04082020-fullbinder

Medline Canada 

Skin Health and Advanced Wound 
Management Program 

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Disclaimer 

The following binder contents are provided as information for Health Care Professionals and to 
serve as a guide to Wound and Skin Care Prevention, Assessment and Management, but not to 
replace the clinical judgement at the bedside. The information contained within is recommended 
to be used as a guide only. 
This document may not be copied or used without permission from Medline Canada Corp. 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Table of Contents 

  Introductory Letter & Educational Resources 

Section 1:    

Section 2:     Pressure Injury Staging  

Section 3:     Wound Assessment & Documentation 

Section 4:     Glossary of Terms 

Section 5:     Skin Care  

Section 6:     Skin Tear Prevention & Management                                                                          

Section 7:     Head to Toe Assessment  

Section 8:     Moisture Associated Skin Damage 

Section 9:     Pressure Injury Prevention & Management                                                       

Section 10:   Diabetic Foot Ulcers                                                                                                               

Section 11:   Lower Leg Assessment & Compression Therapy                                      

Section 12:   Allied Health Care Worker Module  

Section 13:   Wound Care Algorithms                                  

Section 14:   Product Categories and Crosses 

 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Section 1:  
Introductory Letter & 
Educational Resources 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

 

Dear Colleagues, 
 

The world of advanced wound care products has increased vastly in the past ten years. The 
Medline and Medical Mart clinical team recognizes that keeping abreast of these advances can 
be a full time job. 
The clinical team at Medline has created this binder to assist with your facilities with ongoing 
wound care education. 

We have endeavored to include information that we hope will encourage critical thinking skills 
in your registered staff, thereby increasing their knowledge base and confidence in the area of 
wound and skin care. 

To begin we have included this list of references to assist in the creation of policies and 
procedures: 

 

1. Registered Nurses Association of Ontario ‐ www.rnao.ca – Best Practice Guidelines are 
no charge to download i.e. 

‐Assessment and Management of Foot Ulcers for People with Diabetes 
 

‐Assessment and Management of Pressure Injuries for the Interprofessional Team, 3rd Edition 

‐Assessment and Management of Venous Leg Ulcers 

 

2. Wounds Canada – this is an excellent association where one membership gives you access 
to the Wound Care Canada Journal, Diabetic Foot Canada e‐Journal, annual conference 
information and numerous other educational resources 

 

3. International Skin Tear Advisory Panel ‐ www.skintears.org 

 

4. Ontario Hospital Association ‐ www.oha.com‐ several different learning modules: on‐
line and in class courses. 

 

 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

5. Additional Internet Resources Include : 

 

 Nurses Specializing in Wound Ostomy and Continence – www.nswoc.ca 
 

 Lower Extremity Amputation Prevention Program ‐ www.hrsa.gov 
 

 Wound, Ostomy and Continence Nurses Society ‐ www.wocn.org 

 

 Registered Practical Nurses Association of Ontario‐ www.rpnao.org 
 

 National Pressure Ulcer Advisory Panel‐ www.npuap.org 
 

 Canadian Diabetes Association‐ www.diabetes.ca 

 
 
 

We look forward to working in partnership with your facility. 
 
 

 

Sincerely, 

 
 
 

Deanna Lundstrom, BScN|Director of Clinical – Skin Health and Advanced Wound Management 
 
Sue Savoie, RN, BScN| Clinical Specialist Support, Skin Health and Advanced Wound Management 
 
 

 

Email [email protected] 
 

Email [email protected] 

 
 

 

“To  provide  quality  medical  products  with  superior  value  to  healthcare 

providers and end users, improving patient care and the quality of 

people’s lives” 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Educational Resources 

      https://www.woundscanada.ca 
 
   
 
Wounds Canada   

 Best Practice Guidelines 
 Conferences 
 Product picker poster 
 Quick reference guides 

   

Agency for Healthcare Research and Quality (AHRQ  http://www.ahrq.gov 
previously AHCPR) 

Nurses Specializing in Wound Ostomy Continence Nursing      nswoc.ca 

Canadian Diabetes Association  www.diabetes.ca/about‐cda 

Connecting Learners with Knowledge  www.clwk.ca 

Diabetic Foot Care  www.diabeticfootcanadajournal.com 

Diabetic Foot Education  www.diabeticfootcommunity.ca 

ISTAP  http://www.skintears.org/pdf/Skin‐Tear‐ 
Resource‐Kit.pdf 

MOHLTC  www.mohltc.ca 

National Pressure Ulcer Advisory Panel  http://www.npuap.org 

Registered Nurses Association of Ontario  www.myrnao.ca 

Safer Healthcare Now  www.patientsafetyinstitute.ca 
http://www.worldwidewounds.com 
World Wide Wounds 

 

 

Medline Canada 

5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Section 2:  
Pressure Injury Staging 

 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

     
Deep Tissue 
Pressure Injury  Stage 1  Stage 2 
Pressure Injury  Pressure Injury 
 

 
 

    
Stage 2 Pressure Injury: 
Deep Tissue Pressure Injury:  Stage 1 Pressure Injury:  Partial‐thickness skin loss 
with exposed dermis 
Persistent non‐blanchable deep  Non‐blanchable  ‐ Partial‐thickness loss of skin 
with exposed dermis. The 
red, maroon or purple  erythema of intact skin  wound bed is viable, pink or 
red, moist, and may also 
discoloration  – Intact skin with an area  present as an intact or 
ruptured serum‐filled blister. 
‐ Intact or non‐intact skin with  of non‐blanchable  Adipose (fat) is not visible and 
deeper tissues are not visible. 
localized area of persistent non‐  erythema, which may  Granulation tissue, slough and 
eschar are not present. These 
blanchable deep red, maroon,  appear differently in  injuries commonly result from 
adverse microclimate and 
purple discoloration or epidermal  darkly pigmented skin.  shear in the skin over the 
pelvis and shear in the heel. 
separation revealing a dark  Presence of blanchable  This stage should not be used 
to describe moisture 
wound bed or blood filled blister.  erythema or changes in  associated skin damage 
(MASD) including incontinence 
Pain and temperature change  sensation, temperature,  associated dermatitis (IAD), 
intertriginous dermatitis (ITD), 
often precede skin color changes.  or firmness may precede  medical adhesive related skin 
injury (MARSI), or traumatic 
Discoloration may appear  visual changes. Color  wounds (skin tears, burns, 
abrasions). NPUAP 2016 
differently in darkly pigmented  changes do not include 

skin. This injury results from  purple or maroon 

intense and/or prolonged  discoloration; these may 

pressure and shear forces at the  indicate deep tissue 

bone‐muscle interface. The  pressure injury. 

wound may evolve rapidly to  NPUAP 2016 

reveal the actual extent of tissue 

injury, or may resolve without 

tissue loss. If necrotic tissue, 

subcutaneous tissue, granulation 

tissue, fascia, muscle or other 

underlying structures are visible, 

this indicates a full thickness 

pressure injury (Unstageable, 

Stage 3 or Stage 4). Do not use 

DTPI to describe vascular, 

traumatic, neuropathic, or 

dermatologic conditions. 

