papen, MSN, RN, CWS, CWOCN Assess

8 STEP 2: Prevent Skin Care Evaluate patients skin daily for the following: Dry skin Incontinence associated dermatitis Signs of pressure ulcer formation or skin problems such as a fungal infection Excessive moisture or maceration due to episodes of urine and/or fecal incontinence In patients with dry skin, apply Kendall moisturizing lotion to all affected areas daily. Application of a moisturizing lotion is most effective after bathing when skin surfaces are still moist and allow the lotion to penetrate more effectively. If fungal infection is suspected, then consider the use of Kendall antifungal cream. In patients with incontinent episodes, the skin should be cleaned with a ph balanced cleanser like Kendall body wash & shampoo or Kendall 2-in-1 cleanser. Kendall antimicrobial cleanser offers the additional benefit of effectiveness against microorganisms that can cause secondary infection. Pat the skin dry and apply a barrier product like Kendall moisture barrier cream or Kendall soothing ointment. Reapply a barrier product following each episode. For added skin protection, the Kendall moisturizing lotion may be applied to affected areas prior to the use of the Kendall moisture barrier cream or Kendall soothing ointment.

9 Cleanse Moisturize Protect Treat Kendall Body Wash & Shampoo Kendall 2-in-1 Cleanser Kendall Moisturizing Lotion Kendall Moisture Barrier Cream Kendall Soothing Ointment Kendall Antimicrobial Cleanser Kendall Antifungal Cream Wound Care Use of Kendall AMD antimicrobial products over or within a wound provides the following protection: Resists bacterial colonization within the dressing Reduces bacterial penetration through the dressing Effective against gram negative and gram positive microorganisms, MRSA and VRE, and fungi/yeast Kendall AMD antimicrobial dressings are uniformly impregnated with Polyhexamethylene Biguanide (PHMB) and may be applied either dry or moistened. Avoid use with Dakin s Solution cleanser as it renders the PHMB ineffective. Check the Ordering Information section to select the type of Kendall AMD antimicrobial dressing that best suits the wound need. Kendall AMD Antimicrobial Dressing vs. MRSA Prevent

10 STEP 3: Cleanse & Irrigate For clean, granulating wounds, use of normal saline or water is sufficient. Cleanse or irrigate all wounds at each dressing change. For exudating, contaminated, infected or problem wounds, cleanse or irrigate with a specialized commercial wound cleanser or with normal saline. Avoid use of agents that may be cytotoxic to tissue. STEP 4: Fill Wounds with Depth For clean, granulating wounds with depth, filling options include: Kendall AMD Antimicrobial Foam Dressing Kendall AMD Antimicrobial Foam Border Dressing Antimicrobials Curity AMD Antimicrobial Dressing (Moisten) Curity AMD Antimicrobial Packing Strip (Moisten) Kerlix AMD Antimicrobial Super Sponge (Moisten) Hydrogel Curafil * Amorphous Gel/Impregnated Gauze Kerlix AMD Antimicrobial Super Sponges (Moisten) Moist Gauze Curity Saline (Premoistened) Kerlix Saline (Premoistened) Photo courtesy of Judy Papen, MSN, RN, CWS, CWOCN Photo courtesy of Judy Papen, MSN, RN, CWS, CWOCN

11 For exudating or necrotic wounds with depth, filling options include: Antimicrobials Calcium Alginate Kendall AMD Antimicrobial Foam Dressing Kendall AMD Antimicrobial Foam Border Dressing Curity AMD Antimicrobial Dressing (Moisten) Kerlix AMD Antimicrobial Super Sponge (Moisten) Curasorb *, Curasorb * Rope Curasorb * Zinc, Curasorb * Zinc Rope Hypertonic Dressing Curity Sodium Chloride Moist Gauze Kerlix AMD Antimicrobial Super Sponge (Moisten) Kerlix Saline (Premoistened) Curity Saline (Premoistened) Photo courtesy of Diane Krasner, Ph.D, RN, CWOCN For slough, necrotic or infected wounds only Use of water, normal saline, enzymatic debriding agents or amorphous hydrogels (Curafil) are recommended to moisten gauzes, if needed. Avoid use of agents that may be cytotoxic to tissues. Avoid use of Dakin s Solution cleanser as it renders the antiseptic ingredient in Kendall AMD antimicrobial products ineffective. Photo courtesy of Judy Papen, MSN, RN, CWS, CWOCN Cleanse/Fill

