WOUND FACTS
WOUND FACTS
(Updated January 2014)
(Updated January 2014)
• Only Pressure Ulcers are Staged. Stage III & IV Pressure Ulcers are NEVER reverse staged. Stage II Pressure Ulcers are superficial and heal by re-epithelialization – there is no slough or granulation present in a stage II pressure ulcer, and they are documented as “Not healing” on OASIS. When a Stage II pressure ulcer heals, it is gone. (“Deep Tissue Injury” pressure areas are also documented as “Not healing”.) • Presence of slough and/or granulation indicates full-thickness tissue loss of wounds. Presence of 25% SLOUGH indicates “Not healing status” of any open wound (even if there is presence of 75% granulation tissue!). LESS THAN 25% GRANULATION indicates “Not healing status.” • Incisions healing by primary intention do not granulate. “Because of this the only response that could be appropriate for a surgical wound healing by primary intention would be 0-Newly epithelialized or 3-Not healing.” • “0-Newly epithelialized” should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no s/s of infection exist. An incision/surgical wound with epithelial tissue in place for 30 days may be referred to as a scar. It is no longer a surgical wound. • “3-Not healing” status indicates the surgical incision is not well approximated OR s/s of infection or necrosis are present OR epidermal resurfacing is not complete. • Wounds located on lower legs (ankles to knees) are usually venous stasis wounds or wounds of mixed etiology involving venous stasis and arterial disease (pain often indicates arterial disease present). Wounds may also be due to trauma and have a delayed healing time due to venous or arterial disease. • Open wounds on feet are usually neuropathic wounds (i.e. diabetic wounds) or arterial wounds. Heel wounds most likely are due to pressure.
• Only Pressure Ulcers are Staged. Stage III & IV Pressure Ulcers are NEVER reverse staged. Stage II Pressure Ulcers are superficial and heal by re-epithelialization – there is no slough or granulation present in a stage II pressure ulcer, and they are documented as “Not healing” on OASIS. When a Stage II pressure ulcer heals, it is gone. (“Deep Tissue Injury” pressure areas are also documented as “Not healing”.) • Presence of slough and/or granulation indicates full-thickness tissue loss of wounds. Presence of 25% SLOUGH indicates “Not healing status” of any open wound (even if there is presence of 75% granulation tissue!). LESS THAN 25% GRANULATION indicates “Not healing status.” • Incisions healing by primary intention do not granulate. “Because of this the only response that could be appropriate for a surgical wound healing by primary intention would be 0-Newly epithelialized or 3-Not healing.” • “0-Newly epithelialized” should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no s/s of infection exist. An incision/surgical wound with epithelial tissue in place for 30 days may be referred to as a scar. It is no longer a surgical wound. • “3-Not healing” status indicates the surgical incision is not well approximated OR s/s of infection or necrosis are present OR epidermal resurfacing is not complete. • Wounds located on lower legs (ankles to knees) are usually venous stasis wounds or wounds of mixed etiology involving venous stasis and arterial disease (pain often indicates arterial disease present). Wounds may also be due to trauma and have a delayed healing time due to venous or arterial disease. • Open wounds on feet are usually neuropathic wounds (i.e. diabetic wounds) or arterial wounds. Heel wounds most likely are due to pressure.
TO HEAL A WOUND:
TO HEAL A WOUND:
• Address etiology, promote “clean” wound bed (free of slough/any non-viable tissue). • Provide a MOIST wound environment for cell migration (not too wet, not too dry). • Protect surrounding skin. AVOID DAILY dressing changes. Most “state of the art wound care products” require dressing changes 1 to 2x per week. • Provide Systemic Support including GOOD NUTRITION. • Wounds MUST be measured weekly using cm; use”%” to describe wound bed. • Evidence of wound healing progress should be seen within 2 weeks. • Prevent further skin breakdown. Braden Score 18 or less indicates at risk for skin breakdown – evaluate for support surface (i.e. Hill-Rom foam mattress replacement). Implement interventions to prevent skin breakdown.
• Address etiology, promote “clean” wound bed (free of slough/any non-viable tissue). • Provide a MOIST wound environment for cell migration (not too wet, not too dry). • Protect surrounding skin. AVOID DAILY dressing changes. Most “state of the art wound care products” require dressing changes 1 to 2x per week. • Provide Systemic Support including GOOD NUTRITION. • Wounds MUST be measured weekly using cm; use”%” to describe wound bed. • Evidence of wound healing progress should be seen within 2 weeks. • Prevent further skin breakdown. Braden Score 18 or less indicates at risk for skin breakdown – evaluate for support surface (i.e. Hill-Rom foam mattress replacement). Implement interventions to prevent skin breakdown.
