CHAPTER SEVEN. Skin Integrity and Pressure Ulcers: Assessment and Management BACKGROUND ASSESSMENT

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "CHAPTER SEVEN. Skin Integrity and Pressure Ulcers: Assessment and Management BACKGROUND ASSESSMENT"

Transcription

1 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 1 SECTION ONE GENERAL APPROACH TO A HOSPITALIZE PATIENT CHAPTER SEVEN Skin Integrity and Pressure Ulcers: Assessment and Management Jonathan M. Flacker, M BACKGROUN The skin is the first line of defense against the environmental threats of the outside world. Compromised integrity puts patients at risk for discomfort and infection. Anything that breaches the skin barrier, including lacerations, burns, dermatitis, skin tears, and pressure ulcers, can compromise its integrity. This chapter will focus on skin tears and pressure ulcers that are both commonly encountered and often avoidable in the hospital setting. Pressure ulcers are any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are associated with four underlying causes: pressure, shear, friction, and moisture. Pressure, usually on a bony prominence, is the primary cause of such ulcers. Shear, or the interaction of gravity and friction on the skin, contributes to pressure ulcers by causing twisting or kinking of blood vessels. Friction damages the skin at the epidermal/dermal interface (the basement membrane). Moisture contributes to pressure ulcer development by weakening the cell wall of individual skin cells. Taken alone, or more commonly in combination, these four factors place patients at high risk for breakdown of skin integrity. ASSESSMENT Clinical Presentation Prevalence and Presenting Signs and Symptoms The prevalence of pressure ulcers is difficult to pinpoint in the acute-care setting due to the various methodologies used in published studies; the prevalence, however, seems to be % with an incidence of %. One recent large survey found overall hospital pressure ulcer prevalence was 14.8%, with a nosocomial pressure ulcer prevalence of 7.1%. Thus, about half of hospitalized patients with pressure ulcers develop them in the hospital. Staging of pressure ulcers is standardized using a I IV scale (Table 7-1) ranging from superficial redness being stage I to a stage IV ulcer extending into muscle, bone, or supporting structures (Fig. 7-1). Pressure ulcers have important characteristics that should be examined and documented (Box 7-1). Using the black, yellow, red system to describe ulcer bed color gives a sense of the viabil- ity of the exposed tissue. Red corresponds to the presence of muscle or granulation tissue in wound bed. Yellow indicates necrotic tissue or slough in wound bed and/or presence of subcutaneous tissue, fascia, or support structures like ligaments/ tendons. Black wounds have necrotic eschar within or obscuring the wound. The presence of dead space, such as undermining or tunneling must be assessed and managed to prevent complications such as premature wound closure and/or abscess formation. Ulcer margins also have implications for wound healing. When intact, this indicates that the skin surrounding the wound is attached to the edge of the ulcer bed, and epithelialization of the ulcer can occur more readily. Complete circumferential undermining means the ulcer margins are not attached. Skin tears, often a precursor to pressure ulcers, are classified separately from pressure ulcers. Their true prevelance is unknown. The Payne-Martin Classification system is commonly used to stage skin tears. Category I is a skin tear without tissue loss. Category II denotes a skin tear with partial tissue loss. Category III indicates a skin tear with complete tissue loss and absent epidermal flap. ifferential iagnosis Pressure ulcers most commonly occur over area of bony prominences. When they occur elsewhere on the body, an external source of frequent, constant pressure must be present. This external pressure source may be the patient s own limb, as in the case of contractures or orthopedic abnormalities. At other times, the external pressure may come from the patient s environment, such as broken or ill-fitting wheelchair parts, bed frames, or chairs. Tight or ill-fitting clothing, shoes, bra straps, and orthopedic splints may also be a source of external pressure. An ulcer appearing on a part of the body that does not have a source of frequent constant pressure is probably not a pressure ulcer, but rather has another etiology such as vascular insufficiency, infection, or local trauma. Note that so-called stage I ulcers are not yet ulcerated. Stage I ulcers may be more difficult to detect in patients with darker skin, but are often evidenced by a purple discoloration (especially under halogen light) and/or bogginess/induration of the skin. Stage I ulcers may thus be confused with simple bruising. Any new bruise over a bony prominence or an area of frequent pressure should be suspected to be a stage I pressure ulcer.

2 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 2 2 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach Stage 1 Malnutrition Stage 2 Table 7-1 Pressure Ulcer Staging Stage I Stage II Stage III Stage IV Unstageable Pressure Shear Bone Muscle Subcutaneous fat ermis Epidermis Support surface Bone Muscle Subcutaneous fat ermis Epidermis Support surface Malnutrition The pressure area does not penetrate the epidermis, but rather appears as a defined area of persistent redness in lightly pigmented skin, but may be red, blue, or purple in darker skin. Observable pressure related alteration of the intact skin may include one or more of: a. Skin temperature (warmth or coolness) b. Tissue consistency (firm or boggy feel) c. Abnormal sensation such as pain and/or, itching. The ulcer appears as a defined area of persistent redness. Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and may appear as an abrasion, blister, or shallow erosion. Full-thickness skin loss involving damage and/or necrosis of subcutaneous tissue that forms a crater down to, but not through, underlying fascia. Full-thickness skin loss that extends through underlying fascia to involve destruction, necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). A wound bed that is covered or obscured by eschar cannot be staged. Adapted from: NPUAP Position Statement on Pressure Ulcer Prevention, National Pressure Ulcer Advisory Panel, Shear Figure 7-1 Pressure Malnutrition Moisture Algorithm. Stage 4 Stage 3 Shear Pressure Moisture Necrotic tissue Bone Muscle Subcutaneous fat ermis Epidermis Support surface Bone Muscle Subcutaneous fat ermis Epidermis Support surface iagnosis Preferred Studies The diagnosis of a pressure ulcer is a clinical one. Laboratory studies are focused on a good nutritional assessment. Prealbumin is the most sensitive indicator of nutritional status in hospitalized patients. It has a 2-day half-life, whereas albumin has a 21-day half-life and can be affected by hydration status. When quantification of bacterial levels in the ulcer is desired, a correctly done swab, tissue biopsy, and needle aspiration each have similar accuracy, sensitivity, and specificity. 13 To properly swab culture a pressure ulcer, clean the wound thoroughly with normal saline, then debride down to the base of the wound. Roll the swab a full rotation on the deepest part of the wound with the most visible signs of infection. Eschar should never be cultured. With stage IV ulcers, the question of osteomyelitis often arises. Clinical examination is highly inaccurate for determining if osteomyeli-tis is present, and x-rays are typically unhelpful. Bone biopsy remains the gold standard for determining the presence of osteomyelitis. Jamshidi core needle bone biopsy has been shown to have reasonable test characteristics for osteomyelitis (sensitivity of 73%; specificity of 96%) and may be especially useful for guiding therapy prior to surgical closure of a pressure ulcer. CT scans exhibit poor sensitivity for osteomyelitis in patients with pressure sores, while technicium and gallium bone scans have poor specificity. Indium-labeled WBC scans have not been adequately studied in the setting of pressure ulcers. MRI seems to perform significantly better, but clear data on accuracy and costeffectiveness are not yet available. Prognosis uring Hospitalization Recent information on the implications of pressure ulcers for patient prognosis is lacking. One older study found that 67% of patients who develop a pressure ulcer during a hospitalization

