!! YIKES!! WHAT IS THAT AND WHAT DO I DO WITH IT? Presented By: Connie Anderson RN, BSN, WCC Woodburn STEPS Clinic, Woodburn, Oregon Fictional Yay!!! When did you first notice the problem? Was there a specific event that may have caused the problem? Have you been treating this at home? What change made you seek medical attention? Acute Traumatic Parasitic Wound ALIENS THE MOVIE Yikes! Very real. How did this begin? When did the bowel Become involved? What treatments have been used so far? When is the next surgery scheduled? Tell me about your diet and your bowel habits? Chronic Post Operative with Ventral Hernia, Bowel Evisceration and Entero-abdominal Fistula 1
Obtain an accurate and complete history and physical. It is a vital step in the wound treatment process. Develop decision making strategies, utilize screening tools and USE THEM in formulating a wound treatment plan Identify situations that require advanced treatment or specialty care and make referrals. LEARNING OBJECTIVES Family/ Support System Living Situation Occupational History Educational/Cognitive ability Activity Level and ability Health care patterns Economic status Mental/Emotional status Cultural values /beliefs Nutritional Status Attitude/Compliance Social / Environmental Obtain a Complete Medical History FAMILY/SUPPORT care partner, transportation, help/hindrance LIVING SITUATION house, assisted living, foster care, homeless facilities, electricity OCCUPATION working, work environment, hours, duties/activities EDUCATION/COGNITIVE ABILITIES ability to understand, literate, cognitive abilities other than average. ACTIVITY LEVEL mobility, strength, endurance, tolerance HEALTH CARE PATTERNS PCP?, routine check ups, compliance ECONOMIC STATUS insurance, income, ability to pay for treatment/ supplies SOCIAL/ENVIRONMENTAL HISTORY 2
MENTAL/EMOTIONAL STATUS depression, anxiety, angry, dementia CULTURAL VALUES/BELIEFS old wives tales, home remedies, heat/cold NUTRITIONAL STATUS weight, diet, appetite, restrictions, preferences, supplements, availability HABITS smoking, alcohol, narcotics, recreational substances ATTITUDE/COMPLIANCE receptive, interested, compliant SOCIAL/ENVIRONMENTAL HISTORY 78 y/o SWF Lives alone. Daughter close by. Retired industry worker, pension, Medicare and SS. Fully cognizant. Hx depression Ambulatory without Assist. Licensed to drive. Obese, recent bariatric surgery Former smoker Nutritional changes related to Surgery and current intestinal Fistula. Social / Environmental History IDENTIFY FACTORS THAT IMPAIR WOUND HEALING AGE MEDICATIONS/ALLERGIES CARDIOVASCULAR RESPIRATORY GI/GU MUSCULOSKELETAL ENDOCRINE HEMATOLOGIC CANCER AUTOIMMUNE CO-MORBITIES 3
AGE Dermal layer thins Reduced connective tissue, vascular function, sweat glands, sensation Slowed /impaired inflammatory response, tissue regeneration MEDICATIONS/ALLERGIES Corticosteroids- suppresses inflammatory response NSAIDS- ASA, indomethacin: impaired angiogenesis. Anti rejection agents immunosuppression Antineoplastic agents cell destruction,non discriminatory Anticoagulants inhibit fibrin and fibronectin, debridement risks. Herbs and supplements constantly changing, varying effects. Home remedies questionable ingredients, sometimes harmful. CO-MORBIDITIES CARDIOVASCULAR CHF/CAD/Cardiac function PVD stasis PAD - perfusion Anemia Decreased circulating oxygen Hypoxia insufficient oxygen to support biological processes. Temperature ( wound/limb) RESPIRATORY COPD- positioning Pneumonia- Upper respiratory infections Asthma autoimmune? Steroids GI/GU GI bleed: anemia,weakness, blood volume Inadequate absorption Diarrhea- skin breakdown, dehydration Incontinence- skin breakdown, wound contamination Renal failure dietary restriction (Protein), dialysis slow wound healing, time constraints. CO-MORBIDITIES 4
MUSCULOSKELETAL Mobility- pressure,circulation, paralysis Limb function amputation, paralysis,rom, ability to comply. Arthritis/gout- pain, related meds, strength, manual dexterity. Qualify for home health?-scooters. ENDOCRINE Diabetes glucose levels: yeast,fungus, bacteria Neuropathy Circulation CO-MORBIDITIES HEMATOLOGIC CANCER Anemia Fluid/electrolyte balance Hydration/fluid volume Blood disorders- alter normal healing cascade What kind Surgery slow to heal Radiation - tissue injury, pain, scarring Antineoplastic medications cell destroyers Prevent increased tissue loss Dietary/fluid balance issues CO-MORBIDITIES AUTOIMMUNE RHEUMATOID ARTHRITIS PSORIATIC ARTHRITIS ASTHMA MS MEDS CROHNS LUPUS ECT. CO-MORBIDITIES 5
