Wound Care at End of Life - Optum360Coding

Wound Care at End of Life A Guide for Hospice Professionals

2nd edition

Joni Brinker, RN, MSN/MHA, WCC Clinical Nurse Educator

Optum Hospice Pharmacy Services

Bridget McCrate Protus, PharmD, MLIS, BCGP, CDP Director of Drug Information


Jason M. Kimbrel, PharmD, BCPS Vice President of Operations & Clinical Services


DISCLAIMER: All clinical recommendations contained herein are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients attending physicians. Nothing in this document shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Use of product brand names are intended to assist the clinician in identifying products and does not connote endorsement or promotion of any kind. No financial support for the development of this book was provided by any product vendor or manufacturer.

© Optum Hospice Pharmacy Services, 2018 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of Optum Hospice Pharmacy Services, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. Optum Hospice Pharmacy Services 4525 Executive Park Drive Montgomery, AL 36166 Tel: 866-970-7500 Cover design: Scott J. McClusky ISBN-13: 978-0-9889558-6-8

Acknowledgements Kyna Setsor Shonkwiler, RN, BSN, CHPN

Content author for 1st edition; planning & development for 2nd edition Optum Hospice Pharmacy Services

Melissa O’Neill Hunt, PharmD – Collaborator/Algorithm Design


Connie L. Bohn, RN, BSN, CWON Content author & editor/reviewer for 1st edition

To the Staff of Optum Hospice Pharmacy Services The authors wish to thank all of our colleagues for their assistance in the creation of this resource. Without their generous support this work would not have been possible. Their

compassionate commitment to improving end of life care for all individuals is an inspiration.

This book provides guidance for the assessment and palliative management of wounds. Many factors influence whether healing a wound is a realistic goal. Whether the goal is for healing or for symptom relief, untreated wounds can lead to physical discomfort and impair quality of life. It is necessary that they receive appropriate intervention.

How to Use This Book

Wound Care at End of Life is a quick reference guide for palliative management of wounds in hospice care. The authors and collaborators have systematically reviewed and collected the pertinent literature and resources related to palliative wound care.

• For those already skilled in wound care, this book is a resource for support of current practices and a quick treatment lookup tool.

• For those with less wound care experience, this book can serve as a learning guide and resource to ensure best practices for palliative wound management.

• For educators, this book may be used as a training guide to address the basics of palliative wound care and assist learners in developing a comprehensive plan of care for the patient with wounds.

Table of Contents

1. INTRODUCTION Introduction to palliative wound care. Establish goals of care. Communicate realistic expectations. Educate the care team, patient, and family.

1

2. ASSESSMENT AND DOCUMENTATION Complete a comprehensive skin and wound assessment. Consider the legal aspects of wound care documentation and photography.

5

3. ANATOMY AND PHYSIOLOGY OF SKIN Review the anatomy and physiology of the skin.

10

4. PHASES OF WOUND HEALING Discover the phases of wound healing and barriers to the wound healing process.

12

5. WOUND BED PREPARATION Apply the principles of wound bed preparation to relieve distressing wound symptoms in the palliative patient.

17

6. TOPICAL PRODUCTS FOR WOUND MANAGEMENT Recognize the ideal dressing for the palliative care patient. Learn about common topical wound care products. Use wound bed characteristics to select dressings.

25

7. PRESSURE INJURY PREVENTION AND TREATMENT Determine prevention strategies to reduce the risk of developing pressure injuries. Select topical wound care products to alleviate distressing symptoms and promote quality of life.

34

8. KENNEDY TERMINAL ULCERS Identify the defining characteristics of Kennedy Terminal Ulcers.

54

9. MOISTURE-ASSOCIATED SKIN DAMAGE (MASD) Define the four types of moisture-associated skin damage and appropriate treatment interventions for each.

57

10. LOWER EXTREMITY ULCERS Arterial, venous, and diabetic foot ulcers.

61

11. SKIN TEARS Develop prevention strategies to reduce the risk of experiencing skin tears. Select topical wound care products to heal acute skin tears.

81

12. FUNGATING (MALIGNANT) WOUNDS Establish a comprehensive wound care treatment plan to prevent bleeding while managing odor, infection, and exudate.

86

13. RADIATION DERMATITIS Differentiate between dry and moist desquamation and appropriate treatment interventions for each.

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14. NUTRITION Nutritional interventions for the patient with a wound at the end of life.

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15. SPECIAL TOPICS Calciphylaxis, Marjolin’s ulcers, care of the stoma, lymphedema, enterocutaneous fistulas, and common skin rashes.

101

16. OTHER THERAPIES Topical application of lidocaine, metronidazole, morphine, and phenytoin for wound symptom management; topical and medicated agents for skin and wound care; recipes for wound care preparations.

109

17. WOUND CARE GLOSSARY Common terms for wound care.

115

18. RESOURCE LIST Where to turn for additional information: books, journals, websites, and mobile apps.

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INDEX

i - v

DIABETIC FOOT ULCERS

GOALS

Within the confines of the patient’s prognosis and in alignment with the wishes of the patient and family:

• Maintain skin integrity with individualized prevention strategies • Preserve existing areas of ulceration to prevent infection and gangrene • Relieve distressing symptoms and promote quality of life

DEFINITIONS

A diabetic foot ulcer is an ulceration that presents on the foot of a diabetic patient. Diabetic foot ulcers fall into three categories: neuropathic, ischemic, and neuroischemic. The neuropathic diabetic foot ulcer is secondary to lower extremity neuropathic disease (LEND). An individual with lower extremity neuropathic disease will demonstrate sensory, motor, and autonomic neuropathy. Sensory neuropathy leads to the loss of sensation in the foot putting the patient at risk of injury from trauma. Motor neuropathy leads to deformities of the foot placing the patient at risk of abnormal pressure to the bony prominences of the foot, callus formation, and subsequent ulceration. Autonomic neuropathy results in a reduction of oil and moisture to the foot, which will manifest as dry skin that may peel or fissure, placing the patient at risk of developing an infection. Diabetic foot ulcers are also associated with lower extremity arterial disease, either purely ischemic (ischemic diabetic foot ulcers) or a combination of neuropathy and ischemia (neuroischemic diabetic foot ulcers).1 ASSESSMENT

