Ask the Wound Coach

DISCLAIMER: All clinical recommendations 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 consultation shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition.

Frequently Asked Questions

With the release of the MDS 3.0, we are no longer required to reverse (down) stage pressure ulcers, so how will we be able to prove that the pressure ulcers are getting better?

     The demise of reverse staging is an exciting milestone for long term care, however it may prove to be challenging for some clinicians. For the last 20 years or more, we have been trained, re-trained and then trained some more on how to reverse stage pressure ulcers and as they say, old habits die hard.
     Pressure ulcer staging is a classification system for describing the maximum depth of tissue damage that has occurred. It was never designed or intended to demonstrate progress or healing. Staging is only one component of the overall wound assessment. By tracking and monitoring the specific characteristics of a pressure ulcer over subsequent time frames, improvement or decline can be determined.
     To track the progress of a pressure ulcer, weekly assessment and documentation should include:
     1. Pressure ulcer stage. After initial assessment, the stage will always remain the same unless: 
          a. The ulcer worsens 
          b. Unstageable ulcer becomes stageable
     2. Pressure ulcer measurements documented in centimeters 
          a. Length: longest length from head to toe 
          b. Width: widest width side to side perpendicular (90° angle) to length.
          c. Depth: distance from the deepest aspect of the wound to the skin level
          d. Measurement of any tunneling or undermining
     3.  % amount of each tissue type visualized in the wound
     4. Color, amount and odor of any drainage
     5. Appearance of the wound edges and surrounding tissues
     6. Signs symptoms of infection
In addition to documentation, the PUSH (Pressure Ulcer Scale for Healing) Tool is a great form for monitoring the effectiveness of treatment in chronic wounds. The PUSH Tool is available for free download at: 

Could you tell me proper technique on using strips when packing a wound? I am updating our policy on this.

Procedure for Packing Strips - If strip gauze is used as packing, grasp end w/sterile forceps or cotton tipped applicator & lift out the desired length over its container- cut piece w/clean scissors. Drop one end of packing into deepest area of wound, and then "fluff not stuff" pack loosely using sterile/clean instrument . Leave a small "wick" outside of the wound for easy removal. See picture of a wound that is packed w/ gauze strips and the end is left outside of the wound as a "wick" for easy removal.

How can you tell the difference between slough and eschar?

Slough is usually lighter in color, thinner and stringy in consistency; Color - Can be yellow, gray, white, green, brown.

Eschar (pictured to the left) - usually darker in color, thicker and hard consistency black or brown in color.

How many Pressure Ulcers are in the USA?

Over 1 million people with pressure ulcers in the USA. We need more clinicians out there that know about wound care.

I have a saggy wound - How do you re: positioning a patient for wound measurement when the wound edges sag over the wound bed?

Sagging of the wound edges generally occurs with wounds that have undermining. This is due to a lack of subcutaneous support around the wound and when combined with the pull of gravity the edges look droopy and sag making it hard to obtain accurate measurements. Position the resident comfortably with the wound as far from the sleep surface as possible; example: for a right trochanter wound, position resident on left trochanter for measurement. While measuring have an assistant apply uniform tension to both edges to keep sagging to a minimum. Do not apply too much tension that the wound looks over-stretched, just enough that the edges look consistent and the wound bed can be visualized. Upon completion include how the resident was positioned in your documentation so they can be placed in the same anatomical position each time wound measurements are taken. The purpose of measuring wounds is to track and measure the progression of healing from week to week. For the measurements to be useful consistency is the key.

Our facility was recently cited a deficiency for inappropriate treatment due to application of zinc oxide to a stage 2 pressure ulcer on the buttocks. Why is this not an appropriate treatment?

Zinc oxide ointment can be used on stage 2 pressure ulcers. Appropriate use could include: superficial wound free from infection or wound with frequent exposure to moisture. Inappropriate use could include: allergy to zinc oxide, continued use of zinc oxide beyond 7 days with no improvement in wound noted, not following facility protocol - e.g. No policy or procedure in place for using zinc oxide on pressure ulcers.

