Wound Care 101. Wound Classification. Comparison of superficial, partialthickness. wounds. CAPA Conference Heather Grady, MPA, PA-C.

Transcription

1 Wound Care 101 Heather Grady, MPA, PA-C CAPA Conference October 10, 2015 Wound Classification Etiology¹ Surgical/non-surgical Acute and chronic Depth¹ Superficial, partial-thickness, and full-thickness Pressure ulcer staging Comparison of superficial, partialthickness and full-thickness wounds EPIDERMIS Superficial wound Involves only the epidermis DERMIS Partial-thickness wound Affects the epidermis, and may extend into the dermis but not through it SUBCUTANEOUS MUSCLE BONE Full thickness wound Extends through the dermis into tissues beneath; adipose tissue, muscle, or bone may be exposed 1

2 Wound Assessment Model 1 Size Measure and/or trace wound area. Measure depth Surrounding Skin Assess for color, moisture, suppleness Wound Edges Assess for undermining and conditions of margins Wound Assessment Wound Bed Assess for necrotic and granulation tissue, fibrin slough, epithelium, exudate, odor Wound Bed Necrotic tissue Eschar Dry, black or brownish devitalized tissue 2 Slough Formed when a collection of dead cellular debris accumulates on the wound surface 2 Yellow or yellow-white, due to the large amounts of leukocytes present Granulation tissue Indicator of normal healing in full thickness wound 2 Bright red in color Epithelialization newly formed epithelial cells that have a translucent appearance 2 Usually whitish-pink or pinky-purple in color Eschar Granulation Tissue Slough 2

3 Wound progression from slough to granulation tissue Documentation Quantify the estimated percentage of tissue involved (e.g. wound contains ± 50% granulation tissue, ± 25% necrotic tissue and ± 25% fibrin slough) 1 Granulation tissue and epithelialized tissue Granulation Tissue 2 Healthy Granulation Tissue Bright Red Moist Shiny Does not bleed easily Unhealthy Granulation Tissue Dark red/blush discoloration or pale Dehydrated Dull Bleeds easily - fragile Exudate 2,3 Exudate Type Color Consistency Descriptor Significance Serous Clear Thin watery Clear fluid absence of blood, pus debris Sanguinous Red Thin watery Bloody, composed entirely of blood Normal inflammatory/proliferative phases of healing Indicates new vessel growth or disruption Serosanguinous Light red/pink Thin watery Blood mixed withclear fluid Normal inflammatory/proliferative phases of healing Seropurulent Cloudy yellow Thin watery Pus mixed with watery fluid May be first signs of wound infection or autolytic debridement Purulent/Pus Yellow/green Thick, opaque Pus, cloudy, viscous often malodorous Indicates wound infection 3

4 Criteria for Indentifying Wound Infection 2,4 Surface discoloration yellow/green hues Increased exudate Cellulitis and Inflammation Increased odor Superficial pocketing or bridging of wound base Wound Infection Friable granulation tissue bleeds easily Abscess formation Wound deterioration or dehiscence Non-Healing wound Increased discomfort and tenderness Wound Infection Factors Increasing the Risk of Infection 2,5 Reduced perfusion Large wound area/depth Chronicity Necrotic tissue Foreign bodies Metabolic disorders diabetes mellitus Alcohol abuse/smoking Corticosteroid medications 4

5 Antibiotics Systemic antimicrobial therapy should be used when active infection can t be managed with local therapy 2 Fever Underlying deep structure infection Spreading cellulitis Wound Basics Standard of care is no longer wetto-dry dressings This keeps wounds in a constant inflammatory state, slowing down wound healing 6 With any wound, always take care to protect the periwound edges 7 Don t desiccate the wound bed Dressing Basics Type and amount of drainage dictates the type of dressing used If a wound is too dry, hydrate the wound with gels If a wound has too much drainage, use foams to absorb the moisture 6,7 5

6 Film = Poly skin Hydrogel = Duoderm gel Hydrocolloid = Duoderm Alginate = Aquacel, & Aquacel AG Foam = Allyven foam with and without adhesive Specialty dressing Mepitel silicone contact layer Mepilex foam silicone foam dressing with and without adhesive border Polymem foam dressing but with surfactant which cleanses the wound, does not absorb a lot of drainage Interdry AG polyester cloth with silver impregnated in it, kills fungus and bacteria inside skin folds and wicks away moisture Anti-microbial dressings with silver, Acticoat Wound Margin & Surrounding skin Prolonged exposure of the skin to wound exudates can result in skin maceration Indicates Wound dressing is not being changed frequently enough Dressing contains too high of water content The absorptive capacity of the dressing is not aligned to meet with the exuding fluid volume 2 6