Diagnose neuropathic diabetic foot ulcers based on distinguishing characteristics (see Table 4).1-3 Identify neuropathy using the monofilament test and tuning fork. An Ankle Brachial Index rules out ischemic and neuroischemic ulcers in the diabetic patient population. An Ankle Brachial Index of 0.90 or less indicates that arterial disease is present; however, the Ankle Brachial Index can be greater than 1.30 in the diabetic patient, which means that the arteries of the ankle are calcified. If this occurs, obtain a Toe Brachial Index (TBI). The TBI is equal to the toe systolic pressure divided by the brachial systolic pressure. A TBI less than 0.64 indicates that arterial disease is present.2

Use the Wagner classification system to grade the severity of the diabetic foot ulcer. This classification system assigns a grade ranging from 0 (no ulcers present) to 5 (gangrene of the entire foot) by evaluating ulcer depth, presence of gangrene, and loss of perfusion.1

Figure 3. Diabetic Foot Ulcer

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Table 4. Presentation of Diabetic Foot Ulcers1-3

Characteristic Neuropathic Ischemic Neuroischemic

Location • Plantar surface of foot • Areas of the foot that bear

weight – heel, ball of the foot, great toe

• Margins of the feet and toes • Tips of toes

• Margins of the feet and toes • Tips of toes • Under thickened toe nails

Etiology

• Neuropathy (assess using the monofilament test and tuning fork) with unrecognized pressure to bony prominences or trauma as sources of injury

• Ischemia from lower extremity arterial disease with trauma as a source of injury (e.g., poorly fitted shoes)

• Combination of neuropathic changes of the foot and ischemia from lower extremity arterial disease

Wound Bed

• May be hidden under thick callus or have callus around perimeter

• Pink; granulation tissue possible

• Round and “punched out”

• May present as a blister • Necrosis likely • Pale in color • Granulation reduced/absent

• May present as a red area • If callus is present, may be

minimal • Necrosis possible • Granulation reduced/absent

Appearance of Foot

• Dry, flakey skin, fissures • Deformities • Warm

• Cool • Pulses absent • Thin, shiny, hairless skin

• Cool • Pulses absent • Thin, shiny, hairless skin

Pain • Usually painless due to

numbness and loss of sensation

• Painful • May be present or absent

PLAN OF CARE

Develop an individualized plan of care to prevent the development of or treat existing diabetic foot ulcers to guide the actions of all members of the interdisciplinary team. The care plan serves to translate the data gained from completion of the comprehensive assessment into a specific plan of action to prevent or manage diabetic foot ulcers. Table 5 includes potential care plans for diabetic foot ulcers.3,4

Table 5. Plan of Care for Diabetic Foot Ulcers Nursing Diagnosis Related Factors Interventions

Risk for Impaired Skin Integrity • Patient has the potential for

an alteration in skin integrity

• Advanced age • Alcohol abuse • Chemotherapy • Diabetes • Pressure • Cardiovascular disease • Lower extremity arterial

disease • Kidney disease • Smoking • Knowledge deficit • Trauma

• Assess skin, note areas of discoloration, texture, or temperature and any existing skin alterations

• Relieve pain if present • Revascularization surgery if ischemia is present • Maintain adequate nutrition and hydration • Offload pressure and assist with ambulation • Protect from lower extremities from trauma –

monitor lower extremities and feet daily • Assess skin alteration and determine etiology,

reassess regularly, monitor daily • Diabetic foot care • Localized wound care, prevent/treat infection

Impaired Skin Integrity • Partial thickness tissue loss Impaired Tissue Integrity • Full thickness tissue loss

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INTERVENTIONS

Prevention Diabetic foot ulcers are undesirable because they fail to heal and often become infected. Gangrene and the subsequent necessity for amputation are also possible. Therefore, prevention of the diabetic foot ulcer should continue to be a focus for the palliative care patient. Instruct the patient to:3

• Check feet daily – both looking and feeling• Wash feet with warm water and dry thoroughly (even between the toes)• Apply moisturizer to the feet but never between the toes• Ensure socks and shoes fit well – not too loose or too tight• When ambulating, shoes should always be worn – never barefoot• Cut toenails straight across• Rotate shoes throughout the day to vary the pressure on the feet• Refrain from soaking the feet or self-trimming a callus (may use a pumice stone)• Protect the feet from trauma while in bed (e.g., float heels), during transfers from bed (e.g.,

sheepskin or foam boots), and while ambulating (e.g., good-fitting shoes, offload pressure withassistive devices)

Localized Wound Care Treatment of the diabetic foot ulcer varies based on the underlying cause. If ischemia is present, revascularization of the leg may be necessary to achieve wound healing. Tight glycemic control, smoking cessation, and maximizing nutrition are critical. The source of trauma needs to be reversed, whether it is from ill-fitting footwear, deformities of the foot, or the presence of a foreign body. The pressure of the foot must be offloaded, usually through the use of a total contact cast or assistive devices. The callus will need debridement, with sharp debridement being the method of choice. If gangrene is present, amputation is a possible outcome. Collectively, these treatment options impose significant burden on the patient and may not be practical at the end of life. Therefore, for the palliative management of the diabetic foot ulcer, the primary goal will be the prevention of infection and symptom management. Principles of moist wound healing and wound bed preparation will govern the dressing selection for the neuropathic diabetic foot ulcer.3,5 Conversely, principles of dry wound healing will govern dressing selection if ischemia is severe and wound healing is unlikely.6,7 Use the following algorithms and treatment grids to assist in selecting an appropriate dressing.