Should I debride stable heel ulcers?

AHRQ Clinical Practice Guidelines for Pressure Ulcer Treatment: Heel ulcers with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement (e.g., edema, erythema, fluctuance, drainage).

We have an incontinent patient that is continually experiencing skin breakdown in the gluteal folds and buttocks area, would this be considered a pressure ulcer?

If the skin breakdown is related to exposure from urinary and fecal incontinence this is referred to as: incontinence associated dermatitis (IAD). Incontinence Dermatitis is characterized by irritation and inflammation of the skin from prolonged exposure to urine or stool. It can also be caused by the regular use of an absorptive containment device such as an incontinence brief or pad, which raises the pH of the underlying skin and increases production of perspiration. The clinical characteristics of incontinence dermatitis will appear as redness, blistering, erosion; lesions remain partial-thickness and free from necrosis (slough or eschar). The areas of redness may be patchy or consolidated. IAD associated with urinary incontinence tends to occur in the folds of the labia majora in women or the scrotum in men, whereas IAD associated with fecal incontinence tends to originate in the perianal area. A full-thickness wound (tissue destruction into the subcutaneous tissue or deeper), with or without necrosis (slough or eschar), reflects ischemic tissue damage and would be classified as a pressure ulcer not as incontinence dermatitis. Incontinence dermatitis is often referred to by other names including perineal dermatitis, irritant dermatitis, intertrigo, heat rash and diaper rash when noted in children. Another common description for IAD used by many nurses is “excoriated”, however this is incorrect. The definition of excoriation is a linear erosion; destruction of the skin by mechanical means. Loss of epidermis, caused by exposure to urine, feces, body fluids, wound drainage, or friction should be described as “denuded”.

What cause some wounds to stink?

Research has shown that wounds most commonly associated with odor include draining wounds, chronic pressure ulcers, venous leg ulcers, diabetic/neuropathic ulcers, cancerous or malignant lesions and wounds with necrotic tissue. It is believed that most all wound odors are due to tissue degradation (decomposition) or anaerobic bacteria that have colonized within the wound tissues. Another culprit of wound odor is saturated wet dressings and bandages that contain necrotic exudate from the wound. Certain dressings, such as hydrocolloids tend to also produce odor due to their occlusive nature and the chemical reaction that takes place between the dressing and wound exudate.

What do you all recommend for black heels if the wound is dry and intact?

Treatment options for intact stable eschar:provide pressure reduction (elevate calves on pillows in bed) along with topical options: wrap the heel in dry gauze ,or paint with betadine or liquid barrier film (e.g. 3M Cavilon No Sting Barrier Film or Skin Prep Smith & Nephew ). Current standard of care guidelines, recommend that stable intact (dry, adherent, intact without erythema or fluctuance) eschar on the heels should not be removed. The reason: blood flow in the tissue under the eschar is virtually non-existent, therefore the wound is susceptible to infection with limited to no ability to fight off invading bacteria. The eschar acts as a natural barrier to infection, keeping the bacteria from entering the wound. However, should the eschar become unstable (wet, draining, loose, boggy, edematous, red) the eschar should be debrided.

What is Incontinence Dermatitis?

The clinical characteristics of skin breakdown caused by incontinence (incontinence dermatitis) will appear as redness, blistering, erosion; lesions remain partial-thickness and free from necrosis (slough or eschar). The areas of redness may be patchy or consolidated. A full-thickness wound (tissue destruction into the subcutaneous tissue or deeper), with or without necrosis (slough or eschar), reflects ischemic tissue damage and would be classified as a pressure ulcer not as incontinence dermatitis.

What solution is used for specific bacteria eg. psedomonas?

Dakins solution and acetic acid are both bactericidal to Pseudomonas aeruginosa, however studies show that acetic acid is more effective against Pseudomas aeruginosa. Acetic acid is frequently used in wounds as a 0.25-percent or 0.5-percent solution. Here is a link to research article that discusses the use of acetic acid in wounds.

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