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

Nursing Best Practice GuidelineSepsis: The presence of various pus-forming and other pathogenic organisms or their toxins, in theblood or tissues. Clinical signs of blood-borne sepsis include fever, tachycardia, hypotension,leukocytosis and a deterioration in mental status. The same organism is often isolated in both theblood and the pressure ulcer (AHCPR, 1994).Shear: Mechanical force that acts on a unit area of skin in a direction parallel to the body’s surface.Shear is affected by the amount of pressure exerted, the coefficient of friction between the materialscontacting each other (i.e. how easily one surface slides over another), and the extent to which thebody makes contact with the support surface (AHCPR, 1994).Sinus Tract: A cavity or channel underlying a wound that involves an area larger than the visiblesurface of the wound (AHCPR, 1994). It is a pathway that can extend in any direction from the woundsurface, which results in dead space with potential for abscess formation.Skin Equivalent: A material used to cover open tissue that acts as a substitute for nascent(beginning) dermis and epidermis and that has at least some of the characteristics of human skin(e.g., amniotic tissue, xenografts, human allografts). For the purpose of this guideline, only tissue withviable, biologically active cells is given this designation (AHCPR, 1994).Slough: Necrotic (dead) tissue in the process of separating from viable portions of the body (AHCPR,1994). It is seen as the accumulation of dead cellular debris on the wound surface, and tends to beyellow in colour due to the large amounts of leukocytes present. However, yellow tissue is not alwaysindicative of slough but may be subcutaneous tissue, tendon or bone instead.Standard Mattress: A non-pressure reducing institutional mattress usually constructed of coldfoam with 10-20% of the body being supported (Defloor et al., 2005).Static Devices: Outdated term traditionally used to refer to surfaces which remain motionlessexcept in response to body movement and seek to redistribute the body weight by shifting the extraweight or load from areas with bony prominences to areas under low pressure (Holzapfel, 1993).Support Surface: A specialized device for pressure redistribution designed for management oftissue loads, micro-climate, and/or other therapeutic functions (i.e., any mattresses, integrated bedsystem, mattress replacement, overlay, or seat cushion, or seat cushion overlay) (NPUAP, 2006).Components of Support Surfaces (NPUAP, 2006) – can be used alone or in combination:Cell/Bladder: A means of encapsulating a support medium.Viscoelastic Foam: A type of porous polymer material that conforms in proportion to the appliedweight. The air exits and enters the foam cell slowly which allows the material to respond slower thana standard elastic foam (memory foam).77