Wounds! Wounds! Wounds! Amber Kirchner, MSN, CHPN Nurse Educator

Transcription

1 Wounds! Wounds! Wounds! Amber Kirchner, MSN, CHPN Nurse Educator

2 Wound care is arguably the single most difficult topic in medicine. It has no defined solution like insulin for the diabetic... no easy strategy that covers all wounds. -Bruce Gibbins, PhD, Founder, Chief Technical Officer and Chairman of the Board of AcryMed, Inc.

3 Objectives: 1. Describe how a wound becomes infected 2. Detail the importance of pain management for wounds 3. Identify appropriate wound care goals for hospice patients 4. Detail how to choose treatment options for managing wounds and symptoms in the hospice population

4 Background and Numbers Global wound care market- $15.6 billion spent in 2014 $18.6 billion projected 2019 Driving factors: Increasing diabetic and obese population Rising aging population Government support to develop products The average length of stay in hospital is almost three times longer for chronic wounds The mean hospital cost for management of pressure ulcers in the U.S. is $14,426

5 Palliative wound care encompasses (1) symptom management, (2) the improvement of psychosocial well-being, (3) a multidisciplinary team approach, and (4) patient/family-driven goals (Emmons & Lachman, 2010)

6 The National Pressure Ulcer Advisory Panel (NPUAP) produced a white paper in 2010 about pressure ulcers in individuals receiving palliative care. In that paper, they indicated the following:

7 Pressure ulcers occurring in the end of life are often not preventable. It may be impossible to eradicate pressure ulcers in the terminally ill because of the multiple risk factors and co morbid conditions. Healing is sometimes, but not always possible. It is crucial to permit nonhealing of an ulcer as a realistic goal.

8 Careful consideration needs to be placed on what interventions are appropriate, because most treatments are likely painful, distressing, or expensive in terms of time and dollars. In some cases, the focus of care is better directed to reduce or eliminate pain, odor, and infection.

9 Causes of Skin Breakdown? Sensory impairment Friction & shear Vascular issues Medications Moisture

10 What do we see??? Pressure ulcers Venous ulcers Neuropathic ulcers Malignant/fungating ulcers Tumors Arterial ulcers Surgical incisions Skin tears

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13 Infection Infection becomes likely with: High # of a particular microorganism Diverse types of microorganisms Susceptible host Clinical diagnosis is quantitative bacteria count > 100,000/1 gram tissue

14 Infection Local symptoms: Increased exudate, odor, erythema, pain, edema, induration, tenderness Systemic symptoms: Fever, chills, leukocytosis, increased glucose levels

15 Infection More subtle symptoms: Wound bed color change, lack of healthy granulation tissue Necrotic tissue is a source of nutrition for bacteria Ask yourself: Why has the wound stalled?

16 Wound Pain If patient has a wound, expect it to be painful! Major impact on QOL Do a complete pain assessment on wounds

17 Wound Pain Usually more than one cause: The wound itself (inflammatory response) Treatments (dressing removal, debridement, topical treatments, etc) Other pathologies (i.e. ischemia in arterial ulcers)

18 If Pain is not Managed Hyperalgesia Ongoing stimulation of pain pathways Primary Secondary Allodynia Increased pain perception

19 Psychological Factors of Wound Pain What other problems are associated with wound pain? Anxiety Depression Stress Fear Can exacerbate pain perception!

20 Pain Management Begins with dressing selection/frequency Premedicate before dressing changes Opioids Morphine or lidocaine gel Nonpharmacologic Aromatherapy Distraction

21 Odor Management Metronidazole Medical honey Silver dressings Charcoal dressings Debridement Don t forget about room odor!

22 Debridement Autolytic Mechanical Enzymatic Biological* Surgical* Sharp Conservative

23 Exudate Management Appropriate dressings Elevation & compression of extremities (if indicated) Elastic>inelastic Drain pouches/ostomy bags You may have to get creative!

24 Hemorrhage Careful removal of dressings Gentle pressure Alginate dressing Topical hemostatic agents Silver nitrate Epinephrine (1:1000) soaked gauze Afrin (off label use)

25 Treatment Options What are the goals of care??? Ease of use for caregiver, level of knowledge, and comfort with performing wound care need consideration

26 Healing vs. Maintenance vs. Comfort Healing vs. Maintenance vs. Comfort

27 Appropriate goals Promote wound healing Prevent complications of an existing wound Prevent new skin breakdown Verbalize knowledge of skin/wound regimen

28 Treatment considerations If wound healing is a viable option: Control or eliminate causative factors Maintain physiologic wound environment: Cleanse and protect wound Remove dead tissue (prevent infection) Eliminate dead space Moist wound environment

29 Treatment considerations, cont. If wound healing is not viable: Protect wound Symptom management Think comfort

30 Wound Factors to Consider Amount of exudate Location Size Periwound skin Tunneling, undermining Condition of wound bed Necrotic Tissue

31 First Line Dressing Options Semipermeable film Gauzes Non-adherent Hydrocolloid Foams Alginates/Hydrofiber Hydrogel

32 Second Line Dressing Options Honey Silver Cadexomer iodine Hypertonic saline Polyacrylate (polymer) Collagen

33 Frequency of Dressing Changes Minimize the frequency of dressing change Daily dressing changes increase chances of infection and disrupts the healing of tissue Optimal wear time is 3-7 days

34 Don t Forget the Pressure Reduction Devices! Heel protectors Wedges/pillows Mattresses APP Air mattress Gel Overlay Wheelchair cushion

35 Case Study #1 82 year old man diagnosed with squamous cell carcinoma of the scalp and neck. He has multiple growths to his scalp. Malodorous Moderate/heavy exudate Bleeding on left side

36 Case study #1

37 Case Study #1, cont. Ask yourself: Is healing a realistic goal? How do we treat it?

38 Case study #2 80 y/o male with history of smoking, HTN, previous leg ulcers, and heart failure Developed an ulcer on right lower extremity next to lateral malleolus Extremity is edematous and discolored Wound has moderate amounts of drainage and has irregular borders

39 Case Study cont. Functional status: Appetite fair Assistance with bathing, toileting, ambulation w/walker Sleeps in recliner PPS 40%

40 Ask yourself: Is healing a realistic goal? How do we treat it?

41 References Bryant, R. and Nix, D (2010). Acute and Chronic Wounds: Current Management Concepts 4th ed. St. Louis, MO Chrisman, C. (2010). Care of chronic wounds in palliative care and end-of-life patients. International Wound Journal, 7(4), Emmons, K. and Lachman, V. (2010). Palliative wound care: A concept analysis. Journal of Wound, Ostomy, and Continence Nursing, 37(6), Graves, M. and Sun, V. (2013). Providing Quality Wound Care at the End of Life. Journal of Hospice and Palliative Nursing, 15(2), Grocott P. The palliative management of fungating malignant wounds. J Wound Care 1995; 4(5),

42 References Hughes, R., Bakos, A., O Mara, A. and Kovner, C. (2005). Palliative wound care at the end of life. Home Health Care Management & Practice, 17(3) LeBlanc, K. and Baronoski, K. (2009). Prevention and Management of Skin Tears. Advances in Skin & Wound Care: The Journal for Prevention and Healing, 22(7), Margolis, D.J., Verlin, J., and Strom, B. (1993). Risk factors associated with the failure of a venous leg ulcer to heal. Arch Dermatol, 28(3), Mudge, E. and Orsted, H. (2010). Wound infection and pain management. Wounds International, 1(3), 1-6.