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Wound Care for PhysiciansWound Care for Physicians
Assessment, DocumentationAssessment, Documentationand Treatmentand Treatment
Rebecca Roberts RN MSN CWOCNRebecca Roberts RN MSN CWOCN
Gayle MooreGayle Moore--Lisa RN MSN CWOCNLisa RN MSN CWOCNGarth Ireland RN MSN MPA CWOCNGarth Ireland RN MSN MPA CWOCN
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ObjectivesObjectives
By the end of the presentation theBy the end of the presentation theparticipant will be able toparticipant will be able to
accurately assess and document patientaccurately assess and document patientwoundswounds
list basic wound care principleslist basic wound care principles
identify wound care products available atidentify wound care products available atUHCMSUHCMS
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AssessmentWound Measurement
Length: head to footWidth: perpendicularto lengthDepthUndermining:Clock
faceTunnel: tract in thewound
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AssessmentAssessment
Wound measurementWound measurement Wound drawingWound drawing
PhotographyPhotography
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Wound AssessmentWound Assessment
Wound bed:Wound bed: Color: red, black (eschar), yellow (slough)Color: red, black (eschar), yellow (slough)
Exudate:Exudate: ColorColor
OdorOdor
QuantityQuantity
Periwound skinPeriwound skin Erythma, Maceration, denudedErythma, Maceration, denuded
Palpate for induration, warmth, fluctuationPalpate for induration, warmth, fluctuation
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Wound TypesWound Types Pressure UlcersPressure Ulcers
Tissue damage due to pressureTissue damage due to pressure
Staged 1 to 4 based on depth of tissue involvedStaged 1 to 4 based on depth of tissue involved Only staged if wound bed visible otherwise unstageableOnly staged if wound bed visible otherwise unstageable
or deep tissue injuryor deep tissue injury
Usually over pressure pointsUsually over pressure points OcciputOcciput
ElbowElbow
ScapulaScapula
SacrumSacrum
IschiumIschium
MalleolusMalleolus
HipHip
Braces, casts or tubingBraces, casts or tubing
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Pressure Ulcer DefinitionPressure Ulcer Definition
A pressure ulcer is a localized injury toA pressure ulcer is a localized injury to
skin and/or underlying tissue usually overskin and/or underlying tissue usually overa bony prominence a result of pressure, ora bony prominence a result of pressure, orpressure in combination with shear and/orpressure in combination with shear and/or
friction.friction.
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Pressure Ulcer StagingPressure Ulcer Staging
The National Pressure Ulcer AdvisoryThe National Pressure Ulcer Advisory
Panel has divided pressure ulcers intoPanel has divided pressure ulcers into4 stages based on anatomical tissue4 stages based on anatomical tissueloss and has included two additionalloss and has included two additional
categories of suspected deep tissuecategories of suspected deep tissueinjury and unstageable pressureinjury and unstageable pressure
ulcers.ulcers.
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UHCMC FocusUHCMC Focus
University Hospital Case Medical Center isUniversity Hospital Case Medical Center is
committed to the prevention of allcommitted to the prevention of allnosocomial pressure ulcers. The goal isnosocomial pressure ulcers. The goal is
zero incidence of pressure ulcers acquiredzero incidence of pressure ulcers acquired
during hospitalization.during hospitalization.
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Physician RolePhysician Role
CMS is asking that a pressure ulcer beCMS is asking that a pressure ulcer beproperly documented by the physicianproperly documented by the physician
upon admission. A pressure ulcerupon admission. A pressure ulcerdocumented by the physician after thedocumented by the physician after the
admission will be counted as aadmission will be counted as a
nosocomial pressure ulcer. This isnosocomial pressure ulcer. This iseven if there is admissioneven if there is admission
documentation in the chart by otherdocumentation in the chart by otherservices such as nursing or dietaryservices such as nursing or dietary
that the ulcer existed.that the ulcer existed.
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Physician RolePhysician Role
For the admission assessment theFor the admission assessment thephysician must view the patient from headphysician must view the patient from headto toe. Dressings must be removed, ifto toe. Dressings must be removed, if
possible, and the patient turned to viewpossible, and the patient turned to viewpressure points such as the heels, sacrum,pressure points such as the heels, sacrum,occiput , elbows and scapulaocciput , elbows and scapula
Pressure ulcers present on admission needPressure ulcers present on admission needto be documented as such and properlyto be documented as such and properlystaged in the record.staged in the record.
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Why at This Time?Why at This Time?
The Center for Medicare and MedicaidThe Center for Medicare and MedicaidService (CMS) has stated that effectiveService (CMS) has stated that effectiveOctober 1, 2008, hospitals will not be paidOctober 1, 2008, hospitals will not be paidfor the care of nosocomial pressure ulcers.for the care of nosocomial pressure ulcers.
Since many private insurances followSince many private insurances followMedicare guidelines, these private plansMedicare guidelines, these private plans
may also institute similar restrictions.may also institute similar restrictions.
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Current HospitalCurrent Hospital
InitiativesInitiatives Recent replacement of all patient bedsRecent replacement of all patient beds
with pressure reduction surfaces onwith pressure reduction surfaces on
Medical surgical floors.Medical surgical floors.
Evaluation of replacement beds forEvaluation of replacement beds forintensive care units and operatingintensive care units and operating
suites.suites. Extensive nursing inExtensive nursing in--service onservice on
assessment, prevention and treatmentassessment, prevention and treatment
of pressure related skin problems.of pressure related skin problems.
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Stage IStage I
Intact skin with nonIntact skin with non--blanchable redness of ablanchable redness of alocalized area usually over alocalized area usually over a
bony prominence.bony prominence. Pigmented skin may notPigmented skin may not
have visable blanching. Itshave visable blanching. Itscolor may be different fromcolor may be different fromthe surrounding area.the surrounding area.
The area may be painful,The area may be painful,firm, soft, warmer or coolerfirm, soft, warmer or coolerthan adjacent tissue.than adjacent tissue.
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Stage IStage I
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Stage IStage I
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Stage IIStage II
Partial thickness loss of dermis presentingPartial thickness loss of dermis presentingas a shallow open ulcer with a red or pinkas a shallow open ulcer with a red or pink
wound bed. May also present as an intactwound bed. May also present as an intactor open/ruptured serumor open/ruptured serum--filled blister.filled blister.
A shiny or dry shallow ulcer without sloughA shiny or dry shallow ulcer without sloughor bruising (indicative of suspected deepor bruising (indicative of suspected deep
tissue injury).tissue injury).
Does not include: skin tears, tape burns,Does not include: skin tears, tape burns,perineal dermatitis, maceration orperineal dermatitis, maceration orexcoriation.excoriation.
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Stage II Pressure UlcersStage II Pressure Ulcers
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Stage II Pressure UlcersStage II Pressure Ulcers
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Stage II Pressure UlcersStage II Pressure Ulcers
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Stage IIIStage III
Full thickness tissue loss.Full thickness tissue loss.Subcutaneous fat may be visible butSubcutaneous fat may be visible but
not bone, tendon or muscle are notnot bone, tendon or muscle are notexposed.exposed.
The depth of a stage III pressureThe depth of a stage III pressure
varies by anatomical location. Thevaries by anatomical location. Thebridge of the nose, occiput andbridge of the nose, occiput andmalleolus do not have subcutaneousmalleolus do not have subcutaneous
tissue and stage III ulcer can betissue and stage III ulcer can be
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Stage III Pressure UlcerStage III Pressure Ulcer
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Stage IVStage IV
Full thickness tissue loss with exposedFull thickness tissue loss with exposedbone, tendon and/or muscle.bone, tendon and/or muscle.
Slough or eschar may be present inSlough or eschar may be present insome parts of the wound.some parts of the wound.
Often includes undermining orOften includes undermining or
tunneling.tunneling.
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Stage IV Pressure UlcerStage IV Pressure Ulcer
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Unstageable PressureUnstageable Pressure
UlcerUlcer Full thickness tissue loss in which the baseFull thickness tissue loss in which the base
of the ulcer is covered by slough (yellow,of the ulcer is covered by slough (yellow,
tan, brown) and/or eschar (tan, brown ortan, brown) and/or eschar (tan, brown orblack) in the wound bed.black) in the wound bed.
Until enough slough and/or eschar isUntil enough slough and/or eschar isremoved to expose the base of the wound,removed to expose the base of the wound,the true depth and therefore stage can notthe true depth and therefore stage can notbe determined.be determined.
Stable (dry, adherent, intact withoutStable (dry, adherent, intact withouterythema or fluctuance) eschar on the heelserythema or fluctuance) eschar on the heelsserves as the bodys natural cover andserves as the bodys natural cover andshould not be removed.should not be removed.
