Wound Assessment and Treatment
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1 The Nurses Domain Wound Assessment and Treatment Holly Kirkland-Walsh, PhD-c, FNP, MSN, CWCN April 15, 2016
2 Disclosure Information I have no conflict of interest to disclose
3 Objectives: The learner will be able to 1. identify strategies used for assessing wounds 2. identify concepts used for treatment of chronic wounds 3. name at least 3 products used to promote healing in chronic wounds
4 Wound Care Seminar Wound Assessment Strategies
5 Overall assessment Reasons for admission Review co-morbidities / systemic factors affecting wound healing Nutritional status Social Determinants of health
6 Patient History Reason for Admission Disease processes Medications Nutritional Status Therapies received Radiation Functional support Discharge home? Vascular studies- ABI Body habitus Previous wound history
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8 Physical Exam Head to toe skin assessment Rashes Pressure points Scars Edema, capillary refill, hemosiderin staining Callus formation in DM BMI
9 Cause of wound Surgical Traumatic Neuropathic Vascular Mixed Pressure related Fungating
10 Wound Assessment Location Age of wound Size and Shape Tunnelling, undermining, fistulas Exudate color, amount, consistency Surrounding skin discolored, edema, erythema Wound edges: attached or rolled
11 Wound assessment cont d Maceration of edges Erythema, epithelialization, eschar Necrotic tissue: yellow, black or brown % Odor of wound Wound bed: granulation tissue Tenderness to touch, temperature, tautness
12 Measurement Linear measurements of greatest length 12 o'clock to 6oclock or nearest Width perpendicular Depth, undermining, tunnels
13 TIME Framework
14 T is for Tissue Description: wound bed Color: Pink, yellow, grey, brown, green Thickened? Normal for this anatomical site?
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19 I- is for infection or Inflammation Differentiate infection from normal granulation tissue Odor: mostly pseudomonas smells like ammonia Do not culture: The only way to know is to take a deep tissue sample or Gold standard for r/o osteomyelitis is bone biopsy
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22 Infection and inflammation
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27 M- Moisture Balance For those wounds that fall between the cracks For those wounds that are way too wet In wounds the treatment rule is: If it is too wet, dry it- and if it is too dry, wet it
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30 Really? Wound Vac?
31 Challenges with New anatomy
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34 Managing moisture
35 E- Edges Thickened? Thin? Discolored? Scarring? Discrete? Defined? Wounds heal from the edges If a signal goes to the wound saying edges are healed- wound will be stalled The treatment involves debridement
36 Bonus photo: edges & moisture
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38 Goals for Product choice Regular assessment entire patient- engage pt TIME assessment of wound Keep wound bed clean and moist Keep surrounding skin clean and dry Few dressing changes as will allow- (no wet-dry) Decrease pain and edema Change plan of care every 2 weeks if stalled Keep it simple
39 Concepts to Promoting healing Important Aspects of Wound Healing or goals of care Wound cleansing/ odor control Wound debridement strategies Treatment of infection/ bioburden Maintaining moisture balance for epithelialization Management of wound pain
40 Cleanse before application
41 Wet wounds- exuding+++ Apply NPWT if draining more than 100 cc a day use super absorbent dressings- If deep wound-fill wound with hydrofiber or calcium alginate Aquacel ag, Melgisorb, or Mesalt Use peri-wound protection No sting barriers Cavilon,
42 Indications Dehiscence of wounds Necrotizing fasciitis (wound/ defects following surgery) Pressure ulcers: stage III and IV Failed flaps Split thickness skin grafts (before/after graft is applied) Chronic wounds: diabetic, arterial, venous, and radiation
43 Application of NPWT
44 Contraindications Necrotic tissue with eschar present in greater than 20% of wound (debridement is required before application of NPWT) Malignancy in wound Untreated osteomyelitis Non-enteric, unexplored, and non-visible fistula When wound bed is not visible (those like deep cavity or tunneling wounds) Exposed bowels, organs, bones, nerves, ligaments, tendons, and anastomotic sites (unless ordered by a MD with use of contact layer product like Adaptic, Mepitel One and/or Versaform. Directly over an artery Sensitivity to silver (V.A.C. granufoam silver dressing only), arylic adhesives
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50 Dry wounds Need debridement Autolytic- cover with a hydrocolloid, honey, etc Surgical- may not be suitable Enzymatic- Santyl May wet and add bio (maggots)
51 Honey Dressing Promotes autolysis of wounds and the removal of slough and dead tissue Creates a moist, healing environment in which new cells can flourish Neutralizing malodor (within 12 to 24 hours) Special order dressing from unit manager
52 Too Dry
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61 Questions?
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