Skin Champion Education

Robert J. Dole VAMC

SKIN/Wound care education

Objectives• Describe the pathophysiology of wound healing• Explain the difference between acute and chronic wounds• Identify factors that impair wound healing • Describe the benefits of moist wound healing• State the principles of wound management• Explain pressure ulcer risk, skin, and wound assessment

documentation requirements.• Discuss the importance of pressure ulcer prevention• Describe how a pressure ulcer develops• Describe the key elements in pressure ulcer assessment

and staging

Anatomy of the Skin

Epidermis

• Outermost layer (epi- means upon)• Thickness from 0.1mm to 1.0mm• Slightly acidic – avg. pH 5.5• “ACID MEMBRANE”• Contains melanocytes – pigment• Made up of 4 to 5 layers depending on

location

Layers of the epidermis• Stratum corneum - horny layer - dead skin

cells (keratinized epithelium) -environment• Acid mantle protects from some fungi and

bacteria• Shed and replaced every 4 to 6 weeks

• Stratum lucidum - clear layer – single cell layer found where thickest – soles of feet• Intense enzyme activity prepares cells for

stratum corneum even though lacks nuclei

• Stratum granulosum - granular layer – 1 to 5 cells – flat cells with nuclei – aids keratin formation -

Layers of the epidermis• Stratum spinosum – cells begin to flatten

as they migrate – protein precursor of keratinized skin cells synthesized

• Stratum basale / stratum germinativum• One cell thick• Only layer that undergoes mitosis• Forms dermoepidermal junction – protrusions

known as rete ridges or epidermal ridges extend into dermis and are surrounded by vascularized dermal papillae• Support and exchange of fluid and cells

Dermis - deeper layer of skin• Collagen (strength) and elastin (elasticity)

fibers produced by fibroblasts• Extracellular matrix – gives skin its

physical characteristics• Blood and lymphatic vessels – transport O2,

nutrients and remove wastes• Nerve fibers, hair follicles, sweat glands –

contribute to sensation, temperature regulation, excretion and absorption

• Sebaceous glands – sebum lubricates and softens the skin

DermisTwo layers of connective tissue

• Papillary dermis - outermost layer• Composed of collagen and reticular fibers

important in wound healing• Capillaries transport nourishment

• Reticular dermis – innermost• Thick network of collagen bundles anchor it to

subcutaneous tissue, fasciae, muscle and bone

Subcutaneous tissue(Hypodermis)

• Layer of loose connective tissue that contains major blood and lymph vessels and nerves

• High proportion of fat cells• Fewer small blood vessels than dermis• Provides insulation, absorbs shocks to the

skeletal system

Effects of Aging• 50% reduction in cell turnover rate of stratum corneum• 20% reduction in dermal thickness• Reduction in vascularization and blood flow to the skin• Redistribution of subcutaneous tissues to stomach and

thighs• Reduced adhesion between layers• Reduced number of Langerhan’s cells – macrophages that

attack invading bacteria• 50% decrease in fibroblasts and mast cells involved in

inflammatory process• Decrease number of sweat glands• Decreased absorption• Reduced ability to sense pressure, heat and cold

Phases of Wound Healing

• Hemostasis - vasoconstriction and coagulation • collagen fibers in the damaged vessels wall

activate platelets

• Inflammation – defense and healing• Neutrophils engulf debris and bacteria• Monocytes converted to macrophages• Macrophages produce growth factors that

attract cells needed for new vessel growth, collagen for granulation and epithelialization

Phases of Wound Healing

• Proliferation • granulation tissue (connective tissue) fills the

wound• Wound edges retract/contract• Epithelium migrates across the wound

• Maturation• Shrinking and strengthening of the scar• Continues for months and even years – 80%

Hemostasis phase

Inflammatory phase

Proliferation phase

Maturation phase

Non-healing wound

Acute wounds

• Occur by intension or trauma• Begins with a sudden, single insult• Proceeds to heal in an orderly manner