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Unstageable PressureUnstageable Pressure
UlcerUlcer
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Unstageable PressureUnstageable Pressure
UlcerUlcer
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Unstageable PressureUnstageable Pressure
UlcerUlcer
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Suspected Deep TissueSuspected Deep Tissue
InjuryInjury Purple or maroon localized areaPurple or maroon localized area
discolored intact skin or blooddiscolored intact skin or blood--filledfilled
blister due to damage of underlyingblister due to damage of underlyingsoft tissue from pressure and/or shearsoft tissue from pressure and/or shear
The area may be preceded by tissueThe area may be preceded by tissuethat is firm, mushy, boggy, warmer orthat is firm, mushy, boggy, warmer orcooler as compared to adjacent tissue.cooler as compared to adjacent tissue.
The area may evolve rapidly to exposeThe area may evolve rapidly to exposeadditional layers of tissue injury.additional layers of tissue injury.
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Suspected Deep TissueSuspected Deep Tissue
InjuryInjury
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Pressure vs. VascularPressure vs. Vascular
It is important to distinguish betweenIt is important to distinguish betweenpressure and possible vascular causespressure and possible vascular causes
of tissue injury.of tissue injury.
Pressure related injuries occur overPressure related injuries occur overbony prominences or areas ofbony prominences or areas of
shearing. Pressure injury can also beshearing. Pressure injury can also berelated to equipment such as braces,related to equipment such as braces,casts and tubing.casts and tubing.
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Venous UlcersVenous Ulcers
Medial lower legMedial lower leg
Champagne GlassChampagne Glass
legleg Dependent edemaDependent edema
HemosiderinHemosiderinstainingstaining
Weeping woundWeeping woundwith irregularwith irregularbordersborders
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Venous UlcersVenous Ulcers
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Arterial UlcersArterial Ulcers
Cold, hairless legCold, hairless leg
Lack of pulseLack of pulse
Pain on elevationPain on elevation Relief on dependentRelief on dependent
positionposition
Wound with punchedWound with punched
out appearance andout appearance andpale or necroticpale or necroticwound bedwound bed
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Arterial UlcersArterial Ulcers
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Neuropathic/DiabeticNeuropathic/Diabetic
UlcerUlcer Plantar surface of the footPlantar surface of the foot
Round wound surrounded by callasRound wound surrounded by callas
Lack of sensationLack of sensation
Foot deformity: Charcot foot.Foot deformity: Charcot foot.
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Surgical WoundsSurgical Wounds
DehiscenceDehiscence
InfectionInfection
FistulaFistula
NecrosisNecrosis
Altered wound healingAltered wound healing
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Principles of WoundPrinciples of Wound
HealingHealingProtect wound and provideProtect wound and provide
a moist wounda moist woundenvironmentenvironment Cover woundCover wound
Fill in wound cavity
Fill in wound cavity
Moisten dry woundsMoisten dry wounds
Control excessive moistureControl excessive moisture
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Protect and ManageProtect and Manage
MoistureMoisture Wet to Moist NOT Wet to DryWet to Moist NOT Wet to Dry
New post operative wounds to monitorNew post operative wounds to monitor
bleedingbleeding
Twice a day dressing changes thatTwice a day dressing changes thatincrease risk of contaminationincrease risk of contamination
Can reduce frequency of dressing changeCan reduce frequency of dressing changeby adding moisture (Duoderm Hydrogel)by adding moisture (Duoderm Hydrogel)
PainfulPainful
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Protect and ManageProtect and Manage
MoistureMoisture Mepilex Border DressingsMepilex Border Dressings
Silicone dressing of various sizesSilicone dressing of various sizes
Non occlusive to allow for air flowNon occlusive to allow for air flow
Reduces pain and further trauma whenReduces pain and further trauma whenremovedremoved
Change every 3 to 5 daysChange every 3 to 5 days For stage I and II PU, skin tears or forFor stage I and II PU, skin tears or for
cover dressings.cover dressings.
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Protect and ManageProtect and Manage
MoistureMoisture Xenaderm OintmentXenaderm Ointment
Protective barrier to skinProtective barrier to skin
Perineal DermatitisPerineal Dermatitis
Skin TearsSkin Tears
Radiation DermatitisRadiation Dermatitis
Requires MD orderRequires MD order Apply once to twice a day and afterApply once to twice a day and after
incontinenceincontinence
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Protect and ManageProtect and Manage
MoistureMoisture Hydrocolloid (Duoderm)Hydrocolloid (Duoderm)
Wound cover and protectionWound cover and protection
Occlusive for minimal exudateOcclusive for minimal exudate
Change 2 to 3 times per weekChange 2 to 3 times per week
Used in home care to reduce visitsUsed in home care to reduce visits
Can cause trauma to area when removedCan cause trauma to area when removed
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Protect and ManageProtect and Manage
MoistureMoisture Mepilex Transfer DressingMepilex Transfer Dressing
For heavily draining wounds such asFor heavily draining wounds such as
weeping venous wound or bullous lesionsweeping venous wound or bullous lesions
Silicone foam dressingSilicone foam dressing
Easy to remove with little trauma toEasy to remove with little trauma to
tissuetissue Wicks drainage. Requires absorbentWicks drainage. Requires absorbent
cover dressingcover dressing
Change when saturatedChange when saturated
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Principles of WoundPrinciples of Wound
HealingHealingFill wound cavityFill wound cavity
Hydrofiber (Aquacel)Hydrofiber (Aquacel)
For moist and draining woundsFor moist and draining wounds
Easy to apply. Comes in rope and sheetsEasy to apply. Comes in rope and sheets
Change based on amount of drainage. DailyChange based on amount of drainage. Dailyto every 3 days.to every 3 days.