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WOUND TREATMENT GRID: Diabetic Foot Ulcers1-3,5-10

Wound Need Intervention Comments

Cleanse

• Clean wound bed: pour normal saline or wound cleanser

• Infection/necrosis: irrigate with wound cleanser or antiseptic*

• Irrigate with 4-15 psi: piston syringe (4.2 psi), squeeze bottle+irrigation cap(4.5 psi), 35 mL syringe+18 gauge needle (8 psi)

Debridement

• Dry: hydrogel, hydrocolloid • Moist: calcium alginate, hydrocolloid, hydroconductive • Infected: silver alginate, cadexomer iodine,

hydroconductive

• Neuropathic: Sharp debridement of callus. • Ischemia: Debridement is NOT

recommended unless perfusion status is known. See Arterial Ulcer Algorithm, page 65

Exudate

• None/Minimal Exudate: hydrogel, hydrocolloid, PMD* • Moderate Exudate: foam, calcium alginate, PMD* • Heavy Exudate: GFD* (Hydrofiber®), hydroconductive,

PMD* • Stable eschar: paint perimeter with povidone-iodine

• Monitor daily – rapid deterioration of the wound is possible

• Cautious use of occlusive dressings • PMDs* can be used on all exudate levels –

moisten with saline if wound bed is dry

Infection

• None/Minimal Exudate: honey, hydrogel with silver • Moderate Exudate: silver alginate, honey alginate,

silver foam • Heavy Exudate: GFD* (Hydrofiber®) with silver,

cadexomer iodine, hydroconductive

• Decreased inflammatory response so only subtle signs of an infection may be present

• Can lead to gangrene; rule out osteomyelitis • Systemic antibiotics are necessary – wound

culture guides selection*

Malodor

• Cleansers*: hypochlorous acid (Vashe®), sodium hypochlorite (Dakin’s® 0.125%)

• Dressings: cadexomer iodine, honey, charcoal, silver, essential oils (wintergreen or lavender) on dressing

• Environmental strategies: kitty litter, vanilla extract, coffee grounds, or dryer sheets placed in room

• Rule our infection • Wound cleansing aids odor control. • Change dressing more often to manage odor

(e.g., hydrocolloid every 24-48 hours). • Hydrocolloid dressings tend to create odor

(doesn't mean infection is present)

Dead Space

• None/Minimal Exudate: hydrogel, PMD* • Moderate Exudate: foam, calcium alginate, PMD* • Heavy Exudate: GFD* (Hydrofiber®), hydroconductive,

PMD*

• Loosely fill any dead space. • Products are available in different forms,

such as roping, to pack tunnels

Pruritus • Not usually associated with the wound, assess surrounding skin.

• Evaluate for contact dermatitis, hypersensitivity, or yeast dermatitis

Bleeding

• Dressing strategies: calcium alginate (silver alginate is not hemostatic), non-adherent dressing, or coagulants (gelatin sponge, thrombin)

• Topical/local strategies: sclerosing agent (silver nitrate), antifibrinolytic agent (tranexamic acid), astringents (alum solution, sucralfate), vasoconstrictive agents [topical oxymetazoline (Afrin®), topical epinephrine]

• Atraumatic removal of dressings – irrigate with normal saline to remove dressings

• Ask: Is transfusion appropriate? Is patient on warfarin? Is the wound infected?

• Consider checking: platelet count, PT/INR, vitamin K deficiency

• Use topical vasoconstrictors only when bleeding is minimal, oozing, or seeping

Support Surface

• Consider the need for a support surface if pressure was causative injury leading to ulceration

• What was the causative injury?

Pain

Nonpharmacological Interventions: • Procedural: moisture-balanced, non-adherent

dressings; warm saline irrigation to remove dressings; time-outs; patient participation

• Complementary therapies: music, relaxation, aromatherapy, visualization, meditation

Pharmacological Interventions: • Systemic: scheduled and pre-procedural opioid;

tricyclic antidepressant; anticonvulsant

• Rule out infection and wound deterioration • Neuropathic diabetic foot ulcers can be

painless due to loss of sensation • Consider placing: hydrocolloid, foam,

calcium alginate, PMD*, soft silicone, or hydrogel

*Cleansers: Rinse wound bed with normal saline after using antiseptic cleanser to minimize toxic effects ‖GFD: Gelling fiber dressing PMD: polymeric membrane dressing (PolyMem®) Topical Antibiotics: Use of a topical antibiotic is NOT recommended due to the potential for adverse reactions and antimicrobial resistance

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Treatment Algorithm for Diabetic Foot Ulcer

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KEY POINTS

• Diabetic foot ulcers are defined as any skin alteration in the foot of the diabetic patient. They fall into three categories: neuropathic, ischemic, and neuroischemic.

• Because diabetic foot ulcers are associated with a decrease in quality of life, prevention strategies should continue in the palliative care population.

• Principles of moist wound healing and wound bed preparation will govern the dressing selection for the neuropathic diabetic foot ulcer.

CASE STUDY

The nurse is admitting a 64-year-old male patient to hospice with a primary diagnosis of malignant melanoma. While performing a head to toe assessment, the nurse notes a diabetic ulcer to the plantar surface of the right great toe. The nurse performs a comprehensive wound assessment and documents the following:

Full thickness diabetic neuropathic ulcer to the plantar surface of the right great toe measuring 1.3 x 1.9 x 0.7 cm. Wound bed with 100% granulation tissue. Callus surrounds the perimeter of the wound. Moderate serous exudate. No odor, redness, induration, or edema noted. Surrounding tissue is warm, dry, and intact. Numeric pain score 2/10 during wound assessment. ABI is 0.8, and capillary refill is within normal limits. The patient denies the use of any prevention strategies at this time. The patient reports having custom orthotic shoes but stopped wearing them after being diagnosed with cancer. Comorbidities include hyperlipidemia and hypertension. The patient is taking comfort medications only. The patient eats approximately 75% of all meals and weight is stable at 182 pounds. The patient ambulates independently. PPS is 50%. The patient does not wish to pursue intensive treatment for this wound, including surgical/sharp debridement of callus. The family currently cares for the wound by washing daily with soap and water and applying a gauze dressing.