• Surgical wounds• Traumatic wounds: unplanned injury to the

skin• Burns• Skin grafting

Acute wound

Chronic wounds

• Caused by underlying pathology that produces repeated and prolonged insults to the tissues

• Frequently complicated by ischemia, necrotic tissue and heavy bacterial loads

• High levels of inflammatory proteases and low levels of growth factors

Chronic wound

Factors that affect healing

• Nutrition• Oxygenation• Infection• Age• Chronic health conditions• Medications• Smoking

Nutrition• Malnutrition increases the risk of developing

pressure ulcers and delays healing• Protein is crucial for proper healing (0.8 to

1.6g/kg/day)• Collagen formation is reduced or delayed without

adequate protein• Fatty acids (lipids) used in cell structures and

inflammatory processes• Vitamins C, B-complex, A, and E and minerals iron,

copper, zinc, and calcium are important• Zinc deficiency slows epithelialization and decreases

tensile strength

Oxygenation• Wound healing depends on a regular supply of oxygen

• Critical for leukocytes to destroy bacteria and fibroblasts for collagen synthesis

• Impaired blood flow to the wound or the patients inability to take in adequate O2

• Causes of inadequate blood flow to the wound• Pressure, arterial occlusion, prolonged

vasoconstriction, PVD and atherosclerosis• Compromised perfusion more likely to impair healing

• Causes of inadequate systemic blood oxygenation• Acute and chronic conditions such as COPD,

hypothermia hypotension, hypovolemia, cardiac insufficiency

Infection

• Systemic infections (pneumonia, TB) increase metabolism and depletes the fluids, nutrients and O2 the body needs for healing

• Localized from the injury or develops secondary• Inflammatory phase lingers delaying wound healing• Metabolic by-products of bacterial ingestion

accumulate in the wound and interferes with formation of new blood vessels and collagen synthesis

• Signs: new or increased pain, exudate, redness, heat, induration, edema, malodor

Aging• Slower turnover rate in epidermal cells• Decreased O2 at the wound – increasingly fragile

capillaries and reduction in skin vascularization• Altered nutrition and hydration• Impaired function of immune or respiratory

systems• Reduced dermal and subcutaneous mass• Healed wounds lack tensile strength and are

subject to reinjury• Chronic health conditions

Chronic health conditions• Pulmonary disease, atherosclerosis, diabetes and

malignancies increase risk and interfere with wound healing

• Impaired circulation common in diabetes and conditions that cause hypoxia

• Neuropathy associated with diabetes increases risk and can impair leukocyte function

• Dehydration, ESKD, thyroid disease, heart failure, PVD, vasculitis, and other collagen vascular disorders can delay healing

Medications

• Any medication that reduces movement, circulation, or metabolic function• Sedatives • tranquilizers

• Medications that reduce the body’s ability to mount an appropriate inflammatory response• Steroids• Chemotherapeutic agents

Smoking

• Carbon dioxide binds to the hemoglobin in blood in place of oxygen

• Reduces the amount of circulating oxygen• Occurs with exposure to second hand

smoke as well• Nicotine causes vasoconstriction and

increased coagulability

Wounds/Ulcers

Principles of Wound Healing

Prevention

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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)

team is launching a“War on Wounds!”

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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)

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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)

team is launching a“War on Wounds!”

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PUPPI on PatrolThe Pressure Ulcer Prevention Performance Improvement (PUPPI)

team is launching a“War on Wounds!”

BRADEN INTERVENTIONS

 

Sensory Perception Able to respond meaningfully to pressure-related discomfort.

4. No Impairment (Provide routine skin care). 3. Slightly limited a. Encourage turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas. When in W/C assist with position changes to alter pressure points at least every hour. Instruct and encourage active patient/family participation as able.b. Consider elevation of heels off of the bed surface with longitudinal pillows. c. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).d. When elevating HOB, gatch the knee area (elevate 10-20 degrees)e. Consider wheelchair cushion (esp. if existing skin breakdown) 2. Very limiteda. Provide above.b. Limit W/C to 1-2 hour intervals.c. Instruct to shift weight in W/C q 15 minutes.d. Use a turn sheet to lift up in bed or turn. 1. Completely limiteda. Provide all of above as needed.