3 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 3 Box 7-1 Pressure Ulcer Evaluation Key Elements of Assessing the Physical State of the Pressure Ulcer: Size including depth Location Stage Necrotic tissue Slough Exudate Infection Granulation tissue Undermining Tunneling Abscess formation Visible subcutaneous tissue/fascia/ligaments/tendons/ bone Pain Odor Intact margins Assessment should be supported by photography (calibrated with a ruler) where possible. died as compared with 15% of at-risk patients without pressure ulcers. Postdischarge Many factors such as nutrition, mobility, and comorbidities affect healing rates of pressure ulcers. The healing of pressure ulcers requires attention to care and patience for a considerable period of time. Individualized protocols to predict pressure ulcer healing rates have also been developed. In general, a stage II pressure ulcer should heal within 1 2 months in a healthy, mobile, wellnourished older person. eeper stage II and stage III ulcers may take several months to heal. Most stage IV ulcers take more than 6 months to heal. Importantly, pressure ulcers that develop during acute hospitalization are not associated with reduced 1-year survival among high-risk older persons after adjusting for important confounders. MANAGEMENT Treatment The principles of pressure ulcer healing center around three key areas of intervention: pressure management, nutrition optimization, and direct ulcer management. Pressure management includes interventions ranging from improving mobility to special beds that relieve pressure on the area of the wound, while avoiding placing additional areas at risk. Nutrition optimization involves determining and implementing a feeding regimen that the patient can tolerate and that meets their goals of care. irect ulcer management covers the choices of debridement techniques and wound-care products appropriate for the patient s particular Figure 7-2 With good care, even a stage IV pressure ulcer will usually heal. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone, 2003.) 3 ulcer. Although care must be individualized to the patients, general guidelines for ulcer management are indicated in Table 7-2 (Fig. 7-2). Initial Support Surface or Bed The initial step in pressure management is to provide an appropriate support surface. There are three basic types of support surfaces: mattress overlays, mattress replacements, and full specialty beds. Mattress overlays may be foam, air, or gel. Mattress replacements may be foam, air, gel, or water. They may be static, alternating air, low air loss, or immersion. Specialty replacement beds are integrated bed systems that can function as do the mattress replacements, and they sometimes provide an integrated rotation feature. While the choices may seem complex, for patients who have a single small stage II ulcer, a static mattress may suffice. However, for those with multiple stage II ulcers, or stage III or IV ulcers, a mattress overlay or specialty mattress is usually required. The alternating pressure feature is especially useful for patients who have little or no healthy turning surfaces such as those with sacral and ischial ulcers. General guidelines for specialty support surface use are indicated in Table 7-3 (Fig. 7-3). Mobility Improving mobility helps to minimize continuous pressure on a single area of the body. Attention must be paid to how long such patients are left on stretchers awaiting tests or on hard operating room tables. Physical or occupational therapists can be very helpful in this regard. Even if patients are bed bound, a bed trapeze may allow patients to reposition themselves without having to wait for nursing staff to do so. Nutrition Management Nutrition management begins with the determination of whether the patient can take oral feeding. If so, he or she should be fed orally; but if not, discussion of nasogastric or gastrostomy tubes should take place. It is important to note that a recent Cochrane review found that it was not possible to draw any firm 3 Management

4 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 4 4 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach Table 7-2 Management of Pressure Ulcers by Stage Ulcer Stage Nutrition Pressure Interventions Wound Care Wound Products Interventions Interventions to Consider Stage I ietitian consult to OT/PT consult for Cleanse with mild Wound covering products: evaluate intake of: positioning soap and water Transparent film Protein Static pressure Carefully, gently pat dressing Calories reduction dry Hydrocolloid sheet Vitamin C Mattress/wheelchair Zinc pad Stage II ietitian consult as As above Cleanse as above Wound covering products above as above Stage III ietitian consult as As above ebride any eschar Wound packing products: above If progressive ulcer or for nonheel ulcers Saline-dampened gauze ulcers on multiple Hydrogel turning surfaces use Alginate low air loss/alternating pressure mattress overlay/bed Stage IV ietitian consult as Low air loss/alternating ebride any eschar Wound packing products above pressure mattress for nonheel ulcers Saline-dampened gauze overlay/bed Evalute for Hydrogel osteomyelitis Alginate Systemic antibiotics if Wound V.A.C. System infection source Surgical consult if extensive debridement or bone biopsy needed Table 7-3 Special Support Surface Use Patient Characteristic Intervention Individuals at risk for pressure ulcers Use static pressure reduction mattress or 4 6 thick foam overlay Patient can assume multiple positions Use static pressure reduction mattress or 4 6 thick foam overlay Can avoid putting weight directly on the pressure ulcer oes not bottom out Patient can assume multiple positions Use a dynamic support surface Can NOT avoid putting weight directly on the pressure ulcer Bottoms out on a static device Patient has multiple stage III or IV pressure ulcers on Use a low air-loss or air-fluidized bed multiple turning surfaces, OR excess moisture is a significant contributing factor to the ulcer Adapted from: Panel for Pressure Ulcer Treatment, Clinical Practice Guideline No. 15. Rockville, Md: US epartment of Health and Human Services, Public Health Service. Agency for Health Care Policy and Research; 1994, AHCPR Publication No (pp 39 41). conclusions on the effect of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers. Vitamin C is usually recommended at a dose of 500 mg BI to help collagen synthesis and tensile strength. Zinc is given at a dose of 220 mg daily to help with protein synthesis, though higher doses may impair healing. There are fewer data to support the routine use of other vitamins and micronutrients such as copper, manganese, and vitamins A and E. A dietician should be consulted for all patients with pressure ulcers. Wound Management The key aspects of direct wound management increase with increasing stage of the ulcer. Ulcers need a clean base to allow epithelial cells to grow and heal the ulcer, so all necrotic tissue must be removed. Appropriate moisture control is key here. Too much moisture leads to maceration of the wound. Excessive dryness leads to chafing. Both can result in further injury and poor epithelia cell growth.

5 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 5 4 Figure 7-3 An alternating pressure mattress overlay. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone, 2003.) The goal of cleaning or debridement is to remove the unwanted dead tissue, while preserving the granulation tissue that will heal the wound. If cleaning with gauze or sponges, only slight pressure should be applied to avoid disturbing the wound bed. If irrigating, a syringe and 19-guage angiocath with gentle pulsatile lavage can achieve acceptable low pressures of 4 15 psi, or a commercial system may be used. Ulcers should generally be cleaned only with normal saline; do not use the long list of skin cleansers and antiseptic agents ranging from iodine to sodium hypochlorite solution (akin s solution). Although topical growth factors may speed healing, their role and the most costeffective approach to use is unclear. A description of common products used for wound care is indicated in Table 7-4 (Fig. 7-4). Unless the need for sharp debridement is urgent, mechanical, autolytic, and enzymatic debridement are equally acceptable (Table 7-5). If progressive cellulitis or sepsis is present, sharp debridement should be used and should usually take place within 12 hours, along with a tissue biopsy for culture and sensitivity if systemic infection is suspected. Ulcer cleansing and debridement 5 Management Table 7-4 Wound Products Product Cover Pack Absorb ebride Comments Sample Products Type Ulcer Ulcer Exudate Transparent Yes No Light Light Good to reduce erma Film, OpSite, Polyskin, adhesive friction Tegaderm Adaptic, films May cause further Exu-ry,Telfa,Vaseline damage in thin skin Gauze patients Nonadherent Yes No Light No Good for patients with dressing thin skin Gauze rolls Yes Yes Moderate Yes Allow gauze to dry Various and sponges to heavy if debridement desired, otherwise keep damp between changes Foam sheets Yes No Moderate No Allevyn, Curafoam, Flexzan, to heavy Lyofoam, Mitraflex, Polymem Hydrocolloid Yes No Light to Yes Occlusive. o not use CarraSmart, Combiderm, Sheets moderate if anerobic infection. Comfeel Plus, Cutinova, Monitor closely if ermacol, uoerm, diabetic or imunocompromised Exuderm, Replicare, Restore, Sorbex, Tegasorb, Ultec Hydrogel Yes No Light to Yes Soothes minor burns; Aquaflo, Carraress, sheet moderate has cooling effect Elastogel, NuGel,Vigilon Hydrogel No Yes Light Yes Needs cover dressing. Biolex Gel, Carrasyn Gel, amorphous May macerate intact Curafil, Curasol Gel, gel skin Intrasite, Saf-Gel, Tegagel, Wound res Alginate No Yes (Pads) Moderate No Needs cover dressing. AlgiSite, Calcicare, Curasorb, to heavy Comes in pads and FyBron, Kalginate, ropes. May dessicate wound with light or no exudates Hemostatic properties. Hydrofiber No Yes (Rope only) Moderate Some Vertical wicking Aquacel to heavy reduces maceration Enzymatic No No No Yes May take 1 2 weeks to Accuzyme debrider achieve debridement Kaltostat, Seasorb, Sorbsan, Tegagen