The nurse educates the patient and family on preventive strategies for diabetic foot ulcers to prevent further injury to the patient’s feet. The nurse suggests discontinuing the gauze dressing because this places the patient at increased risk of developing an infection. Instead, the nurse recommends an absorptive dressing. The nurse notifies the physician of her assessment and recommendations. The physician agrees with the nurse’s assessment and provides the following wound care orders:

• Cleanse diabetic foot ulcer plantar surface of the right great toe with normal saline. Pat periwound tissue dry. Loosely fill dead space with calcium alginate and cover with a foam dressing. Secure with tape. Change every three days and as needed if soiled.

The nurse reviews the wound care orders with the family, and the family is agreeable to the plan of care. The nurse provides education regarding the application of the dressing. The patient and family return-demonstrate the procedure.

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References 1. Wounds International. Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. London,

UK:Wounds Int’l; 2013. http://www.woundsinternational.com/media/best-practices/_/673/files/dfubestpracticeforweb.pdfAccessed April 23, 2018

2. Wound Ostomy and Continence Nurses Society. A quick reference guide for lower-extremity wounds: venous,arterial, and neuropathic. April 4, 2013. http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28B-C41E24551CCC/A_Quick_Reference_Guide_for_LE_Wounds_(2013).pdf Accessed July 14, 2017.

3. Heitzman, J. Foot care for patients with diabetes. Top Geriatr Rehabil. 2010;26(3):250-263.4. Wayne G. Impaired tissue integrity. September 13, 2016 https://nurseslabs.com/impaired-tissue-integrity/

Accessed October 12, 2017.5. Edmonds, ME, Foster AVM. ABC of wound healing: diabetic foot ulcers. BMJ. 2006;332:407-410.6. Takahashi P. Chronic ischemic, venous, and neuropathic ulcers in long-term care. Ann LTC. 2006;14(7):26-31.7. Williams RL. Cadexomer iodine: an effective palliative dressing in chronic critical limb ischemia. Wounds.

2009;21(1):15-28.8. So-Shn Mak S, Lee MY, Cheung JSS, et al. Pressurized irrigation versus swabbing method in cleansing wounds

healed by secondary intention: a randomized controlled trial with cost-effectiveness analysis. Int J Nurs Stud.2015;52:88-101.

9. Sibbald RG, Krasner DL, Lutz J. SCALE: Skin changes at life’s end: final consensus statement: October 1, 2009.Adv Skin Wound Care. 2010;23(5):225-236.

10. Popescu A, Sal Salcido R. Wound pain: a challenge for the patient and the wound care specialist. Adv SkinWound Care. 2004;17(1):14-20.

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i

INDEX

Abdomen, 101, 107 Abdominal, 18, 59, 104 ABI, 62, 69, 72, 79, 115 Abrasion, 54, 115 Abscess, 27, 102-103, 115, 117 Absorbent, 19, 24, 26-30, 32, 59-60, 88, 116 Absorptive, 21-23, 27-29, 32, 44, 59, 79, 88 Acetic acid, 15, 21, 29, 32, 43-44, 70, 83, 88-89, 113 Actisorb, 26 Acyclovir, 107 Adhesion, 26, 29, 115 Adhesive, 27-29, 32, 82, 93, 105 Adipose, 35 Afrin, 43-44, 64, 70, 77, 83, 87, 94 Albumin, 98 Alcohol, 20-21, 28-29, 75, 93, 109 Algicell, 26 Algiderm, 26 Alginates, 8, 18, 22, 26-28, 30-31, 43-44, 64, 69-70, 77, 79, 83, 87-89, 94, 104-105 Algisite, 26 Alkaline, 105 Allclenz, 29 Alldress, 26 Allergen, 104-105, 107-108 Allergo, 108 Allergy, 26-29, 108, 112 Allevyn, 27, 93-94 Ambulation, 37-38, 61, 64, 68, 75, 116 Amorphous, 8, 27, 111 Amputation, 76, 102, 108, 119 Anaerobic, 19, 86, 88-89, 110 Analgesia, 53, 73, 85, 91, 110-111, 114 Anaphylaxis, 112 Anasept, 28, 31 Anatomical, 7, 10 Anemia, 8, 51, 62 Anesthetic, 109, 112 Ankle, 62, 67-69, 74, 115, 117, 120 Anorexia, 97, 99 Antibacterial, 20, 29, 107, 112 Antibiotic, 15, 18-22, 26, 43-44, 63-64, 69-70, 77, 83, 88, 94, 105, 107, 115 Anticoagulant, 15, 18

Anticonvulsant, 43-44, 64, 70, 77, 83, 88-89, 94 Antidepressant, 43-44, 64, 70, 77, 83, 88-89, 94 Antifungal, 20, 29, 59, 105, 107, 112, 115 Antihistamines, 107 Antimicrobial, 19-28, 30-32, 43-44, 59-60, 63-64, 70, 77, 83, 88-89, 94, 112, 115 Antiplatelet, 15, 64, 87 Antiseptic, 15, 20-21, 27, 29, 32, 43-44, 70, 77, 83, 88-89, 94, 114-115 Antivirals, 107 Appetite, 15, 97-98 Appliance, 58, 60, 104-105, 115 Aquacel, 27-28, 31 Aquaphor, 70, 94, 107 Aqueous, 93-94, 96 Aromatherapy, 43-44, 64, 70, 77, 83, 88-89, 94 Arthritis, 62, 101 Aspirin, 15 Assistive, 37, 40, 76, 82 Astringents, 43-44, 64, 70, 77, 83, 89, 94 Atherosclerosis, 61 Atopic, 107-108 Atraumatic, 27, 43-44, 64, 70, 77, 83, 89, 94 Autoimmune, 105, 107, 117 Autolytic, 2, 17-18, 23, 26-29, 51, 63, 73, 88-89, 93 Autonomic, 74 Avascular, 117 Axilla, 91, 107 Azathioprine, 15 Bacitracin, 15, 26, 31, 112 Bactericidal, 112 Bacteriostatic, 15, 24, 32, 115 Bacteroides, 110 Bactroban, 20, 26, 112 Balmex, 112 Balsam, 112 Bandaging, 69, 103, 115 Barefoot, 63, 76 Barrier, 4, 7-8, 10-11, 23, 26-31, 40-41, 43-44, 51, 59, 70, 72, 82-83, 85, 89, 98, 104, 112, 115 Bathing, 59 Baza, 112 Bedbugs, 108 Bedpans, 40 Benzalkonium, 29