7 Exceptions to the Rule If the patient has decreased vascularity and you want to keep the bacterial count down Keep the wound dry and paint it with betadine Eschar often can be used as a physiologic dressing (especially with wounds on the feet) and wound will heal under the eschar 7 Wound Pain Surveys have shown that clinicians identify dressing removal as the most painful part of dressing procedure and that gauze is most likely to cause pain Newer products were less likely to cause pain and skin trauma. These include hydrogels, alginates and silicone dressings 2,8 Wounds and Nutrition Protein is essential for the formation of new granulation tissue. Severe protein malnutrition results in Slower wound healing Decreased immunocompetence Increased susceptibility to infection 2,9 7

8 Aging Population Patient population is getting older and the disease processes associated with these patients are increasing 7 Medications and co-morbidities need to be taken into account when addressing wound care because they can impede wound healing Medications impact wound healing ie. steroids, NSAIDs, anti-coagulation Co-morbid diseases also affect healing ie. COPD, DM, A-fib, pneumonia Types of Dressings Old School of Thought Wet-to-Dry dressings Gauze is inserted wet, covered with dry gauze and it dries out, then removed after adhering to surface tissue 6 Typically intended for use in the debridement of devitalized tissue from a wound bed 6 or to keep a wound open that may have a small skin opening but tunnels more deeply Types of Dressings New Technology NPWT - Negative pressure wound therapy 10 Creates an environment that promotes wound healing by secondary or tertiary intention (delayed primary) by: Preparing the wound bed for closure Reducing edema Promoting granulation tissue formation and perfusion Removing exudate and infectious material 10 Advanced wound healing therapy 8

9 Skin Tears Skin Tears Seen mostly in older patients skin becomes thinner as we age Address medications and co-morbidities Surrounding edema will affect healing as well Treatment 1. Stop bleeding 2. Attempt to approximate skin edges 3. Don t cause additional trauma to surrounding skin 4. Can take up to 4 weeks to heal 7 Hemostasis Achieving hemostasis can be hard, especially if patients are on anticoagulants such as Coumadin or Plavix or if they are on steroids May need products such as Surgicel or other agents that help prevent formation of hematoma 9

10 Approximating Skin Edges If skin edges or skin flap remains, attempt to approximate Apply skin prep first (or Benzoin) to skin flap and intact skin Hold in place with steri-strips, leaving a space between each steri-strip to allow for drainage Cover with silicone dressing (Mepitel) that helps absorb drainage and is less traumatic Use Telfa, covered with Kerlix or Cling and stockinette (great for use on extremities) 7 Steri-Strip Wound Types of Dressings Silicone Dressings Does not adhere to skin Great on fragile, thin skin Used on skin tears 10

11 Silicone Dressing Additional Thoughts Treat with antibiotic or antimicrobial if concerned about infection or contamination Don t apply a transparent dressing such as op-site Once evaluated, leave area alone for 5 days May use xeroform as last resort Complications Skin flap doesn t take Debride the area and treat as an open wound Hematoma Evaluate if it needs to be evacuated 11

12 Additional Dressings Polymem surfactant and glycerine dressing that won t stick to the wound Can be left on for 7 days Ok to shower with dressing in place Good for contaminated wounds to keep the wound clean Ointments apply antibiotic ointment if concerned about infection Bacitracin ointment on the face Triple antibiotic ointment on all other surfaces Cover with Telfa, silicone dressing or Polymem Hematomas To evacuate or not?? Need to really look at comorbid diseases Hematomas are a breeding ground for bacteria; however, evacuating a hematoma leaves an open wound and bleeding may persist if patient remains on anti-coagulant 7 When not evacuating wound Silicone or antibiotic silicone dressing can be used and it won t disrupt the hematoma but still allows for close monitoring Cover the silicone dressing with a foam or padded dressing to help protect the hematoma Patients must be monitored very closely It will take time for the hematoma to be reabsorbed 12

13 Evacuation If eschar is forming then the wound will need to be evacuated If wound is evacuated, you must see the base of the wound to fully evaluate it Apply pressure if bleeding continues once hematoma is evacuated May need to use products such as coban to assist with applying pressure 7 Additional Problems with Hematomas Older patients may have vascular insufficiency adding to edema and decreased oxygenation to the tissues causing stagnant blood Especially seen in patient with renal failure and vascular insufficiency 7 Antibiotics Don t recommend antibiotics unless signs of infection or contaminated process such as wound occurred in dirt (think fungus or yeast) Suggest using Augmentin or Bactrim Keflex is not a good option on soft tissue, especially on lower extremity wounds Diabetic Foot Ulcers 13