6 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 6 6 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach 5 Table 7-5 ebridement Techniques ebridement Technique for Removal Indications Contraindications Relevant Wound Type of evitalized Tissue Care Products Autolytic Natural Necrotic tissue ry gangrene Include, but not limited to: ry eschar ry ischemic wounds Transparent films Hydrocolloids Hydrogels Alginates Gauze Mechanical Outside force Necrotic wounds Foul odor Include, but not limited to: evitalized tissue Wet to dry dressings Macerated tissue Whirlpool Wound irrigation Enzymatic Topical application of Necrotic wounds Clean wounds Include, but not limited to: specialized protein ry gangrene Accuzyme dry Ischemic Wounds Panafil Hypersensitivity Santyl Sharp Sharp instruments Necrotic wounds Arterial insufficiency Sepsis Gangrene Progressive cellulitis Stable heel ulcers Callus formation Inability to identify structures in wound Figure 7-4 A stage IV pressure ulcer in need of debridement. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone ) may also reduce bacterial colonization in stage II IV ulcers. Some stage III or IV ulcers can take a long time to be fully debrided, and frequent treatments may be needed in the presence of purulent drainage or foul odor. Enzymatic products like Accuzyme (papain urea) are effective debridement agents, but they take longer than sharp debridement. Often, they are used with Iodosorb gel or Iodoflex pads (small hydrophilic beads with 0.9% cadexomer iodine) that adsorb bacteria and cellular debris by capillary action, leading to less inflammation and odor. Whirlpool treatment is best for ulcers with heavy slough, exudate, or necrotic tissue and should be stopped when the ulcer is clean. If debridement is associated with bleeding, apply a dry dressing initially, followed by a moist dressing after 8 to 24 hours. 1 Based on expert opinion, stable heel eschar without erythema, edema, or drainage should not be debrided, but needs to be assessed daily for complications that may necessitate debridement. 1 A wide range of products can be applied to ulcers (see Table 7-3). For a typical stage I ulcer, one should protect the skin; and reduce pressure, shear, and friction. For a stage II ulcer, one should additionally protect and hydrate the wound. A stage III ulcer further requires debridement as necessary. A stage IV ulcer requires all of the above, as well as obliteration of dead space. In grade III or IV pressure ulcers, treatment using first alginate and then hydrocolloid dressing yields more rapid improvement that hydrocolloid alone. Pain control is also critical, and patients with pressure ulcers report pain and tend to receive inadequate analgesia, perhaps due to the false belief that stage III IV pressure ulcers are painless due to nerve fiber destruction. The treatment of skin tears is a bit more straightforward, but follows the principles of pressure ulcer management. The size of the tear shoud be documented along with a drawing if helpful. In general, the area should be gently cleaned with normal saline and allowed to air dry or dry by gentle patting. The skin flap should be approximated and held in place with either Steri-Strips or a moist nonadherent dressing. Clear film dressings are acceptable, but care must be taken when removing the dressing to avoid further skin injury or reinjury. An arrow drawn on the dresssing that identifies the direction of the skin tear can help in this regard. Although it is important for the hospital physician to understand the basic tenets of pressure ulcer management, it is equally important that physicians understand the components of a Skin Integrity team. Such teams are typically composed of a nurse who has advanced training in wound care (Skin Clinical Nurse Specialist), a nutritionist, and a therapist. The nurse will typically advise on local wound care measures and assist in selecting from the hundreds of available skin products according to the patient s need and hospital formulary. A nutritionist is important to ensure that negative nitrogen balance is avoided, and to advise on the type, route, and composition of feeding. Finally, a therapist (in some places this will be a Physical Therapist and in others an Occupational Therapist) is essential to advise on positioning techniques, pressure reduction devices, and optimization of mobility.

7 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 7 Subsequent Care One should expect to see signs of healing in a clean ulcer by 2 4 weeks. An accurate skin assessment must be performed and documented when patients are transferred to other health care facilities. For patients being discharged to home, visiting nurse services skilled in pressure ulcer management should be arranged, along with any special equipment, including hospital bed, special support mattresses, and lifts. Caregivers should be instructed on wound care and turning procedures prior to discharge of the patient. If a clean ulcer on an inpatient has persistent exudate and/or shows no signs of healing despite optimal care for 2 4 weeks, then a 2-week trial of topical antibiotics should be considered. A culture is usually not needed, as culture results are not likely to alter the treatment since these infections typically do not involve deep tissue invasion. Vacuum-assisted closure is a reasonable intervention for large chronic pressure ulcers. Color photos taken on initial assessment and reevaluation are helpful in monitoring changes in the ulcer as long as the photo accurately depicts the appearance of the ulcer. The appropriate role of various growth factors in speeding healing is the subject of active investigation. Operative intervention is a last resort and should take place after a careful analysis of risks and benefits. Important factors to consider are medical stability, prognosis, nutritional status, risks of blood loss, postoperative immobility, quality of life, treatment goals, patient preferences, and risk of recurrence. Because smoking, spasticity, bacterial colonization of wound, and incontinence may impair wound healing, these should be addressed before surgical intervention. PREVENTION Pressure ulcer prevention shares similarities with pressure ulcer treatment. Important keys to pressure ulcer prevention can be found in Box 7-2. Important aspects include staff education. This 7 Prevention Box 7-2 Keys to Pressure Ulcer Prevention 1. Staff Education A. Focus on nurses and nursing assistants. i. Clear Assessment Expectations a. Complete skin assessment on admission b. Complete skin assessment every 48 hours c. Complete skin assessment whenever the patient s condition significantly changes ii. Clear ocumentation Expectations a. Assessment with reliable and standardized tool such as Braden or Norton Scales iii. Clear Action Expectations a. Triggered prevention protocols implemented within 12 hours b. Communication with physician regarding assesment and protocol implementation c. Home caregiver instruction 2. Pressure management A. Patient-Centered i. Keeping the patient as active as possible ii. Instruction patient to perform small weight shifts every 15 minutes when able iii. Limit head of bed elevation to no more than 30 degrees iv. Trapeze to assist with self-mobility B. Caregiver Centered i. Turn every 2 hours if consistent with overall care goals ii. Hourly repositioning of chair or wheelchair bound patients iii. Always use transfer sheet to move the patient C. Material-Centered i. Special support surface such as thick foam or static pressure mattress ii. Cushions to keep bony prominences from direct contact with each other iii. Cushions or devices to raise heels of bedbound patients off the bed iv. Protect the patient s elbows, heels, sacrum, and back of the head if he where exposed to friction v. Heel and elbow protectors vi. No Massage of reddened bony prominences vii. No donut devices 3. Moisture Management A. Treat Excess moisture i. Identify source ii. Regular use of a bedpan or urinal iii. Cleaning the skin quickly after any soiling iv. Absorbent pads that wick moisture v. Barrier dressings or creams B. Treat excess dryness i. Lotion use after bathing ii. No hot water iii. No drying soaps 4. Nutrition management 1. Assure adequate nutrition i. ietitian consultation if at risk ii. Increase protein, calorie, and/or vitamin intake as needed. iii. Give a cup of water given with the turning schedule to maintain hydration iv. Monitor NPO status due to multiple tests v. Peripheral parenteral nutrition (PPN) if NPO over several days

8 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 8 8 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach Figures 7-5, 7-6 The heels and greater trochanter are common sites for the development of pressure ulcers. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone, 2003.) includes proper use, documentation, and implementation of protocols based on assessment tools such as the Braden or Norton Scales. For example, factors assessed by the Braden Scale include sensory perception, moisture, activity, mobilty, nutrition, friction, and shear. Braden scale scores range from 0 23, with increased risk indicated by a score of 18 or below for elderly and persons with darkly pigmented skin, and 16 or below for other adults. Other helpful prevention techniques indicated in the Agency for Healthcare Research and Quality (AHRQ) prevention recommendations 1 target the key areas of pressure management, moisture management, nutrition management, and friction/shear minimization (Figs. 7-5, 7-6). The heels are an area of special risk. Preventive heel precautions include assessment of the feet twice daily. Use of a transparent film, hydrocolloid dressing, or even socks can minimize friction. Heel pressure can be removed through the use of pillows, blanket rolls, or heel lift devices. Active and/or passive range of motion of the ankle can be achieved through ankle movements twice daily. For patients not able to place the ankle in neutral position easily, occupational or physical therapy consultation is helpful. For skin tears, prevention consists of the basic principles of pressure ulcer prevention. In addition, high-risk patients can wear long sleeves or pants to protect their extremities. Adequate lighting reduces the risk of bumping into furniture or equipment. A safe area for wandering should be provided if possible. Nursing assistants need to understand how to protect patients from selfinjury or injury during routine care and turning. angling arms and legs should be supported with pillows or blankets. Padding equipment, such as wheelchair arm and leg supports, offers additional protection from accidental injury. Elderly, frail skin should have only nonadherent dressings, and only paper tape should be used on the skin. Gauze wraps, stockinettes, or other wraps that can be taped to themselves to secure dressings are useful in frail patients. CLINICAL ALGORITHM(S) There are many studies and protocols suggested for use in longterm care facilities, and algorithms specific to the inpatient setting appear to be based on these. The AHRQ guidelines on pressure ulcer prevention and treatemnt of pressur ulcers are available online at ISCHARGE/FOLLOW-UP PLANS For patients returning home, appropriate support surface should be arranged, and Visiting Nurse referral made. For complicated ulcers, a Skin Clinical Nurse Specialist should be specifically requested. A wound clinic referral, when available, is a useful adjuvant for difficult ulcers. For patients being transferred to another facility, pressure ulcer location, depth, size, stage, and treatment should always be documented in the transfer records. Patient Education Patient educational should address basic information such as the etiology and risk factors for pressure ulcers, and the basics of skin assessment. If a special support surface is needed, home caregivers should be instructed on its use as well as positioning techniques. The use of lifts, transfer sheets, and wound-care techniques also must be clearly explained. Outpatient Physician Communication It is best if the outpatient physician contact information be provided to the home health agency and wound clinic so the primary care provider can assume management of the ulcer after discharge. The Primary Care provider, however, must be provided information regarding the stage, size, and treatment plan for the ulcer, as well as contact information for the home health agency and wound clinic that will be providing assistance with ulcer management.

