Wound Care Pearls 2013 Kellie Dowell, RN, CWCN, CWS
Functions of the Skin Thermoregulation Protection Sensation Water retention Synthesis of Vitamin D Expression of Emotion
The Skin Overview Largest organ of the body Weighs between 6-8 pounds Receives 1/3 or the body s blood volume Thickness varies from 0.5-0.6m
Risk Factors for Skin Breakdown Poor Nutrition Tissue perfusion Cardiac or Pulmonary Effusion Tissue cannot heal without oxygen
The Whole Patient Do not just look at the hole in the patient Current Medical History Current Medication Regime Nutritional Evaluation Lab Values Albumin. Prealbumin, HgA1c, CRP
Differentiating Wound Types Incontinence Associated Dermatitis Pressure Ulcers Neuropathic/Diabetic Ulcers Arterial Ulcers Venous Ulcers
Incontinence Associated Dermatitis Moisture from Urine or Stool which leads to skin breakdown Cleanse skin after each episode Apply moisture barrier after skin is cleansed
Incontinence Associated Dermatitis
Pressure Ulcers Localized areas of tissue necrosis that develop when soft tissue compressed between a firm surface and underlying bony prominence. Any wound caused by unrelieved pressure Should not use bed sore or decubitus Can occur in less than two hours The National Pressure Ulcer Advisory Panel used to stage ulcers
Stage 1 Pressure Ulcer Nonblanchable erythema or intact skin May be characterized by changes in local temperature, tissue consistency or sensation
Stage 1 Pressure Ulcer
Stage 2 Pressure Ulcer Superficial ulcer that presents as a shallow crater or blister Tissue involved: partial-thickness ulcer involving the epidermis, dermis, or both
Stage 2 Pressure Ulcer
Stage 2 Pressure Ulcer
Stage 3 Pressure Ulcer Deep ulcer that presents as a deep crater; may have undermining Tissues involved: full-thickness ulcer involving the epidermis, dermis, and subcutaneous tissue.
Stage 3 Pressure Ulcer
Stage 4 Pressure Ulcer Deep Ulcer with extensive necrosis, may have undermining or sinus tracts Tissues involved: full-thickness ulcer involving the epidermis, dermis, subcutaneous tissue, fascia and underlying structures, such as muscle, tendon, joint capsule, or bone.
Stage 4 Pressure Ulcer
Stage 4 Pressure Ulcer
Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure/or shear The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent skin.
Suspected Deep Tissue Injury
Unstageable A Pressure ulcer should be described as unstageable if the base is obscured by eschar or slough Tissues involved: unknown. Likely to be full-thickness with or without deep tissue destruction.
Unstageable
Diabetic Ulcerations i.e.. Neuropathic Round punched out lesion on the sole of the foot; base may have drainage due to infection. Patient walks on the ulcer without any discomfort Pulses in feet may be accentuated do to vessel calcification Structural deformities of the feet and toes (i.e. Charcot deformities)
Neuropathic Ulcer
Charcot Deformity
Arterial Insufficiency Ulcers Caused by decreased arterial blood supply Maybe caused by trauma, acute embolism,diabetes mellitus, Rheumatiod Arthritis, Buerger s disease or Arteriosclerosis May have ischemic rest pain or pain that increases with activity or elevation Almost always in lower extremities
Arterial Wound Presentation Ulcers begin as small, shallow wounds that gradually increase in size and depth Normally round and regular in appearance Granulation tissue, if present is pale or gray Possible necrotic tissue Minimal bleeding Dependent rubor
Arterial Ulcer
Buerger s Disease
Venous Stasis Ulcers Most common type of leg ulcer Venous system stores 70%-80% of total blood volume Valves in veins prevent retrograde blood flow, preventing increased venous back pressure as know as venous hypertension Most common cause is vein dysfunction and calf muscle pump failure Risk Factors are CHF, Pregnancy, Obesity, hereditary.