 

Moisture 

Degree to which skin is exposed to moisture.  

  

4. Rarely moista. Instruct resident to request care as neededb. Assess and provide routine skin care as needed to keep skin clean and dry. 3. Occasionally moista. Provide above with use of incontinent care products as needed (No Rinse pH balanced cleanser, protective ointment, absorbent briefs with protective liner to prevent trapping of moisture against skin.)b. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).c. When elevating HOB, gatch the knee area (elevate 10-20 degrees) 2. Very moist.a. Provide all of above as needed.b. Assess and address cause for fecal/urinary incontinencec. Consider fecal/urinary incontinence containment device (esp. if existing skin breakdown) 1. Constantly moista. Provide all of aboveb. Apply fecal/urinary incontinence device, as able.

 

Activity Degree of physical activity.

4. Walks frequentlya. Encourage activity as tolerated 3. Walks occasionallya. Provide above.b. Teach patient/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes.c. Consider wheelchair cushion (esp. if existing skin breakdown) 2. Chair fasta. Provide all of aboveb. Obtain wheelchair cushion.c. Limit W/C to 1-2 hour intervals. Instruct to shift weight in W/C q 15 minutes.d. Assist as needed with turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas.e. Consider elevation of heels off of the bed surface with longitudinal pillows. 1. Bedfasta. Provide all above, as needed.b. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)

 

Mobility 

Ability to change and control body position.

4. No Limitation(Provide routine skin care). 3. Slightly limiteda. Assist as needed with turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas.b. Instruct to shift weight in W/C q 15 minutes. Consider W/C cushion (esp. if existing skin breakdown).c. Consider elevation of heels off of the bed surface with longitudinal pillows. d. Consider use of foam wedges to help maintain positioning.e. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).f. When elevating HOB, gatch the knee area (elevate 10-20 degrees) 2. Very Limiteda. Provide aboveb. Limit W/C to 1-2 hour intervals 1. Completely immobilea. Provide above.b. Consider Wound Care Nurse consult for higher level support surface (esp. if there is existing skin breakdown).

 

Nutrition Usual food intake pattern.

4. Excellent(Provide tray set up and other routine assistance as needed). 3. Adequatea. Encourage meals and assist with meals as needed.b. Offer ordered supplements.c. Assess needs for oral care, assist PRN 2. Probably inadequatea. Provide aboveb. Consult dietician 1. Very poora. Provide aboveb. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)

 Friction & Shear      

3. No apparent problem (Provide routine skin care) 2. Potential problema. Use a turn sheet to lift up in bed or turn.b. When elevating HOB, gatch the knee area (elevate 10-20 degrees)c. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).d. Consider heel/elbow pads or socks. 1. Problema. Provide aboveb. Consider use of assisting devices (i.e. trapeze)

Types of Wounds

• Treat Based on Drainage• Pressure Ulcers• Diabetic Ulcers• Venous Insufficiency Ulcers• Arterial Ulcers

• Specific Treatments• Incontinence Dermatitis• Perineal Candidiasis• Skin Tears

Types of Wounds

• Found in diabetic patients with peripheral neuropathy; usually on the ball of the foot or tops of toes; prone to infection

• Approximately 15% of patients with diabetes develop foot ulcers.

