7/30/2012. Increased incidence of chronic diseases due

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1 Dianne Rudolph, DNP, GNP bc, CWOCN Discuss management of wound care in older adults with focus on lower extremity ulcers Identify key aspects of prevention Explain basic principles of wound management Identify appropriate topical and nutritional therapies for wound management Increased incidence of chronic diseases due to DM, PAD, ASCVD, and mobility issues Chronic wounds should be considered a symptom of an underlying disease process 70% of pressure ulcers occur in the older adult 10.7% prevalence of Pressure ulcers in LTC 2.5% prevalence of LE ulcers 8.9/1000 older adults have LE ulcers 70 90% of all LE ulcers Typically associated with family history, obesity, trauma, pregnancy, surgery, occupations, obesity Location: gaiter area Sx: hemosiderin stains, exudative, lipodermatosclerosis, dermatitis, ankle flare, champagne bottle deformity SOC: compression/absorption 1

2 Films (Opsite, Tegaderm): dry to minimal exudates Hydrogels (Saf Gel, Curasol): Minimal exudates Hydrocolloids(Duoderm, Exuderm): min to mod exudates Foams(Allevyn, Versiva): Mod to heavy Alginates/hydrofibers (Aquacel, Sorbsan, Kaltostat): Mod to heavy Iodine: povidone, cadexomer (Iodosorb, Iodoflex) Silver: Silversulfadiazine, Silver nitrate, ionized silver (Aquacel AG, Arglaes, Prisma, Silvasorb) Gentian Violet (Hydrofera Blue) Honey: Leptospermum (Manuka honey) Sodium Hypochlorite (Dakins, Eusol) Acetic acid.25% Mucipirocin (bactroban) ABI Ankle/brachial Index: normal.6.8 moderate <.6 severe TBI of <.50 =PVD 2

3 Trophic changes, distal areas Arterial doppler Vascular consult Avoid repetive trauma/pressure Keep dry gangrene dry Moist would healing only if wound is open 3

4 Plantar surface, variable depth Address underlying disease Debride hyperkeratotic tissue Offload pressure, offload pressure, offload pressure Address infection Moist wound healing 4

5 inconsistency in staging still common if you see necrotic tissue it s stage III no matter how small the ulcer Slough vs. fat: stage after cleaning not before Unstageable No reverse staging but indicate percentage of granulation and or epithelialization Is it a pressure ulcer or something else? 5

6 Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue (NPUAP, 2007) Identify at risk patients Frequent positioning (30 30 rule) Appropriate support surface ( Low air loss mattress, gel, roho) Correct/contain incontinence Manage moisture,friction, shear Appropriate wound care Aggressive nutritional interventions Manage comorbidities Surgical consult: osteo, extensive necrosis, infection Assess and manage pain 6

7 S: skin assessment T: turn and reposition O: offer fluids and food M: manage moisture P: protect heels IHI, 2011 Category I: Skin tear without loss of tissue. The epidermal flap either completely covers the dermis or covers the dermis to within 1mm of the wound margin Ia: Linear type Ib: Flap type Category II: Skin tears with partial tissue loss IIa: Scant tissue loss (25% or less) IIb: Moderate to large loss of tissue (more than 25% loss of the epidermal flap) Category III: Skin tears with complete tissue loss. 7

8 Adequate caloric (30 35 kcal/kg) and fluid intake (25 35 ml/kg) per day Protein: gms/kg per day Micronutrients: Vitamin C Zinc Vitamin A/retinoids Albumin Prealbumin CRP Orixegenics: megesterol acetate? mirtazepine oxandrolone dronabinol 8

9 Master or at least understand staging No need to learn all products names One size doesn t fit all Protocols are there to guide only. (beware of conflicts of interest) Drainage and moisture: Dry when it its wet and maintain moisture if its dry. Moist dressing for ALL wounds is not appropriate Establish goal of wound care Cause and complicating factors: it s hard to treat an ulcer or skin injury if we don t know what s causing it or making it worse. If we expect a wound to heal faster than it can we will likely end up changing treatments needlessly instead of accepting slow positive progress. Many wounds will heal if we let them 9

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