12 STEP 5: Cover all wounds Minimal or no drainage Gauze Sponge Impregnated Gauze Island Dressing Nonadherent Transparent Film Hydrogel Hydrogel Sheet Kerlix AMD Antimicrobial Super Sponge, Curity AMD Antimicrobial Sponge Curity Non-adhering Dressing, Vaseline * Petrolatum, Curity Moist Non-adherent Gauze Dressing, Xeroform Petrolatum Gauze Telfa AMD Antimicrobial Island Telfa AMD Antimicrobial Pad Polyskin II Curafil * Amorphous Gel, Curafil * Impregnated Gauze Aquaflo Hydrogel Sheet Photo courtesy of Judy Papen, MSN, RN, CWS, CWOCN

13 Moderate drainage Antimicrobial Sponge Curity AMD Antimicrobial Sponge, Kerlix AMD Antimicrobial Super Sponge Calcium Alginate Curasorb *, Curasorb * Zinc Dressing Composite Viasorb Absorbent Dressing Telfa Plus Island Dressing Kendall AMD Antimicrobial Foam Dressing, Kendall AMD Foam Antimicrobial Foam Border Dressing, Kendall Foam Dressing, Kendall Foam Dressing w/topsheet, Copa Island Dressing Gauze Sponge Curity AMD Antimicrobial Sponge, Kerlix AMD Antimicrobial Super Sponge Hydrogel Sheet Aquaflo Hydrogel Hydrocolloid Ultec Pro Alginate Hydrocolloid Heavy drainage ABD Pad Calcium Alginate Composite Foam Curity Wet Pruf Abdominal Pad, Dermacea Abdominal Pad Curasorb *, Curasorb * Zinc Dressing Telfa Plus Island Dressing Kendall AMD Antimicrobial Foam Dressing, Kendall AMD Antimicrobial Foam Border Dressing, Kendall Foam Dressing, Kendall Foam Dressing w/topsheet, Copa Island Dressing Occlusive dressings are not indicated for infected wounds. Cover Photo courtesy of Diane Krasner, Ph.D, RN, CWOCN Photo courtesy of Debra Dubuc, RN, MSN, APRN- BC, CWON

14 STEP 6: Secure all dressings Once a cover dressing is applied, it may need to be secured. Options include: Gauze Rolls Conforming Stretch Bandage Tape Transparent Film Composite Dressing Kerlix AMD Antimicrobial Dressing, Kerlix Dressing, Dermacea Low Ply Dressing Kendall Cohesive Bandage Kendall Silk Tape, Kendall Cloth Tape, Kendall Paper Tape Polyskin II Transparent Film, Viasorb Dressing, Telfa AMD Antimicrobial Island Dressing Photo courtesy of Diane Krasner, Ph.D, RN, CWOCN

15 STEP 7: Evaluate Evaluate wounds at least once a week or as often as is clinically indicated to ensure treatment efficacy. Secure/Evaluate

16 Glossary of Terms 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. Abrasion Circumscribed removal of the superficial layers of skin. Bacteremia The presence of viable bacteria in the circulating blood. Cellulitis Inflammation of cellular or connective tissue. Inflammation may be diminished or absent in immunosuppressed individuals. Clean Dressing Dressing that is not sterile but is free of environmental contaminants such as water damage, dust, pest and rodent contaminants, and gross soiling. Clean Wound Wound free of purulent drainage, devitalized tissue or dirt. Contaminated Containing bacteria, other microorganisms or foreign material. The term usually refers to bacterial contamination and, in this context, is synonymous with colonized. Wounds with bacterial counts of 10 5 organisms per gram of tissue or less are generally considered contaminated; those with higher counts are generally considered infected. Culture (Bacterial) Removal of bacteria from a wound for the purpose of placing them in a growth medium in the laboratory to propagate to the point where they can be identified and tested for sensitivity to various antibiotics. Swab cultures are generally inadequate for this purpose. Dead Space A cavity remaining in a wound. Debridement Removal of devitalized tissue and foreign matter from a wound. Various methods may be used for this purpose: Autolytic Debridement The use of synthetic dressings to cover a wound and allow eschar to self-digest by the action of enzymes present in wound fluids. 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. Fascia A sheet or band of fibrous tissue that lies deep below the skin or encloses muscles and various organs of the body. Friction Mechanical force exerted when skin is dragged across a coarse surface such as bed linens. Full-Thickness Tissue Loss Loss of tissue below the dermis level, involving subcutaneous and possibly other tissue layers, to include loss of fascia, tendons, muscles, bone or other underlying structures. Full-thickness wounds heal by formation of granulation tissue, contraction, and epithelialization. Granulation Tissue The 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. Healing A dynamic process in which anatomical and functional integrity is restored. This process may be monitored and measured. For wounds of the skin, it involves repair of the dermis (granulation tissue formation) and epidermis (epithelialization). Healed wounds represent a spectrum of repair; they can be ideally healed (tissue regeneration), minimally healed (temporary return of anatomical continuity) or acceptably healed (sustained functional and anatomical result). The acceptably healed wound is the ultimate outcome of wound healing but not necessarily the appropriate outcome for all patients. Primary Intention Healing Closure and healing of a sutured wound. Secondary Intention Healing Closure and healing of a wound by the formation of granulation tissue and epithelialization. Tertiary Healing Wound left open above the fascia layer which is surgically closed at a later time.