14 Diabetic Ulcers Never what they appear, always look benign Usually associated with other underlying diseases that affect healing such as PVD and arterial disease For this reason, must always assess vascularity leading to wounds If there is no blood flow under wound, it WON T heal Assessing Diabetic Ulcers Always do 3 view x-ray or MRI (especially of foot) to r/o osteomyelitis. If unable to get one of these imaging studies, get bone scan Always probe wound The inflammatory process is usually delayed resulting in possible undermining, tunneling, fluid collections or edema Treatment of Diabetic Ulcers Always evaluate shoes! Inside and out Look for dirt, foreign bodies, etc. Perform neuro exam Off-load foot. May need to add foam to shoes. Limb salvage Refer directly to a podiatrist if you do not see signs of healing (partner with a podiatrist to help treat these types of wounds) Wound may need to be incised and drained 14

15 Treatment continued Treat wound with antimicrobial agents Hydrofiber, alginate or anti-microbial gels Evaluate for proper management of DM If you see signs/symptoms of infection, refer out to vascular surgeon, podiatry, Infectious Disease, etc. If no evidence of infection, may treat for 3-4 weeks before referring to podiatry Types of Dressings Hydrofiber Highly absorbent dressing made of 100% hydrocolloid. The hydrocolloid is spun into fibers that make a soft, non-woven fleece-like dressing that comes as a sheet or ribbon 11 Used as an alternate to alginate dressing. This dressing retains a high quantity of water without releasing it, thereby forming a thick comfortable gel 11 Types of Dressings Alginate A dressing made from seaweed, creating a gel form of dressing 11 Best used in moderate to highly exudating wounds 11 15

16 Types of Dressings Hydrogels Comes as a sheet or a gel Sheets are used for shallow or low exuding wounds 11 Gels are used for cavities and are effective for desloughing and debriding wounds. Gels have a high water content which aids the rehydration of hard eschar and promotes autolysis in necrotic wounds 11 To prevent possible maceration, a secondary barrier film may be applied to peri-wound area 11 Recalcitrant Wounds Biofilm can develop and nothing can impregnate it keeping wound in the inflammatory stage Wound will need sharp debridement Evolving field Lab in Texas will tailor treatment based on tissue specimen, genetics, bloodwork and location of wound Pressure Ulcers 16

17 Pressure Ulcers Currently classified into 4 stages Discussions to change classification to suspected deep tissue injury Stage 1 and Stage 2 More from shearing and friction Stage 3 and Stage 4 Deep tissue injury Suspect deep tissue injury if dark red/purple/maroon, hard/bony surface, won t blanche Staging System Should be used as an admission diagnosis system only 2,7 Not designed to capture changes that occur during the healing process Changes in the wound status should be documented as area and depth assessment, not reverse staging 2,7 Pressure Ulcers Stage 1 and 2 Early stages may start to evolve Will start to look diffuse with edges not well defined. Pink edges, purple area may open up and evolve to an open wound stage ulcer Stage 1 Stage 2 17

18 Treatment of Pressure Ulcers Stage 1 and 2 Always off-load Observe frequently Silicone products will off-load and absorbs drainage Some wounds may heal with silicone alone May also use hydrocolloids (DuoDerm) or Foam dressings Types of Dressings Hydrocolloids Waterproof, occlusive dressing that consists of a mixture of pectin, gelatine, sodium carboxymethylcellulose and elastomers 11 - Creates an environment that encourages autolysis to debride wounds that are sloughing or necrotic 11 Types of Dressings Foams Dressing produced from polyurethane - soft, open cell sheets 11 These are non-adherent and can absorb large amounts of exudate 11 Also available impregnated with charcoal (attracts and traps bacteria and odor) and with waterproof backing 11 Silver dressing Dressing impregnated with Silver anti-microbial dressing Used to treat infected wounds 18

