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

Nursing Best Practice GuidelineInfection: The presence of bacteria or other microorganisms in sufficient quantity to damage tissueor impair healing. Clinical experience has indicated that wounds can be classified as infected whenthe wound tissue contains 10 5 or greater microorganisms per gram of tissue. Clinical signs ofinfection may not be present, especially in the immunocompromised patient or the patient with achronic wound (AHCPR, 1994).Local Clinical Infection: A clinical infection that is confined to the wound and within a fewmillimeters of its margins.Systemic Clinical Infection: A clinical infection that extends beyond the margins of the wound.Some systemic infectious complications of pressure ulcers include cellulitis, advancing cellulitis,osteomyelitis, meningitis, endocarditis, septic arthritis, bacteremia and sepsis (AHCPR, 1994).Moisture: In the context of this document, moisture refers to skin moisture that may increase therisk of pressure ulcer development and impair healing of existing ulcers. Primary sources of skinmoisture include perspiration, urine, feces, drainage from wounds or fistulas (AHCPR, 1994).Necrosis/Necrotic Tissue: Describes devitalized (dead) tissue (e.g., eschar and slough).Partial Thickness: Loss of epidermis and possible partial loss of dermis.Polypharmacy: The administration of many drugs concurrently, usually meaning that a patientis receiving an excessive number of medications. Polypharmacy may negatively affect adherence tothe pressure ulcer treatment plan (AHCPR, 1994).Pressure (Interface): Force per unit area that acts perpendicularly between the body and thesupport surface. This parameter is affected by stiffness of the support surface, the composition of thebody tissue, and the geometry of the body being supported (AHCPR, 1994).Pressure Redistribution: The ability of a support surface to distribute load over the contactareas of the human body (NPUAP, 2006). The goal of this approach is to create an even interface pressureover the entire contact area, to reduce the overall pressure and avoid areas of focal pressure. In thepast, the terms pressure reduction and pressure relief have been used to describe this approach.Pressure reduction: Outdated term traditionally used to describe the reduction of interface pressurebetween the body surface and the resting surface but does not consistently maintain pressure belowcapillary closing pressure (AHCPR, 1994; Mulder, Fairchild, & Jeter, 1995).Pressure relief: Outdated term traditionally used to describe the consistent reduction of interfacepressure between the body surface and resting surface below capillary closing pressure (AHCPR, 1994;Mulder, Fairchild, & Jeter, 1995).75