9 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 9 Key Points Stage 1 pressure ulcers identify at risk areas that have not broken down yet. Pressure ulcers most commonly occur over areas of bony prominences. An ulcer appearing on a part of the body that does not have a source of frequent constant pressure is probably not a pressure ulcer. The principles of pressure ulcer healing center around three key areas of intervention: pressure management, nutrition optimization, and direct ulcer management. 11. Langer G. Schloemer G. Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcer. Coch atabase Syst Rev 2003; (4):C Thomas R. The promise of topical growth factors in healing pressure ulcers. Ann Intern Med 2003; 139(8): Belmin J, Meaume S, Rabus M, et al. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc 2002; 50: Cullum N, eeks J, Sheldon TA, et al. Beds, mattresses & cushions for pressure sore prevention & treatment (Cochrane Review). In: The Cochrane Library, 2, Oxford Update Software; ow G. Bacterial swabs and the chronic wound: when, how, and what do they mean. Ostomy Wound Manage 2001; 49(5A, suppl): Argenta LC, Morykwas M. Vacuum-assisted closure: A new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38:(6): Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res 1987; 36(4): Norton, McLaren R, Exton-Smith AN. Pressure Sores: An Investigation of Geriatric Nursing Problems in Hospital. New York: Churchill Livingstone, Suggested Reading The Hospital s Skin Integrity Team should be utilized early on as collaborators in the care and management of patients with pressure ulcers. Standardized assessment tools should be routinely used to identify patients at increased risk for pressure ulcers. REFERENCES SUGGESTE REAING 1. Agency for Health Care Policy & Research.Panel for Pressure Ulcer Treatment, Clinical Practice Guideline Number 15. Rockville, M. US epartment of Health & Human Services. Public Health Service. AHCPR Publication No ; 1994:1. 2. The National Pressure Ulcer Advisory Panel (NPUAP); Cuddigan J, Ayello EA, Sussman C, editors. Pressure Ulcers in America: Prevalence, Incidence and Implications for the Future. NPUAP. Reston,VA, Amlung SR, Miller WL, Bosley LM. The 1999 national pressure ulcer prevalence survey: a benchmarking approach. Adv Skin Wound Care 2001; 4(6): Payne RL, Martin ML. efining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993; 39(5):16 20, 22 24, George S, Bugwadia N. Nutrition & wound healing. Med Surg Nurs 1996; 5(4): Livesley NJ, Chow AW. Infected pressure ulcers in elderly individuals. Clin Infect is 2002 ec; 1;35(11): Epub Han H, Lewis VL Jr, Wiedrich TA. The value of Jamshidi core needle bone biopsy in predicting postoperative osteomyelitis in grade IV pressure ulcer patients. Plastic Reconstr Surg 2002; 110(1): Allman RM, Laprade CA, Noel LB, et al. Pressure sores among hospitalized patients. Ann Intern Med 1986; 105: Wallenstein S. Brem H. Statistical analysis of wound-healing rates for pressure ulcers. Am J Surg 2004; 188(1A Suppl): Thomas R. Goode PS. Tarquine PH, et al. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc 1996; 44(12): Amlung SR, Miller WL, Bosley LM. The 1999 national pressure ulcer prevalence survey: a benchmarking approach. Adv Skin Wound Care 2001; 14(6): Livesley NJ, Chow AW. Infected pressure ulcers in elderly individuals. Clin Infect is 2002; 35(11): Epub Wallenstein S, Brem H. Statistical analysis of wound-healing rates for pressure ulcers. Am J Surg 2004; 188(1A Suppl): Thomas R, Goode PS, Tarquine PH, et al. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc 1996; 44(12): Langer G, Schloemer G, Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcer. Coch atabase Syst Rev 2003; (4):C Thomas R. The promise of topical growth factors in healing pressure ulcers. Ann Intern Med 2003; 139(8): Belmin J, Meaume S, Rabus M, et al. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc 2002; 50: Cullum N, eeks J, Sheldon TA, et al. Beds, mattresses & cushions for pressure sore prevention & treatment (Cochrane Review). The Cochrane Library, 2, Oxford Update Software; ow G. Bacterial swabs and the chronic wound: When, how, and what do they mean. Ostomy Wound Mgt 2001; 49(5A, suppl):8 13. Argenta LC, Morykwas M. Vacuum-assisted closure: A new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38(6): Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res 1987; 36(4):

10 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 10 QUERY FORM uring the preparation of your manuscript for publication, the questions listed below have arisen. Please attend to these matters and return this form with your proof. Many thanks for your assistance. Query Query Remarks References 1 AU: Pls supply author 2 AU: Pls clarify call-outs and referenced items as either a figure, a table, or a box 3 AU: pls supply city 4 AU: Pls supply city 5 AU: Pls supply city 6 AU: city? CHM007

APPLICATION OF DRY DRESSING

APPLICATION OF DRY DRESSING G-100 APPLICATION OF DRY DRESSING PURPOSE To aid in the management of a wound with minimal drainage. To protect the wound from injury, prevent introduction of bacteria, reduce discomfort, and assist with

More information

Wound Care: The Basics

Wound Care: The Basics Wound Care: The Basics Suzann Williams-Rosenthal, RN, MSN, WOC, GNP Norma Branham, RN, MSN, WOC, GNP University of Virginia May, 2010 What Type of Wound is it? How long has it been there? Acute-generally

More information

7/11/2011. Pressure Ulcers. Moisture-NOT Pressure. Wounds NOT Caused by Pressure

7/11/2011. Pressure Ulcers. Moisture-NOT Pressure. Wounds NOT Caused by Pressure Assessment and Documentation of Pressure Ulcers Jeri Ann Lundgren, RN, BSN, PHN, CWS, CWCN Pathway Health Services July 19, 2011 Training Objectives Describe etiologies of pressure ulcers Discuss how to

More information

WOUND MANAGEMENT PROTOCOLS WOUND CLEANSING: REMOVING WOUND DEBRIS FROM WOUND BASE

WOUND MANAGEMENT PROTOCOLS WOUND CLEANSING: REMOVING WOUND DEBRIS FROM WOUND BASE WOUND MANAGEMENT PROTOCOLS PURPOSE: Provide nursing personnel with simple guidance regarding appropriate dressing selection in the absence of wound specialist expertise Identify appropriate interventions

More information

Wound and Skin Assessment. Mary Carvalho RN, BSN, MBA Clinical Coordinator Johnson Creek Wound and Edema Center

Wound and Skin Assessment. Mary Carvalho RN, BSN, MBA Clinical Coordinator Johnson Creek Wound and Edema Center Wound and Skin Assessment Mary Carvalho RN, BSN, MBA Clinical Coordinator Johnson Creek Wound and Edema Center Skin The largest Organ Weighs between 6 and 8 pounds Covers over 20 square feet Thickness

More information

Position Statement: Pressure Ulcer Staging

Position Statement: Pressure Ulcer Staging Position Statement: Pressure Ulcer Staging Statement of Position The Wound, Ostomy and Continence Nurses (WOCN) Society supports the use of the National Pressure Ulcer Advisory Panel Staging System (NPUAP).

