Staging Wounds

Wound Staging adapted from Dr. Duggan's Geriatrics Guide

Wound Care by Amanda Bailey, NP

 

  • Document ALL wounds that are present on admission. This affects reimbursement.
  • Use the Haiku app on your cellphone to document images of wounds in pt chart

 

Feature

Deep Tissue Injury

Stage 1

Stage 2

Stage 3

Stage 4

Skin Consistency

Boggy

Boggy

Variable

N/A

N/A

Skin color/nature of lesion

Non-blanching purple or maroon, may appear as blood-filled blister

Non-blanching erythema

Abrasion, blister, or shallow crater

Variable

Variable.

If eschar, must be removed in order to stage, or is unstageable

Depth

Epidermis intact

Epidermis intact

Through surface of epidermis and outer dermis

SQ tissue to, but not through, fascia

Full-thickness loss w/ destruction, necrosis, or damage to muscle, bone, supporting structures

 

Pressure Ulcer Stages

 

Recall other types of ulcers to consider in your differential:

  • Arterial: shallow, well-defined borders, pale/necrotic wound bed, minimal exudate due to poor blood flow, cramping pain or a constant deep ache
  • Diabetic: Plantar surface of foot, callused wound margins; usually painless due to neuropathy
  • Venous: medial malleolus, irregular edges, ruddy red with yellow slough and copious exudate

 

Non Acute Wound

  • Order “Inpatient Consult to Adult Simple Wound Ostomy VUH” for:
    • Pressure Injuries – stage 1, stage 2, deep tissue injury
    • Skin tears – partial thickness
    • Moisture Associated Skin Damage – diarrhea, tube drainage, skin folds
    • Partial thickness wounds – other
    • Peri-tube skin problems – peg, trach skin issues
    • Fistulas
  • Order “Inpatient Consult to Complex Wound” for:
    • Pressure injuries – stage 3, 4, unstageable
    • Wounds with pathology
      • Diabetic – areas of pressure
        • For routine diabetic foot wounds even if they need debridement but are not frankly infected, consult COMPLEX WOUND
        • Caveat: If frank pus or erythema is spreading up leg, consult “Ortho foot-ankle”
        • Caveat: If pt is being followed by Drs. Hicks, Trenner or Deeter, consult “Ortho Foot-Ankle.” Use the Epic search tool to determine this
    • Arterial – distal on digit
    • Venous – gravity dependent areas
    • Calciphylaxis
    • Pyoderma Gangrenosum
    • Fungating Lesion
    • Vasculitis
    • Abscess (already drained, just needs packing instructions)
    • Surgical wounds (for pts without VUMC surgeon)
    • If pt has VUMC surgeon, consult appropriate surgical team (see below)
    • Hematoma with no active bleeding but with overlying skin necrosis/wound
    • Wound with underlying osteomyelitis
    • IV infiltrate –contact team pharmacist or inpatient pharmacy (615-875-6337) for protocol

 

Acute Wound

  • Abscess, Hematoma, Osteomyelitis with overlying wound
    • Whom to consult for drainage/debridement:
      • Face – Face
      • Chest/Sternum – CT surgery
      • Breast – General Surgery
      • Spine – Spine
      • Arm (hand to elbow) – Hand
      • Lower leg (foot to knee) – Ortho
      • Labial – OB/GYN
      • Scrotal – Urology
      • Buttock, thigh (knee to hip), arm (elbow to shoulder)– EGS consult
      • Perirectal/Rectal
        • Acute abscess – EGS
        • Chronic due to IBD – Colorectal surgery

 

Necrotizing Fasciitis

  • Whom to consult for URGENT/EMERGENT surgical eval:
    • Genitalia – Urology
    • Buttocks, perineum, abdomen – EGS
    • Upper extremity (shoulder to hand) – Hand
    • Lower extremity (hip to toes) – Ortho

 

Pressure Injury

  • If concerned for sepsis, consult EGS
  • If EGS deems no URGENT or EMERGENT surgical needs, consult Complex Wound
  • If EGS recommends consult to plastic surgery for “flap, debridement, wound care, etc.” and there are no URGENT or EMERGENT surgical needs, consult Complex Wound

 