WOUND FACTS
WOUND FACTS
(Updated January 2014)
(Updated January 2014)
• Only Pressure Ulcers are Staged. Stage III & IV Pressure Ulcers are NEVER reverse staged. Stage II Pressure Ulcers are superficial and heal by re-epithelialization – there is no slough or granulation present in a stage II pressure ulcer, and they are documented as “Not healing” on OASIS. When a Stage II pressure ulcer heals, it is gone. (“Deep Tissue Injury” pressure areas are also documented as “Not healing”.) • Presence of slough and/or granulation indicates full-thickness tissue loss of wounds. Presence of 25% SLOUGH indicates “Not healing status” of any open wound (even if there is presence of 75% granulation tissue!). LESS THAN 25% GRANULATION indicates “Not healing status.” • Incisions healing by primary intention do not granulate. “Because of this the only response that could be appropriate for a surgical wound healing by primary intention would be 0-Newly epithelialized or 3-Not healing.” • “0-Newly epithelialized” should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no s/s of infection exist. An incision/surgical wound with epithelial tissue in place for 30 days may be referred to as a scar. It is no longer a surgical wound. • “3-Not healing” status indicates the surgical incision is not well approximated OR s/s of infection or necrosis are present OR epidermal resurfacing is not complete. • Wounds located on lower legs (ankles to knees) are usually venous stasis wounds or wounds of mixed etiology involving venous stasis and arterial disease (pain often indicates arterial disease present). Wounds may also be due to trauma and have a delayed healing time due to venous or arterial disease. • Open wounds on feet are usually neuropathic wounds (i.e. diabetic wounds) or arterial wounds. Heel wounds most likely are due to pressure.
• Only Pressure Ulcers are Staged. Stage III & IV Pressure Ulcers are NEVER reverse staged. Stage II Pressure Ulcers are superficial and heal by re-epithelialization – there is no slough or granulation present in a stage II pressure ulcer, and they are documented as “Not healing” on OASIS. When a Stage II pressure ulcer heals, it is gone. (“Deep Tissue Injury” pressure areas are also documented as “Not healing”.) • Presence of slough and/or granulation indicates full-thickness tissue loss of wounds. Presence of 25% SLOUGH indicates “Not healing status” of any open wound (even if there is presence of 75% granulation tissue!). LESS THAN 25% GRANULATION indicates “Not healing status.” • Incisions healing by primary intention do not granulate. “Because of this the only response that could be appropriate for a surgical wound healing by primary intention would be 0-Newly epithelialized or 3-Not healing.” • “0-Newly epithelialized” should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no s/s of infection exist. An incision/surgical wound with epithelial tissue in place for 30 days may be referred to as a scar. It is no longer a surgical wound. • “3-Not healing” status indicates the surgical incision is not well approximated OR s/s of infection or necrosis are present OR epidermal resurfacing is not complete. • Wounds located on lower legs (ankles to knees) are usually venous stasis wounds or wounds of mixed etiology involving venous stasis and arterial disease (pain often indicates arterial disease present). Wounds may also be due to trauma and have a delayed healing time due to venous or arterial disease. • Open wounds on feet are usually neuropathic wounds (i.e. diabetic wounds) or arterial wounds. Heel wounds most likely are due to pressure.
TO HEAL A WOUND:
TO HEAL A WOUND:
• Address etiology, promote “clean” wound bed (free of slough/any non-viable tissue). • Provide a MOIST wound environment for cell migration (not too wet, not too dry). • Protect surrounding skin. AVOID DAILY dressing changes. Most “state of the art wound care products” require dressing changes 1 to 2x per week. • Provide Systemic Support including GOOD NUTRITION. • Wounds MUST be measured weekly using cm; use”%” to describe wound bed. • Evidence of wound healing progress should be seen within 2 weeks. • Prevent further skin breakdown. Braden Score 18 or less indicates at risk for skin breakdown – evaluate for support surface (i.e. Hill-Rom foam mattress replacement). Implement interventions to prevent skin breakdown.