17 Biologic The topical application of sterile maggots to break down devitalized tissue. Enzymatic (Chemical Debridement) The topical application of proteolytic substances (enzymes) to break down devitalized tissue. Mechanical Debridement 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 wet-to-dry dressings, wound irrigation, whirlpool and dextranomers. Sharp Debridement Removal of foreign material or devitalized tissue by a sharp instrument such as a scalpel. Laser debridement is also considered a type of sharp debridement. Dehiscence Separation of the layers of a surgical wound. Denude Loss of epidermis. Dressing The material applied to a wound for the protection of the wound and absorption of drainage. Edema Presence of abnormally large amounts of fluid in the interstitial space. Epibole Edges or top layers of epidermis have rolled down to cover lower edges of epidermis, including basement membrane, so that the epithelial cells cannot migrate from wound edges; also described as closed wound edges. Epithelialization The stage of tissue healing in which the epithelial cells migrate (move) across the surface of a wound. Erythema Redness of the skin. Blanchable Erythema Reddened area that temporarily turns white or pale when pressure is applied with a fingertip. Blanchable erythema over a pressure site is usually due to a normal reactive hyperemic response. Nonblanchable Erythema Redness that persists when fingertip pressure is applied. Nonblanchable erythema over a pressure site is a symptom of a Stage I pressure ulcer. Eschar Thick, leathery, necrotic, devitalized tissue. Excoriation Linear scratches on the skin. Incontinence Associated Dermatitis Irritation, inflammation, and erosion associated with prolonged exposure of the skin to urine and/or stool Induration Abnormal firmness of tissue with a definite margin. Infection Overgrowth of microorganisms capable of tissue destruction and invasion, accompanied by local and/or systemic symptoms. Irrigation Cleansing by a stream of fluid, preferably saline. Ischemia Deficiency of blood supply to a tissue, often leading to tissue necrosis. Macerate To soften by wetting or soaking. In [a healing] context, it refers to degenerative changes and disintegration of skin when it has been kept too moist. Moisture In the context of this document, moisture refers to skin moisture that may increase the risk of pressure ulcer development and impair healing of existing ulcers. Primary sources of skin moisture include perspiration, urine, feces, drainage from wounds or fistulas. Necrotic Tissue Tissue that has died and has, therefore, lost its usual physical properties and biological activity. Also called devitalized tissue. Osteomyelitis Inflammation of the bone marrow and adjacent bone, often due to infection. Pressure (Interface) Force per unit area that acts perpendicularly between the body and the support surface. This parameter is affected by the stiffness of the support surface, the composition of the body tissue and the geometry of the body being supported. Pressure Reduction Reduction of interface pressure, not necessarily below the level required to close capillaries (i.e., capillaryclosing pressure). Pressure Relief Reduction of interface pressure below capillaryclosing pressure. Glossary of Terms