• 23% of this group develop osteomyelitis

• Incidence of vascular disease is at least four times higher in patients with diabetes and increases with age and disease duration

Diabetic/Neuropathic Ulcers

Diabetic/Neuropathic Ulcers-Causes

• Pressure, secondary to peripheral neuropathy and/or arterial insufficiency• Plantar aspect of foot• Over metatarsal heads• Under heel

• Poor microvascular circulation

• Poor blood sugar control• Lack of sensation

Diabetic/NeuropathicUlcer Characteristics

• Below the ankle• Poor circulation• Neuropathy• Sites of pressure,

friction, shear• Sites of trauma

• Even wound margins

• Peri-wound callous• Round• Hemorrhagic

callous• Increased potential

for infection

Types of Wounds

Usually due to minor trauma; pretibial area of shin or above the medial ankle; superficial but difficult to heal

Venous Insufficiency Ulcers

Venous Ulcers - Causes

• Problems with venous blood return to heart

• Non-functioning or inadequate calf muscle pump

• Incompetent perforator valve

• Incompetent valves in the vein

• All lead to venous hypertension

• Venous blood pools in lower extremity and foot

Characteristics of Venous Insufficiency Ulcers

• Edema• Hyperpigmentation • Gaiter distribution• Ankle flare• Atrophy of skin• Eczema • Lipodermatosclerosis• Palpable pulses

• Irregular borders• Usually shallow• Weepy • Located on medial lower

leg and malleolus• can be circumferential

• Pain relieved by elevation• Heavily contaminated

Types of WoundsArterial Ulcers

Due to arterial occlusive disease which results in tissue necrosis; usually occur on the ankle or bony areas of the foot; painful, dry, and pale; pedal pulses diminished or absent

Characteristics of Arterial Ulcers

• Absence of hair• Atrophy below level

of occlusion• Pain upon elevation• Absence of palpable

pulse• Sites of trauma• Often bright red

granulation tissue

• Well defined borders/punched out appearance

• Minimal drainage• Usually full thickness• Usually lateral foot, can

be anywhere• Dependent rubor• Tendon exposure

Types of Wounds

Incontinence Dermatitis

Injury to the skin caused by exposure to excessive moisture, urine, and/or stool

Characterized by inflammation, rash, and possibly denuded skin

Anywhere in the sacral/coccyx, buttock, or perineal area

Types of Wounds

• Fungal/Candida infection characterized by erythematous papules and satellite lesions, and/or scaly borders

Perineal Candidiasis

Types of Wounds

Traumatic wound occurring principally

on the extremities of older adults as a result of friction and/or shearing forces which separate the epidermis from the dermis, or separate both the epidermis and the dermis from underlying structures

Incision-like skin lesion Classified based on the presence and amount of the skin flap

Skin Tears

Stage I Pressure Ulcers

• 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.

Stage I Pressure UlcersThe area may be painful,

firm, soft, warmer, or cooler as compared to adjacent tissue

Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk persons” (a heralding sign of risk).

Stage II Pressure Ulcer Partial thickness loss

of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

May present as an intact or open/ruptured serum filled blister or a shiny or dry shallow ulcer without slough or bruising

Stage II Pressure Ulcer 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 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.

Stage III Pressure Ulcer

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.

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.

Stage IV Pressure UlcerThe 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 Pressure Ulcer

Full thickness 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.

Unstageable Pressure Ulcer

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 heels serves as “the body’s natural (biological) cover” and should not be removed.

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.

Suspected Deep Tissue Injury

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 a thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Definitions• Eschar: wound is covered with

thick, dry, black necrotic tissue. Eschar may be allowed to slough off naturally, or it may require surgical removal (debridement)

• Slough: a mass or layer of dead tissue separated from the surrounding or underlying tissue, usually cream or yellow in color

• Granulation Tissue: new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process

Definitions• Undermining: The wound

extends under the visible opening; a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissue

• Tunneling: A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation

• Maceration: The softening and eventual breakdown of tissue due to excess moisture, making the wound prone to infection

Pressure Ulcers—Understanding and Staging Pressure Ulcers

Treatment Goals:

MOIST wound healing Protect from trauma Moisture balance

Dressings serve to protect the wound from trauma and contamination, and facilitate healing by absorption of exudate and protection of healing surfaces

Select dressings based on wound drainage:• Dry wound (Dessicated): Wet it• Moist wound: Maintain it, prevent maceration• Mod-High draining wound (Heavy Exudate): contain

Use skin prep to protect skin from skin tears.