Benzodiazepine, 101 Betadine, 20, 29, 44, 64, 70 Betaine, 21, 30 Betamethasone, 112 Biguanide, 28, 32 Bioburden, 17, 115 Biochemical, 16, 116 Biofilm, 14, 21, 24, 30, 32, 115 Biopsy, 20, 102 Biosurgical, 17-18, 23 Biotherapy, 119 Bismuth, 83, 87, 89 Bites, 107 Blanchable, 35 Bleeding, 13, 18-19, 25, 43-44, 64, 70, 77, 83, 85-87, 89, 91, 94, 102 Blister, 35, 54, 75, 106 BMI, 98 Bone, 12-13, 19, 34-35, 116-117 Bony, 34, 37, 51, 54-55, 58, 74-75 Brachial, 62, 74, 115, 117 Braden scale, 36, 38-39, 51-52, 119 Breast, 86, 91 Bruising, 5, 9 Bullous, 107-108 Buttocks, 58, 101, 107 Cachexia, 97, 99, 115 Cadexomer, 21, 26, 30, 33, 43-44, 63-64, 66, 70, 77, 80, 83, 88-89, 112 Caffeine, 63 Calamine, 68, 107 Calcicare, 26 Calcification, 62, 101, 108, 115 Calciphylaxis, 101, 108, 115 Callus, 74-77, 79 Calorie, 14, 98 Candidiasis, 105, 107 Cardiovascular, 15, 62, 75 Caregiver, 1-4, 25, 27, 36, 55, 61, 86, 97-98, 105, 119 Carraklenz, 29 Cartilage, 35 Catheters, 5, 40, 59 Cauterization, 22 Cavitating, 18, 27 Cavity, 28-30, 115 Celestone, 112 Cellulitis, 19, 69-70, 102, 107-108, 115 Centany, 112 Century, 32 Cephalexin, 20, 107 Cetaphil, 89 Cetirizine, 107

ii

Champagne, 67 Charcoal, 26, 43-44, 64, 70, 77, 83, 88-89, 91, 94, 101, 104 Chemotherapy, 75, 96, 111 CHF, 68, 72 Chlorhexidine, 15, 20, 29-30, 43-44, 70, 83 Chloroxylenol, 29 Cilostazol, 64 Cirrhosis, 101 Claudication, 61, 116 Cleanser, 18, 29, 40-41, 43-44, 59, 64, 70, 77, 83, 89, 94, 103, 110 Clindamycin, 107 Clobetasol, 107, 112 Clot, 13 Clotrimazole, 20, 112 Cobblestoned, 116 Coccyx, 54-55 Cognition, 81-82 Colchicine, 15 Colitis, 104 Collaboration, 4 Collagen, 10-11, 13-15, 18, 26, 30-31, 40, 87, 109, 111, 115 Collagenase, 18, 24, 88, 101, 112 Colonization, 19, 21, 115 Colostomy, 106 Combativeness, 39 Communication, 2-5 Comorbidities, 6-8, 51, 72, 79, 93 Composite, 22, 26, 30-31, 89, 91 Compression, 30, 41, 68-70, 72-73, 103, 115, 120 Connective, 11-12, 116-117 Constipation, 110 Contamination, 19, 27, 38, 115 Contraction, 13, 103, 115 Convatec, 31 Corneocytes, 10 Corneum, 10 Cortaid, 70, 112 Corticosteroids, 15, 69-70, 98, 105, 107, 112 Cortizone, 112 Covaderm, 26 Crater, 86 Crosshatching, 18 Crust, 106, 116-117 Crusting, 59, 94, 104-105, 115 Crystal, 105 Curasalt, 23, 28 Curative, 59 Curity, 28

Cutimed, 27 Cutisorb, 29 Cyanotic, 62 Cyclosporine, 105 Cytokines, 13 Cytotoxic, 29 DACC, 27, 31 Dakin, 15, 20, 29-30, 32, 43-44, 70, 77, 83, 88-89, 113 Dangling, 62, 64 Debride, 17-18, 21, 26, 28, 30, 42, 63 Debris, 11, 13, 19, 25, 29, 102, 116-117 Decongestive, 102, 115 Decontaminate, 15 Deformities, 74-76 Delirium, 110 Demarcation, 63, 116 Dementia, 99 Denuded, 6-7, 28, 59, 104-105, 115-116 Deodorants, 93, 104 Deodorization, 110 Deposition, 67, 111 Deposits, 117 Deprivation, 86 Depth, 7, 26-27, 29, 35, 58, 74 Dermadress, 26 Dermarite, 118 Dermatitis, 15, 43-44, 58-60, 64, 69-70, 73, 77, 83, 89, 92-96, 105, 107-108, 112, 117 Dermatome, 107 Dermis, 10-13, 16, 35, 67, 81, 107, 116-117 Desitin, 112 Desquamation, 92-94, 96, 116 Detergents, 106 Devitalized, 7, 23, 30, 115, 117 Dexamethasone, 15, 98 Diabetes, 14, 20, 51, 62-63, 75, 80, 115, 120 Dialysis, 101 Diarrhea, 41 Diet, 98-99, 101 Dietician, 82, 93, 97-98 Diflucan, 107 Dilantin, 111 Dimethicone, 59 Diphenhydramine, 107 Diprolene, 112 Discoloration, 37, 55, 58, 62, 68, 75, 82, 87, 93, 106