   NPUAP 2016 

New Staging‐ Medical Device Related Pressure

     

Stage 3  Stage 4  Unstageable 
Pressure Injury  Pressure Injury  Pressure Injury 

     
Stage 3 Pressure Injury: Full‐  Stage Pressure Injury: Full‐ 
thickness skin loss  thickness skin and tissue loss  Unstageable Pressure Injury: 
‐ Full‐thickness loss of skin, in  ‐ Full‐thickness skin and tissue  Obscured full‐thickness skin 
which adipose (fat) is visible in  loss with exposed or directly  and tissue loss 
the ulcer and granulation tissue  palpable fascia, muscle,  ‐ Full‐thickness skin and 
and epibole (rolled wound  tendon, ligament, cartilage or  tissue loss in which the 
edges) are often present.  bone in the ulcer. Slough  extent of tissue damage 
Slough and/or eschar may be  and/or eschar may be visible.  within the ulcer cannot be 
visible. The depth of tissue  Epibole (rolled edges),  confirmed because it is 
damage varies by anatomical  undermining and/or tunneling  obscured by slough or 
location; areas of significant  often occur. Depth varies by  eschar. If slough or eschar is 
adiposity can develop deep  anatomical location. If slough  removed, a Stage 3 or Stage 4 
wounds. Undermining and  or eschar obscures the extent  pressure injury will be 
tunneling may occur. Fascia,  of tissue loss this is an  revealed. Stable eschar (i.e. 
muscle, tendon, ligament,  Unstageable Pressure Injury.  dry, adherent, intact without 
cartilage and/or bone are not  NPUAP 2016  erythema or fluctuance) on 
exposed. If slough or eschar  an ischemic limb or the 
obscures the extent of tissue  heel(s) should not be 
loss this is an Unstageable  removed. NPUAP 2016 
Pressure Injury. NPUAP 2016 

e Injury & Mucosal Membrane Pressure Injury  

Section 3:  
Wound Assessment & 
Documentation 

 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Wound Assessment & Documentation  

Wound Assessment: 

1. Location 
2. Measuring wound: 

o Length is the measurement from head to toe, at the longest part of the wound   
o Width is from hip to hip at the widest part of the wound 
o Depth is the deepest part of the wound using a wound probe 
3. Odour‐ Assess after cleansing wound 
 No odour, strong, foul, pungeant, fecal, musty , sweet  
4. Undermining‐ loss of tissue that occurs under intact skin under the wound edges 
Tunneling‐ narrow opening that extends from any part of the wound through the subcutaneous tissue or 
muscle Fistula‐ abnormal connection between 2 different parts of the body ie. From the wound to an organ 

 

5. Wound Edges: 
 Flat 
 Rolled (Epibole) 
 Raised  
 Epithelialized 

 
 

6. Drainage Description: 
 Serous‐ Straw colored 
 Purulent ‐ cloudy yellow, green drainage; may be thin or thick 
 Sero‐sanguinous ‐ is a combination of blood and serous 
drainage. The drainage would be thin watery, pale red or pink  
 Sanguinous‐ frank red blood 

 

 

Drainage Quantity Descriptions: 

 None‐ no exudate on dressing 
 Scant‐ minimal exudate on dressing 
 Small‐ less than 25% of dressing is covered in exudate 
 Moderate‐ between 24%‐50%  
 Large‐ more than 75% up to complete dressing is covered in exudate 
 Copious‐ dressing is completed saturated requiring frequent changes   

 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

7. Edema‐ Using your thumb and applying gentle pressure to the leg above the medial malleolus or on the 
top  of  the  foot.  Hold  for  10‐15  seconds  prior  to  removing.  Measure  the  depth  of  the  indentation. 
Describe as follows: 

Grade 1: 0‐2 mm depression, immediate rebound 
Grade 2: 3‐4 mm deep pit, a 
few seconds to rebound  
Grade 3: 5‐6 mm deep pit, >10‐
12 seconds to rebound 
Grade 4: 6‐8 mm deep pit, >20 seconds to rebound 
 
8. ABPI: Assess dorsalis pedis and posterior tibial pulses. Add picture? 
An ABPI (Ankle Brachial Pulse Index) is an integral part to a lower leg assessment  

 

 
9. Increasing pain maybe an indicator that the wound is worsening and should be 
assessed for possible infection. 

 

 Diabetic foot ulcer, where the resident suffers from loss of sensation, that 
suddenly goes from no sensation to painful needs immediate 
investigation 

 
10. Monitor for variances from assessment with each dressing change. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Wound Cleansing 
 

 Use normal saline, Ringer’s lactate, sterile water or non‐cytoxic wound cleansers for wound 
cleansing ‐ at room temperature 

 RNAO BPG recommends cleansing with 100‐150 cc should be done with each dressing change 
 To ensure cleansing of the wound base using a 35 cc syringe with a 19 G angio cath or an 18 G 

blunt cannula will provide the necessary PSI to dislodge debris from the wound base. 
Alternatively use a 100 ml normal saline squeeze bottle 

 
 
 

As per RNAO Best Practice Guidelines: A thorough assessment will include: 

 

 Wound Etiology 
 General health status, preference, goals of care and environment 

o Concurrent diseases, Cardiac, Diabetes, Arthritis, Cancer, Auto Immune Disease, 
Renal Failure 

 Lifestyle: Smokers, Obesity 
 Quality of life: Pain management, Mobility, Client expectations 
 Exudate: type and amount 
 Risk of infection 
 Risk of recurrence 
 Phase of the wound healing process; 
 Comfort and cosmetic appearance; 
 Where and by whom the dressing will be changed 
 Adjunctive therapies 
 Consider caregiver time when selecting a dressing 
 Allergies 
 Medication: Plavix, Methotrexate, Blood thinners 

 

Consider the following criteria when selecting an interactive dressing: 

o Maintains a moist environment 
o Controls wound exudate 
o Maintains a consistent wound bed temperature 

 Maintains its integrity and does not leave fibres or foreign substances within the wound 
 Does not cause trauma to wound bed on removal 

 
 
 
 
 
 

 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Wound Assessment & Documentation 

 

 

Wound Measurement 
Best practice dictates that wounds be measured in a consistent manner, using the Clock Method 
for point marking. Where the wound is considered as a face of a clock. 
 

Location 

 
Measure length from head to toe  

 
 
 
 
 
 
 
 
 

Measure width along next widest aspect of wound at a 90 degree angle to the length 
Measure depth by gently inserting a sterile cotton tipped applicator into the deepest portion of 
the wound. Place gloved fingers along the applicator at skin level and remove applicator. 
Without moving fingers, line up the applicator along measuring guide and document the 
measurement. 
 
