TREATMENT PROTOCOLS. Wound Cleansing Choosing the Best Treatment Pressure Ulcer Treatment Matrix Wound Care Protocols...

Transcription

1 TREATMENT PROTOCOLS Contents Wound Cleansing Choosing the Best Treatment Pressure Ulcer Treatment Matrix Wound Care Protocols Alginate Silver Alginate Antimicrobial Powder Collagen Silver Collagen Foam Hydrocolloid Hydrogel Hydrogel Sheet Polyacrylate Transparent Film Special Considerations Tunneling and Undermining Skin Tears

2 Contents (continued) Lower Extremity Wounds Arterial Venous Insufficiency Neuropathic/Diabetic Ankle-Brachial Index (ABI) ABI Procedure Compression: A Real Example of its Use Comparison of Compression Wraps Compression Stocking Classifications Compression Protocols Four-Layer Compression Bandage System Unna Boot Skin Care Protocols Dimethicone Barrier Second Generation Barrier

3 Worth remembering... Wound cleansing removes bacteria and surface contaminants to allow the wound to progress more rapidly from the inflammatory to the proliferative phase. While developing a treatment plan for wounds, you should assess not only the wound, but the entire patient. The factors that affect wound healing need to be included in the overall treatment plan. A clean pressure ulcer with adequate innervation and blood supply will show evidence of healing within two weeks. Failure to do so should prompt a re-evaluation of the plan of care (POC), an evaluation of adherence to the plan, and a possible modification of the plan. Wound Cleansing The Agency for Healthcare Research and Quality (AHRQ) recommends that wounds be cleansed initially and at each dressing change. Optimal wound healing cannot occur until all foreign material is removed from the wound. Wound cleansing removes bacteria and surface contaminants to allow the wound to progress more rapidly from the inflammatory to the proliferative phase. While cleansing, minimize chemical and mechanical trauma because traumatized wounds are more prone to infection and slower to heal. Cleansing protects the healing wound and minimizes the risk of infection. For clean, granulating wounds, normal saline is a good flushing solution. Commercial wound cleansers utilize cleansing agents for optimal removal of debris and bacteria. These cleansers also utilize surface tension between the wound and the debris, allowing for more effective cleansing. The delivery method of commercial cleansers is between 4 to 15 pounds per square inch (PSI); 8 PSI is optimal. Wounds with necrotic tissue, debris or drainage may need more frequent wound cleansing. The challenge is to clean effectively while not harming living tissue. Use of appropriate cleansing agents and PSI will assist with this challenge. Examples of products and their PSI 2 PSI bulb syringe 8 PSI 35 ml syringe with a 19-gauge needle or an angiocatheter 8.6 PSI trigger spray bottle containing commercial cleanser set on the stream setting 42 PSI waterpik set on number three 3

4 Topical antiseptics are chemicals that are damaging to normal wound tissue and destroy fibroblasts. Fibroblasts are responsible for building collagen and granulation tissue. If you choose to use topical antiseptics for wound cleansing, consider using the lowest concentration documented to be effective. Re-evaluate the wound as necessary. Once bacterial contamination is eliminated, resume non-antiseptic cleansing. Consider instituting policies that limit how long fibroblasttoxic agents can be used. Choosing the Best Treatment W O U N D Remember the mnemonic W-O-U-N-D? Following is an example of its use. Wound healing status: If the wound is healing or progressing, an optimal moist wound environment is the goal. If the wound is not healing, there may be several reasons. However, adding a product that will stimulate the process, such as collagen, may be necessary. Microbial content: A wound that has an increased bacterial load or is showing signs of infection may need an antimicrobial dressing. There are many antimicrobial dressings on the market that use silver or an iodine base for antimicrobial activity. They are also available in just about every form, such as silver hydrogels, powders, sheet dressings, foams and alginates. Optimal moisture: A dry wound may need a product that will donate moisture, such as a hydrogel or hydrogel impregnated gauze. The wound may also need a product that will retain moisture, such as a transparent film dressing. A heavily draining wound may require an alginate, foam or a combination of both. Understand the periwound skin: When choosing a dressing for the wound, examine the periwound skin closely. It may help you determine whether to use an adhesive dressing or a nonadhesive alternative. Periwound protection with barrier products like skin prepping wipes or barrier creams should also be considered. Amount of necrotic tissue in the wound bed: If a wound has a significant amount of slough or eschar, debridement may be necessary. There are dressings that will aid in the debridement process, such as polyacrylate debriders. If the wound bed is free of necrotic tissue, the goal is optimal moisture management. Wound depth: Addressing the dead space in the wound bed is crucial to preventing premature closure of the wound. The goal is to allow the wound to close from the bottom up without abscess formation. 4