18 Pressure Ulcer A pressure ulcer is localized injury to the skin and/ or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Suspected 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. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 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 and may indicate at risk persons (a heralding sign of risk). 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. *Bruising indicates suspected deep tissue injury. 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. Purulent Discharge/Drainage A product of inflammation that contains pus i.e., cells (leukocytes, bacteria) and liquefied necrotic debris. Qualitative Data Information that describes the nature or qualities of a subject. Quantitative Data Information obtained of a subject that is measurable. Reactive Hyperemia Reddening of the skin caused by blood rushing back into ischemic tissue. Sepsis The presence of various pus-forming and other pathogenic organisms, or their toxins, in the blood or tissues. Clinical signs of blood-borne sepsis include fever, tachycardia, hypotension, leukocytosis, and a deterioration in mental status. The same organism is often isolated in both the blood and the pressure ulcer. Shear Mechanical force that acts on a unit area of skin in a direction parallel to the body s surface. Shear is affected by the amount of pressure exerted, the coefficient of friction between the materials contacting each other, and the extent to which the body makes contact with the support surface. Sinus Tract A cavity or channel underlying a wound that involves an area larger than the visible surface of the wound. Skin Flap A procedure that moves a section of skin and associated subcutaneous tissue from one part of the body to another, with the vascular supply maintained for nourishment. The vascular attachment can be the original vessel, rotated along with the flap, changed from one part of the flap to another; or reestablished by microvascular anastomoses once it has been placed in the new location. One disadvantage of local flap closure is that the flap essentially redistributes an already inadequately perfused tissue and is randomly dependent on an unpredictable local blood supply.

19 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. 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. 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. Further description 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. The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal dermatitis and those due to deep tissue injury. Prevalence The number of cases present in a population at one point in time. psi Pounds per square inch a unit of pressure, in this case, the pressure exerted by a stream of fluid against one square inch of skin or wound surface. Skin Graft A procedure that moves a segment of dermis and a portion of epidermis. The graft is completely separated from its blood supply and donor site and moved to a recipient site. Skin grafts contain varying portions of epidermis and dermis and can be full thickness or partial thickness, depending upon how much dermis is included in the graft. One disadvantage of skin grafts applied to granulating bone is that there is no padding and they quickly erode. Slough Necrotic (dead) tissue in the process of separating from viable portions of the body. This tissue can present as dried out, tenacious and without odor, or soft, stringy, very moist, and odiferous. Stasis Ulcer Ulceration associated with ambulatory venous hypertension. Stratum Corneum Outermost layer of the epidermis. Surfactants A surface-active agent that reduces the surface tension of fluids to allow greater penetration. Tissue Biopsy Use of a sharp instrument to obtain a sample of skin, muscle or bone. Topical Antibiotic A drug known to inhibit or kill microorganisms that may be applied locally to a tissue surface. Tunneling A passageway under the surface of the skin that is generally open at the skin level; however, most of the tunneling is not visible. Underlying Tissue Tissue that lies beneath the surface of the skin such as fatty tissue, supporting structures, muscle and bone. Undermining A closed passageway under the surface of the skin that is open only at the skin surface. Generally, it appears as an area of skin ulceration at the margins of the ulcer with skin overlying the area. Undermining often develops from shearing forces. Glossary of Terms

20 Ordering Information Code HCPCS Per Ship Number Description Code Carton Case Aquaflo Hydrogel Wound Dressing (8884-) " Disk (7.6 cm) A ¾" Disk (12.1 cm) A Copa Island Dressing 55544B 4" x 4" (2" x 2" Pad) A B 6" x 6" (4" x 4" Pad) A B 8" x 8" (6" x 6" Pad) A Curafil * Amorphous Gel 9250 ½ oz. tube A oz. tube A oz. tube A Curafil * Hydrogel Impregnated Gauze Dressings " x 2" Pad (¼ oz gel) A " x 4" Pad (1 oz gel) A " x 8" Pad (2 oz gel) A " x 36" Packing Strip A Curasorb * Calcium Alginate Dressings " Rope A " Rope A " Rope A " x 2" A " x 4" A " x 4" Plus A " x 8" A " x 10" A " x 24" A " x 5 ½" A Curasorb * Zinc Calcium Alginate Dressings " Rope A " x 2" A " x 4" A " x 8" A Curity AMD Antimicrobial Gauze Sponges " x 2" 8-Ply Sterile 2 s in Peel-Back Pkg A /tray " x 4" 12-Ply Sterile 2 s in Peel-Back Pkg A /tray " x 4" 12-Ply Sterile 10 s in Plastic Tray A /tray 1280 Code HCPCS Per Ship Number Description Code Carton Case Kendall AMD Antimicrobial Foam Dressings with Topsheet 55535PAMD 3 ½" x 3" Fenestrated, A PAMD 4" x 4" A Kendall AMD Antimicrobial Foam Border Dressings 55523BAMD 1 ¾" x 3 ¼" (1 x 1 ¾" Pad) A BAMD 3 ½" x 3 ½" (2" x 2" Pad) A BAMD 3 ½" x 5 ½" (2" x 4" Pad) A BAMD 5 ½" x 5 ½" (4" x 4" Pad) A BAMD 7 ½" x 7 ½" (6" x 6" Pad) A Kendall AMD Antimicrobial Foam Disc 55511AMD 1" Diameter, 4 mm Hole A AMD 1" Diameter, 7 mm Hole A Kendall Cloth Tape 9411C 1" X 10 Yds. 12 Packs/Case 24 Kendall Foam Dressing " x 2" A " x 3" A ½" x 3" Fenestrated A " x 4" A " x 6" A " x 8" A " x 8" A Kendall Foam Dressing with Topsheet 55522P 2" x 2" A P 3" x 3" A P 3 ½" x 3" Fenestrated A P 4" x 4" A P 6" x 6" A P 4" x 8" A P 8" x 8" A Kendall Paper Tape 1596C ½" x 10 Yds. 10 Boxes/Case C 1" x 10 Yds. 10 Boxes/Case S1 1" x 1 ½ Yds. 5 Boxes/Case T ½" x 10 Yds. Tan 10 Boxes/Case T 1" x 10 Yds. Tan 10 Boxes/Case 120