Disinfectant, 27, 116 Diverticulitis, 103 Documentation, 5, 7-9, 34-35, 72, 120 Domeboro, 59 Donut, 39 Doxycycline, 107 Drainage, 8, 22, 27, 29-30, 51, 56, 85, 102-103, 115 Drawtex, 29, 116 Duoderm, 27, 29 Dusting, 59, 115 DVT, 68, 98 Eczema, 69, 73, 107 Edema, 5, 9, 14, 19-20, 27-28, 51, 66-70, 72, 79, 92, 111, 115 Effluent, 57-58, 60, 89, 103-105, 108, 116 Elasticity, 10-11 Elbows, 30, 107 Electrolytes, 103 Elevation, 38, 62, 64, 67-68, 70, 99 Embarrassment, 4, 86, 88, 101 Embolism, 68 EMLA, 43-44, 70, 83, 88-89, 109, 112 Emollients, 69-70, 107 Encrustations, 105 Enteral, 99 Enterococcus, 117 Enterocutaneous, 101, 103-104, 108, 116 Enterostomal, 104, 120 Enzymatic, 2, 17-18, 23, 28, 63, 88 Enzymes, 18, 41, 115-116 Epibole, 6-8, 22-24, 30, 32, 35, 51, 102, 116 Epidermal, 14, 29, 58, 106 Epileptics, 15 Epinephrine, 15, 43-44, 64, 70, 77, 83, 87, 89, 94 Epithelialization, 13-14, 21, 30, 116-117 Eruptions, 108 Erythema, 19, 23, 34, 92-93, 96, 107, 116 Eschar, 7, 17-18, 26-27, 30, 35, 42-44, 49, 63-64, 66, 70, 77, 83, 101, 116-117 Ethanol, 109 Eucerin, 70, 107 Excipients, 109 Excoriation, 106, 116 Exfoliation, 106

iii

Extravasation, 67 Extrinsic, 6, 13, 36 Eyelids, 107 Fabric, 28, 32 Fascia, 35, 116 Fasciitis, 18 Fecal, 40-41, 59 Feces, 104 Feeding, 5, 99-100 Feet, 41, 62-63, 66, 75-76, 79, 107 Fever, 19, 106 Fibrin, 15, 112 Fibroblast, 11, 13-14 Fibrotic, 67 Fillers, 28-29, 59 Films, 29 Fingers, 44, 70, 107, 116 Fingerstick, 51 Fissure, 74-75 Fistula, 18, 28-29, 88-89, 101, 103-104, 108, 116 Flaking, 92, 96, 116 Flammable, 28 Flap, 81, 83, 85 Flexigel, 29 Float, 37, 40, 43-44, 76 Floating, 8, 51 Flora, 115 Fluctuance, 18, 116 Fluidized, 39 Fluocinolone, 112 Fluocinonide, 112 Flush, 105 Foam, 8, 16, 18, 22-23, 27-28, 30, 32, 37-39, 41, 43-44, 56, 69-70, 72, 76-77, 79, 83, 88-89, 93-94, 104, 112 Follicles, 67, 105, 107, 116 Footwear, 76 Forearm, 85 Fracture, 39, 67 Fragrances, 69 Friable, 116 Fungal, 20, 59, 105, 107, 115 Fungating, 86-88, 90-91, 110 Furniture, 82, 117 Gabapentin, 101 Gangrene, 18, 63-64, 74, 76-77 Garments, 103 Gastrointestinal, 86, 103-104, 108, 116 Gentamicin, 15 Gentian violet, 23, 27, 30, 43-44, 70, 83, 112

GFD, 43-44, 64, 70, 77, 83, 89 Gingival, 111 Glycerin, 27 Gold, 32, 72, 102 Grafting, 93 Granulation, 1, 7-8, 13, 15, 18-19, 22, 28, 30, 34-35, 51, 67, 72, 75, 79, 111, 116 Granuloma, 105-106, 116 Groin, 58 Hairless, 62, 75 Healable, 2, 19 Heel, 7-8, 18, 30, 37-38, 40-44, 51, 63, 70, 75-76 Hemorrhaging, 87, 92 Hemosiderin, 67, 107 Hemostasis, 13, 16 Hemostatic, 26, 43-44, 64, 70, 77, 83, 87, 89, 94 Heparin, 15 Herpes, 108 Hibiclens, 20 Histiocytes, 11 Hives, 107 Homeostasis, 10-11 Honey, 27, 43-44, 70, 77, 83, 89, 91, 94, 112 Horseshoe, 54-55 HoRT, 36 Humidity, 39 Hydrocell, 27 Hydrocolloid, 18, 22, 27, 30, 43-44, 69-70, 77, 88-89, 104-105 Hydroconductive, 29, 70, 77, 116 Hydrocortisone, 15, 59, 93-94, 96, 107, 112 Hydrofera, 27, 31, 43-44, 70, 83 Hydrofiber, 22, 27, 30-31, 43-44, 64, 70, 72, 77, 83, 89, 104-105 Hydrogel, 8, 18, 22, 27-28, 30, 43-44, 70, 77, 83, 88-89, 94, 109, 111, 113 Hydroxyurea, 15 Hygiene, 5, 107 Hyperbaric, 120 Hypergranulation, 23-24, 30, 33, 102, 116 Hyperkeratotic, 103 Hyperlipidemia, 63, 72, 79 Hyperpigmentation, 67 Hyperplasia, 105, 111, 116 Hypertension, 8, 51, 55, 60, 63, 72, 79 Hypoallergenic, 28