 
 
 
 
 
 
 
 
Measurement and Documentation of Undermining , Tunneling and Sinus 
 The location of undermining and tunneling should be documented. 

o Sinus Tracts are identified when unable to identify the base of the wound when using a 
cotton tipped applicator 

 The “clock face” is oriented according to the location of the wound on the client’s body, with the 
head of the body at 12 o’clock and the feet at 6 o’clock. 

 With gloved hand insert the cotton‐tipped applicator into the undermined or tunneled areas 

 Grasp the applicator where it meets the wound edge 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

 Pull the applicator out, place it next to the measuring guide, and document the measurement 
 

Example of undermining

 
 
 
 
 
 
 

Example of tunnelin 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

 

Section 4:  

Glossary of Terms 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Wound Care Skin
Glossary of Terms Health

2019-04-23

Welcome.

This handy Glossary of Definitions was created to help you
understand, assess and manage a wide range of skin injuries.
You’ll also find suggested products to help promote healing
and improve skin outcomes.

When it comes to wound care, these are the terms you
should know.

Wound Care Glossary: Alginate > Biofilm 2019-04-23

AAlngoinn-attoexic('ablijop'noālyt)mer with Antiseptic (an-t -'sep-tik) A substance that
absorbent and hemostatic kills microorganisms.
characteristics, sourced from Approximate ( -'präk-s -m t) To bring together, usually
brown seaweed used in referring to cut edges of tissue as in a surgical incision.
wound dressings.
Arterial Ulcer (är-'tir-ē- l ' l-s r)
Suggested products include A wound caused by decreased or
Maxorb® II and Maxorb ES. absent arterial blood flow.

Altered Tissue Perfusion ('ôlt r 'tiSHōō p r'fyōōZH( )n) sAtriftfeerniiongscolef arortseirsie(säwr-'htiirc-hē-cōa-nskclau-'sreō-rsedsu)cTehdicbkloeondinfgloawndto
Oxygenated blood flow to tissue is impaired or reduced.
organs and tissues.
Ankle-Brachial Index (ABI) Autolysis, Autolytic Debridement
(o-'tä-l -s s, o-t -'li-tik di-'brēd-m nt) A highly selective
s('carNeGenk(fo)lr'pberārikpēhel,r'ablraarkt-e'riny'ddieskesa)seA(nPoAnDin).vAaBsiIvies method to process that occurs naturally in wounds that involves
a comparison
TheraHoney®
of blood pressure measured at the ankle and arm. A low Suggested products include
TheraHoney Gel, HD, and sheet
ankle-brachial index number indicates impaired blood flow. support autolytic debridement.

Compression therapy should be avoided until vascular studies breakdown of nonviable tissue and cellular debris by the body’s
white blood cells known as macrophages.
are completed. Avascular ( (')ā-'vas-ky -l r) Lacking blood flow.
Bdeascttreoryisc bidaaclte(rbiaa.k-'tir- -'sī-d l) An agent that
tAhnetriebpalcictaetrioianla(nadn'gtīrboawkt'thiroēf l) A means of disrupting Bgraocwtethrioofs btaactticeri(ab.ak-'tir-ē-ō-'stat) An agent that prevents
bacteria. Can also refer to

disinfection or elimination of bacteria. A broad term that

includes antibiotics, antiseptics and disinfectants.

tAhnattidbeiosttriocy(saonr'tiīnbhī'äibdiitks)gAronwatthuroafl or synthetic medication
bacteria. Can be given by

mouth or feeding tube, IV, or applied directly to affected area.

Not effective against viruses.

Antimicrobial (an-ti-mī-'krō-bē- l) An agent that kills
or inhibits growth of microorganisms. A broad term that

includes antiseptics, disinfectants and antibiotics.

e

Suggested products include Opticell
Ag, Maxorb Ag, Ag+, and SilvaSorb
gel and powder contain silver which
has antimicrobial properties.

3 of 12

Wound Care Glossary: Blanching > Connective Tissue 2019-04-23

MBiiocrfiolomrga('nbiis-(m')ōs-w'fihlmic)h clump sourced from shellfish
together and form a protective film, exoskeletons used
which is not affected by topical to control bleeding
antibiotics and not recognized by and treat wounds.
white blood cells. See Chytoform.
Blanching (bla n(t)∫iŋ) Skin pales or
Suggested products
becomes white due to temporary with chytoform include
reduction of blood flow, such as OpticellTM Opticell and
when applying gentle pressure. Opticell Ag
Skin tone returns to normal
when Chronic or Stalled Wound
pressure is removed. Wounds which have stopped progressing through the healing

Suggested product: process over a period
Maxorb® Extra Ag+. of 3 months, or wounds
which have not healed
wtChaarlllb-s's.oeWxl-yhymen-e'liōtnhsc)yoSrl pCoofetrl,alautbelodsosienrbt(oeCnaMtdfCirb)ees(rsksiändrg-e',brwiävoke-udsnēfd-r'omdmrea-pinlaangtecell in an expected period
has a gelling effect on CMC. of time.

fCoarvmitaatitoinonof(o'kpae-nv -'tā-sh n) The CChhiytotsoafno-rbmase('dkītgoe'lflôinrgm)
space in a body
Suggested wound dressings include
tissue or an organ. Puracol PlusTM and Puracol® Plus Ag+.

fiber present in Opticell and Opticell Ag.

aCriercauomr efencreirncltiniagla(slimr'bk. mf 'ren(t)SH( )l) Surrounding an

Cell Migration (sel mī'grāSH( )n) Movement of cells across Collagen
a wound bed in the healing process. ('kä-l -j n) The main
supportive protein of
iCnefellcutlioitnisof('sskeiln-yan-'dlī-stusb)cBuatacnteeroiauls skin and connective
tissues, typically with redness and tissue. A part of
swelling, usually painful. connective tissue scar
formation during the wound healing process.

Collagenase (k -'la-j - nās) An enzyme that specifically
breaks down collagen. '

Chitosan ('kīto san) A biologic material Suggested products include CoFlex TLC, Threeflex, and Fourflex.
'
Suggested product: PluroGel® has been

demonstrated to be effective on chronic

or stalled wounds.

Colonized (w'koäu-lnd-',noīzreind)thPerebsoednyctehoaftbcaacutseerinaoosrygmerpmtosms
on skin, in a

or illness.

Compression Therapy (k m'preSH n 'THer pē) Application

4 of 12

Wound Care Glossary: Contamination > Extracellular Matrix (ECM) 2019-04-23

of external pressure to an extremity in order to control contains blood vessels, nerve endings, hair follicles, sebaceous
edema and aid the return of venous blood to the heart. (oil) glands, and nerves.
Can be achieved by multi-layer wraps, such as CoFlex TLC,
Threeflex, and Fourflex, or a powered device (compression Desiccated ('de-si-'kā-t d) Dehydrated, dried up, lack
pump) that cycles inflation and deflation of air chambers in a of moisture.
reusable wrap.

