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Wound Prevention Wound Care SOAR JULY 2011

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Other Dressings and Supplies. Calcium alginate- Is a filler for wound with depth. Can be used in infected wounds. Absorbs large amounts of fluid – PowerPoint PPT presentation

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Title: Wound Prevention Wound Care SOAR JULY 2011


1
Wound PreventionWound CareSOAR JULY 2011
  • Debbie Christensen, RN,WOCN

2
Skin The Largest Organ of
the Body
3
  • Burden of Wounds
  • Cost for hospital stays for adults with wounds
    totaled 11 billion in 2006
  • An estimated 2.5 million patients are treated
    each year in U.S. acute care facilities for
    pressure ulcers
  • Approximately 60,000 patients die each year of
    pressure ulcer complications
  • Court - tried as abuse

4
  • Skin Breakdown Pressure Ulcers are Preventable
  • Begins with identifying patients at risks and
    reliably implementing prevention strategies for
    prevention, malnutrition wound healing

5
PRE-EXISTING MEDICAL CONDITIONS
  • Poor circulation
  • Arteriosclerosis
  • Diabetes Smoking
  • Hypertension Radiation
  • Aging
  • Renal Failure
  • Liver disease

6
MEDICATIONS
  • Aspirin and other NSAIDs
  • Chemotherapy
  • Steroids
  • Coumadin

7
FOREIGN BODIES
  • Glass
  • Slough
  • Eschar
  • Metal
  • Wood

8
MAL-NUTRITION
  • Vitamins
  • Nutrients are needed for wound repair
  • Zinc
  • Protein
  • Calories
  • Minerals and trace elements

9
NUTRITIONAL SUPPLEMENTS
  • Hyperal TPN
  • Tube feeding
  • In between meal feeding
  • High protein drinks

10
CULTURES
  • Wound---remove surface Exudate by wiping with
    normal saline (STERILE) wait 10-15 minutes before
    swabbing. Do not force large piece of tissue
    into small collection tuberather use sterile
    collection cup.
  • a). Open abscess aspirate if possible, or pass
    swab deep into lesion and firmly sample lesions
    advancing edge.

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12
  • Skin Assessment
  • Assess on admission to the hospital, daily, and
    any time the patient condition changes.
  • Skin breakdown risk factors
  • Hyperglycemia
  • Dehydration
  • Malnutrition
  • Just 5 unintentional weight loss in 30 days
  • Obesity
  • Fat does not provide good nutrients for healing

13
  • Edema
  • Immobility
  • Appliances
  • Skin Integrity
  • Age
  • Diagnosis/Medications
  • Incontinence

14
  • Skin Assessment
  • Look at areas of greatest risk on the skin
  • Bony prominences
  • Heels, sacrum, coccyx, hip, elbows occiput
  • Skin contact anything that touches the skin
  • Braces, TED hose, Bi-PAP masks, tubes, O2 tubing,
    NG tubing, heel/elbow foot protectors, Foley
    catheter, I.V. tubing and hubs, jewelry etc.
  • If it is covered uncover and inspect site
  • Turn patient to do head to toe skin assessment

15
  • ASSESSMENT
  • Assessment is the starting point in preparing to
    treat to manage an individual with any type of
    wound.
  • Assessment involves the entire person, not just
    the wound, and is basis for planning treatment
    and evaluating its effects
  • Adequate assessment is also essential for
    communication among caregivers

16
  • Assessment continues
  • Goal is to have no facility acquired skin
    breakdown due to pressure . If not assessed in
    first 24 hours it is assumes that breakdown is
    hospital acquired
  • MD should be notified if a pressure ulcer is
    found so he can record in admission dictation or
    a progress note. (required for hospital at this
    time stay tuned)
  • Make sure if you are calling a wound pressure
    that it truly is from pressure over a bony area

17
  • Assess, Observe Document
  • Breakdown
  • Redness
  • Abrasion
  • Poor skin turgor
  • Dry skin can also be a risk factor for ulceration
  • Look in all folds, cracks crevices
  • DOCUMENT any variation from normal
  • Braden Scale

18
  • ASSESSING THE WOUND
  • Initial assessment Assess the wound for
    location, stage/thickness, size (length, depth
    and width), undermining, tunneling, Exudate,
    necrotic tissue, and the presence or absence of
    granulation tissue and epithelialization

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21
  • Pressure Ulcer Staging
  • Based on the depth and type of tissue damage
  • Initial presentation may not reveal the actual
    extent of tissue damage
  • May be a wide variance among staff

