Download

Nursing Best Practice Guideline
Microbiologic States of the Wound:
• Clean – Free of bacterial proliferation eliciting no response from the host.
• Contamination – The presence of bacteria on the wound surface without proliferation.
• Colonization – Presence and proliferation of bacteria eliciting no response from the host.
• Infection – Invasion of bacteria which proliferates and elicits a response from the host e.g.,
erythema, pain, warmth, edema, exudates (Gilchrist, 1997).
Moisture: In the context of this document, moisture refers to skin moisture that may
increase the risk of maceration and impair healing of existing ulcers. Primary sources of skin
moisture include perspiration, urine, feces, drainage from wounds, or fistulas.
MRSA: Methicillin-resistant staphylococcus aureus (MRSA) is a strain of the staphylococcus
bacterium which is resistant to the main groups of antibiotics.
83
Necrosis/Necrotic Tissue: Describes devitalized (dead) tissue as a result of a reduced
or inadequate blood/nutritional supply (e.g., eschar, slough and fibrin).
Needle Aspiration: Removal of fluid from a cavity by suction, often to obtain a sample
(aspirate) for culturing.
Osteomyelitis: A bone infection which can be both localized and generalized.
Partial Thickness: Loss of epidermis and possible partial loss of dermis.
Phagocytosis: The process of ingestion and digestion of bacteria, cells, necrotic tissue, or
white blood cells in an injured area.
Photoplethysmography: Photoplethysmography uses infra-red light to assess
changes in the blood volume in the micro-circulation. This provides information about the
presence of deep or superficial venous disease and the effectiveness of the calf muscle pump.
Pinch Graft: A small, circular, deep graft of skin only a few millimetres in diameter.