19 Considerations with Treatment What is the causative agent of the ulcer? Nutritional status? May need to add Ensure, Megace or tube feedings Hydration? Is the patient dehydrated? UTI? Frequent pneumonia? Local care is needed to heal wound but must also find the underlying cause and address it 2,7 There may be a short term cause such as a fracture but if there is no short term cause, need to find the reason for the ulcer Pressure Ulcers Stage 3, Stage 4 and Unstageable Stage 3 Stage 4 Unstageable Treatment of Pressure Ulcers Stage 3 and 4 Clean wound bed Surgical debridement Autolytic debridement (hydrocolloids) Transparent dressings (op-sites) soften up eschar to allow for debridement later Medical grade honey, if no bee allergy (Manuka Honey - Medline) Hypertonic solution/pad can be used for sloughing wound will withdraw fluid and debride wound If odorous, use ¼ strength Dakin s solution on gauze. This will improve odor and debrides. Use for about 3-4 days 19

20 Autolytic Debridement Results in little to no pain or wound trauma However, it is a slower method of debridement May be contraindicated if there is a high bacterial burden in the wound 2 Treatment of Pressure Ulcers Stage 3 and 4 Always protect periwound skin with ointment (moisture retentive) to protect healthy skin from maceration caused by excessive drainage Calmoseptine or A&D ointment Apply ointment under foam or ABD pad that will allow the drainage to be soaked up Can use fiber type fillers such as alginate or hydrofiber to fill dead space Stage 4 Pressure Ulcer When to treat with wound vac vs flap? Evaluate overall physical and mental health, including life expectancy Previous hospitalizations, operations, or ulcerations Diet and recent weight changes Bowel habits and continence status Presence of spasticity or flexion contractures Tobacco, alcohol, and recreational drug use 7 20

21 Stage 4 Pressure Ulcer When to treat with wound vac vs flap? Pressure ulcers should be closed surgically if it does not respond to other wound care (including vac treatment) and if there are no other contraindications to surgery When rapid closure is indicated Some contraindications include tobacco use, poor nutrition, infection, noncompliance, recent failed flap 7 Local Rotation Fasciocutaneous Flap Cellulitis 21

22 Cellulitis Cellulitis is a spreading bacterial infection of the skin and tissues beneath the skin The bacteria usually responsible for cellulitis are Staphylococcus and Streptococcus, although many types of bacteria can be the cause Signs and symptoms include redness, tenderness, swelling, and warmth of the affected area Abscess Abscess Cellulitis/induration is not an indication for incision and drainage Must have an area of palpable fluctuance or imaging documenting deeper fluid collection to perform I & D Always mark border of erythema with a pen or marker which allows assessment of treatment with antibiotics and/or drainage of wound 22

23 Abscesses If patient thinks it is a spider bite, always I&D, open wound and pack Must be drained Likely MRSA or Staph Skin poppers Iodasorb gel or Cadoximer Iodine for treatment Easy for patient to do themselves and protects against many organisms Sustained released of orange fluid placed on wound bed and absorbs drainage Comes in a tube that is applied to wounds by patient Ok to shower MRSA MRSA Methicillin-resistant Staphylococcus aureus If an abscess is admitted to the hospital for treatment, assume MRSA until proven otherwise If possible, place patient on isolation precautions Treatment includes IV antibiotics such as Vancomycin and/or Rifampin and oral antibiotics such as Bactrim DS Once diagnosed, suggest patients shower with CHG (chlorhexidine gluconate) until wounds resolve, and in the future at the first sighting of any erythema to the skin 23

24 Road Rash Road Rash Must be very diligent to scrub all debris from wound within first 24 hours If debris is not removed, patient will get tattoo from wound Shower daily with CHG (Chlorhexadine Gluconate) for 2 weeks Apply Xeroform over the area then a gel pad This will absorb the fluid and is more comfortable for the patient because it deters dressing from sticking and dressing changes will be less frequent Other Wound Care Dakins solution Used for malodorous, soupy wounds with stringy/yellow debris Or used if you suspect pseudomonas (greenish appearance to wound or drainage) Non-healing wounds Always need biopsy to r/o SCC or other possible inflammatory process 24

25 NPWT (Wound VAC Vacuum Assisted Closure) Used for treatment of open wounds Negative pressure therapy Controls edema and provides support to incision/wound Improves healing and decreases treatment time 10 Creates an environment that promotes wound healing 10 Microstrain Reduces edema Promotes perfusion Promotes granulation tissue formation Macrostrain Draws wound edges together Removes exudate Removes infectious materials Cell mitosis/proliferation Fibroblast migration Types of Wounds 10 Chronic Acute Traumatic Subacute Dehisced Wounds Partial-Thickness Burns Ulcers (such as diabetic, pressure, venous) Flaps and Grafts 25

