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informational purposes only. It is for the attendees general knowledge
and is not a substitute for legal or medical advice. Although every
effort has been made to provide accurate information herein, laws
change frequently and vary from state to state. The material provided
herein is not comprehensive for all legal and medical developments and
may contain errors or omissions. If you need advice regarding a specific
medical or legal situation, please consult a medical or legal
professional. Gordian Medical, Inc. dba American Medical Technologies
shall not be liable for any errors or omissions in this information.
Objectives
Describe the importance of wound assessment
Describe ulcer and periulcer characteristics
Explain components of wound bed preparation
Assessment
Photodocumentation
-Informed consent/Authorization
-HIPAA compliant
-Criteria about who can take the photograph
-Method of validating individuals competency to
do photograph
-Frequency of revalidation of competence
-Frequency (serial photographs)
-Type of equipment used
Location
Shape
Ulcer edges and wound bed
Condition of surrounding
tissues
All of which factor into the
treatment plan
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Assessment
Evaluation includes verification and interpretation of the observations
made
Complement the clinical judgment in resident management
Use of standardized risk assessment tool
-Bates-Jensen Wound Assessment Tool (BWAT - existing pressure ulcer)
-Pressure Ulcer Scale for Healing Tool (Push - existing pressure ulcer)
Assessment
Bates Wound Assessment Tool (BWAT)
Functions as a 2-in-1 tool
-Monitors wound healing
-Yields data useful for plan-of-care development
13 parameters
-Size, depth, edges, undermining or pockets, necrotic tissue type, necrotic tissue amount,
exudate type, exudate amount, surrounding skin color, peripheral tissue edema, peripheral
tissue induration, granulation tissue, and epithelialization
-Two additional items, location and shape, are noted but not scored
-Five-point rating scale, with lower scores indicating greater desirability
-Total scores range from 13 (skin intact but at risk for further damage) to 65 (profound
tissue degeneration)
Assessment
Assessment
National Pressure Ulcer Advisory
Panel (NPUAP)
Pressure Ulcer Scale for Healing (PUSH
Tool)
Assessment
Comprehensive Assessment
Consider all recumbent dependant or seated dependant residents or
those whose inability to reposition to be at-risk
-Multi-system organ failure or an end-of-life condition
-Residents refusing care and treatment (why?/alternatives notification, documentation)
Assessment
Comprehensive Assessment
Resident having no signs of progression toward healing within 2 to 4
weeks:
-Review documentation
-Ulcer characteristics
-Residents condition
-Complications
-Time needed to determine the effectiveness of a treatment
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Pain
Types of Pain
Acute
-Abrupt onset and limited duration, often associated with an adverse chemical, thermal r
mechanical stimulus such as surgery, trauma and acute illness
Background pain
-Pain at rest (related to wound etiology, infection, ischemia)
Incident Pain
-Predictable and related to precipitating events (walking, coughing, transferring, dressing)
or actions (wound care)
Breakthrough
-Sudden flare-up of severe pain, associated with inadequate pain medication levels
Pain
Pain Assessment (WILDA)
What does the pain feel like?
-When possible, allow the resident to chose their own words to describe the pain
-Sharp/dull/stabbing/burning/crushing
Pain
Pain Assessment (WILDA)
Duration and frequency of pain (constant/intermittent)
-When did the pain start?
-How often does it occur?
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Pain
Non Verbal Resident
-Aphasic
-Language barrier
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Pain
Observation
Vocalization of pain
Body language
-Constant muttering
-Clenched fist
-Moaning/groining
Breathing
-Strenuous
-Labored
-Negative noise on inhalation or expiration
Movement
-Restless
-Altered gait
-Forceful touching
-Rubbing of body parts
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Pain
Develop quantifiable objectives for the highest level of functioning the
resident may be expected to attain, based on the comprehensive
assessment:
-Type/quantity of pain
-Consequences of unrelieved pain
-Pharmaceuticals
-Dosing
-Understanding addiction and tolerance
Control measures
-Effective medication
-Therapeutic positioning
-Support surfaces
-Non-pharmacological interventions (comfort touch, active listening/distraction, relaxation,
imagery, music)
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Ulcer Cleansing
Cleansing
Completed at each dressing change
Clean with non-cytotoxic nonirritating cleanser
-Normal saline is considered the most
appropriate solution
Area Measurements
Length/Width/Depth
Measurements must be
taken in a consistent manner to
be accurate and repeatable
Multiple measurements
taken in close proximity may
be averaged to determine the
length, width and depth
Depth cannot be measured if
debris or necrotic material
cover the ulcer
Use centimeters, millimeters
or volume when recording the
measurements (cm3)
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NPUAP Definitions
Stage I Pressure Ulcer
Presents as intact skin with nonblanchable 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.
Further description. The area may be
painful, firm, soft, and warmer or cooler
as compared to adjacent tissue. Stage I
ulcers may be difficult to detect in
individuals with dark skin tones and may
indicate at risk persons (a heralding
sign of risk).
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NPUAP Definitions
Stage II Pressure Ulcer
Characterized by partial-thickness loss of
dermis presenting as a shallow open ulcer with
a red-pink wound bed without slough. It also
may present as an intact or open/ruptured
serum-filled blister.
Further description. A Stage II ulcer also may
present 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.
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NPUAP Definitions
Stage III Pressure Ulcer
Characterized by full-thickness tissue loss.
Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does
not obscure the depth of tissue loss. Stage III ulcers may
include undermining and tunneling.
Further description. 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; Stage III ulcers in these locations
can be shallow. In contrast, areas of significant
adiposity can develop extremely deep Stage III pressure
ulcers. Bone/tendon is not visible or directly palpable.
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NPUAP Definitions
Stage IV Pressure Ulcer
Presents with full-thickness tissue loss with
exposed bone, tendon, or muscle. Slough or
eschar may be present on some parts of the
wound bed. These ulcers often include
undermining and tunneling.
Further description. The depth of a Stage IV
pressure ulcer varies by anatomical location.
The bridge of the nose, ear, occiput, and
malleolus do not have subcutaneous tissue;
Stage IV ulcers in these locations can be
shallow. Stage IV ulcers can extend into muscle
and/or supporting structures (eg, fascia,
tendon, or joint capsule); osteomyelitis is
possible. Exposed bone/tendon is visible or
directly palpable.
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NPUAP Definitions
Unstageable
Full-thickness tissue loss in which the base of
the ulcer is covered by slough (yellow, tan,
gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed may render
a wound unstageable.
Further description. Until enough slough
and/or eschar is removed to expose the base
of the wound, the true depth (and therefore,
the stage) cannot be determined. Stable (dry,
adherent, intact without erythema or
fluctuance) eschar on the heels serves as the
bodys natural (biological) cover and should
not be removed.
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Ulcer Characteristics
A precise description of the ulcer
Location - anatomical terms
Area - L x W x D
Odor - Type/amount
Periulcer Characteristics
Ulcer Edge - color, thickness, attachment and
rolling of the edges
Edema - amount of fluid in the interstitial
space, associated with venous disease
Erythema - diffuse redness of the skin due to
vasodilatation
Ulcer Characteristics
Venous Insufficiency Ulcer
Lipodermatosclerosis
-Deposition of hemosiderin in the skin
-Discoloration of the skin (brownish color)
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Ulcer Characteristics
Diabetic Foot Ulcer
Pressure build up: a callus is usually
present
Black, intact, stable heel
-Pad and protect
Infection/gangrene
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35
Terminal Ulcer
Cause is unknown
Possible the result of a perfusion deficit
exacerbated by multi-system failure
Rapid breakdown of the skin
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Contamination
Bioburden
Colonization
The presence of replicating bacteria at a ulcer
site not causing harm or injury to the host
Critical Colonization
Bioburden reaches a level in which it interferes
with healing, but does not produce the classic
signs and symptoms of infection
Infection
The deposition and multiplication of bacteria in
the tissue resulting in host response that leads to
non healing or a decline in the ulcer
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Bioburden
Local signs of Infection
Erythema
Warmth
Edema
Induration
Pain
Purulent drainage
Crepitation
Foul odor
Pocketing at the base of the wound
Discolored/friable granulation tissue
Bioburden
Systemic Signs
Fever
Leukocytosis
Altered mental status
Elevated pulse
Urosepsis may mimic clinical signs
of infection
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Infection
Types of Infection
Abscess
Cellulites
Osteomyelitis
Gangrene
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Infection
Abscess
Involves the fascia or
tendon tissue
Treatment
-Incise and drain
-Debridement of necrotic/infected
tissue
-Tissue graft may be necessary
-Antibiotics therapy is variable
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Infection
Cellulites
Most common soft tissue infection
Signs and symptoms
-Include warmth, swelling, tenderness,
erythema, fever
Rule of 2 (cm)
mild/moderate/severe
Usually caused by Group A
streptococcus
Treatment
-Oral antibiotic for localized infection
-Hospitalization with IV antibiotics for spreading
cellulitis
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Infection
Osteomyelitis
Usually involves toes and small
bones of the foot
Associated with a non-healing or a
recurring ulcer
Treatment
-Bacterial culture is required
-Debridement of necrotic tissue/bone
-Hospitalization with IV antibiotics may be
required
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Infection
Gangrene
Diabetic neuropathy vs. microvascular insufficiency
Arterial occlusion/thrombosis
Dry gangrene - due to loss of arterial blood
supply to the tissue or part
Wet "gangrene - infectious component and
requires surgical debridement and/or antimicrobial
therapy to control the infection
Fetid foot - combined infection involving bone and
soft tissue
Treatment
Debridement of necrotizing fasciitis
Vascular reconstruction if possible
44
Ulcer Culturing
Ulcers should not be routinely cultured
All ulcers are contaminated
Ulcers should be cultured if changes in appearance
occur resulting in local signs of infection or if
systemic signs resulting in sepsis occur
45
Ulcer Culturing
A clinical infection is determined by
a bacteria colony count
A biopsy is the most definitive
method of quantifying bacteria
46
Antimicrobial Therapy
The routine use of topical
antimicrobial agents may lead to:
Local cell/tissue damage
Systemic toxicity
Contact sensitivity
Antibiotic resistance due to a
disturbance of normal skin ecology
Common antimicrobial
agents include:
Povidone - Iodine Agents
Sodium Hypochlorite
Solutions (Dakins - 0.025%
-0.054%)
Acetic Acid
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Debridement
Debridement
Removal of dead or devitalized tissue
predisposes to infection:
-Sharp (surgical)
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Skin Integrity
Maintenance
Daily skin inspections
-Over bony prominences
-Assess for compromised peripheral circulation
Moisture Control
-Use non-alcohol based moisturizers
-Establish continence training bowel or bladder training programs
-Avoid skin contact with plastic surface to reduce sweating
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Ulcer Dressing
Types
MEASURES
-Gauze
-Transparent films
-Alginates
-Hydrocolloid
-Hydrogel
-Foam
-Composite
-Collagen
-Debriders
-Hydrofibres
-Ionic Silver
-Biologicals
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Ulcer Dressing
Resident/Patient
Medical status (Immunocompromised)
Vascular status (arterial/venous)
Compliance (education)
Ulcer Criteria
Ulcer characteristics (granulation tissue,
necrotic tissue, odor, exudate, pain)
Location (joint, soft tissue)
Dimensions (length, width, and depth)
Periulcer characteristics (induration,
erythema, maceration, scaling, pain)
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Ulcer Dressing
Setting
Caregiver education
Environmental constraints
Ulcer Dressing
Safe (hypoallergenic)
Therapeutic benefit
-Exudate control , decrease pain, promote
granulation tissue repair and epithelialization,
prevent necrotic tissue formation
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Ulcer Dressing
Obliterate
dead space
Prevent
infection
Promote
granulation
Absorb
Insulate
Hydrate
Protect
Protect
Cover
Stage I
Absorb
Insulate
Hydrate
Obliterate
dead space
Prevent
infection
Promote
granulation
Absorb
Insulate
Hydrate
Protect
Protect
Cover
Cover
Cover
Stage II
Stage III
Stage IV
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Ulcer Dressing
Amount of Drainage
Light
Hydrogel
Thin Film
Heavy
Hydrocolloid
Gauze
Calcium Alginate
Hydrofiber
Collagen
Foam (primary)
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Thank you
Questions?
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References
Cohen K, Diegelmann RF, Yager DR, et al: Wound Care and Wound
Healing. In: Schwartz SI, Shires GT, Spencer FC, Daly JM, Fischer JE,
Galloway AC, eds. Principles of Surgery. 7th ed. New York, NY: McGrawHill; 263-96, 1999.
CMA Manual System, Publication 100-07 State Operations, Provider
Certification, Guidance to Surveyors for Long Term Care Facilities.
November 12, 2004.
Cuddingan J, Ayello EA, Sussman C, Baranoski S, (Eds) (2001) Pressure
Ulcers in America: Prevalence, Incidence and Implication for the Future.
National Pressure Ulcer Advisory Panel Monograph (pp.181). Reston VA:
NPUAP.
Fleck C, Differentiating MMPs, Biofilms, Endotoxins, Exotoxins and
/Cytokines Advances in Skin & Wound Care. 19(2):77-81, Mar, 2006.
56
References
Ayello EA, Baranoski S, Kerstein MD, & Cuddugan J, (2003) Wound
Debridement. In Baranoski S & Ayello EA, eds) Wound Care Essentials:
Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins.
CMA Manual System, Publication 100-07 State Operations, Provider
Certification, Guidance to Surveyors for Long Term Care Facilities. (2004).
November 12.
Bergstrom N, Bennett MA, Carlson CE, et al., (1994) Treatment of
Pressure Ulcers Adults (Publication 95-0652). Clinical Practice Guidelines,
15, Rockville, MD: U.S. Department of Health and Human Services,
Agency for Health Care Policy and Research.
Kingsley A. A Proactive approach to wound infection. Nursing Standard.
15(30):50-58, 2001.
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References
Kjaer ML,Mainz J, Soerensen LT, et al. Clinical quality indicators of
venous leg ulcers: development, feasibility, and reliability.
Ostomy/Wound Management. 51:64-74, 2005.
Levenson SA, (2005) Medical Director and Attending Physicians Policy
and Procedure Manual for Long Term Care. Dayton, Ohio: MedPass.
Maklebust, J, & Sieggreen, M, Pressure Ulcers: Guidelines for
Prevention and Management (3rd ed., pp. 49). Springhouse, PA:
Springhouse, 2001.
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