More information

OASIS-C Integument Assessment: Not for Wimps! Part I: Pressure Ulcers

OASIS-C Integument Assessment: Not for Wimps! Part I: Pressure Ulcers OASIS-C Integument Assessment: Not for Wimps! Part I: Pressure Ulcers Presented by: Rhonda Will, RN, BS, COS-C, HCS-D Assistant Director, OASIS Competency Institute 243 King Street, Suite 246 Northampton,

More information

WOCN Society Position Statement: Pressure Ulcer Staging

WOCN Society Position Statement: Pressure Ulcer Staging WOCN Society Position Statement: Pressure Ulcer Staging Originated By: Wound Committee Date Completed: 1996 Reviewed/Revised: July 2006 Revised: August 2007 Reviewed/Revised: April 2011 Definition of Pressure

More information

PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT

PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT PRESSURE ULCER GUIDELINES FOR TOPICAL TREATMENT The following are suggested guidelines for treatment of pressure ulcers using products from Swiss-American Products, Inc. and are intended to supplement

More information

Pressure Ulcers: Facility Assessment Checklists

Pressure Ulcers: Facility Assessment Checklists Pressure Ulcers: Facility Assessment Checklists This is a series of self-assessment checklists for nursing home staff to use to assess processes related to managing pressure ulcers in the facility, in

More information

7/30/2012. Increased incidence of chronic diseases due

7/30/2012. Increased incidence of chronic diseases due Dianne Rudolph, DNP, GNP bc, CWOCN Discuss management of wound care in older adults with focus on lower extremity ulcers Identify key aspects of prevention Explain basic principles of wound management

More information

Diabetic Foot Ulcers and Pressure Ulcers. Laurie Duckett D.O. Plastic and Reconstructive Surgeon Oklahoma State University Center for Health Sciences

Diabetic Foot Ulcers and Pressure Ulcers. Laurie Duckett D.O. Plastic and Reconstructive Surgeon Oklahoma State University Center for Health Sciences Diabetic Foot Ulcers and Pressure Ulcers Laurie Duckett D.O. Plastic and Reconstructive Surgeon Oklahoma State University Center for Health Sciences Lecture Objectives Identify risk factors Initiate appropriate

More information

Pressure Ulcers Assessing and Staging. Anne Pirzadeh RN CWOCN University of Colorado Hospital June 2010

Pressure Ulcers Assessing and Staging. Anne Pirzadeh RN CWOCN University of Colorado Hospital June 2010 Pressure Ulcers Assessing and Staging Anne Pirzadeh RN CWOCN University of Colorado Hospital June 2010 Never Events: Pressure Ulcers Pressure Ulcer Codes: MD documentation of pressure ulcers determines

More information

Pressure Ulcers in Neonatal Patients. Rene Amaya, MD Pediatric Specialists of Houston Infectious Disease/Wound Care

Pressure Ulcers in Neonatal Patients. Rene Amaya, MD Pediatric Specialists of Houston Infectious Disease/Wound Care Pressure Ulcers in Neonatal Patients Rene Amaya, MD Pediatric Specialists of Houston Infectious Disease/Wound Care Objectives Review skin anatomy and understand why neonatal skin is at increased risk for

More information

Wound Classification Name That Wound Sheridan, WY June 8 th 2013

Wound Classification Name That Wound Sheridan, WY June 8 th 2013 Initial Wound Care Consult Sheridan, WY June 8 th, 2013 History Physical Examination Detailed examination of the wound Photographs Cultures Procedures TCOM ABI Debridement Management Decisions A Detailed

More information

Understand nurse aide skills needed to promote skin integrity.

Understand nurse aide skills needed to promote skin integrity. Unit B Resident Care Skills Essential Standard NA5.00 Understand nurse aide s role in providing residents hygiene, grooming, and skin care. Indicator Understand nurse aide skills needed to promote skin

More information

Skin & Wound Care Prevention & Treatment. By Candy Houk, RN Skin & Wound Program Manager

Skin & Wound Care Prevention & Treatment. By Candy Houk, RN Skin & Wound Program Manager Skin & Wound Care Prevention & Treatment By Candy Houk, RN Skin & Wound Program Manager OBJECTIVES Classify Stage 1 and 2 pressure ulcers Recognize suspected Stage 3, 4, DTI, and unstageable pressure ulcers

More information

Illinois Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION. Statement of LICENSURE Violations

Illinois Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION. Statement of LICENSURE Violations (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Final Observations Statement of

More information

Managing cavity wounds Journal of Community Nursing March 1998 Author: Rosemary Pudner

Managing cavity wounds Journal of Community Nursing March 1998 Author: Rosemary Pudner Managing cavity wounds Journal of Community Nursing March 1998 Author: Rosemary Pudner It has been seen in recent years, that an increasing number of patients are being discharged early into the community,

More information

Use of a Pressure Ulcer Protocol: Benefits and Recommendations

Use of a Pressure Ulcer Protocol: Benefits and Recommendations Use of a Pressure Ulcer Protocol: Benefits and Recommendations Elizabeth L. Enriquez RN,BSN,MPH,CWOCN Wound Care Specialist/Infection Control Morningiside House 1000 Pellham Parkway, Bronx, NY 10461 Wound

More information

FUNCTIONS OF THE SKIN

FUNCTIONS OF THE SKIN FUNCTIONS OF THE SKIN Skin is the largest organ of the body. The average adult has 18 square feet of skin which account for 16% of the total body weight. Skin acts as a physical barrier for you to the

More information

Summary of Recommendations

Summary of Recommendations Summary of Recommendations *LEVEL OF EVIDENCE Practice Recommendations Assessment 1.1 Conduct a history and focused physical assessment. IV 1.2 Conduct a psychosocial assessment to determine the client

More information

NR33 WOUND MANAGEMENT

NR33 WOUND MANAGEMENT Page 1 of 7 Critical Thinking Strategies Scenario 1 NR33 WOUND MANAGEMENT Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6

More information

Pressure Ulcer Passport

Pressure Ulcer Passport Pressure Ulcer Passport Information for patients This is a record of the treatment you are receiving for your pressure ulcer injury. Please bring it with you to all your healthcare appointments. This will

More information

Assessment of the Pressure Ulcer:

Assessment of the Pressure Ulcer: Unstageable Ulcer Slough Eschar Staging According to the National Pressure Ulcer Advisory Panel (NPUAP), pressure ulcers should not be down staged or reverse staged, however the RAI manual directs the

More information

RENFREW VICTORIA HOSPITAL SKIN AND WOUND CARE PROGRAM TRAINING RISK ASSESSMENT OF SKIN BREAKDOWN AND TREATMENT OF WOUNDS AND PRESSURE ULCERS

RENFREW VICTORIA HOSPITAL SKIN AND WOUND CARE PROGRAM TRAINING RISK ASSESSMENT OF SKIN BREAKDOWN AND TREATMENT OF WOUNDS AND PRESSURE ULCERS RENFREW VICTORIA HOSPITAL SKIN AND WOUND CARE PROGRAM TRAINING RISK ASSESSMENT OF SKIN BREAKDOWN AND TREATMENT OF WOUNDS AND PRESSURE ULCERS SELF-LEARNING MODULE For Registered Nurses and Registered Practical

More information

Wound, Ostomy and Continence Nurses Society s Guidance on OASIS-C1 Integumentary Items: Best Practice for Clinicians

Wound, Ostomy and Continence Nurses Society s Guidance on OASIS-C1 Integumentary Items: Best Practice for Clinicians Wound, Ostomy and Continence Nurses Society s Guidance on OASIS-C1 Integumentary Items: Best Practice for Clinicians Acknowledgments Wound, Ostomy and Continence Nurses Society s Guidance on OASIS-C1 Integumentary

More information

SECTION M: SKIN CONDITIONS. M0100: Determination of Pressure Ulcer Risk. Item Rationale Health-related Quality of Life.

SECTION M: SKIN CONDITIONS. M0100: Determination of Pressure Ulcer Risk. Item Rationale Health-related Quality of Life. SECTION M: SKIN CONDITIONS Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers. This section also notes other skin ulcers, wounds, or lesions, and documents

More information

NURSING DOCUMENTATION

NURSING DOCUMENTATION NURSING DOCUMENTATION OBJECTIVES 1. The learner will be able to state 2 components of documentation that meet the 2. The learner will be able to identify 4 characteristics of a complete skin assessment

More information

Pressure Ulcers Risk Management and Treatment

Pressure Ulcers Risk Management and Treatment Pressure Ulcers Risk Management and Treatment Objectives State reasons why individuals initiate lawsuits. Define strategies to reduce the risk of litigation. Determine appropriate treatment for the patient.