5 Pressure Ulcer Treatment Matrix Note: Clinical judgment is required if the drainage is moderate. Once the dressing choice is made, proceed with the following protocols. 5

6 Wound Care Protocols ALGINATE (Maxorb Extra) Stage III and IV, full-thickness Moderate to heavy drainage 1. Clean the wound with a wound cleanser (Skintegrity ) at each dressing change. 3. Apply an alginate dressing. 4. If necessary, cover the wound with dry gauze. 5. Secure the dressing with a composite island (Stratasorb ), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 6. If the wound is draining heavily, use a foam dressing. 7. Change the dressing every 1 to 7 days, depending on the amount of drainage. SILVER ALGINATE (Maxorb Extra Ag) Stage III and IV, full-thickness Moderate to heavy drainage 1. Clean the wound with an antimicrobial wound cleanser (MicroKlenz ) at each dressing change. 3. Apply a silver alginate dressing. 4. If necessary, cover the wound with dry gauze. 5. Secure the dressing with a composite island (Stratasorb ), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 6. If the wound is draining heavily, use a foam dressing. 7. Change the dressing every 1 to 7 days, depending on the amount of drainage. 6

7 ANTIMICROBIAL POWDER (Arglaes Powder) Stage II, partial-thickness Stage III and IV, full-thickness Moderate to heavy drainage 1. Clean the wound with an antimicrobial wound cleanser (MicroKlenz) at each dressing change. 3. Sprinkle the silver powder on the wound bed. 4. Place gauze over the powder, if necessary. 5. Secure the dressing with a composite island (Stratasorb), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 6. Change the dressing every 1 to 5 days, depending on the amount of drainage. COLLAGEN (Puracol Plus) Stage II, partial-thickness Stage III and IV, full-thickness All levels of drainage Slow healing wounds 1. Clean the wound with a wound cleanser (Skintegrity) at each dressing change. 3. Apply the collagen directly to the wound bed. 4. The dressing may be cut if necessary to match the wound size. 5. If the wound is dry, the dressing may be moistened with saline. 6. Secure the dressing with a composite island (Stratasorb), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 7. Change the dressing every 1 to 7 days, depending on the amount of drainage. 7

8 SILVER COLLAGEN (Puracol Plus Ag) Stage II, partial-thickness Stage III and IV, full-thickness All levels of drainage Slow healing wounds 1. Clean the wound with an antimicrobial wound cleanser (MicroKlenz ) at each dressing change. 3. Apply a silver collagen dressing. 4. The dressing may be cut if necessary to match the wound size. 5. If the wound is dry, the dressing may be moistened with saline. 6. Secure the dressing with a composite island (Stratasorb), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 7. Change the dressing every 1 to 7 days, depending on the amount of drainage. FOAM (Optifoam, Optifoam Ag) Stage II, partial-thickness Stage III and IV, full-thickness Moderate to heavy drainage 1. Clean the wound with a wound cleanser (Skintegrity) at each dressing change. 3. Apply a foam dressing that is at least 1½ inches larger than the wound. 4. Secure the dressing with rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 5. Change the dressing every 1 to 7 days, depending on the amount of drainage. 8