Turns to gel. Easy and less painful to removeTurns to gel. Easy and less painful to removeand apply.and apply.
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Principles of WoundPrinciples of Wound
HealingHealing Negative Pressure TherapyNegative Pressure Therapy
KCI Wound VACKCI Wound VAC (Vacuum Assisted Closure)(Vacuum Assisted Closure)
Wound filled with sterile foam. Covered withWound filled with sterile foam. Covered withocclusive drape and attached to negativeocclusive drape and attached to negativepressure pump.pressure pump.
Removes exudate from woundRemoves exudate from wound
Promotes angiogenesis and wound contractionPromotes angiogenesis and wound contraction
Changed 3 times per weekChanged 3 times per week
Reduces exposure to contamination and painReduces exposure to contamination and pain
Expensive.Expensive.
Can be used at home with insurance approval.Can be used at home with insurance approval.
Not covered at home by MedicaidNot covered at home by Medicaid
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Principles of WoundPrinciples of Wound
HealingHealing Promote a clean wound base freePromote a clean wound base free
from infectionfrom infection Irrigate wound with each dressing change withIrrigate wound with each dressing change with
normal saline or wound cleaner to reducenormal saline or wound cleaner to reducebioburdenbioburden
Antimicrobial dressingsAntimicrobial dressingsAquacel AGAquacel AG
Mesalt (Hypertonic saline)Mesalt (Hypertonic saline)
Wound VAC Silver DressingWound VAC Silver Dressing
Appropriate antibiotic therapyAppropriate antibiotic therapy
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Anti infective AgentsAnti infective Agents
Antibacterial fluids can be added toAntibacterial fluids can be added towet gauze dressings:wet gauze dressings:
Sulfamylon (mafenide)Sulfamylon (mafenide)
Dakins Solution (for short period forDakins Solution (for short period forinfected, odorous wounds)infected, odorous wounds)
Same concerns as previously noted forSame concerns as previously noted forwet to moist dressingswet to moist dressings
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Principles of WoundPrinciples of Wound
HealingHealing Remove nonviable tissue from theRemove nonviable tissue from the
wound to promote new growthwound to promote new growth
and reduce medium for infectionand reduce medium for infection DebridementDebridement
Surgical:Sharps: immediateSurgical:Sharps: immediate Excisional Debridement removal of tissue and notExcisional Debridement removal of tissue and not
just loose tissue fragments.just loose tissue fragments. Enzymatic: Collagenase/Santyl oint.Enzymatic: Collagenase/Santyl oint.
Apply once or twice a day.Apply once or twice a day.
Cover with dry dressingCover with dry dressing
Necrotic Tissue needs to be scored with scalpelNecrotic Tissue needs to be scored with scalpel
Can be slow processCan be slow process
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Principles of WoundPrinciples of Wound
HealingHealing Investigate and resolve underlying causesInvestigate and resolve underlying causes
Pressure UlcersPressure Ulcers Pressure reliefPressure relief
Reduce risk of shearReduce risk of shear
Incontinence careIncontinence care
Venous InsufficiencyVenous Insufficiency Compression if arterial involvement ruled outCompression if arterial involvement ruled out
Arterial IschemiaArterial Ischemia RevascularizationRevascularization
Neuopathic/Diabetic UlcersNeuopathic/Diabetic Ulcers Glucose ControlGlucose Control
Off loading footwearOff loading footwear
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Principles of WoundPrinciples of Wound
HealingHealing CollaborationCollaboration
Physician: Plastics, Vascular, Dermatology,Physician: Plastics, Vascular, Dermatology,
Infectious DiseaseInfectious Disease Nursing, WOCNNursing, WOCN
DietitianDietitian
Diabetic EducatorDiabetic Educator
Physical TherapyPhysical Therapy Social ServiceSocial Service
Home CareHome Care
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Thank YouThank You