Connective Tissue (k 'nektiv 'tiSHōō) A framework of Dynamic Support Surface (dī'namik s 'pôrt 's rf s) A
protein fibers and cells that surrounds, supports, and holds powered support surface that is designed to cyclically change

together tissues such as fat, ligaments, tendons, cartilage, its support characteristics such as alternating pressure or

and bone. lateral rotation.

Contamination (k Ecchymosis (d'eu-ekit-o'mbōlo-sods)coAlletyctpiengofubnrdueirsethreessuklitnin. g in
polluting, poisoning, blotching skin
onr-'mtaa-mking-'nimā-pshuren;)aTwheouancdtiownhoicfhsoiling,

contains infectious or foreign matter. Edema (i-'dē-m ) An abnormal, localized or generalized,

Contraction (k n-'trak-sh n) The buildup of fluid in body tissues.
pulling together of wound edges in Endothelium, Endothelial

the healing process.

tChyattoktiollsxcicell(s's.ī-t -'täk-sik) An agent (end 'THēlē m) A layer of flat cells lining the interior of
blood vessels.

Envelopment (en-vel-uh p-muh nt)
Ability of a support surface to fit
around body contours.

Debridement (d 'brēdm nt) The Eprnoztyeimn esec('reent-e'zdīmby) Specialized
removal of unhealthy or dead tissue cells that
from a wound. Can be autolytic,
enzymatic, mechanical, or sharp. See acts as catalyst to induce
Autolytic Debridement.
biochemical changes.
Deep Vein Thrombosis (DVT) (dēp vān THräm'bōs s) The
formation of a blood clot in a deep vein.e

Dehiscence (di-'hi-s n(t)s) Rupture of a surgical incision. Epibole ('epibōlē) The edges of a wound have rolled down or
curled under which stops healing.
Denuded (d 'n(y)ōōd) Loss of the skin’s surface layer. See
EPIDERMIS. Epidermis ( e-p -'d r-m s)
The surface la' yer of skin.
Dermal, Dermis
('d rm( )l, 'd rm s) Layer of skin under the epidermis which

5 of 12

Wound Care Glossary: Exudate > Hydrophilic 2019-04-23

mEpigitrhateeliaaclrizoasstinoenw('teis-spue-'tohnēa-lēw-o-uln-d'zsāu-rsfhacne)aCsepllasrt of the Eblxouoddacteells(,eakn-ds(yce)üll-u'dlaārt)deFbluriids wmhaidche up of cells, proteins, red
proliferation phase of wound healing. oozes or drains from a

wound. If infectious white blood cells may be detected.

mEreymthberamnaes(r'eersu'lTtiHnēgmfro)mRdeidlanteastsioonf the skin or mucous Fascia ('fā-sh(ē-) ) A flat layer of connective tissue, mainly
and congestion collagen, covering muscles and separating tissues.

of capillaries. Fibroblast ('fī-br - blast) A
cell found in connect'ive tissue
Eschar ('eskär) Necrotic
or devitalized tissue on the responsible for making proteins that
surface of a wound. This
can be black, brown, gray, make up collagen.
or yellow. The tissue can be

Suggested absorbent dressings
include OpticellTM and Optilock.

loose or firmly adherent; hard, soft, or somewhat soggy. Fibrosis, Fibrotic (fī'brōs s, fī-'brō-s s) The formation of
excessive fibrous tissue during a reparative or reactive process.
ēE-x'āc-oshriant)ioLnine(\ar(')meka-r'skksōorr-
abrasions of the skin caused Fissure ('fi-sh r) Linear crack or split in the epidermis; not as
by scratching. Incorrectly deep as a laceration.

Suggested product Hyalomatrix Fluctuant ('fl k-ch -w nt) A
acts as a scaffold to promote description of fluid under the skin
fibroblast proliferation. which can be detected by applying
gentle pressure. The area “gives” and
used to refer to erosion or destruction of the skin from may feel mushy, soft, or boggy.
moisture or incontinence.
Friable ('frī- -b l) Readily crumbled;
Extracellular Matrix N(EoCnM-c)ell(u'elak-rstr
-'sel-y -l r 'mā-triks) brittle, fragile tissue.

material made by cells and released Friction ('frik-sh n) Resistance of motion between two
bodies in contact sliding against each other e.g. sacrum and
bed, foot in a poorly fitting shoe. Can cause skin trauma
such as blisters, abrasions, tears, and contribute to pressure
injury development.

Full Thickness (f l 'THikn s) Tissue
destruction of epidermis and dermis
extending into the subcutaneous
layer or deeper.

into the surrounding medium. The main function is to support
surrounding cells structurally and biochemically. Adhesion
of cells, communication between cells, and tissue segregation
are some of the other functions of the ECM.

6 of 12

Wound Care Glossary: Hydrophobic > Interface Pressure 2019-04-23

Fdeusntgroicyisdfiuanl g(u'fs.n-j -'sī-d l) A chemical or organism thate s) Maintenance and regulation to achieve stability needed for
e cells and organisms to properly function.

Gaiter Area, Gaiter Region ('gād r 'erē 'gād r 'rēj n) Hydrophilic ('hī-dr -'fi-lik) Water attracting.
A term used to describe the area from below the knee to above WHyadterrorpehpoelbliincg.('hī-dr -'fō-bik)

the ankle.

Gangrene ('gaŋ- grēn) Body tissue death due to infection or sHuybdmreortshioenrainpywa(t'heīr-,dorr -'ther- -pē) Use of whirlpool,
inadequate blood'flow. Can be dry or moist; tissue can have pressurized fluid for cleansing.

pale to red, blue to purple, or brown to black discoloration.

Can affect digits and extremities as well as muscle and organs.

Gelatin ('je-l -t n) The result of äHky-spi-ejrb-'naār-icshOxny) gTehneraatpioynin(vHoBlvOin)g(i'nhhī-aplart-i'obnero-fik100%
degraded, or denatured, collagen oxygen in an enclosed chamber under controlled increased
atmospheric pressure. Promotes wound healing.
Suggested product PluroGel is comprised
of micelles that have hydrophilic and bHlyoopderinemcaipaill(a'hriīe-ps r-'ē-mē- ) The active process of excess
hydrophobic properties. and/or arterioles.

Hypergranulation Tissue

('hī-p rb'egyroannd-yw-h'lāa-tsihs nnee'tdi-e('d)sthoür)eOplvaecregtrioswsuteh aobf sgernatnfurloamtioan
tissue

wound; can delay wound healing.

when the three stands of collagen’s triple-helix structure are oHfyeppeidrekremraistoinsriessp('hoīn-pse rt-o'kierrri-ta-t'tioōn-s, s) Abnormal thickening
broken apart. rubbing, or pressure.