9 HYDROCOLLOID (Exuderm Odorshield, Exuderm Satin) Stage II, partial-thickness Shallow Stage III and IV, full-thickness Moist to moderate drainage 1. Clean the wound with a wound cleanser (Skintegrity) at each dressing change. 3. Apply a hydrocolloid dressing that is at least 2 inches larger than the wound. 4. If it is a sacral wound, or an ulcer located in the sacral or coccyx area, use a sacral or butterfly-shaped dressing. 5. Border the dressing with retention tape (Medfix Retention Dressing Sheet) if the dressing does not have a border or additional support is needed. 6. Change the dressing every 3 to 5 days, depending on the amount of drainage, and if the dressing is loose or soiled. 7. Use an adhesive remover while changing the dressing to ease discomfort. HYDROGEL (SilvaSorb Antimicrobial Gel, Skintegrity) Stage II, partial-thickness Stage III and IV, full-thickness Dry-to-moist 1. Clean the wound with a wound cleanser (Skintegrity) at each dressing change. 3. Use a hydrogel to line the wound bed (do not completely fill the cavity) or dampen the gauze. If using hydrogel impregnated gauze, line the wound so that the gauze is covering the entire wound bed. 4. If necessary, cover the wound with dry gauze. 5. To address bioburden in the wound, us an antimicrobial gel. 6. Secure the dressing with a composite island (Stratasorb), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 7. Change the dressing every 1 to 3 days, depending on the amount of drainage. 9

10 HYDROGEL SHEET (Dermagel) Skin tears Stage II, partial-thickness Shallow Stage III and IV, full-thickness Dry to moderate drainage 1. Clean the wound with a wound cleanser (Skintegrity) at each dressing change. 3. Apply a hydrogel sheet that is at least 2 inches larger than the wound. 4. Secure with retention tape (Medfix Retention Dressing Sheet), net dressing (Elastic Net) or rolled gauze. 5. Change the dressing every 3 to 5 days, depending on the amount of drainage, and if the dressing is loose or soiled. POLYACRYLATE (TenderWet Active) Stage II, partial-thickness Stage III and IV, full-thickness All levels of drainage Necrotic tissue, eschar and slough May be used in place of wet-to-dry dressings 1. Apply a polyacrylate (TenderWet Active Superabsorbent Polymer) pad to the wound bed. 2. If the wound is flat or shallow, apply a pad so that it slightly overlaps the periwound skin. 3. If the wound is a cavity, the pad should be placed inside the wound, in direct contact with the wound bed. 4. Secure the dressing with a composite island (Stratasorb), bordered gauze (Bordered Gauze), rolled gauze, retention tape (Medfix Retention Dressing Sheet) or net dressing (Elastic Net). 5. Change the dressing every 24 hours. 10

11 TRANSPARENT FILM (Arglaes Antimicrobial Film, SureSite ) Stage I, Lower extremity ulcers Stage II, partial-thickness All levels of drainage Secondary dressing 1. Clean the wound with a wound cleanser (Skintegrity) at each dressing change. 3. Cover the wound with a transparent dressing that is at least 2 inches larger than the wound. 4. To address bioburden in the wound, use an antimicrobial film. 5. Change the dressing every 1 to 5 days, depending on the amount of drainage, or if the dressing is loose or soiled. Special Considerations Tunneling and Undermining In general, wounds with tunneling should not be covered with an occlusive dressing. Depending on the characteristics of the wound, specifically drainage, the tunnel may be loosely filled with a dry gauze packing material. If the wound is not draining, a hydrogel impregnated into the packing-strip may be appropriate. The goal is to address the tunnel, but never pack it tightly. Consider your ability to realistically retrieve the material placed in the wound. If the tunnel is narrow and long, for example, an alginate rope that may come apart might not be the best choice. If there is undermining, the wound care dressing (such as hydrogel gauze) should be loosely tucked inside the wound so that it comes in direct contact with the entire wound bed. 11 Skin Tears Choosing a wound care dressing for a skin tear will depend upon several factors. If a skin flap is present, after routine cleansing the flap should be approximated, or brought together. Then, continue dressing the wound as necessary. If a skin flap is not present, the area should be considered an open wound and treated as such. Since skin tears are directly related

