CMS Manual System - Louisiana Department of Health and Hospitals

DEFINITIONS
Definitions are provided to clarify clinical terms related to pressure ulcers and their
evaluation and treatment.
―Pressure Ulcer‖- A pressure ulcer is any lesion caused by unrelieved pressure
that results in damage to the underlying tissue(s). 1 Although friction and shear
are not primary causes of pressure ulcers, friction and shear are important
contributing factors to the development of pressure ulcers.
―Avoidable/Unavoidable‖ Pressure Ulcers
o ―Avoidable‖ means that the resident developed a pressure ulcer and that
the facility did not do one or more of the following: evaluate the resident‘s
clinical condition and pressure ulcer risk factors; define and implement
interventions that are consistent with resident needs, resident goals, and
recognized standards of practice; monitor and evaluate the impact of the
interventions; or revise the interventions as appropriate.
o ―Unavoidable‖ means that the resident developed a pressure ulcer even
though the facility had evaluated the resident‘s clinical condition and
pressure ulcer risk factors; defined and implemented interventions that are
consistent with resident needs, goals, and recognized standards of practice;
monitored and evaluated the impact of the interventions; and revised the
approaches as appropriate.
―Cleansing/Irrigation‖
o ―Cleansing‖ refers to the use of an appropriate device and solution to clean
the surface of the wound bed and to remove the looser foreign debris or
contaminants in order to decrease microbial growth. 2
o ―Irrigation‖ refers to a type of mechanical debridement, which uses an
appropriate solution delivered under pressure to the wound bed to
vigorously attempt to remove debris from the wound bed. 3
―Colonized/Infected‖ Wound
4, 5
o ―Colonized‖ refers to the presence of bacteria on the surface or in the
tissue of a wound without the signs and symptoms of an infection.
o ―Infected‖ refers to the presence of micro-organisms in sufficient quantity
to overwhelm the defenses of viable tissues and produce the signs and
symptoms of infection.