More information

EPIDEMIOLOGY COMPLICATIONS FROM PRESSURE ULCERS

EPIDEMIOLOGY COMPLICATIONS FROM PRESSURE ULCERS CHAPTER 30 PRESSURE ULCERS EPIDEMIOLOGY COMPLICATIONS FROM PRESSURE ULCERS RISK FACTORS AND RISK-ASSESSMENT SCALES PREVENTION MANAGEMENT ANNOTATED REFERENCES Pressure ulcers are a serious and common problem

More information

Protection and treatment of pressure ulcers. A Coloplast Wound Care quick guide

Protection and treatment of pressure ulcers. A Coloplast Wound Care quick guide Protection and treatment of pressure ulcers A Coloplast Wound Care quick guide Table of content Foreword... 3 Introduction to pressure ulcers... 4 Good clinical practice... 5 Pressure ulcer guide... 6

More information

WOUND OSTOMY CONTINENCE NURSES SOCIETY GUIDANCE ON OASIS-C INTEGUMENTARY ITEMS

WOUND OSTOMY CONTINENCE NURSES SOCIETY GUIDANCE ON OASIS-C INTEGUMENTARY ITEMS Wound Ostomy Continence Nurses Society Guidance on OASIS-C Integumentary Items WOCN OASIS Taskforce Members: Ben Peirce (Chairperson), RN, BA, CWOCN, COS-C Dianne Mackey, BSN, RN, PHN, CWOCN Laurie McNichol,

More information

Beverlin Allen, PhD, RN, MSN, ARNP

Beverlin Allen, PhD, RN, MSN, ARNP Pressure Ulcers & Nutritional Deficits in Elderly Long-Term Care Patients: Effects of a Comprehensive Nutritional Protocol on Pressure Ulcer Healing, Length of Hospital Stay & Health Care Charges Beverlin

More information

Corporate Medical Policy Pressure Reducing Support Surfaces

Corporate Medical Policy Pressure Reducing Support Surfaces Corporate Medical Policy Pressure Reducing Support Surfaces File Name: Origination: Last CAP Review: Next CAP Review: Last Review: pressure_reducing_support_surfaces 7/2006 9/2015 9/2016 9/2015 Description

More information

Silicone pressure-reducing pads for the prevention and treatment of pressure ulcers

Silicone pressure-reducing pads for the prevention and treatment of pressure ulcers S46 Product focus Silicone pressure-reducing pads for the prevention and treatment of pressure ulcers Abstract Pressure ulcers, a key quality of care indicator, cause emotional distress to the patient,

More information

Preventing pressure ulcers

Preventing pressure ulcers Golden Jubilee National Hospital NHS National Waiting Times Centre Preventing pressure ulcers Patient information guide for adults at risk of pressure ulcers Agamemnon Street Clydebank, G81 4DY (: 0141

More information

Pressure Injury Prevention and Management Policy

Pressure Injury Prevention and Management Policy Pressure Injury Prevention and Management Policy Owner (initiating the document): Dr Amanda Ling Contact name and number: Rachel Dennis (Ph: 9222 2197) Version: 1.5 Approved by: Professor Bryant Stokes,

More information

Algidex Ag. wet - moist - dry wound

Algidex Ag.  wet - moist - dry wound Algidex Ag wet - moist - dry wound Algidex Ag is a unique combination of silver, alginate and maltodextrin. It provides immediate and sustained antimicrobial action against a broad spectrum of wound pathogens

More information

Pressure Ulcer Prevention Prevention Is The Cure

Pressure Ulcer Prevention Prevention Is The Cure The new name for Central Essex Community Service Pressure Ulcer Prevention Prevention Is The Cure Lorraine Grothier Clinical Nurse Specialist Tissue Viability Is Prevention Important? An estimated 4-20%

More information

Management of Burns. The burns patient has the same priorities as all other trauma patients.

Management of Burns. The burns patient has the same priorities as all other trauma patients. Management of Burns The burns patient has the same priorities as all other trauma patients. Assess: - Airway - Breathing: beware of inhalation and rapid airway compromise - Circulation: fluid replacement

More information

NPUAP PRESSURE ULCER ROOT CAUSE ANALYSIS (RCA) TEMPLATE

NPUAP PRESSURE ULCER ROOT CAUSE ANALYSIS (RCA) TEMPLATE Purpose: The development of a facility acquired pressure ulcer brings with it both a financial impact to an institution and a performance or quality of care impact that may be reportable to state or government

More information

Inservice: Wound Care and Dressings. Friday, June 26, 2009. A. Closed Wounds tissue is injured but skin is not BROKEN

Inservice: Wound Care and Dressings. Friday, June 26, 2009. A. Closed Wounds tissue is injured but skin is not BROKEN f Inservice: Wound Care and Dressings Friday, June 26, 2009 WOUNDS: Are injuries of the skin and underlying subcutaneous tissues and muscles (Nursing Manual by Lippincott) Are disruptions in the integrity

More information

Wound Assessment & Treatment

Wound Assessment & Treatment Wound Assessment & Treatment Cathy Lyle Advanced Practice Nurse Providence Care, SMOL site LTC Physicians CME June 2011 Outline Is it healing? Will it heal? What colour is it? How wet is it? Is it infected?

More information

NPUAP PRESSURE ULCER ROOT CAUSE ANALYSIS (RCA) TEMPLATE National Pressure Ulcer Advisory Panel March 2014

NPUAP PRESSURE ULCER ROOT CAUSE ANALYSIS (RCA) TEMPLATE National Pressure Ulcer Advisory Panel March 2014 Purpose: The development of a facility acquired pressure ulcer brings with it both a financial impact to an institution and a performance or quality of care impact that may be reportable to state or government

More information

SKIN CARE & WOUND MANAGEMENT POLICY AND PROCEDURE

SKIN CARE & WOUND MANAGEMENT POLICY AND PROCEDURE Department: Description: Adventist Aged Care Document Name: Skin Care and Wound Management 14/04/2014 SKIN CARE & WOUND MANAGEMENT POLICY AND PROCEDURE TABLE OF CONTENTS 1.0 PURPOSE... 2 2.0 SCOPE... 2

More information

Reducing Hospital. of Pressure Damage. Spread the Learning and celebrate the successes

Reducing Hospital. of Pressure Damage. Spread the Learning and celebrate the successes Reducing Hospital Acquired Pressure Ulcers Prevention & Management of Pressure Damage Spread the Learning and celebrate the successes Prevalence & Cost Prevalence ranges from 10% to 18% in the UK (Clark

More information

Pressure Ulcers- The Extent of the Problem and Clinical Challenges. Keith Harding

Pressure Ulcers- The Extent of the Problem and Clinical Challenges. Keith Harding Pressure Ulcers- The Extent of the Problem and Clinical Challenges Keith Harding Head of Department of Dermatology & Wound Healing Director of Innovation & Engagement School of Medicine Clinical Director

More information

CHAPTER V CONCLUSION AND RECOMMENDATIONS. findings are presented, implications for nursing practice and education are discussed,

CHAPTER V CONCLUSION AND RECOMMENDATIONS. findings are presented, implications for nursing practice and education are discussed, CHAPTER V CONCLUSION AND RECOMMENDATIONS In this chapter, a summary of the findings and conclusion drawn from the findings are presented, implications for nursing practice and education are discussed,

More information

PERFORMANCE MEASURE TECHNICAL SPECIFICATIONS

PERFORMANCE MEASURE TECHNICAL SPECIFICATIONS PERFORMANCE MEASURE TECHNICAL SPECIFICATIONS 1. Rate of Emergency Department Visits The number of visits experienced by PACE participants to acute care hospital Emergency Departments, urgent care clinics,

More information

Topical Oxygen Wound Therapy (MEDICAID)

Topical Oxygen Wound Therapy (MEDICAID) Topical Oxygen Wound Therapy (MEDICAID) Last Review Date: September 11, 2015 Number: MG.MM.DM.15C6v2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or

More information

Moisture lesions. Sara-jane Kray Clinical Nurse Specialist (Honorary contract KCHT)

Moisture lesions. Sara-jane Kray Clinical Nurse Specialist (Honorary contract KCHT) Moisture lesions Sara-jane Kray Clinical Nurse Specialist (Honorary contract KCHT) Aim To differentiate between moisture lesions and pressure ulcers. To understand the effects of urine and faeces on skin