26 VAC Dressing Types 10 V.A.C. Granufoam Dressing V.A.C. White Foam Dressings Reticulated (open) pore Polyurethane ideal for: Deep acute wounds Traumatic wounds Diabetic & Pressure ulcers Draining or dry wounds Flaps and grafts (with non-adherent) Dense (higher tensile strength) openpore Polyvinyl Alcohol ideal for: Tunneling/tracts/undermining Painful wounds Wounds requiring controlled growth of granulation tissue Superficial wounds Reticulated (open) celled Polyurethane microbonded with silver to provide a protective barrier to reduce aerobic, gram-/+ bacteria, yeast and fungi. Ideal for: Deep acute wounds Traumatic wounds Diabetic & Pressure ulcers Draining or dry wounds Flaps and grafts (with non-adherent) % of pathogens eliminated Within the first 30 minutes V.A.C. Drape Easy as 1 2 Blue V.A.C. Canisters 26

27 Contraindications 10 Do not place foam dressings of the V.A.C. Therapy System directly in contact with exposed blood vessels, anastomotic sites, organs, or nerves Malignancy in the wound Untreated osteomyelitis Non-enteric and unexplored fistulas Necrotic tissue with eschar present (after debridement V.A.C. Therapy may be used) Sensitivity to silver Warnings, Precautions and Safety Tips Protect Vessels and Organs: All exposed or superficial vessels and organs in or around the wound must be completely covered and protected prior to the administration of V.A.C. Therapy Protect Tendons, Ligaments and Nerves: Tendons, ligaments and nerves should be protected to avoid direct contact with V.A.C. Foam Dressings. These structures may be covered with natural tissue, meshed nonadherent material, or bio-engineered tissue to help minimize risk of desiccation or injury 10 Warnings, Precautions and Safety Tips V.A.C. Therapy On: Never leave a V.A.C. Dressing in place without active V.A.C. Therapy for more than 2 hours. If therapy is off for more than 2 hours, remove the old dressing and irrigate the wound. Either apply a new V.A.C. Dressing from an unopened sterile package and restart V.A.C. Therapy; or apply an alternative dressing at the direction of the treating clinician Bleeding: With or without using V.A.C. Therapy, certain patients are at high risk of bleeding complications 1000 ml Canister: DO NOT USE the 1000 ml canister on patients with a high risk of bleeding or on patients unable to tolerate a large loss of fluid volume. MRI, X-Ray & HBO 10 27

28 Dressing Application Basic Dressing Target Pressure 125 mmhg ( white foam) Continuous first 48 hrs Intermittent if tolerated Dressing change every hrs Tunneling: White foam and GranuFoam Target Pressure 125 mmhg ( white foam) Continuous Dressing change every hrs 28

29 Framing: Wounds with Small Openings Target Pressure 125 mmhg ( white foam) Continuous first 48 hrs Intermittent if tolerated Dressing change every hrs Bridging Final Thoughts Wound assessment is as important as treating the wound itself Type and amount of drainage now dictates the type of dressing used Take care to protect the periwound area Identifying and treating the underlying cause aids in the overall management of chronic and acute wounds 29

30 Resources KCI Advantage Center /7! Reps On-Call Territory Manager KCI1.com Service Consultants References 1. Van Rijswijk L. Wound assessment and documentation. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, Pa: HMP Communications; 2001: Smith & Nephew. Wound Bed Preparation: A Guide to Advanced Wound Management 3. Mulder, GD. (1994) Quantifying wound fluids for the clinician and researcher. Ostomy/Wound Management; 40(8): Flanagan, M. (1997) Wound Management, Churchill Livingstone 5. Schultz, GS, Sibbald GR, Falanga, V, et al. (2003) Wound Bed Preparation: A systematic approach to wound management. WoundRepair and Regeneration; 11(2): Ovington, LG. Hanging Wet-to-Dry Dressings Out to Dry. Advances in Skin & Wound Care. Vol 15 No 2. March/April 2002: P Milnes, WOCN. Personal Communication, August 13, Moffatt, C, Franks, P, Hollinworth, H. (2002) Understanding wound pain and trauma: an internationtal perspective. EWMA Position Document: Pain at Dressing Changes: Mazzotta MY. (1994) Nutrition and wound healing. Journal of American Podiatry Medical Association; 84: KCI Product Information Pain Dictionary. (2009). Retrieved September 14, 2013, from Dictionary 12. Mölnlycke Health Care Medline Product Information ConvaTec Product Information. 30