21 Curity AMD Antimicrobial Packing Strips 7831AMD ¼" x 1 Yd. A AMD ½" x 1 Yd. A AMD 1" x 1 Yd. A Curity Moist Non-adherent Gauze Dressings (8884-) " x 2" A " x 9" A " x 8" A " x 3 Yds.. A Curity Sodium Chloride Dressing 3335 ½" x 5 Yds. Packing Strip A Bottles/case " x 6 ¾" A Curity Oil Emulsion Dressings 6111 ½" x 4 Yds. A " x 3" A " x 8" A " x 16" A " x 8" (3 Dressings per Pkg) A " x 9" A Curity Packing Strips 7634 Plain, 2" x 5 Yds. A Iodoform, 2" x 5 Yds. A Curity Unna Boot Bandage " x 10 Yds. A " x 10 Yds. A " x 10 Yds. with Calamine A " x 10 Yds. with Calamine A Curity Wet Dressings " x 4" Saline (2 Dressings per Pkg) A Excilon AMD Antimicrobial Drain Sponges " x 4" Pad, 6-Ply A " x 2" Pad, 6-Ply A Kendall AMD Antimicrobial Foam Dressings 55522AMD 2" x 2" A AMD 3 ½" x 3" Fenestrated A AMD 4" x 4" A AMD 6" x 6" A AMD 4" x 8" A AMD 8" x 8" A Kendall Silk Tape 7137C ½" x 10 Yds. 10 Boxes/Case C 1" x 10 Yds. 10 Boxes/Case 120 Kendall Skin Wellness System in-1 Cleanser, 4 fl oz Spray bottle in-1 Cleanser, 8 fl oz Spray bottle Body Wash & Shampoo, 5 fl oz Foamer Body Wash & Shampoo, 9 fl oz Foamer Moisture Lotion, 2 fl oz Tube Moisture Lotion, 4 fl oz Tube Moisture Lotion, 4 ml Packet Moisture Barrier Cream, 2 fl oz Tube Moisture Barrier Cream, 4 fl oz Tube Moisture Barrier Cream, 4 ml Packet Soothing Ointment, 2 fl oz Tube Soothing Ointment, 4 fl oz Tube Soothing Ointment, 4 ml Packet Antimicrobial Cleanser, 4 fl oz Spray bottle Antimicrobial Cleanser, 8 fl oz Spray bottle Antifungal Cream 4 fl oz Tube 12 Kerlix AMD Antimicrobial Rolls ½" x 4 ¹/10 Yds. Rigid Tray A ½" x 4 ¹/10 Yds. Soft Tray A Kerlix AMD Antimicrobial Super Sponges 6662 Medium Sterile 2 s A /tray Medium Sterile 5 s A /tray Medium Sterile 10 s A /tray 480 Kerlix Wet Dressings " x 6 ¾" Saline (2 Dressings per Pkg) A Polyskin II Transparent Dressings ½" x 1 ½" A " x 2 ¾" A " x 4 ¾" A " x 8" A " x 8" A " x 10" A Ordering Information Continues on next page