More information

University Health Network Policy & Procedure Manual

University Health Network Policy & Procedure Manual University Health Network Policy & Procedure Manual Clinical Manual Skin & Wound Assessment & Management This policy is under review and revision. Some of the procedures may not reflect current practice

More information

PATIENT TEACHING GUIDE: Wound Care Handbook

PATIENT TEACHING GUIDE: Wound Care Handbook PATIENT TEACHING GUIDE: Wound Care Handbook PATIENT TEACHING GUIDE: WOUND CARE Design by Mariscal Design, Illustrations by Lysa Hawke. The Wound Care Self Care Guide was written and prepared by: Barbara

More information

THE DEVELOPMENT OF A CARE BUNDLE FOR THE CRITICALLY ILL

THE DEVELOPMENT OF A CARE BUNDLE FOR THE CRITICALLY ILL PRESSURE ULCER PROPHYLAXIS THE DEVELOPMENT OF A CARE BUNDLE FOR THE CRITICALLY ILL Barb Duncan RN, BScN Heather Harrington RN, BScN, CNCC(c) Louanne Rich vanderbij, RN, BScN, MSc., WOCN CWCN Barb Duncan

More information

HCPCS AMERIGEL HYDROGEL DRESSINGS CODING GUIDANCE FOR:

HCPCS AMERIGEL HYDROGEL DRESSINGS CODING GUIDANCE FOR: HCPCS CODING GUIDANCE FOR: AMERIGEL HYDROGEL DRESSINGS FORM 1500 MUST HAVE THE FOLLOWING: APPROPRIATE HCPCS CODE APPROPRIATE A MODIFIER ACCURATE POS = 12 The Centers for Medicare and Medicaid Services

More information

5 Pressure Ulcer Classification

5 Pressure Ulcer Classification 5 Pressure Ulcer Classification Carol Dealey and Christina Lindholm Introduction Pressure ulcer classification is a method of determining the severity of a pressure ulcer. A classification system describes

More information

Policies & Procedures. Title: I.D. Number: 1160

Policies & Procedures. Title: I.D. Number: 1160 Policies & Procedures Title: NEGATIVE PRESSURE WOUND THERAPY (NPWT) I.D. Number: 1160 Authorization: [X] SHR Nursing Practice Committee Source: Nursing Date Revised: March, 2010 Date Effective: November,

More information

Care of Your Wounds After Amputation Surgery by Paddy Rossbach, RN

Care of Your Wounds After Amputation Surgery by Paddy Rossbach, RN Care of Your Wounds After Amputation Surgery by Paddy Rossbach, RN Depending on the reason for your amputation and the state of your limb at the time of surgery, definitive closure of the wound may take

More information

Critically evaluate the organization of diabetic foot ulcer services and interdisciplinary team working

Critically evaluate the organization of diabetic foot ulcer services and interdisciplinary team working Rationale of Module Accurate nursing assessment is the key to effective diabetic foot ulcer prevention, treatment and management. A comprehensive assessment identifies ulcer aetiology and the factors which

More information

Skin Care In Bladder And Bowel Dysfunction Wendy Ness Colorectal Nurse Specialist

Skin Care In Bladder And Bowel Dysfunction Wendy Ness Colorectal Nurse Specialist Skin Care In Bladder And Bowel Dysfunction Wendy Ness Colorectal Nurse Specialist Function Of The Skin Healthy skin serves several purposes it protects the internal organs physically, chemically and biologically

More information

Wound Healing. Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates

Wound Healing. Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates C HAPTER 9 Wound Healing Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates As the above quote suggests, conduct regular and systematic wound assessments, and seize

More information

Common Pathology Diagnoses: ICD-9 to ICD-10 Mapping

Common Pathology Diagnoses: ICD-9 to ICD-10 Mapping PERFORMANCE THAT MATTERS NUMBER OF CODES 14,000 69,000 ICD-9 DIAGNOSIS CODES ICD-10 DIAGNOSIS CODES CODE STRUCTURE ICD-9-CM CODE FORMAT ICD-10-CM CODE FORMAT X X X X X X X X X X X X CATEGORY ETIOLOGY,

More information

TAKING CARE OF WOUNDS KEY FIGURE:

TAKING CARE OF WOUNDS KEY FIGURE: Chapter 9 TAKING CARE OF WOUNDS KEY FIGURE: Gauze Wound care represents a major area of concern for the rural health provider. This chapter discusses the treatment of open wounds, with emphasis on dressing

More information

Skin/Wound Referral Resource

Skin/Wound Referral Resource Skin/Wound Referral Resource This resource was designed by the University of Michigan Health System Multidisciplinary Pressure Ulcer Prevention Committee for nursing and physician use. This document s

More information

Vacuum-Assisted Wound Closure ISSN: 0002-936X American Journal of Nursing

Vacuum-Assisted Wound Closure ISSN: 0002-936X American Journal of Nursing Vacuum-Assisted Wound Closure ISSN: 0002-936X American Journal of Nursing Author(s): Chua Patel, Christy T. MS, RN; Kinsey, Gail C. MS, RN, CNS; Koperski-Moen, Kelley J. ADN, RN; Bungum, Lisa D. BSN, RN

More information

Anyone who has difficulty moving can get a pressure sore. But you are more likely to get one if you:

Anyone who has difficulty moving can get a pressure sore. But you are more likely to get one if you: Patient information from the BMJ Group Pressure sores Anyone can get a pressure sore if they sit or lie still for too long without moving. People who are old or very ill are most likely to get them. Careful

More information

Pressure Sores (Decubitus Ulcers)

Pressure Sores (Decubitus Ulcers) Pressure Sores (Decubitus Ulcers) Judith Stevens, M.Ed. With thanks to Dr. Toni Benton, Jennifer Thorne-Lehman, Araceli Domingo for contributing resource information. Thanks to Ann Chase Stevens for sharing

More information

Individualized Care Plans Fully Developed

Individualized Care Plans Fully Developed Appendix Individualized Care Plans Fully Developed A Refer to Chapter 1 The Nursing Process: A Synopsis, p. 32: Two Individualized Care Plans Fully Developed; Care Plan 1 for Mr. John Walters, Care Plan

More information

Government of Western Australia Department of Health North Metropolitan Health Service. Preventing Pressure Injuries

Government of Western Australia Department of Health North Metropolitan Health Service. Preventing Pressure Injuries Government of Western Australia Department of Health North Metropolitan Health Service Preventing Pressure Injuries This document can be made in alternative formats, such as large print, cd or electronically,

More information

Post-surgical V.A.C. VeraFlo Therapy with Prontosan Instillation on Inpatient Infected Wounds * COLLECTION OF CASE STUDIES

Post-surgical V.A.C. VeraFlo Therapy with Prontosan Instillation on Inpatient Infected Wounds * COLLECTION OF CASE STUDIES COLLECTION OF CASE STUDIES Post-surgical V.A.C. VeraFlo Therapy with Prontosan Instillation on Inpatient Infected Wounds * *All patients were treated with systemic antibiotics Post-surgical V.A.C. VeraFlo

More information

Best Practice Guidelines BPG 1 Pressure Ulcer Prevention & Management

Best Practice Guidelines BPG 1 Pressure Ulcer Prevention & Management Best Practice Guidelines BPG 1 Pressure Ulcer Prevention & Management DOCUMENT STATUS: Approved DATE ISSUED: 14.4.15 DATE TO BE REVIEWED: 13.10.17 AMENDMENT HISTORY VERSION DATE AMENDMENT HISTORY V 1 9.9.13

More information

Pressure ulcers prevention and treatment. A Coloplast quick guide

Pressure ulcers prevention and treatment. A Coloplast quick guide Pressure ulcers prevention and treatment A Coloplast quick guide Table of Contents Pressure ulcers prevention and treatment... 3 What is a pressure ulcer?... 4 How do pressure ulcers occur?... 5 Who develops

More information

Preventing Pressure Ulcers and Assisting With Wound Care

Preventing Pressure Ulcers and Assisting With Wound Care Preventing Pressure Ulcers and Assisting With Wound Care C H A P T E R 19 A nursing assistant makes an occupied bed. Providing clean, wrinkle-free linens is just one way that nursing assistants help to