Hypochlorous, 21, 24, 30, 32, 43-44, 70, 77, 83, 88-89, 94 Hypopigmented, 67 Hypoxia, 61-62, 66 IAD, 59 Ice, 87, 99 Immobility, 34, 37-38, 41, 55 Impermeable, 10, 29 Incision, 27-28 Incontinence, 7-8, 37, 40-41, 51, 55-60, 120 Indurated, 6-7, 102 Induration, 23, 51, 66, 72, 79, 116 Indwelling, 40 Infiltrated, 86, 91 Integumentary, 24 Interdry, 28, 32, 59-60 Intergluteal, 58 Interstitial, 28, 102-103, 108, 116 Intertriginous, 57-60 Intertrigo, 108 Intrasite, 111, 113-114 Iodine, 15, 20-21, 26, 29-33, 42-44, 63-64, 66, 70, 77, 80, 83, 88-89, 101, 108, 112 Iodoflex, 26 Iodosorb, 21, 26, 30-31, 112 Irrigate, 26, 29-30, 43-44, 51, 70, 77, 83, 85, 89, 91, 94 Ischemia, 18, 33, 62-64, 66, 74-77, 80, 117 Itch, 69, 107 Keflex, 20 Kenalog, 70, 112 Kennedy Terminal Ulcer, 54-55 Keratin, 112 Keratinocytes, 10 Kerlix, 28, 72 Ketamine, 101 Ketoconazole, 112 Kidney, 67, 75, 102, 105 KTU, 54-55 Laceration, 7, 12 Lamina, 10 Larval therapy, 18 Lavender, 43-44, 64, 70, 77, 83, 89, 94 Leakage, 4, 59, 88 Leathery, 30, 116 Leukocytes, 115-117 Lichenification, 106 Lidex, 112 Lidocaine, 43-44, 70, 83, 88-89, 109, 112-113

iv

Ligament, 35 Limb, 33, 62-63, 66-67, 80, 103 Lindane, 107 Lipodermatosclerosis, 67 Liver, 67-68, 102 Loratadine, 107 Lotrimin, 20, 112 Lotrisone, 112 Lubriderm, 70, 89, 107 Lung, 86, 96, 102 Lymphedema, 60, 86, 101-103, 108, 115-116 Lymphocyte, 98 Maceration, 6, 23, 25, 27-28, 30, 40-41, 57-58, 69, 107, 116 Macrophages, 13 Macular, 107 Maculopapular, 107 Malignancy, 28, 30, 87, 102 Malleolus, 7, 67 Malnutrition, 14, 97-99, 103, 116, 119 Malodor, 43-44, 64, 70, 77, 83, 86, 89, 94, 110 Manuka, 27 Marjolin’s ulcer, 101-102, 108 MASD, 57-59, 107 Mattress, 6, 37-38, 40, 52, 59 Measuring, 8, 51, 55, 66, 72, 79, 85 Medicaid, 5, 9 Medihoney, 27, 112 Meditation, 43-44, 64, 70, 77, 83, 88-89, 94 Megestrol, 98 Melanoma, 79 Menthol, 109 Mepilex, 28, 93-94 Mepitel, 26 Mesalt, 23, 28, 30-31, 44, 70, 89 Mesh, 26 Metastasis, 102 Methotrexate, 15 Metrogel, 112 Metronidazole, 20, 43-44, 70, 83, 88-89, 91, 94, 110, 112-114 Miconazole, 20, 112 Microbes, 27, 29, 115 Microclimate, 38-41, 59 Microorganism, 10, 15, 20, 115-116 Milkshakes, 99 Mirtazapine, 99 Mitosis, 10 Mnemonic, 17, 19, 23 Moisturizer, 41, 76, 89, 103

Monostat, 112 Morphine, 43-44, 53, 70, 73, 85, 88-89, 91, 110-111, 113-114 Mottling, 101, 115 MRSA, 26-29, 32, 43-44, 70, 83, 107, 112, 116 MSSA, 43-44, 70, 83, 112, 116 Mucosal, 34, 117 Mucositis, 99, 111 Mupirocin, 15, 20, 26, 31, 43-44, 70, 83, 112 Mycolog, 112 Myofibroblasts, 13, 115 Nausea, 98 Necrosis, 15, 27, 29, 44, 61, 64, 70, 75, 77, 83, 86, 101, 115 Neomycin, 15, 26, 112 Neosporin, 26, 112 Nerds, 7, 19-20, 23-24, 30, 33 Netting, 59, 82-83, 89, 94 Neuroischemic, 74-75, 79 Neuropathic, 7, 32-33, 66, 72, 74-77, 79-80, 88, 101 Neutrophils, 13 Nicotine, 15 Nociceptive, 7, 88 Nodule, 86, 102, 105-106, 116 Nonadherence, 4 Nonblanchable, 34 Noncompressible, 62, 117 Nonhealing, 26 Nonpharmacological, 7, 43-44, 64, 70, 77, 83, 87, 89, 94, 98 Nonverbal, 55 NPWT, 22 NSAIDs, 15 Numbness, 75 Nystatin, 20, 59, 112 Nystop, 20, 112 Obesity, 67-68, 93 Occlusive, 23, 26-27, 29, 63-64, 77, 117 Offload, 37, 63, 75-76 Offloading, 7, 37, 51, 120 Oily, 106 Oozing, 43-44, 64, 70, 77, 83, 94 Opsite, 29 Opticell, 27 Osteomyelitis, 18, 20, 28, 77 Oxygen, 5, 29, 34, 62, 86 Oxymetazoline, 43-44, 64, 70, 77, 83, 87, 89, 94 PAINAD, 8, 51 Painless, 75, 77, 107