Cleanse ALL wounds with NS or Wound Cleanser

Date all dressings

Treatment

• Heavy Exudate• An absorptive dressing should be employed to avoid

build up of chronic wound fluid that can lead to wound maceration and inhibition of cell proliferation and healing.

• An appropriate wound dressing can remove excess wound exudate while maintaining a moist environment to accelerate wound healing

• Dressings with absorptive qualities include alginates, foams, and hydrofibers

Treatment

• Dessicated • Dessicated ulcers lack wound fluids, which provide

tissue growth factors to facilitate re-epithelialization. • Pressure ulcer healing is promoted by dressings that

maintain a moist wound environment while keeping the surrounding intact skin dry.

• Choices for a dry wound include saline moistened gauze, transparent films, hydrocolloids, hydrogels, and Tenderwet

Incontinence Dermatitis

• Moisturizing• Water-repellent protective

barrier• Apply BID, PRN

• Use: Incontinence and Radiation Dermatitis; Superficial skin breakdown causing pain

• Creates moist wound environment by stimulating capillary bed, promotes epithelium, assists in pain control.

• Does not require secondary dressing

• Apply BID & PRN

Aloe Vesta Barrier Cream

Carrington moisture barrier

Butt paste

Xenaderm Ointment (Castor Oil/Balsam Peru/Trypsin)

Wound Dressings• Wound Gel

• Hydrogel (Carrington/Carasyn)• Santyl Collagenase

• Foam• Mepitel and Lyofoam

• Non-adherent Dressing• Petrolatum Gauze• Oil/Emulsion Dressing (Adaptic)

Wound Gel

• Adds moisture• Autolytic debridement• Softens eschar

Wound-specific

Foam Dressing

Uses: dry, moist, minimal-mod drainage

Stage II, Shallow III, skin tears, abrasions, venous stasis ulcers,

Change qd, PRN

Mepilex Border

Lyofoam(special rx)

Non-adherent Dressing

Uses: Prevent adherence of dressing to wound bed; Keeps wounds/meds moist; Maintains placement of skin grafts; Decreases pain

May be used in conjunction with wound vac to prevent adherence of foam to wound

Oil based products can cause too much moisture creating macerated tissue over rims

Requires secondary dressing Usually change Daily Others: Telfa – lifts no/minimal

debris from wound base

Petrolatum Gauze

Oil/Emulsion (Adaptic)

Enzymatic Debridement

• Uses: Stage III-IV Pressure Ulcers

• Debrides mixed viable tissue

• Must be kept moist • Change daily

Collagenase ointment

Moist to Low Draining Wounds• Wound Gel

• Hydrogel (Carrasyn) • Foam• Mepilex Border

• Hydrocolloid• Restore Hydrocolloid 4x4• Restore Extra Thin 4x4 (caution!)

• Antimicrobial Gel/Ointment• Bacitracin/Bactroban

• Iodosorb Gel• Silvadene Cream

Hydrocolloid Dressings

Uses: dry, moist, minimal drainage

Stage I & II, shallow III Primary/secondary

dressing Change q 3-7 days and

PRN soiled/loose May be cut to fit Do not use on infected

wounds; caution w/diabetic wounds

Restore Hydrocolloid 4x4

Restore Extra Thin 4x4

Antimicrobial Gels/Ointments

Uses: Diabetic Foot ulcers, infected wounds-high drainage

Cadexamer Iodide based gel, provides sustained antimicrobial coverage to wounds without causing toxicity, absorbs drainage but does not allow wound to dry out

Requires secondary dressing

Change daily; potent to 72hours

Iodosorb Gel

Antimicrobial Gels/Ointments

Provides silver with significant antimicrobial properties

Can not be used on patients allergic to sulfa drugs

Requires secondary dressing

Change daily

Silvadene Cream – antibiotic gel

Antimicrobial Gels/Ointments

For wounds with dry to moderate exudate.