• Address etiology, promote “clean” wound bed (free of slough/any non-viable tissue). • Provide a MOIST wound environment for cell migration (not too wet, not too dry). • Protect surrounding skin. AVOID DAILY dressing changes. Most “state of the art wound care products” require dressing changes 1 to 2x per week. • Provide Systemic Support including GOOD NUTRITION. • Wounds MUST be measured weekly using cm; use”%” to describe wound bed. • Evidence of wound healing progress should be seen within 2 weeks. • Prevent further skin breakdown. Braden Score 18 or less indicates at risk for skin breakdown – evaluate for support surface (i.e. Hill-Rom foam mattress replacement). Implement interventions to prevent skin breakdown.
WHAT IS CONSIDERED A SURGICAL WOUND:
WHAT IS CONSIDERED A SURGICAL WOUND:
(Updated January 2014)
(Updated January 2014)
• • • • • • • • • • • • • • • • • • • • • • • • • •
Orthopedic pin sites – YES (each pin site a separate wound) Stapled or sutured surgical incision – YES (each staple not a separate wound) Closed incision remains “newly epithelialized” for 30 days, then is classified as a scar Mediport/port-a-cath – YES (if accessed or scabbed, or s/s of infection, may be non-healing status); Not being used – mark as newly epithelialized Central Lines – YES; Implanted infusion devices – YES (newly epithelialized) unless recently placed and incision present and not yet newly epithelialized Muscle flap performed to surgically replace a pressure ulcer – YES Skin graft placed over pressure ulcer – NO (remains a pressure ulcer) Debrided wound – NO (debridement is considered a treatment, not surgery) Peritoneal dialysis catheter – YES AV Shunt – YES (even if it is no longer used and has no bruit – document newly epithelialized) Pacemaker – NEWLY IMPLANTED, YES (there is a new incision present) OTHERWISE, NO (is not an “implanted venous access device”) Thoracentesis site – NO Thoracentesis site with a drain placed – YES (most likely non-healing status) Paracentesis site – NO Paracentesis site with a drain placed – YES (most likely non-healing status) Chest Tube site – NO – it is considered a thoracostomy and ostomies are excluded when considering surgical wounds in the oasis assessment Gastrostomy, Colostomy, Ileostomy, Urostomy – NO Abdominal incision related to ostomy creation – YES Ostomy allowed to close on its own – NO “Take-down” of an ostomy done as a surgical procedure – YES I&D – NO; I&D involving removal of necrotic tissue, mass, mesh, etc – YES I&D with a drain placed – YES Shave, punch or excisional biopsy to remove / diagnose skin lesion – YES Cardiac cath site done by puncture with a needle into femoral artery – NO Cardiac cath site involving cut down – YES Trauma wound sutured – NO; Required surgery to repair (i.e. torn tendon) – YES
• • • • • • • • • • • • • • • • • • • • • • • • • •
Orthopedic pin sites – YES (each pin site a separate wound) Stapled or sutured surgical incision – YES (each staple not a separate wound) Closed incision remains “newly epithelialized” for 30 days, then is classified as a scar Mediport/port-a-cath – YES (if accessed or scabbed, or s/s of infection, may be non-healing status); Not being used – mark as newly epithelialized Central Lines – YES; Implanted infusion devices – YES (newly epithelialized) unless recently placed and incision present and not yet newly epithelialized Muscle flap performed to surgically replace a pressure ulcer – YES Skin graft placed over pressure ulcer – NO (remains a pressure ulcer) Debrided wound – NO (debridement is considered a treatment, not surgery) Peritoneal dialysis catheter – YES AV Shunt – YES (even if it is no longer used and has no bruit – document newly epithelialized) Pacemaker – NEWLY IMPLANTED, YES (there is a new incision present) OTHERWISE, NO (is not an “implanted venous access device”) Thoracentesis site – NO Thoracentesis site with a drain placed – YES (most likely non-healing status) Paracentesis site – NO Paracentesis site with a drain placed – YES (most likely non-healing status) Chest Tube site – NO – it is considered a thoracostomy and ostomies are excluded when considering surgical wounds in the oasis assessment Gastrostomy, Colostomy, Ileostomy, Urostomy – NO Abdominal incision related to ostomy creation – YES Ostomy allowed to close on its own – NO “Take-down” of an ostomy done as a surgical procedure – YES I&D – NO; I&D involving removal of necrotic tissue, mass, mesh, etc – YES I&D with a drain placed – YES Shave, punch or excisional biopsy to remove / diagnose skin lesion – YES Cardiac cath site done by puncture with a needle into femoral artery – NO Cardiac cath site involving cut down – YES Trauma wound sutured – NO; Required surgery to repair (i.e. torn tendon) – YES