Venous System
Variocose Veins
Tests and Measures for Venous Insufficiency
Ankle Brachial Index Should be performed on all patients with suspected arterial or venous insufficiency A routing referral to a vascular surgeon is recommended if the ABI is <0.8 An urgent referral is ABI is <0.5
Characteristics of Venous Ulcers Pain dull, aching leg pain or heaviness Position Medial aspect of lower leg or medial malleolus Wound Presentation Superficial, irregular in shape, moderate to high drainage Peri wound area-hemosiderin (dark pigmented skin, Lower leg edema, subtle erythema
Venous Leg Ulcer
Intervention for Venous Ulcers Compression Therapy Multilayer compression bandage Systems Paste Bandages i.e. unna boots Vein Surgery Vein ligation Vein Stripping Sclerotherapy
So now what do we do to fix all of this????
Wound Dressings: Systematic Approach Matching the dressing to the patient, wound and setting Patient Criteria: Overall Treatment plan or goal of therapy Compliance and frequency of dressing changes
Dressing Criteria Absorbency Adhesive/non Adhesive Moisture Retentive Occlusive User Friendly
Gauze Dressings Woven Gauze Can be used as primary or secondary dressing Inexpensive May dehydrate wound Common Uses Infected and non infected wounds of any size, shape, depth, or etiology Frequent Dressing changes Wounds requiring packing
Impregnated Gauze Dressings Mesh gauze impregnated with petrolatum, bismuth, or zinc Dressings with bismuth (Xeroform) are cytotoxic Used as contact layer on granulating wound bed Prevents exposed tendons or tendon sheaths from dehydrating or adhering to wound Burn wounds
Films Thin, flexible sheets of transparent polyurethane with adhesive backing Little absorptive capabilities so do not use with heavy drainage Should be secured to 1-2cm border of intact skin Should not be used on infected wounds. Superficial wounds, lacerations abrasions Partial-thickness wounds, sutured wounds, donor graft sites Maybe used in areas of friction
Sheet Hydrogels 80%-90% water or glycerin-based wound dressings Available in sheets, gels, or impregnated gauzes Absorb minimal amount of fluid May decrease pain Permeable to gas and water Indicated for minimally or moderately draining wounds Effective for softening eschar
FOAMS Polyurethane foam with a hydrophillic wound side and hydrophobic outside Provide thermal insulation Less likely to cause trauma upon removal Easy to Apply Good for pressure ulcers Permeable to gas but not to bacteria Used on donor sites, ostomy sites, minor burns, diabetic ulcers and venous ulcers Not indicated for dry or arterial ulcers
Hydrocolloids Contain hydrophillic colloidal particles with a strong film or foam adhesive backing Vary in absorption abilities Provides thermal insulation Partial and full thickness wounds Contraindicated in infected wounds Do not use on wounds with exposed tendon/fascia
Alginates Salts of alginic acid extracted from brown seaweed and converted into calcium/sodium salts React with serum and wound exudate to form a hydrophilic gel to provide a moist wound environment Available in three forms, sheets, ropes and alginate tipped applicators Used to absorb up to 20 times their weight Ideal for infected wounds Not to be used on burns, tendon, joint capsule or bone.
Antimicrobials Silver Antiseptic agent that has been incorporated into all classes of dressings May be used as a primary or secondary Vary in absorptive capabilities Should be used with caution in epithelializing or granulating because of cytotoxicity Remove is patient is to undergo a MRI
Cadexomer iodine Slow release antimicrobial Releases iodine into the wound over time to reduce microorganisms Kills bacteria without retarding normal wound healing Effective against many microorganisms Available in sheet or tube
Other Dressings Hydrofera blue bacteriostatic properties Charcoal Dressings Honey Dressings antibacterial action Negative Pressure Apligraft Dermagraft Collagen Dressings Silicone Dressings
TEAMWORK Wound care is a team approach Many disciplines are involved ie. Plastic Surgery, Podiatrists, Cardiology, Radiologists, General Surgery, Infection Control, Diabetic Educators, Nurses, Nutritional Educators, Home Health and the list goes on.
Other Forms of Therapy Hyperbaric Oxygen Therapy Negative Pressure Wound Therapy
In Conclusion
THE END