22 Ordering Information (continued) Code HCPCS Per Ship Number Description Code Carton Case Telfa AMD Antimicrobial Island Dressing " x 5" A /tray " x 8" A /tray " x 10" A /tray " x 14" A /tray 50 Telfa AMD Antimicrobial Pads " x 4" A /tray " x 8" A /tray 600 Telfa Island Dressings 7539LF 2" x 3 ¾" (1 1/4" x 2" Pad Size) A Telfa Plus Barrier Island Dressing " x 6" (2" x 4" Pad Size) A " x 7" (4" x 4 ½" Pad Size) A " x 10" (3" x 8" Pad Size) A " x 8" (6" x 6"Pad Size) A Ultec Pro Alginate Hydrocolloid Dressing " x 4" A " x 6" A " x 8" A " x 5" Sacral A " x 7" Sacral A ½" x 2 ½" Border A " x 4" Border A " x 6" Border A Code HCPCS Per Ship Number Description Code Carton Case Vaseline * Petrolatum Gauze (8884-) ½" x 72" A " x 36" A " x 9" A " x 18" A " x 36" A " x 36" A " x 8" A ½" x 72" with Overwrap A " x 36" with Overwrap A " x 9" with Overwrap A " x 18" with Overwrap A " x 36" with Overwrap A " x 36" with Overwrap A " x 8" with Overwrap A Viasorb Wound Dressing (8884-) " x 3" A " x 6" A " x 7" A " x 10" A Xeroform Petrolatum Gauze Dressings (8884-) " x 8" with Overwrap A " x 9" with Cverwrap A " x 3 Yds. A " x 8" A " x 2" A " x 4" A " x 9" A

23 References The Centers for Medicare and Medicaid Services was the primary source of any HCPCS information contained in this document. Covidien does not represent or guarantee that any HCPCS information contained in this document is complete, accurate, or applicable to any particular patient or third-party payer and disclaims all liability for any consequence resulting from any reliance on such information. The final billing-related decisions for any product must be made by the health care provider considering the medical necessity of the product furnished as well as the requirements of third-party payers and any local, state, or federal laws and regulations that apply to the product furnished. Covidien is providing this information in an educational capacity with the understanding that Covidien is not engaged in rendering legal, accounting, or other professional services. Covidien encourages all health care providers to consult with their own advisors regarding coding and payment. Association for the Advancement of Wound Care (AAWC), Wayne, PA web site: Ayello, E.A., and Lyder, C.H. Pressure Ulcers in Persons of Color: Race and Ethnicity in Cuddigan, J., et.al., eds. Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. Reston, VA: NPUAP, Baranoski, S., Ayello, E. (2004) Wound Care Essentials, Lippincott, Williams, & Wilkins, p.c7; 253. Bryant, R. (2000). Acute and chronic wounds nursing management. (2nd ed.) St. Louis, MO: Mosby Year Book. Guideline for prevention and management of pressure ulcers (2003). WOCN Clinical Practice Guideline Series. Glenview, IL. Krasner, D., Rodeheaver, G. & Sibbald, R.G. (2001). Chronic wound care: a clinical source book for healthcare professionals, (3rd ed.). Wayne, PA: HMP Communications. Lyder, C.H. (2003). Pressure Ulcer Prevention and Management. JAMA, 289(2), Milne, C.; Corbett, L.; Dubuc, D. Wound, ostomy and incontinence nursing secrets. Philadelphia: Hanley and Belfus Multiple Choices (1997). A wound care procedural guide from Kendall [Booklet]. Mansfield, MA. Developed in conjunction with Sharon Aronovitch, RN, CETN, Ph.D., Diane Krasner, MS, RN, CETN, and Tania Phillips, MD. National Pressure Ulcer Advisory Panel (NPUAP) February, web site: Panel for the Prediction and Prevention of Pressure Ulcers in Adults, Treatment of Pressure Ulcers. Clinical Practice Guideline, Number 15, AHCPR Publication # Rockville, MD: Agency for Healthcare Policy and Research, Public Health Science, US Department of Health and Human Services, December, Sussman, C. & Bates-Jensen, B. (1998). Wound care: a collaborative practice manual for physical therapists and nurses. Gaithersburg, MD: Aspen Publishers, Inc. Wound, Ostomy and Continence Nurses Society (WOCN), Glenview, IL web site:

24 Photo credit: Comstock/Thinkstock TM* Curafil and Curasorb are trademarks of Beiersdorf AG and are used under license; Vasaline is a trademark of Unilever Supply Chain, Inc. and is used under license COVIDIEN, COVIDIEN with logo and Covidien logo are U.S. and internationally registered trademarks of Covidien AG. Other brands are trademarks of a Covidien company Covidien. H6270 5M 1211