Gelatinase ('jel t nās, -āz, j 'lat n ā) A subtype of matrix Calluses and corns are forms of hyperkeratosis.
metalloproteinases '(MMPs) that spe'cifically breaks down
Hypertrophic Scarring

gelatin into amino acids and peptides. (hī-p r-'trō-fi skärēŋ) Benign, excess scar tissue which is

confined to the area of a wound.

Granulation Tissue Ian laVbiotrraoto(irny.'vē'trō) Outside a living organism, usually in
( gran-y -'lā-sh n 'ti-( )shü)
P' ink to red, cobblesto'ne-appearing tissue covering a wound

surface during the healing process. In Vivo ( in 'vēvō) Within a live
body or o'rganism.
Growth Factors ('grōth 'fak-t
r) Signaling proteins that promote wIrritihgaatgioenntl(e'i,rs-te-'agdāy-sshtrena) mFluosfhing
growth and differentiation of cells, fluid.
affect inflammation and wound

healing. Ischemia (i-'skē-mē- ) Insufficient
Healing ('hēl ēŋ) A dynamic process involving synthesis of blood flow into an area of the body

new tissue for repair of skin and soft due to narrowing or obstruction
tissue defects.
Homeostasis ('hō-mē-ō-'stā-s

7 of 12

Wound Care Glossary: Intertrigo > Nongranulating 2019-04-23

of vessels. sKcealrotiidssu('keēe-x'ltoeidn)dEinxgcebsesyivoend
Ischial Tuberosity ('is-kē- l the original injury.
tü-b -'rä-s -tē) A rounded bony
' Kennedy Terminal Ulcer
('ke-n -dē 't rm-n l ' l-s r)
prominence of the ischium, located on the lower part of the
pelvis. A weight bearing area of the body in sitting position, Suggested products include
commonly known as the sit bone. TheraHoney Sheet, Gel, HD,
and Foam.

Immersion (i-'m r-zh n) The extent of sinking into a Tissue damage of sudden onset in the sacrococcygeal area that
support surface. appears six weeks to a few days prior to death. Typically has
a pear or butterfly appearance and can be red, purple, yellow
Induration ('in-d -'rā-sh n) Localized firmness of soft tissue. or black.

Infection (in-'fek-sh n) The result of harmful microorganisms Lesion ('lē-zh n) Tissue damage due to disease or trauma.
invading the body. Symptoms can be local or systemic and
range from mild to fatal. Leukocyte ('lü-k -'sīt) A general term for different types of

iInnffleactmiomn,aotrioirnrita('tinio-nfl -'mā-sh n) Tissue reaction to injury,
characterized by redness, heat, swelling,

and pain. white blood cells which are part of
the body’s immune defense system.

TInhteeprfearpceenPdriecuslsaurrfeorc('einb-tetrw-'efāesn'pbroed-yshanrd) support surface, Lymphangitis (lim fan'jīd s)
measured in unit per area. This measurement is altered by Inflammation of the 'lymphatic
support surface stiffness, body tissue composition, and the
vessels, commonly seen as red

supported body geometry. streaks on skin near a focus of infection.

Intertrigo, Intertriginous (int- of lLyymmpphhateicdveemssael(s'liwmh(pic)h-fic-a'duēs-ems ) Damage to or removal of
r-'trij- -n s) Superficial irritation lymph fluid to accumulate with
caused by contact and rubbing

resultant swelling in an extremity.

Lysis ('lī-s s) Destruction of cell walls.

opposing skin surfaces, particularly folds and creases. Skin eMpaidceerrmatailolanye('rm(sat-rsat-u'rmā-schornne) uOmv)errehsyudltriantgioinn of the outer
appears red and moist, and may be sore, burn or itch. Skin softened tissue
may crack or erode with development of oozing and fungal
infection. Ultrasorbs placed in folds can aid treatment that is pale, wrinkly and friable.
of intertrigo.

Macrophage ('ma-kr i-n'fvāojl)vAed in
white blood cell that is

identification and destruction of

pathogens and harmful organisms.

8 of 12

Wound Care Glossary: Nosocomial Infection > Pressure Redistribution 2019-04-23

Also releases cytokines as part of the inflammatory response. are considered nosocomial if they
first appear 48 hours or more after
Manuka ('män k ) A plant (leptospermum scoparium) in New admission or within 30 days after
Zealand from which pollen and nectar are extracted to produce discharge. Also known as HAI or HCAI
medical grade honey for wound care products. (health care acquired infection).

Matrix Metalloproteinases Occlusive Dressing
(MMP) ('mā-triks) A group of ( -'klü-siv 'dre-siŋ)
structurally related protein-
degrading enzymes that degrade Type of dressing that prevents air, pathogens, and liquid from

contacting a wound.

and remodel the extracellular matrix during wound healing. Odifsflploaacidnignpgre(ossf-u'lrōed ēŋ) Reducing or

Suggested product: SurePrep® by

Mottled, Mottling ('mädld, 'mät-liŋ) Vascular changes Rapid Dry.
resulting in irregular or patchy discolored skin that may appear

as reddish or purple spots, streaks, or marbling. Can be a

symptom of disease or signify end of life.

Necrosis, Necrotic using orthotics, walking boots, or total contact casts.
(n -'krō-s s, n -'krä-tik) Irreversible damage leading to tissue A necessary part of diabetic foot ulcer treatment.

death; caused by trauma, toxins, or inadequate blood flow.

Neuropathy (nu-'rä-p -thē) Autonomic, motor, or sensory tOhlaetogsroamdueaslly('ōrelēleōa'ssōemo)veNrattimurealalyndenpcraopvsiduelaltoendgoils
nerve damage. When extremities are affected this is peripheral lasting moisturization. Also refers to floating/protecting
neuropathy. Symptoms include but are not limited to: tingling, heels, relieving pressure to any area at risk of or with existing
numbness, hypersensitivity to touch, burning pain, and pressure injury.
muscle wasting.

Non-Blanchable Erythema Osmosis (äz-'mō-s s) Movement of molecules in liquid from a
less concentrated area to a more concentrated area.
(nän d'bolaenscnho'tāp-balle'ewr-he-'tnhgēe-mntle) Persistent redness of the skin
that pressure is applied. A sign of a

stage 1 pressure injury. bOysbteaoctmeryiaeliinttirsod('uäc-setdē-tōh-r'omuīg-h-t'lrī-atums)aBoornseuirngfeercyt,iofrnocmauased
wound, or via the bloodstream.
Nongranulating

(gnräannu'glarar;nf-ryee-'olāftgērŋa)nuWlaotuionndtsisusrufea.cCealonobkes smooth rather than Palpation (pal-'pā-sh n) Using the hands to touch or feel as
an indication of a part of a physical examination.

stalled wound or biofilm.