WHAT IS CONSIDERED A SURGICAL WOUND:
WHAT IS CONSIDERED A SURGICAL WOUND:
(Updated January 2014)
(Updated January 2014)
• • • • • • • • • • • • • • • • • • • • • • • • • •
Orthopedic pin sites – YES (each pin site a separate wound) Stapled or sutured surgical incision – YES (each staple not a separate wound) Closed incision remains “newly epithelialized” for 30 days, then is classified as a scar Mediport/port-a-cath – YES (if accessed or scabbed, or s/s of infection, may be non-healing status); Not being used – mark as newly epithelialized Central Lines – YES; Implanted infusion devices – YES (newly epithelialized) unless recently placed and incision present and not yet newly epithelialized Muscle flap performed to surgically replace a pressure ulcer – YES Skin graft placed over pressure ulcer – NO (remains a pressure ulcer) Debrided wound – NO (debridement is considered a treatment, not surgery) Peritoneal dialysis catheter – YES AV Shunt – YES (even if it is no longer used and has no bruit – document newly epithelialized) Pacemaker – NEWLY IMPLANTED, YES (there is a new incision present) OTHERWISE, NO (is not an “implanted venous access device”) Thoracentesis site – NO Thoracentesis site with a drain placed – YES (most likely non-healing status) Paracentesis site – NO Paracentesis site with a drain placed – YES (most likely non-healing status) Chest Tube site – NO – it is considered a thoracostomy and ostomies are excluded when considering surgical wounds in the oasis assessment Gastrostomy, Colostomy, Ileostomy, Urostomy – NO Abdominal incision related to ostomy creation – YES Ostomy allowed to close on its own – NO “Take-down” of an ostomy done as a surgical procedure – YES I&D – NO; I&D involving removal of necrotic tissue, mass, mesh, etc – YES I&D with a drain placed – YES Shave, punch or excisional biopsy to remove / diagnose skin lesion – YES Cardiac cath site done by puncture with a needle into femoral artery – NO Cardiac cath site involving cut down – YES Trauma wound sutured – NO; Required surgery to repair (i.e. torn tendon) – YES
• • • • • • • • • • • • • • • • • • • • • • • • • •
Orthopedic pin sites – YES (each pin site a separate wound) Stapled or sutured surgical incision – YES (each staple not a separate wound) Closed incision remains “newly epithelialized” for 30 days, then is classified as a scar Mediport/port-a-cath – YES (if accessed or scabbed, or s/s of infection, may be non-healing status); Not being used – mark as newly epithelialized Central Lines – YES; Implanted infusion devices – YES (newly epithelialized) unless recently placed and incision present and not yet newly epithelialized Muscle flap performed to surgically replace a pressure ulcer – YES Skin graft placed over pressure ulcer – NO (remains a pressure ulcer) Debrided wound – NO (debridement is considered a treatment, not surgery) Peritoneal dialysis catheter – YES AV Shunt – YES (even if it is no longer used and has no bruit – document newly epithelialized) Pacemaker – NEWLY IMPLANTED, YES (there is a new incision present) OTHERWISE, NO (is not an “implanted venous access device”) Thoracentesis site – NO Thoracentesis site with a drain placed – YES (most likely non-healing status) Paracentesis site – NO Paracentesis site with a drain placed – YES (most likely non-healing status) Chest Tube site – NO – it is considered a thoracostomy and ostomies are excluded when considering surgical wounds in the oasis assessment Gastrostomy, Colostomy, Ileostomy, Urostomy – NO Abdominal incision related to ostomy creation – YES Ostomy allowed to close on its own – NO “Take-down” of an ostomy done as a surgical procedure – YES I&D – NO; I&D involving removal of necrotic tissue, mass, mesh, etc – YES I&D with a drain placed – YES Shave, punch or excisional biopsy to remove / diagnose skin lesion – YES Cardiac cath site done by puncture with a needle into femoral artery – NO Cardiac cath site involving cut down – YES Trauma wound sutured – NO; Required surgery to repair (i.e. torn tendon) – YES