12 to the lack of both internal and external hydration, restoring and maintaining fluid balance must be addressed. Dressings such as hydrogel sheets provide protection, help maintain an optimal moist wound environment and minimize adherence to the wound. Lower Extremity Wounds Arterial Wounds In general, do not use compressing or constricting garments and avoid temperature extremes when treating arterial wounds. If the blood flow status is unknown, a diagnostic evaluation such as an ankle brachial index (ABI) is necessary before treatment can be completed. If perfusion is found to be compromised, yet adequate for healing, choose a dressing based on the actual wound characteristics. If the blood flow is determined to be inadequate for healing, surgical revascularization should be considered. Until blood flow is restored, the wound should be kept clean, dry and free from infection. Venous Insufficiency Wounds When treating venous wounds, the key to healing lies in compression. It is very important that this system is applied correctly. Applying a compression wrap requires training. Blood flow status must be evaluated and deemed adequate before compression garments or dressings may be used. The wound itself will need to be dressed based on its specific characteristics, such as drainage and size. The lower extremity, in general, may need additional moisturization and barrier protection. Neuropathic/Diabetic Wounds Wounds that occur on the feet, or specifically the tips of the toes, are often neuropathic/diabetic in nature. Treatment will focus on the actual wound assessment, but there are a few points to be aware of. Typically, these wounds are surrounded with a callous that must be removed for the wound to close. Many times serial debridement of the callous is required. Relieving pressure from the wound by wearing offloading footwear, for example, will decrease callous buildup. Diabetes control and close monitoring of blood sugars and A1C are necessary for wound healing. Another important factor, as with all lower extremity wounds, is assessing blood flow. Assessment measures such as Doppler or color scanning may be necessary in someone with diabetes. 12

13 Ankle-Brachial Index (ABI) An ABI is the comparison of the blood flow pressures in the lower leg to those in the upper arm. This measurement screens patients for significant arterial flow problems to the extremities. An ABI will identify patients for whom compression would not be appropriate. This test might not be accurate for diabetics, whose vessels are often calcified, resulting in a false positive. ABI Procedure Items needed: Appropriately-sized blood pressure cuff, Doppler, Acoustic Gel. Procedure: 1. Place the patient in a supine position 5 to 15 minutes before the test. 2. Obtain brachial systolic pressure in each arm using a blood pressure cuff and a doppler probe. 3. Record the highest brachial systolic pressure. 4. Place a cuff around the affected ankle. 5. Apply acoustic gel over the dorsalis pedis or posterior tibial pulse. 6. At approximately a 45-degree angle, lightly touch the doppler probe to the skin at either pulse location. Listen for the pulse. 7. Inflate the cuff higher than the brachial systolic pressure. 8. Slowly deflate the cuff, listening for the return of the pulse. The point at which the arterial signal returns is recorded as the systolic ankle pressure. 9. Repeat the procedure over the other pedal pulse to obtain the ankle pressure on the affected extremity. Use the higher of the two values. To determine the ABI, divide the higher of the two ankle pressures by the higher of the two brachial pressures. If only one ankle pressure could be obtained, use it. Ankle Pressure Brachial Pressure = ABI Interpretation of the Ankle-Brachial Index: >1.3 Abnormally high range (more studies needed) 0.95 to 1.3 Normal range 0.80 to 0.95 Compression is considered safe at this level <0.8 to 0.5 Indicates mild to moderate arterial disease <0.5 Severe arterial insufficiency 13

