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Wound Bed Preparation – TIME Mnemonic

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As we have seen, the TIME mnemonic can be used to capture the fundamental principles of wound bed preparation.1,2 Become a professional at appropriate dressing selection for the different stages of wound healing within the TIME trick. As no single wound dressing is suitable for all wound types or healing stages, wounds should be assessed…

Mistaking COVID-19 Symptoms as Pressure Injuries
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Mistaking COVID-19 Symptoms as Pressure Injuries

Patients with COVID-19 may be especially susceptible to unavoidable pressure injuries because of the way the COVID-19 virus interferes with the human body’s normal processes.  Background: What is Considered an Unavoidable Pressure Injury? The National Pressure Ulcer Advisory Panel (NPUAP) has defined an unavoidable pressure injury as one where the proper evaluation was completed and…

Diagnosing Wound Infections: Types of Wound Cultures

Diagnosing Wound Infections: Types of Wound Cultures

Your patient arrives a day early for a scheduled dressing change. As you prepare to remove and change the bandage, the patient tells you that he has had increased pain in the days since the last dressing change, and also an increased amount of drainage which you can see for yourself. You take the dressing…

Diabetic Foot Ulcer Classification Systems
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Diabetic Foot Ulcer Classification Systems

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It is crucial to apply a standardized measurement system to evaluate whether a diabetic foot ulcer is responding to care, as a result several classification systems have been proposed. At the present time no specific system has been universally accepted.  Even so, most clinicians use one of the available systems when assessing and documenting a diabetic ulcer. In this article we…

How to Measure Wound Undermining

How to Measure Wound Undermining

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 Wound Undermining Wound undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt.  The amount of undermining is the distance from the…

Pressure Ulcer – Stage IV
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Pressure Ulcer – Stage IV

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Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury….

Wound Assessment: Assessing the Periwound and Surrounding Skin

Wound Assessment: Assessing the Periwound and Surrounding Skin

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In addition to noting the characteristics of the wound itself, clinicians should also examine the periwound and the surrounding skin, comparing this tissue to the skin outside the affected area, as well as comparing the opposite (contralateral) side where possible. Structure and Quality When assessing the periwound and surrounding skin, the following should be noted:…

Wound Assessment- Wound Drainage and Odor

Wound Assessment- Wound Drainage and Odor

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When assessing wounds, it is important to assess the amount and type of wound drainage, as well as any odor associated with the wound. Drainage and odor can provide important clues regarding wound health, such as the possible presence of infection. Wound Drainage Wound drainage can be described according to the following four characteristics/descriptors: Type-…