Nosocomial Infection (f'ancäil-isty--'akcōq-umirēe-dlininf-e'fcetkio-snh. Innf)ections Panniculitis a(ppp-e'nairki-nyg -'līt- s) Subcutaneous fat and
A hospital or health care inflammation as firm, thickened nodules

plaques, reddened or darkened skin over the area with

associated pain and tenderness.

9 of 12

Wound Care Glossary: Prone > Surfactant 2019-04-23

Panniculus (p -'nik-y -l s) A sheet or layer of tissue, acids, DNA, and RNA. Plastic is a synthetic polymer.
commonly describing an obese abdomen. The term
Pannus refers to corneal vascular inflammation or synovial Pressure Injury ('pre-sh r 'inj-rē) The current NPUAP
granulation tissue inflammation seen in rheumatoid term to describe localized skin and/or soft tissue damage,
arthritis. commonly over a bony area. This can be related to a device,
medical or nonmedical. It can appear as intact skin or an open
Suggested products:
Advantage Graphite wound, caused by sustained
Mattress and Equalize Aire and/or severe pressure or
shear in conjunction with
pressure. Also referred to as
Pressure Ulcer, Decubitus

Suggested products include
Remedy Essentials, Phytoplex
Hydraguard barrier creams, and
Remedy Hydraguard-D Intensive
Skin Therapy.

Partial Thickness ('pär-sh l 'THikn s) Damage involving the Capability to distribute of load over
epidermis; extending to but not through the dermis. areas of the human body which are
Pathogen (\ 'pa-th -j n) A biological agent that invades a in contact with a support surface,
host and causes illness or disease. such as Advantage Graphite and
Perfusion (\ (')p r-'fyüz) Oxygenated blood flow to tissue. Equalize Aire. Replaces the terms
Pressure Reduction, Pressure Relief.
Periwound The skin around
a wound. Ulcer, or Bedsore.

Scab Prone ('prōn) Lying in face
Pdorwesns uporesitRioend.istribution

('pre-sh r 'rē-d -'stri- bu-sh n)
Purulent ('pyur- -l nt) Composed

of, creating, or draining pus.

Pus ('p s) Thick fluid containing

dPyhianggoceclylst,em(i'cfrao-gorg-'asnīti)smAsw, ahnitde blood cell that ingests dead or leukocytes, exudate, and cellular debris which can be indicative
foreign particles. of infection or presence of a foreign body.

cPohnossisptihnogloipfiadpsh(o'fsäpsh-faōt-e'lig-proudp) A cell membrane component, Scab ('skab) Common term for a dried sanguineous crust
and fatty acids which has on the surface of a wound.

hydrophilic and hydrophobic properties.

Plantar Flexion ('plan-t r 'flek-sh n) Movement of the foot or
toes downward, “pointing” the toes.

Pliable ('plī- -b l) Bendable, flexible.

Polymers (päl m rs) Long chains of natural or synthetic
molecules. Proteins are natural polymers made up of amino

10 of 12

Wound Care Glossary: Tinea > Wound Edge 2019-04-23

Semi-Occlusive Dressings ('se-mē- -'klü-siv 'dre-siŋs) aSrielicwoanteer(r'seis-list-a'knōtn, )drGyetnoetrhael tteorumchf,oarnsdilincoonn-pooclcylmuseivres that
Dressings which are permeable to moisture vapor. when

Semi-Permeable ('se-mē-'p r-mē- Suggested products include Remedy Phytoplex Antifungal powder
-b l) and Phytoplex Antifungal cream
See Semi-Occlusive Dressings.

Senescence (si-'ne-s n(t)s) An irreversible state of aging cellse
when division stops but the cells do not die.

CSoenpdsiitsio, nSecaputisceedmbiyab(a'scetepr-isalsin\fe'scetpio-nt -'sē-mē- ) Can cause
in the blood.

illness including high fever and low blood pressure. Severe used in skin moisturizers.

cases result in tissue damage, organ failure, and death. Sinus Tract ('sī-n s 'trakt) An abnormal narrow dead space
in tissue with one open end that has the potential to form an
Formerly referred to as blood poisoning. abscess. Sinus Sinus Tract ('si-n 'trakt)
An abnormal narrow dead space in tissue with one open end
Serosanguineous (sir-ō-san-'gwin-ē- s) A type of wound
drainage referring to blood tinged clear to yellow fluid. that has the potential to form an
abscess. Can extend down or away
Shear ('shir) Exertion against a from a wound such as a pressure
surface of parallel force per unit injury. Also known as a Tunnel.
area. Comfort Glide reduces shear
during lateral transfers from bed Slough ('slü) Non-viable or dead
to cart. tissue containing fibrin, protein,
bacteria and neutrophils. Detaches
Suggested products: easily with mechanical cleansing or
Skintegrity® Wound Cleaner various types of debridement. Can
be moist or dry and varies in color

11 of 12

Wound Care Glossary: Wound Repair > Xerosis 2019-04-23

from cream to yellow to tan. types include ringworm, athlete’s
foot, and jock itch.
Stasis ('stā-s s) Referring to Trophic ('trō-fik) Refers to changes
stagnation or impairment of in tissue surrounding a wound
such as hyperpigmentation, rough
venous blood flow, particularly in bumpy skin, loss of normal skin color,

the lower extremities. decreased or absent sensation, calluses, hair loss, thick nails
along with skin temperature changes.
Stasis Dermatitis ('stā-s s d Tunnel, Tunneling ('t -n l 't-n l ēŋ) See Sinus Tract.
r-m -'tī-t s) Inflammation of 'skin Ulcer (' l-s r) An open sore; erosion or destruction of skin

on the lower extremities caused and/or underlying tissue.
TUinssdueerdmeisntirnugcti(o'nnu-ndder-r'mthīne ēeŋd)ges of
by venous stasis. Skin can be itchy, a wound which create a wound larger
than the external opening appears.
scaly, and discolored. ee

Stratum Corneum ('strā-t m -'kor-nē- m) Dead cells
comprising the outermost layer of the epidermis. Protects
the underlying layers of skin.

Subcutaneous Fat
A('sdipbo-ksyeul-a'tyāe-rnbēe-nsea'ftaht)the skin.

aSsualfsautrefa(c'staln-'tfāwt)heAncuosmedpoinuncdleaconnsetarsin. iCnrgesautelfsufrotahmataancdts
removes oil and sebum when mixed with water. Can be
irritating to sensitive skin.

Supine (su-'pīn) Lying face up.

Support Surface (s -'port 's r-f s) A mattress, seat
cushion, overlay or bed system designed specifically to
redistribute pressure, perform therapeutic functions,
manage tissue loads and alter micro‑climate.

ASucrofmacptoannetnt((o')fsclre-a'fnaske-trsnwt)hich attract and trap oil, dirt,
and
sebum and excessive oil. A
harsh surfactant can strip
skin of beneficial oils.

Tinea ('ti-nē- ) General term for a variety of contagious
fungal infections of the skin which are contagious. Common

12 of 12

Looking for more skin health
insights and expertise?