14 Compression: A Real Example of its Use Mrs. PJ enters your hospital with her family and a vague description of poor circulation and a lot of swelling in both of her legs. You note a small shallow wound on her left lower extremity. She is 76-years-old and obese. She has stress incontinence that is managed by a pant and liner system. She also has dementia and is no longer able to perform her activities of daily living (ADLs). After the initial assessment, you realize that more information is needed before you can begin appropriate treatment. When you call her primary care physician s office, you are told that she has been diagnosed with lowerextremity venous disease (LEVD). The gold standard of LEVD treatment is to use adequate compression. However, before any form of compression is applied, her arterial perfusion status must be determined. If the lower extremity has either arterial or mixed (arterial and venous) disease, applying compression is usually contraindicated and could lead to negative results. A fairly simple diagnostic test, the ABI, is often what is required to determine if compression is appropriate. Her ABI is 0.85; while not ideal, it is adequate and appropriate for compression. There are several different ways to address wounds on the lower extremity. As with Mrs. PJ, the initial assessment led to further investigation and some detective work on the part of the nurse. Obtaining all of the information from the family as well as the primary care physician s office allowed Mrs. PJ to receive the best treatment for her LEVD. Since the wound was small, had some drainage, and there was a concern for bioburden, a silver alginate dressing and a four-layer compression wrap was the dressing chosen. The entire dressing is changed every 5 to 7 days. The dressing chosen is based on factors such as: The wound s characteristics. The frequency of dressing changes. A daily wound dressing is not the best choice with a compression wrap that is typically left in place for seven days. The ability of the patient or caregiver to apply the dressing. Reimbursement issues. 14

15 There are no studies that indicate a specific type of dressing, or frequency of dressing change, that is appropriate for all LEVD wounds. In addition to dressing choice, it is wise to consider a short course of topical antimicrobial if the ulcer has a high level of bacteria. One of the most common complaints echoed by clinicians is my patient is noncompliant, and they will not leave their compression system in place because they say it hurts. Realize that edema associated with LEVD can be very painful. The challenge is to persuade your patient to continue the treatment until the edema is reduced. Discuss with your patient that this pain is not uncommon and usually lessens over time with treatment. Talk with the primary physician about prescribing appropriate analgesics for the first several weeks of therapy. How much compression is enough compression? It is documented that some compression therapy is more effective than no compression therapy for the treatment of LEVD wounds. High compression (30 to 50 mmhg) is more effective than low compression; however, there are no differences in the effectiveness of the different types of products available for high compression therapy. The most commonly used products for compression are wraps or stocking-like products. Bandaging wraps should not be applied by an inexperienced clinician. Proper technique is crucial and requires training. Wraps that are applied incorrectly can apply too much compression to the wound, leading to limb loss or damage. Too little compression can cause a delay in healing, or even a decline in the wound s condition. 15

16 Comparison of Compression Wraps Type of Compression Examples Amount of Compression Application of Compression Performance Characteristics Long-stretch elastic bandages Matrix, SureWrap, Ace 17 mmhg pressure Figure-eight from the toe to the knee, with a 50 percent overlap. Not reusable. It loses its stretch after the first application. Zinc paste bandages (inelastic compression) Primer Boot, Unna Boot, Dome Paste Bandage Initial pressure is 29.8 mmhg. However, it falls to 10.4 mmhg at 24 hours. Applied in an overlapping fashion from the toe to the knee, with a 50 percent overlap. Not reusable. Light-compression, support Medigrip, Tubigrip 12 to 15 mmhg pressure in a single layer. Cannot apply graduated compression as it does not conform to the leg. Washable, but not dryer safe, for up to 6 months. Multilayer FourFlex, Three- Flex, Profore, Dynaflex 40 mmhg pressure for up to one week. Refer to package insert for instructions. Not reusable. Cohesive or Self adherent bandage Co-Flex, Coban, Flex-wrap 23 mmhg pressure Applied at 50 percent stretch, with a 50 percent overlap in a spiral. Not reusable. Used with other products to produce therapeutic compression. High Elastic Compression Setopress, Surepress Up to 40 mmhg pressure Refer to individual package for instructions. Can be washed up to 20 times. 16