Use SilvaSorb Gel for a three-day (72hr) antimicrobial barrier, plus the moisture donating benefits of hydrogel.

• (we do not have this at RJD, at this time.)

Silvasorb gel

Moderate to Heavy Draining Wounds

• Calcium Alginate (heavy drainage)• Calcium Alginate – silver/AG ca+ alginate

• 7 day potency products

• Antimicrobial Gel/Ointments (moderate drainage)• Iodosorb Gel – 72hr potency• Silvadene Cream – 24hr potency

Calcium Alginate/Hydrofibers

Use: mod-large drainage Stage II, III, IV, skin tears,

venous stasis ulcers, surgical wounds, Dehisced wounds

Change daily , QOD, or PRN strikethrough drainage

May be cut to fit Needs secondary dressing Contraindicated for dry

wounds and third degree burns - adheres easily

Calcium Alginate (Restore)

Others: Aquacel Ag

Tape

• 1 or 2 inch Paper Tape• General purpose• Hypoallergenic and

latex-free • Preferred choice for

wound care to prevent skin stripping

• Vital use skin prep to protect skin pre-tape

Wound Cleanser

Cara KlenzGentleNo rinse

Normal Saline SyringeUsed to irrigate the

woundNon-antibacterial

soap

Skin Cleansing

• No-rinse, gentle cleanser

• Moisturizes and conditions skin

Aloe vesta foam cleanser

Skin Prep

Hollister prep wipes

• Protects Skin from additional breakdown from tape or moisture with plastic, copolymer layer on skin

• This layer lifted off with tape removal, not repeat lift-off top skin layer.

Moisturizers• Aloe Vesta Protective

Ointment• Provides an effective

barrier that seals out moisture, contains emollients to moisturize and is non-sensitizing and fragrance free

• A&D Ointment• Helps heal, protects,

smoothes/soothes

• Carmol Urea 20%• Carmol Urea 40%

• Exfoliates as it moisturizes

• May sting

• Primary use by our podiatrist.

Ace Bandages, Gauze, & Packing

Ace Bandages 2”, 3”, 4”, and 6”

Gauze 4x4 Sterile 2x2 Sterile ABD (abdominal pad) Kling- elastic, 3” Kerlix- 4.5” sterile bandage

Packing (emphasis ‘filling’) Plain Packing – ¼”, ½”, 1” – nu-gauze Silver alginate

Wound Care Reference GuidePressure Ulcer Policyguidelines for choices

and application

Consulting Wound Care Nurse

When to call for help: • Notify of ALL new admissions with

pressure ulcers• New onset pressure ulcers• Other wound development, from Stage I• And/or partial, full-thickness wounds

Documentation

Requirements

• Braden Skin assessments are due:• On admission• On transfer (both sending and receiving wards)• On discharge• When there is a change in condition• Daily in acute care and ICU• Weekly in long-term care

Who Can Do Assessments?

• Only RN can do initial assessment in this

VAMC• RN completes CPRS re-assessment with

Sometimes input requested of other nsg

staff members, LPNs, nurse technicians, nurse assistants, & to add care plan

interventions

Which Template Do I Use?

• On admission, use initial skin assessment that is embedded in the Initial Assessment

• Skin Re-Assessment per embedded re-• Assessment template tool• Inpatient wound dressing change:

• Wound assessment/size• Applied care completed

Initial Skin Assessment Template

Part 1 – Braden Scale

Part 2 – Additional Risk Factors

Part 3 – Current Skin Assessment

Skin Problems

Skin Problems - Pressure Ulcer

Pressure Ulcer Stage and Location

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Pressure Ulcer - Size

Part 4 - Interventions

Interventions

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CPRS Final Note

Skin Reassessment Template

Part 1 – Braden Scale

Part 2 - Skin Assessment

Skin Problems

Pressure Ulcer Informationfrom Previous Assessment

New Pressure Ulcer

Part 4 - Interventions

To update ALL current interventions must be entered