RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineHealing: A dynamic process in which anatomical and functional integrity is restored. This processcan be monitored and measured. For wounds of the skin, it involves repair of the dermis (granulationtissue formation) and epidermis (epithelialization). Healed wounds represent a spectrum of repair:they can be ideally healed (tissue regeneration), minimally healed (temporary return of anatomicalcontinuity), or acceptably healed (sustained functional and anatomical result). The acceptably healedwound is the ultimate outcome of wound healing but not necessarily the appropriate outcome for allpatients (AHCPR, 1994).Primary Intention Healing: Closure and healing of wound edges using sutures, staples, steristripsor skingrafts.Secondary Intention Healing: Closure and healing of a wound by the formation of granulation tissueand epithelization.Hydrotherapy: Use of whirlpool or submersion in water for wound cleansing (AHCPR, 1994).Incidence of pressure ulcers: The new cases appearing during a specified period in the “atrisk” population identified in the prevalence survey. For instance, a surgical nursing unit that hadadmitted 100 patients over a month and showed documentation of 10 ulcers would have an incidencerate of 10%. The rate is generally calculated by case with a new occurrence (10) over all the cases (100)present during a specified time period (one month). Definition for quality improvement purposesmay take into account all new occurrences even if it is a multiple occurrence during the time-frame foran individual. For example, if 5 of the 10 cases on the surgical unit had two ulcers during the one-monthperiod the incidence rate would be 15%. It is important to make the formula you are using explicit.Induration: Engorgement of tissues, evidenced as a hard, elevated area of inflammation.Infection: Refer to Microbiologic States of the Wound.Inflammatory Response: A localized protective response elicited by injury or destruction oftissues that serves to destroy, dilute, or wall off both the injurious agent and the injured tissue. Clinicalsigns include pain, heat, redness, swelling and loss of function. Inflammation may be diminished orabsent in immunosuppressed patients (AHCPR, 1994).Interdisciplinary: A process where health care professionals representing expertise from varioushealth care disciplines participate in a prevention-based program standardizing and practicingpressure ulcer management.73