Simple and Complex Wound Service Hours:

  • Both services are Monday through Friday
  • Consults placed on weekends and holidays are addressed on the next business day
  • If there is an urgent/emergent wound need i.e. needs surgery for debridement or I&D then consult the appropriate surgical service
  • While awaiting consultation, utilize the wound orders below to initiate topical care

 

Order Wound Care Until Consult Complete:

  • Superficial wounds
    • Stage 1 or 2 Pressure injuries, Moisture Associated Skin Damage, Skin Tears
      • Order “Adult skin Care Guidelines” and use the order set to guide you
    • Shallow Stage 3 (i.e., <1cm deep), diabetic foot ulcers
      • Order “Wound Care”: Frequency 2x weekly and prn; Cleanse with NS; Protect periwound with Mepilex foam (type in comments)
  • Painful superficial wounds no infection (i.e. vasculitis, PG, calciphylaxis)
    • Order “Wound Care”: Frequency 2 times daily; Cleanse with NS; Apply Vaseline; Protect periwound with Xeroform and dry gauze (type in comments)
      • If wound is on the hand, arm, foot, or lower leg consider wrapping in Kerlix
      • If wound is on the trunk (i.e., abdomen or buttocks), consider covering with an ABD pad and secure with medipore tape
  • Infected superficial wounds
    • NOTE: Odor alone is NOT infection; wounds with necrotic tissue may have odor
    • Order “Wound Care”: Frequency 2 times daily; Cleanse with NS, Apply Silvadene; Protect periwound with Xeroform and dry gauze (type in comments)
      • If wound is on hand, arm, foot, or lower leg consider wrapping in a Kerlix
      • If wound is on the trunk (i.e., abdomen or buttocks), consider covering with an ABD pad and secure with medipore tape
    • Medication order required: Silvadene q12h; in Admin Inst put “per wound care orders”
  • All Deep wounds > 1cm deep (i.e., deep stage 3, 4 or deep diabetic foot wound)
    • Order “Wound Care”: Frequency 2 times daily; Cleanse with NS, pack with Dakin’s 0.025% (1/20 strength) soaked continuous Kerlix roll; Protect Periwound with ABD pad & medipore tape (type in comments).
    • If wound care is painful, consider changing to daily dressing changes
    • Medication order required: Dakin’s 0.025% solution q12h; in Admin Inst put “per wound care orders”
  • Deep tissue injury Pressure injury
    • Medication order required: Venelex (balsam peru- castor oil) ointment q4h; in Admin Inst put location to apply ointment and put “no dressing”
  • Fungating mass
    • Order “Wound Care”: Frequency 2 times daily; Cleanse with baby shampoo and water, NS, Metrogel (type in comments); Protect with Xeroform, ABD pad, medipore tape
    • Medication order required: metrogel q12h; in Admin Inst put “per wound care orders”
  • Wound VAC present
    • Vanderbilt surgeon – consult Vanderbilt provider to provide care
      • Ensure connected to VUMC wound VAC. Pt shouldn’t use home unit while admitted
      • Order “nursing communication” to “Obtain wound VAC hospital machine and canister from service center to connect pt to hospital machine.”
      • Wound VAC should not be left without suction for more than 2 hours
      • Settings: 125 mmHg continuous
    • Non VUMC surgeon (i.e., gets wound care at outside hospital/wound care center)
      • Discontinue wound VAC as soon as possible
      • Remove all of the clear plastic drape just like you would remove tape
      • Remove all of the sponge just like you would remove gauze packing
      • Examine the wound to ensure no residual sponge by gently probing site
      • Rinse with saline, initiate care based wound type as above
  • Leg Wrap present (i.e., Unna’s boot, ACE and 2, 3, or 4 layer compression)
    • Remove by cutting the wrap off
    • Assess the wound and order dressing based on type of wound as above
    • Order ACE bandage wrapped toe-to-knee. Remove q12h to assess skin
  • Debridement Needed
    • Complex wound care can provide non-urgent/non-emergent bedside debridement
    • The presence of necrotic, odorous, black, grey, yellow or loose dead debris does not require emergent or urgent debridement by a surgical service and in most cases can be managed with dressings described above until wound consult team can assess pt