More information

APPENDIX 1: INTERDISCIPLINARY APPROACH TO PREVENTION AND MANAGEMENT OF DIABETIC FOOT COMPLICATIONS

APPENDIX 1: INTERDISCIPLINARY APPROACH TO PREVENTION AND MANAGEMENT OF DIABETIC FOOT COMPLICATIONS APPENDIX 1: INTERDISCIPLINARY APPROACH TO PREVENTION AND MANAGEMENT OF DIABETIC FOOT COMPLICATIONS Template: Regional Foot Programs should develop a list of available health professionals in the following

More information

Skin Tear Resource Kit

Skin Tear Resource Kit Skin Tear Resource Kit 136473_Broch.indd 1 10/16/13 8:55 PM Skin Tear: A Clinical Problem An Often Painful But Largely Preventable Health Care Issue Skin tears affect all ages and continue to be a common

More information

Skin Care Educational Pocket Guide

Skin Care Educational Pocket Guide Skin Care Educational Pocket Guide Moisture-Associated Skin Damage Moisture-Associated Skin Damage is the injury to the skin by repeated or sustained exposure to moisture. Intertriginous dermatitis Incontinence-associated

More information

Introduction to Wound Management

Introduction to Wound Management EWMA Educational Development Programme Curriculum Development Project Education Module: Introduction to Wound Management Latest revision: October 2012 ABOUT THE EWMA EDUCATIONAL DEVELOPMENT PROGRAMME The

More information

Management of Skin Tears in the Elderly using 3M Tegaderm Absorbent Clear Acrylic Dressing. Author: Joanne Biddix, RN, CWCN

Management of Skin Tears in the Elderly using 3M Tegaderm Absorbent Clear Acrylic Dressing. Author: Joanne Biddix, RN, CWCN Management of Skin Tears in the Elderly using 3M Tegaderm Absorbent Clear Acrylic Dressing Author: Joanne Biddix, RN, CWCN Management of Skin Tears in the Elderly using 3M Tegaderm Absorbent Clear Acrylic

More information

Pressure Ulcers Among Nursing Home Residents: United States, 2004

Pressure Ulcers Among Nursing Home Residents: United States, 2004 Pressure Ulcers Among Nursing Home Residents: United States, 2004 Eunice Park-Lee, Ph.D., and Christine Caffrey, Ph.D., Division of Health Care Statistics Key findings Data from the National Nursing Home

More information

Nutrition and Wound Healing

Nutrition and Wound Healing Nutrition and Wound Healing Geoffrey Axiak M.Sc. Nursing (Manchester), B.Sc. (Nursing), P.G. Dip. (Nutrition & Dietetics) Registered Nutritionist & Clinical Nutrition Nurse-in-charge Factors Affecting

More information

Case Series: The use of AQUACEL Ag Extra dressing on Chronic and Acute Wounds

Case Series: The use of AQUACEL Ag Extra dressing on Chronic and Acute Wounds Case Series: The use of AQUACEL Ag Extra dressing on Chronic and Acute Wounds Executive Summary ConvaTec, the company that brings you the anti-microbial dressing, AQUACEL Ag, has taken its Hydrofibe r

More information

Patient Safety Call to Action. Road Map to a Comprehensive Skin Safety Program

Patient Safety Call to Action. Road Map to a Comprehensive Skin Safety Program Road Map to a Comprehensive Program Road Map to a Comprehensive Program S A F E S K I N based on the ICSI Protocol, Adverse Health Event Learnings I n f r a s t ru c t u r e S Coordination and Team Approach

More information

Pressure Ulcers. Occupational Therapy. This leaflet is for both yourself and Carers

Pressure Ulcers. Occupational Therapy. This leaflet is for both yourself and Carers Pressure Ulcers Occupational Therapy This leaflet is for both yourself and Carers Contents What is a pressure ulcer? 3 Who is at risk of developing a pressure ulcer? 4 How can I avoid developing a pressure

More information

CCME CNE Course Announcement

CCME CNE Course Announcement CCME CNE Course Announcement Activity Title: NoCVA Pressure Ulcer Webinar The Carolinas Center for Medical Excellence (CCME) is accredited as an approved provider of continuing nursing education by North

More information

Use of Packing for Surgical Wounds. Maggie Benson Clinical Problem Solving II

Use of Packing for Surgical Wounds. Maggie Benson Clinical Problem Solving II Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II Purpose Present patient management s/p Incision and Drainage in an outpatient setting Examine evidence for the use of wound

More information

STANDARDIZED PROCEDURE BONE MARROW ASPIRATION

STANDARDIZED PROCEDURE BONE MARROW ASPIRATION I. Definition: This protocol covers the task of bone marrow aspiration by an Allied Health Professional. The purpose of this standardized procedure is to allow the Allied Health Professional to safely

More information

PRA Disclosure Statement

PRA Disclosure Statement PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB

More information

Pressure Ulcers in the ICU Incidence, Risk Factors & Prevention

Pressure Ulcers in the ICU Incidence, Risk Factors & Prevention Congress of the Critical Care Society of South Africa Sun City, 10-12 July 2015 Pressure Ulcers in the ICU Incidence, Risk Factors & Prevention Stijn BLOT Dept. of Internal Medicine Faculty of Medicine

More information

CELLULITIS. Cellulitis is a common presentation to the Emergency Department.

CELLULITIS. Cellulitis is a common presentation to the Emergency Department. CELLULITIS Introduction Cellulitis is a common presentation to the Emergency Department. The term cellulitis refers to an uncomplicated non-necrotizing acute infection of the skin that involves the mid

More information

A Pocket Guide. Application and Cutting Guide

A Pocket Guide. Application and Cutting Guide A Pocket Guide Application and Cutting Guide Developed by Pia Carlsen, RN, Denmark Jacqui Fletcher, Principal Lecturer, MSc BSc (Hons) PG Dip (ED) RN ILT, UK Maria Mousley, AHP, Consultant Podiatrist,

More information

The New F-tag 314: Prevention and Management of Pressure Ulcers David R. Thomas, MD

The New F-tag 314: Prevention and Management of Pressure Ulcers David R. Thomas, MD CLINICAL PRACTICE IN LONG-TERM CARE The New F-tag 314: Prevention and Management of Pressure Ulcers David R. Thomas, MD Saint Louis University Medical Center, Saint Louis, MO. Address correspondence to

More information

Cutimed PROTECT Medical skin protection. Protect Preserve Prevent

Cutimed PROTECT Medical skin protection. Protect Preserve Prevent PROTECT Medical skin protection Protect Preserve Prevent PROTECT Ordering information PROTECT is available in foam applicators and spray bottle PROTECT REF No. Size Unit of Measure HCPCS Spray 7265300

More information

Pressure injuries prevention and treatment

Pressure injuries prevention and treatment After 30 years in wound care, we at Coloplast believe that absorption is the key to better healing. Our Biatain portfolio brings superior absorption to daily wound care needs, making Biatain the simple

More information

Coding and Payment Guide for the Physical Therapist. An essential coding, billing, and payment resource for the physical therapist

Coding and Payment Guide for the Physical Therapist. An essential coding, billing, and payment resource for the physical therapist Coding and Payment Guide for the Physical Therapist An essential coding, billing, and payment resource for the physical therapist 2013 Contents Introduction...1 Coding Systems... 1 Claim Forms... 3 Contents

More information

Pressure Injury Prevention

Pressure Injury Prevention Clinical Contents Policy... 1 Purpose... 2 Scope/Audience... 2 Definitions... 2 Associated documents... 2 Objectives... 3 Personnel Authorised to Perform Procedure... 3 Initial Skin and Pressure Injury

More information

How does Diabetes Effect the Feet

How does Diabetes Effect the Feet How does Diabetes Effect the Feet What Skin Changes May Occur? Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that

More information

Adult Forearm Fractures

Adult Forearm Fractures Adult Forearm Fractures Your forearm is made up of two bones, the radius and ulna. In most cases of adult forearm fractures, both bones are broken. Fractures of the forearm can occur near the wrist at

More information

Wound Healing Community Outreach Service

Wound Healing Community Outreach Service Wound Healing Community Outreach Service Wound Management Education Plan January 2012 December 2012 Author: Michelle Gibb Nurse Practitioner Wound Management Wound Healing Community Outreach Service Institute

More information

Pediatric Port An Implantable Vascular Access Device

Pediatric Port An Implantable Vascular Access Device Pediatric Port An Implantable Vascular Access Device This handout will explain what a port is and how to care for it once you are home. If you have any questions, please ask. Our staff is here to help

More information