Risk Assessment

WoundSource Practice Accelerator's picture
Clinical Challenges in Diagnosing Infected Wounds

by the WoundSource Editors

Given the impact of infection on delayed wound healing, determining the presence of colonization and infection is imperative to achieving healed outcomes.Chronic wounds are always contaminated, and timely implementation of management and treatment interventions is a key component of the plan of care.

WoundSource Practice Accelerator's picture
complications associated with MASD

by the WoundSource Editors

Best practice in skin care focuses on the prevention of skin breakdown and the treatment of persons with altered skin integrity. When we ask what causes skin damage we should consider the conditions that can harm the skin, including excessive moisture and overhydration, altered pH of the skin, the presence of fecal enzymes and pathogens, and characteristics of incontinence such as the volume and frequency of the output and whether the output is urine, feces, or both. If left untreated or not treated appropriately, moisture-associated skin damage or MASD can lead to further complications such as Candida infections, bacterial overgrowth, pressure injuries, and medical adhesive-related skin injury (MARSI). These can occur individually or overlap, which can make them even more difficult to manage. Today our focus is to discuss each of these complications of MASD in more detail and address some of the most common issues leading to their development.

Holly Hovan's picture
patient repositioning

By Holly Hovan MSN, APRN, CWOCN-AP

Friction and shear… what’s the difference and how do they cause pressure injuries? Are wounds caused by friction and shear classified as pressure injuries? What’s the easiest way to explain the differences between these critical components of the Braden Scale for Predicting Pressure Sore Risk® that are not always understood? How do I know if my patient is at risk?

Holly Hovan's picture
patient mobility and activity

By Holly Hovan MSN, APRN, CWOCN-AP

The Braden Scale for Predicting Pressure Sore Risk® category of activity focuses on how much (or how little) the resident can move independently. A resident can score from 1 to 4 in this category, 1 being bedfast and 4 being no real limitations. It is important to keep in mind that residents who are chairfast or bedfast are almost always at risk for skin breakdown

Blog Category: 
Holly Hovan's picture
enteral nutrition feeding

By Holly Hovan MSN, APRN, CWOCN-AP

A common misconception by nurses is sometimes predicting nutritional status based on a resident's weight. Weight is not always a good predictor of nutritional status. Nutritional status is determined by many factors and by looking at the big picture.

Blog Category: 
Holly Hovan's picture
Moisture on Skin

By Holly Hovan MSN, APRN, CWOCN-AP

When nurses hear the term moisture, they usually almost always think of urinary or fecal incontinence, or both. There are actually several other reasons why a patient could be moist. Continued moisture breaks down the skin, especially when the pH of the aggravating agent is lower (urine, stomach contents—think fistula, stool). When there is too much moisture in contact with our skin for too long, we become vulnerable to this moisture, and our skin breaks down. Increased moisture places a patient at risk for a pressure injury as the skin is already in a fragile state.

Jeffrey M. Levine's picture

By Jeffrey Levine MD

Pressure injury prevention and management are sometimes overlooked in the hospital setting, where the focus is generally on acute illness. Given the immense implications in terms of cost, complications, reputation, and risk management, it is in the interest of all facilities to maximize quality of care with regard to wounds. This post will offer some suggestions on how this can be accomplished in hospitals by tweaking the system for maximum quality.

Blog Category: 
Martin Vera's picture
diabetic foot ulcer

By Martin D. Vera LVN, CWS

In this last of our three-part series on lower extremity wounds, we will focus our attention on diabetic foot/neuropathic ulcers. Research indicates that the United States national average for diabetes mellitus (DM) accounts for a little over 8% of the nation, or roughly over 18 million Americans afflicted with this disease—what the industry refers to "the silent killer" for the amount of damage it causes. DM has the capacity to affect vision and circulation, as well as increase the incidence of stroke and renal disease, just to name a few associated problems. Over 20% of individuals with diabetes will develop ulcerations, with a recurrence rate of over 50% for diabetic foot ulcers (DFUs) alone. Overall, lower extremity wounds have recurrence rate of 40-90%. We have our work cut out for us. So, let's put our deuces up, recognize early intervention, and try our best to manage and prevent complications associated with DM.

Blog Category: 
WoundSource Editors's picture
WoundSource 2017

By Miranda Henry, Editorial Director of WoundSource

Twenty years ago, WoundSource™ became the first-ever comprehensive wound care reference guide for clinicians. It contained just nine product categories and did not yet include such innovations as hand-held wound assessment systems and cellular-based wound treatments, which have now become a part of standard wound management practice.

Blog Category: 
Martin Vera's picture
venous assessment

By Martin D. Vera, LVN, CWS

Wound clinicians across the nation (and the world) are commonly faced with the difficult task of managing lower extremity wounds. Lower extremity wounds come in many different forms. We are not faced with a generic type, but several—in fact, we never know what we'll be presented with day-to-day.

Blog Category: