Pathway Health Services Wound Documentation Guidelines

tract/tunnel by the clock method (i.e., 3cm at 3 o'clock). If there is more than one sinus tract/tunnel, number each clockwise. 5. WOUND BASE DESCRIPTION: describe the wound bed appearance. If the wound base has a mixture of these, use the percentage of its extent (i.e., the wound base is 75% granulation tissue with 25% slough tissue).

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WOUND CARE WORKSHOP - prd-medweb-cdn.s3.amazonaws.com

Base of wound covered by slough (yellow, tan, grey, green, brown) or eschar (tan, brown, black) and no tunneling that has 40% slough vs fibrinous tissue, 40% muscle tissue and 20% granulation tissue with copious, nonodorous, clear drainage and the surrounding skin has an erythematous papular rash with coalescence at the margins of the wound with satellite lesions extending out from the

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PRESSURE INJURY AND STAGES

can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. STAGE 4 PRESSURE INJURY Full-thickness loss of skin and tissue: Full-thickness skin and tissue loss with exposed or directly : palpable fascia, muscle, tendon, ligament

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Procedure: Wound Cleansing - CLWK

Title Procedure: Wound Cleansing Practice Level Nurses in accordance with health authority/agency policy. Background Wound cleansing and irrigation are defined as the application of fluid to a wound to remove exudate, slough, necrotic debris, bacterial contaminants and dressing residue without adversely impacting cellular activity vital to the wound healing process, or inoculating the

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Wound assessment: A step-by-step process :

Tunneling is a narrow course or pathway that can extend in any direction from the wound and results in dead space with a potential for abscess formation. Measure tunneling by moistening a sterile cotton tip applicator with sterile 0.9% sodium chloride and gently inserting it into areas of dead space. Measure the distance in centimeters and document the location.

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Wound with Depth, Slough, Undermining &

Wound with Depth, Slough, Undermining & Tunnel. Deep wound to hips or gluteals with slough, undermining and tunnel, sometimes called a bed sore or pressure ulcer. May be found on any part of the body. Wound care example: Clean wound and surrounding skin with tap water, saline, or wound cleanser. Thoroughly rinse inside wound to be sure all packing material is removed. Blot excessive

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Extensive Tunneling Lower Leg Wounds with Exposed Tendons

Extensive Tunneling Lower Leg Wounds with Exposed Tendons Closed Quickly Using Various PolyMem Dressings IN ITIATI ON AF TER ON LY 8 WEE K S OF PO LY M EM . Extensive Tunneling Lower Leg Wounds with Exposed Tendons Closed Quickly Using Various PolyMem Dressings Linda Benskin, BSN, RN, SRN (Ghana), Peter Bombande, SRN (Ghana), MA, Church of Christ Mission

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Extensive Tunneling Lower Leg Wounds with Exposed Tendons

Extensive Tunneling Lower Leg Wounds with Exposed Tendons Closed Quickly Using Various PolyMem Dressings IN ITIATI ON AF TER ON LY 8 WEE K S OF PO LY M EM . Extensive Tunneling Lower Leg Wounds with Exposed Tendons Closed Quickly Using Various PolyMem Dressings Linda Benskin, BSN, RN, SRN (Ghana), Peter Bombande, SRN (Ghana), MA, Church of Christ Mission

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Assessment and Management of Sacral

The wound bed is viable, and there is no granulation tissue, slough, or eschar present in the wound. Importantly, Stage 2 should not be used to describe moisture-associated skin damage such as medical adhesive-related skin injury (MARSI) or traumatic wounds (e.g. burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss

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Creative Closure of Tunneling and

By Beth Hawkins Bradley RN, MN, CWON Wounds treated with negative pressure wound therapy (NPWT) are not often straightforward. They occur in interesting places, have anything from slough to hardware visible in the bases, and have nooks and crannies that are not visible to the clinicians peering into the wound. A gentle probe is necessary during wound assessment to identify tunnels and

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Wound and Pressure Ulcer Management

Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Often include undermining and tunneling. Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

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PRESSURE INJURY AND STAGES

can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. STAGE 4 PRESSURE INJURY Full-thickness loss of skin and tissue: Full-thickness skin and tissue loss with exposed or directly : palpable fascia, muscle, tendon, ligament

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Hydrofera Blue CLASSIC foam dressing APPLICATION GUIDE

wound, the new dressing can be left in place for up to 3 days. • If the dressing turned white or lightened in color, continue daily dressing changes until blue color is retained. Moisture Balance • As with many wound care dressings, moisture balance is key. If the dressing is dry, thoroughly remoisten with sterile saline or sterile water, then gently remove the dressing. Tunneling Dressing

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Staging Guide 092208 - Indiana

Pressure Ulcer Staging Guide Pressure Ulcer Staging Guide STAGE IV Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the

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Wound Measurement & Documentation Guide final092112

Tunneling/Sinus Tract A narrow channel or passage- way extending in any direction from the base of the wound. This results in dead space with a potential risk for abscess formation. Undermining Open area extending under intact skin along the edge of the wound. Wound Measurement & Documentation Guide Wound Location: • Designate left, right, top, bottom, side, front, middle, etc., as

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Wound Classification - Agency for Healthcare Research and

wound bed, without slough. • May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Description • Presents as a shiny or dry shallow ulcer . without slough or bruising. • This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation. Source: National Pressure Ulcer Advisory Panel

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V.A.C. Therapy Clinical Guidelines - School of Engineering

Wound Healing Progression with Effective V.A.C. These V.A.C.® Therapy Clinical Guidelines are for use with the V.A.C. ® Classic, V.A.C.® ATS™ and V.A.C.Freedom® therapy systems. Not all systems have the same features nor require the same guidelines. Please refer to the specific Quick Reference Guide, User Manual, On-Screen User Guide and Disposable Instructions for Use (as

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Wound Measurement & Documentation Guide final092112

Tunneling/Sinus Tract A narrow channel or passage- way extending in any direction from the base of the wound. This results in dead space with a potential risk for abscess formation. Undermining Open area extending under intact skin along the edge of the wound. Wound Measurement & Documentation Guide Wound Location: • Designate left, right, top, bottom, side, front, middle, etc., as

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Example Wounds & Dressings | LHSC

Example Wounds & Dressings Wet wound with granulating tissue, yellow slough, and some black eschar (not infected) Cellulitis Diabetic foot Sacral ulcer Clean wound with granulating tissue Dry, black eschar on a heel Hip wound with yellow slough (Stage X) Deep wound with tunneling (Stage 4) Top Stories. Research & Innovation. Provincial funding enables coronavirus research in London

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How to Measure Wound Granulation: 11 Steps

29.03.2019· To measure wound granulation over time, start with a proper assessment of the wound, including how it as acquired, and where it's located on the body. Next, use a ruler to measure the length and width of the wound in centimeters. Additionally, measure the depth by carefully inserting a saline-soaked cotton pledget in the wound, and measure that mark against a ruler. Wash hands with soap

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