Check out our Wound Care Guidelines
available at Medline University.
This handy reference tool is your
starting point for treatment based
on wound bed characteristics.

Subscribe to Skin Health Top Stories and get the latest skin
and wound care insights, articles, videos and more delivered
straight to your inbox every month.

Learn more at MedlineSkinHealth.com

We want to hear from you.

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with us at [email protected].

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©2019 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT19W198374 / 19113493 / 69

Section 5:  

Skin Care 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

October 16 2019

Remedy 
Product 
Review

Phyto In Phytoplex

What’s the Phyto in Phytoplex?

Plant Based Complex:
• Blue‐Green Algae
• Soy Proteins
• Clove Flower Extract
• Green Tea Extract

243©2019 Medline Industries, Inc.

GREEN IS FOR CLEAN Unique Colour
PURPLE IS FOR PROPER MOISTURIZATION Coding System

BLUE IS FOR BARRIER BEFORE  Colour Coding
BREAKDOWN
• Medline was the first company 
ORANGE IS FOR OPEN SKIN to utilize a simple color‐coding 
system to make compliance for 
244©2019 Medline Industries, Inc. staff easy. The colors are based 
on functionality of the product. 
Unscented options available for 
all products. 

No Potential Irritants

Paraben free

Minimal  Sulfate free
fragrance

Aloe Free Phthalate 
free

245©2019 Medline Industries, Inc.

Hydrating 
Cleanser

246©2019 Medline Industries, Inc.

Phytoplex: Hydrating Cleanser

• Gel • Spray

– Low Suds Formulation – Mild, tear‐free

– No‐rinse, tear‐free – Leaves no scent or soapy feeling

– Can be diluted – Dimethicone film

– All ages, Oncology, ICUs – Used to cover large area

• Foam • Lotion
– Mild, tear‐free – 3‐in‐1 cleansing
– Clings where applied  – No‐rinse 
– Will remove barriers – Dimethicone film
– Dimethicone film – Trigger spray for easy application

247©2019 Medline Industries, Inc.

Nourishing 
Skin Cream

248©2019 Medline Industries, Inc.

Phytoplex: Nourishing Skin Cream

• Indications: Moisturizes dry skin, beneficial for face, hands, body and feet
• Enhanced with Phytoplex: Botanicals and essential fatty acids to help maintain the skins 

natural moisture balance 
• Oleosomes – Long Lasting Moisture
• Additional natural oils
• Leaves soothing film

249©2019 Medline Industries, Inc.

June 6 2019

HydraGuard

Phytoplex: HydraGuard®

• 24% silicone blend
• Breathable barrier protection
• Oleosome technology
• Not labeled as an OTC
• Unscented option available

251©2019 Medline Industries, Inc.

Remedy Essentials –

Zinc Protectant Paste ®

Orange is for Open Skin

Product Uses: 

– Temporarily protects and helps relieve chapped or cracked skin, including 
skin reddened or excoriated due to incontinence

– Temporarily protects minor cuts, scrapes, and burns

Directions:

– For Skin Protection: Apply as needed
– For Incontinence Associated Dermatitis (IAD): Change wet and soiled 

briefs promptly, cleanse area and allow to dry, apply to affected area as 
needed with each absorbent product change

Product Ingredients:

– Petrolatum 75%
– Zinc 20%
– Mineral Oil 5%

Ordering Information:

– MSCCA092ZP04
– Zinc Protectant Paste 113g (4oz), 12/case 
252©2019 Medline Industries, Inc.

Section 6: 

Skin Tear Prevention and 

Management 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Skin Tear 
Prevention 

and 
Management

Skin Tear Prevalence

• Skin tear prevalence is not well 
known and/or tracked, but this is 
changing

• Systematic review of studies 
worldwide : 3.3%‐22% in acute care, 
5.5%‐19.5% in Home care, 14.5% 
Palliative Care (one study only)

• US 16‐33%, Australia 10‐54%

230©2019 Medline Industries, Inc.

Journal Review

231©2019 Medline Industries, Inc.

Journal Review 

Journal of palliative care nursing, 2018, Vol 24., no 6

• Six key factors to skin tears in palliative care needs 
MMINDS (Woo, K; LeBlanc, K)
• Mechanical trauma from friction, skin tears and skin stripping
• Moisture
• Intrinsic factors
• Noxious chemical and irritants, including strong alkaline urine and feces
• Drugs and diseases of the skin (long term steroid use or psoriasis)
• Skin allergies

232©2019 Medline Industries, Inc.

Study Findings 

• 4 LTC in Western Canada
• 678 residents, 66‐94, mean age 75
• Skin tears are not among the wound types 

recorded in RAI
• Classified as acute skin tear or laceration
• P value of <0.05 for stat sign
• Prevalence was 14.7% , 15.8%
• Most common areas: knees, ankles, arms, 

shoulders 
• Wide range of drsg used: foam , non adh, clear acr, 

antimicrobial, 28% no dressing
• Men higher than women
• Relationship between risk of PI and risk of skin 

tear/s 

233©2019 Medline Industries, Inc.

ISTAP‐ Skin Tear Prevention & Management

Wounds international, 2018. LEBLANC, k ET AL.

• Intrinsic Risk Factors
• Extrinsic Risk Factors
• Causes
• Identification 
• Assessment
• Classification
• Treatment goals and product selection
• Prevention program
• HCP education 

234©2019 Medline Industries, Inc.

Skin Tear Prevention Study 

• To evaluate the effectiveness of BID  Carville,K. et al. International Wound Journal, 2014 446‐452. 
moisturizing regimen as compared to “usual” 
skin care for reducing skin tear incidence

• 14 Western Australia facilities, 980 beds 
• pH neutral, perfume‐free moisturizer on 

extremities
• 6 months of data 
• 1396 skin tears on 424 residents
• The application of moisturizer twice daily 

reduced the incidence of skin tears by almost 
50%. 

235©2019 Medline Industries, Inc.

Skin Tear Prevention and Management

236©2019 Medline Industries, Inc.

Type 1 Skin Tear / Déchirure Cutanée Type 1

1

Flap/Lambeau Linear/ Linéaire

NO SKIN LOSS SANS PERTE CUTANÉE

Linear or Flap Tear which can be  Déchirure cutanée linéaire ou un lambeau 

repositioned to cover the wound bed  qui peut être repositionné pour recouvrir 

(ISTAP 2014)  la plaie (ISTAP 2014)

1 Cleanse with normal saline. 1 Nettoyer avec une solution de saline normale.

2 Bring together wound edges with a  2 Rapprocher les rebords de la plaie avec un 

cotton tip applicator. applicateur en coton.