78 y/o ASA 81mg,, MTV, PRN vicodin, clonazepam,spironolactone,lasix, neurontin, colace, MOM, fosamax, zyrtec, cymbalta, spiriva (ABX?, B12?) Hypertension - resolved COPD(emphysema/asthma/GERD) Gastric bypass, hernia,fistula constipation /diarrhea,possible nutritional deficit. Arthritis, osteoporosis Diabetic diet controlled, neuropathy (feet) Anemia / low protein/ low albumin Asthma / meds Case Study : Co- Morbidities WOUND HISTORY When Where How Why now? WOUND ASSESSMENT Location Classification Measurements Wound bed Tracts and tunnels Wound edges Peri tissue Other considerations Wound History/Assessment WOUND HISTORY Cause of wound Duration History of prior/similar wounds Treatment history What health care providers have treated wound WOUND ASSESSMENT Location Classification Full thickness Partial thickness Burn - extent and location Skin tear Traumatic puncture, laceration WOUND ASSESSMENT/HISTORY 6
Classification continued Surgical Diabetic Foot Venous /Arterial ulceration Pressure ulcer Staging Other cancer, MRSA, parasitic, pyoderma gangrenosum Measurements length/ width/depth Wound base(bed) assessment Tissue type Exudate type,amount Odor before and after cleansing Foreign bodies suture, bone chip, pet hair, maggots Tracts / tunnels and undermining use the clock Wound edges WOUND ASSESSMENT/HISTORY Peri Wound Color Temperature Pigmentation Edema/induration Scarring Other considerations Pain Prior treatments/ response Pt toleration of treatments Referrals Labs Wound Assessment Chronic, full thickness, surgical wound with intestinal evisceration at 10 o'clock. Enteroabdominal fistula at distal (superior) end of eviscerated bowel. 3 visible sutures, 29cm x 18cm x 5 cm Wound bed pink, 80% granulation tissue, 20% slough Undermining 12 to 12, 2cm Exposed bowel has active fistula at 12(o), blistering at 4 and 7 (o) ecchymosis at 6 (o) Pink tissue with yellow slough Exudate heavy, fecal, brown Odor foul before cleansing none after. Wound edge- defined intact, rolled No pain Case Study : Wound Assessment 7
SCREENING TOOLS Rule of 9 Burns Push tool Pressure ulcers ABI Leg Ulcers Wound cultures Punch biopsies Diagnostic imaging osteo, vascular status, foreign body University of Texas Foot Risk Classification System Lab values anemia,infection, nutritional status, immune response DECISION TREE Algorithms What is your goal? Address systemic barriers to healing : infection, anemia nutritional deficits, diabetes, circulatory,etc Control pain level oral, topical Prep the wound bed debride, cleanse Decision Time Moisture control add or remove Treat the peri tissue- rash, dry, wet, fragile Topical antimicrobial, antifungal, steroidal needed? cover layer : frequency of dressing change Securing : patient tolerance, environment, activity level, economy. EDUCATION continuous and repetitive CONTINUED TREATMENT How often Who will provide the care Where to get supplies Follow up appointments and reassessment Wound should show response in 2 weeks Decision Time GOAL : Control exudate, prevent infection, maintain healthy wound bed for surgical intervention. BARRIERS TO HEALING: age, diabetes, fecal material, asthma, steroidal meds anemia, nutritional status, BOWEL IN THE WOUND BED. PLAN : Contact PCP What s the Plan? Surgeon Surgical repair? TPN? Treat eviscerated bowel as stoma Protect the exposed bowel Educate patient and family Control Cost to patient and clinic Case Study Treatment Plan 8
Saline irrigation Fill wound with alginate Cover with large exudry pad cut slit for bowel section Secure all with occlusive drape. ( vac drape) Ostomy bag over occlusive dressing. Ostomy paste to obtain seal Change 3 times weekly. Treatment Plan Wound smaller Bowel remains tissue improved No S/S of infection Nutritional Status minimal change No plans for surgery Has not kept referral appointments Current dressing not controlling fecal material well. Patient concerned about costs Case Study - Reassessment SPECIALTY DRESSINGS Anything you don t stock in the office Alginates/hydro fibers Honey/enzymatic debridement Silver products Foams Specialty absorptives ADVANCED TREATMENT Negative pressure wound therapy Electrical stimulation Ultrasound stimulation Hyperbaric Skin substitutes/grafts Whirlpool Pulsed lavage Specialty Dressings/Advanced Treatment 9
MULTI-DISCIPLINARY APPROACH Wound clinic/wcc Physical therapy Social services Mental health Nutritionist Home health care REFERRALS- keep communication lines open Surgeon Podiatrist Burn center Infectious disease Vascular specialist Plastic surgeon Cardiology nephrology MAKE THE REFERRAL Surgical repair and closure Post operative infection Oral abx Debridement Suture removal Alginate + foam Resolved in 4 weeks Pt remarried, doing well. Case Study - Resolved The history and physical is essential in the formulation of a successful wound treatment plan. Develop treatment algorithms and utilize screening tools to Help guide the decision making process. Identify situations that need specialty care or advanced treatment and make the referral. Objectives 10
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