17 Compression Stocking Classifications Class Description Ankle Pressure Indication Class 1 Light support 20 to 30 mmhg Treatment of varicose veins. Class 2 Medium support 30 to 40 mmhg Treatment and prevention of LEVD. Class 3 Strong support 40 to 50 mmhg Treatment of LEVD. Class 4 Very strong support 50 to 60 mmhg Compression Protocols Treatment of LEVD with the close supervision of a certified wound specialist. FOUR-LAYER COMPRESSION BANDAGE SYSTEM (FOURFLEX) 1. Clean the surface of the wound bed with a commercial cleanser (Skintegrity) or normal saline at each dressing change. 3. Apply the barrier cream (Nutrashield) to the entire lower extremity. Begin above the toes and extend to below the knee. Apply the cream to the wound margins and avoid the area between the toes. 4. Apply the appropriate wound dressing. 5. Apply the four-layer compression bandage system. Layer #1 - Cast Batting - Apply in a spiral with a 50 percent overlap. Begin just above the toes. Do not stretch. This layer applies padding and provides for absorbency. Layer #2 Short Stretch Crepe - Apply in a spiral with a 50 percent overlap over the first layer. Do not stretch. This layer smoothes down the first layer and provides additional absorbency. Layer #3- Long Stretch Bandage - Apply at a 50 percent stretch in a figure 8, covering the 2nd layer. Layer #4- Self-Adherent Wrap - Apply in a spiral at a 50 percent overlap and a 50 percent stretch. Make sure that you release several feet of dressing and then roll it back up before applying it. 6. Change the dressing every 5 to 7 days, or when the drainage breaks through the top layer. It may be necessary to change the four-layer wrap more frequently in the beginning as the drainage initially increases. 17

18 UNNA BOOT 1. Clean the surface of the wound bed with a commercial cleanser (Skintegrity) or normal saline at each dressing change. 2. Pat the periwound area dry. 3. Apply the unna boot bandage. Beginning just above the toes, apply the wrap in a spiral fashion, stopping just below the gatch of the knee. 4. Cover the unna boot with a self-adherent bandage (CoFlex). Begin just above toes and wrap in a spiral at 50 percent stretch with a 50 percent overlap. 5. Change every 5 to 7 days, or when the drainage strikes through the secondary dressing. Skin Care Protocols DIMETHICONE BARRIER (Remedy Nutrashield) Stage I Prevention 1. Clean the wound as necessary. 2. Apply a dimethicone moisture barrier to the wound and surrounding area. 3. If the area is on the lower extremity, elevate the patient s heels. 4. If the wound is in the perineal area, this barrier may be used as part of incontinence care. 5. Apply the barrier to the wound daily or every 8 to 12 hours, as needed. Note: All products shown in italics are distributed by Medline Industries, Inc. and are used for example purposes only. 18

19 SECOND GENERATION BARRIER (Remedy Calazime ) Stage I, partial-thickness Dermatitis related to venous disease of the lower extremity Multiple open areas related to incontinence 1. Clean the wound as necessary. 2. Apply a protectant paste to the wound and surrounding area. 3. If the area is on the lower extremity, elevate the patient s heels. 4. If the wound is in the perineal area, this barrier may be used as part of incontinence care. 5. Apply the barrier to the wound daily or every 8 to 12 hours, as needed. Note: All products shown in italics are distributed by Medline Industries, Inc. and are used for example purposes only. References: Blair SD, Wright DDI, Backhouse CM, et al. Sustained compression and healing of chronic venous ulcers. British Medical Journal. 1988;297: Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers: guideline for management of wounds in patients with lower extremity venous disease. Wound Ostomy and Continence Nurses Society. 2005;4(2):13. Larson-Lohr V, Fleck CA. Modern Wound Dressings: Principles, form and function. In: Sheffield PJ, Smith APS, Fife CE, eds. Wound Care Practice. 2 nd Edition. Best Publishing. Flagstaff, AZ. 2007: Moffatt CJ. Compression bandaging the state of the art. Journal of Wound Care. 1992;1(1): Moffatt CJ, Dickson D. The charing cross high compression four-layer bandage system. Journal of Wound Care. 1992;2(2):

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