Pallor, 117 Palpable, 35, 106 Papillary, 10-11 Papule, 105-107 Parathyroid, 101 Pathophysiology, 16, 60, 101, 103 PEG, 99 Pemphigoid, 107-108 Peptostreptococci, 110 Perfume, 69, 93 Perianal, 40 Perineal, 58, 88 Peristomal, 57-60, 101, 104-106, 108, 115 Permethrin, 107 Perspiration, 40, 57-58, 60, 116 Petrolatum, 59, 69-70, 83, 85, 87, 89, 107 pH, 15, 41, 57, 59, 103 Pharmacokinetic, 110 Pharmacological, 7, 43-44, 64, 70, 77, 83, 87-89, 94 Phenytoin, 15, 111 PHMB, 21, 28, 30 Photography, 5, 8-9, 120 Physiology, 10 Pigment, 10 Pillow, 29, 37, 40, 51 Pitting, 92 Placebo, 111 Plantar, 75, 79 Platelet, 13, 15, 43-44, 64, 70, 77, 83, 89, 94 Pletal, 64 Plurogel, 27 Polyhexamethylene, 28, 32 Polyhexanide, 21, 30 Polymem, 28-29, 32, 43-44, 51, 64, 70, 77, 83, 89, 93-94 Polymyxin, 26, 112 Polysporin, 26, 112 Popsicles, 99 Positioning, 38-39, 41-42 Pouch, 29, 32, 40, 59, 104-105, 108 Pouching, 88, 104-105 Povidone, 15, 20, 29-30, 32, 42, 44, 63-64, 66, 70, 77, 101, 108 Prealbumin, 98 Prednisolone, 107 Prednisone, 15, 98 Pregabalin, 101 Preventable, 2, 41, 85 Prilocaine, 109, 112

v

Prognosis, 1, 6-7, 34, 54, 56-57, 61, 67, 74, 81, 86, 92, 97, 101 Proliferation, 13, 16, 86, 88 Promogran, 26 Prontosan, 21, 24, 30, 32 Protease, 14, 21 Protectant, 28, 41 Proteoglycans, 13 Proteolytic, 18 Protozoa, 20, 112, 115 Pruritus, 25, 27, 43-44, 59, 64, 70, 77, 83, 87, 89, 93-94, 96, 107 Pseudomonas, 18, 21, 29-30, 43-44, 70, 83, 113 Psychosocial, 86, 91 Pulses, 62, 75 Punched, 62, 75 Purulent, 7, 102, 117 Quikclot, 87 Rash, 40, 59, 92, 101, 105-108 Razor, 93, 105, 107 Recipes, 109, 113 Refractory, 101, 114 Remeron, 99 Remodeling, 13-16 Renal, 26, 29, 62, 68, 101 Repositioning, 7-8, 37-38, 40, 51, 56, 117 Resurfacing, 15 Revascularization, 62-63, 75-76 Rheumatoid, 101 Rolled, 7, 22, 30, 85, 116 Roping, 44, 70, 77, 83, 89, 94 Sacrum, 8, 41, 54 Saliva, 57, 60, 116 Sanguineous, 7, 117 Santyl, 18, 24, 88, 101, 112 Scab, 117 Scabies, 107-108 SCALE, 1 Scaling, 107 Scalp, 93 Scar, 12, 14, 16, 102, 117 Sclerosing, 43-44, 64, 70, 77, 83, 89, 94 Seal, 88-89 Sealant, 27, 41 Seaweed, 26 Sedation, 99, 110 Sepsis, 18-19, 103 Serosanguineous, 7, 117 Serous, 7-8, 51, 56, 72, 79, 85, 117 Shampoo, 93 Shaving, 93, 105, 107

Shearing, 10, 27, 37, 41, 58 Sheepskin, 76 Shingles, 107-108 Silicone, 26, 29, 43-44, 70, 77, 83, 89, 94 Silvadene, 112 Skintegrity, 27, 29 Slimy, 21, 30 Slough, 7-8, 17, 27, 30, 35, 43, 49-51, 63-64, 67, 72, 83, 91, 115, 117 Soap, 59, 66, 79, 93, 106-107 Sorbact, 27 Sorbsan, 26 Staging, 10, 12, 34-35, 42-43, 45, 51-52, 117-118 Staining, 67, 107 Stalling, 23 Stasis, 69-70, 107-108 Steroids, 14, 93, 107 Stimulant, 98 Sting, 27-28, 31 Stoma, 29, 58-59, 104-106 Stomahesive, 59, 115 Stomatitis, 100 Sucralfate, 43-44, 64, 70, 77, 83, 89, 94 Sulfadiazine, 112 Surfactant, 21, 29-30 Tacrolimus, 105 Tegaderm, 29 Telfa, 26 Temovate, 112 Tenderwet, 18 Tendon, 35 Thighs, 58, 101, 107 Thrombin, 43-44, 64, 70, 77, 83, 87, 89, 94 Thrombosis, 67 Thyroid, 26, 29 Toenails, 62, 76 Toileting, 58-59 Tranexamic acid, 43-44, 64, 70, 77, 83, 87, 89, 94 Transferrin, 98 Transfusion, 43-44, 64, 70, 77, 83, 89, 94 Triamcinolone, 105, 112 Triclosan, 29 Trimethoprim, 107 Trochanter, 38 Tumor, 86-89, 102, 108, 110 Tunneling, 6-8, 23, 26-28, 35, 44, 51, 58, 70, 113, 117 Turgor, 5, 9

Undermining, 6-8, 23, 26-28, 35, 51, 58 Unna boots, 68 Unstable, 39, 66, 101, 116 Unstageable, 35, 40 Urostomy, 105 Urticaria, 107 Vaccinations, 102 Valacyclovir, 107 Vancomycin, 117 Vanilla, 43-44, 64, 70, 77, 83, 89, 94 Varicella, 107 Varicose, 67 Vashe, 21, 30, 43-44, 70, 77, 83, 88-89, 94 Vasoconstrictive, 43-44, 64, 70, 77, 83, 87, 94 Vasodilation, 13, 15, 116 Vegan, 26 Venelex, 112 Vinegar, 105, 113 Virulence, 115 Virus, 107, 112 Vomiting, 98 VRE, 27-28, 43-44, 70, 83, 117 Warfarin, 14-15, 43-44, 64, 70, 77, 83, 89, 94 Wheelchair, 6, 43-44 Whirlpool, 18 Wicking, 28, 32 Xeroform, 83, 87, 89 Xerostomia, 99 Xylocaine, 112 Yeast, 26, 28, 43-44, 64, 77, 83, 89, 94 Zinc, 59, 68, 99, 112

Wound Care at End of Life - Optum360Coding

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