3 Pat skin area dry with gauze. 3 Sécher la peau avec un gaze. 
4 Apply MARATHON with linear strokes 4 Appliquer MARATHON avec un mouvement 

to reposition flap and periwound. linéaire pour repositionner le lambeau cutané 

5 Leave 2 cm coverage to periwound area  ainsi que recouvrir le périmètre de la plaie.

(see ruler on cotton tip applicator). 5 Appliquer sur une zone de 2 cm au périmètre 

de la plaie (voir règle sur l’applicateur en 

Medline Canada coton).

1‐800‐396‐6996

www.medline.ca

[email protected] Images courtesy ISTAP Copyright 2016, All rights reserved

Remove here for documentation. Retirez ici para la documentation.

1 Type 1 Skin Tear /  1 Type 1 Skin Tear / 
Déchirure Cutanée Type 1 Déchirure Cutanée Type 1

Name/Nom: Name/Nom:
Date: Date:
Staff/Personnel Initial:  Staff/Personnel Initial: 

237©2019 Medline Industries, Inc.

Type 2 Skin Tear – Dry to Scant
Déchirure Cutanée Type 2 – Sec ‐ Peu

2

PARTIAL FLAP LOSS PERTE PARTIELLE DU LAMBEAU 

CUTANÉ

Linear or Flap Tear which can be  Le lambeau ne peut être repositionné 

repositioned to cover the wound bed  pour couvrir la plaie (ISTAP 2014)
(ISTAP 2014)  1 Nettoyer avec une solution de saline 

1 Cleanse with normal saline. normale.

2 Bring together wound edges with a cotton 2 Rapprocher les rebords de la plaie avec 

tip applicator. un applicateur en coton.
3 Pat skin area dry with gauze. 3 Sécher la peau avec un gaze. 

4 Apply SUREPREP RAPID DRY to  4 Appliquer SUREPREP RAPID DRY au 

periwound skin and allow to dry. périmètre de la plaie et laisser sécher.

5 Cover with OPTIFOAM BORDER  5 Couvrir avec un OPTIFOAM BORDER 
SILICONE. SILICONE.

Medline Canada Images courtesy ISTAP Copyright 2016, All rights reserved
1‐800‐396‐6996
www.medline.ca
[email protected]

Remove here for documentation. Retirez ici para la documentation.

2 Type 2 Skin Tear /  2 Type 2 Skin Tear / 
Déchirure Cutanée Type 2 Déchirure Cutanée Type 2

Name/Nom: Name/Nom:
Date: Date:
Staff/Personnel Initial:  Staff/Personnel Initial: 

238©2019 Medline Industries, Inc.

Type 2 or 3 Skin Tear – Moderate to Heavy
Déchirure Cutanée Type 2 ou 3 – Mod à Grand

2/3

PARTIAL/TOTAL FLAP LOSS PERTE PARTIELLE/TOTALE DU LAMBEAU CUTANÉ

Type 2‐ Le lambeau ne peut être repositionné 

Type 2‐ Linear or Flap Tear which can be  pour couvrir la plaie (ISTAP, 2014)

repositioned to cover the wound bed (ISTAP, 

2014)  Type 3‐ Perte totale du lambeau cutané. Le lit 

Type 3‐ Total flap loss. Entire wound bed is  de la plaie est exposé (ISTAP, 2004)

exposed (ISTAP, 2014) 1 Nettoyer avec une solution de saline normale.

1 Cleanse with normal saline. 2 Rapprocher les rebords de la plaie avec un 

2 If there is skin that can be repositioned, bring applicateur en coton.

together wound edges with a cotton tip applicator. 3 Sécher la peau avec un gaze. 
4 Appliquer SUREPREP RAPID DRY au périmètre de la 
3 Pat skin area dry with gauze.
4 Apply SUREPREP RAPID DRY to periwound skin and  plaie et laisser sécher.
5 Remplir la cavité avec un OPTICELL.
allow to dry.
6 Couvrir avec un OPTIFOAM BORDER SILICONE.
5 Fill with OPTICELL. 

6 Cover with OPTIFOAM BORDER SILICONE.

Medline Canada Images courtesy ISTAP Copyright 2016, All rights reserved
1‐800‐396‐6996
www.medline.ca
[email protected]

Remove here for documentation. Retirez ici para la documentation.

2/3 Type 2 or 3 Skin Tear /  2/3 Type 2 Skin Tear / 
Déchirure Cutanée Type 2 Déchirure Cutanée Type 2

Name/Nom: Name/Nom:
Date: Date:
Staff/Personnel Initial:  Staff/Personnel Initial: 

Skin Tear Guidelines

240©2019 Medline Industries, Inc.

Takeaways

• Medline has a full line of product to both prevent and 
manage skin tears

• We have the guidelines and tools to assist with 
transferring knowledge to bedside

• We know that Skin tears can be reduced by twice 
daily moisturizing

241©2019 Medline Industries, Inc.

Section 7: 

Head‐to‐Toe Assessment 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Medline Canada 
5150 Spectrum Way, Suite 300  

Mississauga, ON L4W 5G2 

Head to Toe 
Assessment

Long term care = Unsung hero’s 

• 2013 – 564,000 adults with dementia
• 2016 – 940,000 adults with dementia
• Considered a health crisis – The World 
Dementia Counsel 

191©2019 Medline Industries, Inc.

The WHOLE resident not the HOLE in the 
resident 

Look, listen & ask before you touch:
‐ Resident history – past & present Health 

status: 
‐ Main medical condition‐ physical & 
cognitive
‐ Co morbidities‐
‐ Structural & medical
‐ Medications – prescribed, OTC & herbals

192©2019 Medline Industries, Inc.

The WHOLE resident not the HOLE in the 
resident 

• Know what medications the resident is 
currently taking

• On average adults  > 65 yrs take 9 
medications/day

• Anti inflammatory meds ‐stall phase 2 of 
the healing process 

193©2019 Medline Industries, Inc.

The WHOLE resident not the HOLE in the 
resident 

Ask the resident & family: 
When did this wound happen?
How did the wound happen?
What's been done to date – did it work?

Note: bleach 

194©2019 Medline Industries, Inc.

The WHOLE resident not the HOLE in the 
resident 

• Blood thinners – may affect/slow phase 
1 of the healing process

• NSAIDS – frequently used for pain 
numerous contraindications – cardiac, 
renal

• Immunosuppressant's – may increase 
risk of infection

195©2019 Medline Industries, Inc.

PAIN

• “….elderly residents incorrectly believe that pain is a normal process 
of aging.”

• Research suggests it undertreated & under reported
– Etiological identifier – i.e. Venous vs Arterial, Pyoderma 
Gangrenous
– Geriatric recognition of pain – by the time they complain of pain 
it’s significant

196©2019 Medline Industries, Inc.

OPIODS

• Exaggerated  risk & fear of addiction:
– Resident & family: knowledge base, Fentanyl crisis & the press 
coverage
– Medical staff – need to educate & reassure
– Dosing needs to be increased slowly
– Over sedation increase risk of falls
– CONSTIPATION‐ compounding issue

197©2019 Medline Industries, Inc.