22
  • Stage one
  • Light pigmented skin non- blanchable erythemia
    of intact skin
  • Darkly pigmented skin changes in pigmentation,
    darkening, change in hue to gray or purple
  • Difference in temperature from surrounding tissue
  • Change in texture---boggy

23
Not a Stage one
24
Stage One
25
  • Stage two
  • Partial thickness skin loss involving the
    epidermis and /or dermis
  • Blister open or closed
  • Painful
  • Shallow crate

26
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27
  • Stage Three
  • Full thickness skin loss involving damage of the
    subcutaneous tissue that may extend down to the
    underlying fascia
  • Presents as a deep crater with or without
    undermining adjacent tissue
  • Slough and Eschar may be seen

28
Stage Three
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30
  • Stage Four
  • Full thickness skin loss with extensive
    destruction, tissue necrosis or damage to muscle
    bone or tendons
  • Undermining and tunneling may be associated with
    Stage 4 pressure ulcers

31
Stage Four
32
  • Deep Tissue Injury
  • A recently defined presentation of tissue trauma
    that appears as a dark purple or deep red site
    that is non-blanchable and does not resolve when
    pressure is relieved. May feel warm and firm to
    touch. Will progress to a deeper level if tissue
    injury over a period of time.

33
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  • Non Stagable
  • When Eschar is present accurate staging is not
    possible until the Eschar has bee sloughed or the
    wound has been Debrided.

35
Non Stageable
36
  • Staging
  • Once staged, the ulcer should not be back staged,
    rather the wound should be described in terms if
    size, shape, color, drainage and odor
  • Describe as a healing or healed stage two

37
  • Wound Care and Dressings
  • It is important to know the history of the
    patient and the history of his wound.
  • Initial care of a wound involves debridement,
    wound cleansing and the application of dressings
    and possible adjunctive therapy

38
  • Debridement
  • Removal of devitalized tissue
  • Method selection
  • Sharp
  • Mechanical
  • Enzymatic
  • Autolytic

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40
  • Wound Cleanser
  • Dont put anything in the wound that you could
    not put in your own eye
  • Prevent potential trauma to the wound bed by
    cleansers and cleansing
  • The ideal pressure depends on the stage of wound
    healing 8-15psi (30cc syringe with 19 gauge
    needle)
  • Avoid antiseptics
  • Betadine
  • Hydrogen peroxide
  • Cytoxic cleansers

41
  • The RIGHT Dressing
  • Wounds require dressings to maintain their
    physiologic integrity.
  • Dressings should protect the wound, be
    biocompatible and provide ideal hydration
  • The cardinal rule is to keep the wound tissue
    moist and the surrounding tissue intact and dry.

42
  • Dressing Selection
  • Select a dressing that will keep the ulcer bed
    continuously moist (wet-to-moist dressings should
    be used only for debridement and are not the same
    as continuous moist saline dressings, which keep
    the wound bed moist)

43
  • Dressings to Moisten a
    Wound Bed
  • Hydrocolloids-Examples-replicare, duoderm
    triangle, thin replicare
  • Need to be larger than the wound
  • Have an odor which is not infection
  • Provide some moisture to the wound
  • Can be used under compression wraps and as
    prevention on granulating wounds. For stage II-IV
    wounds

44
  • Hydrocolloid dressings
  • Advantage
  • Facilitates autolytic debridement
  • Self adherent
  • Comfortable
  • Thermal insulation
  • Average wear time-3-5 days

45
  • Hydrocolloid dressings
  • Disadvantages
  • Not recommended for heavy drainage or fragile
    skin
  • Odor noted with removal may be mistaken for
    infection

46
  • Transparent Film dressings
    (will moisten a wound bed)
  • Examples- Opsite and Tegaderm
  • Uses Primary or secondary dressing
  • Partial thickness wounds
  • Stage 1-2 Pressure Ulcers
  • Superficial burns
  • Donor sites
  • Dry eschar

47
  • Transparent Film dressings
  • Advantages
  • Ease of wound inspection
  • Impermeable to fluid and bacteria
  • Promotes autolytic debridement
  • Numerous sizes
  • Can change daily (less expensive)

48
  • Transparent Films
  • Disadvantages
  • Non-absorptive
  • May adhere to some wounds
  • Not for draining wounds
  • Fluid retention may lead to maceration of peri-
  • wound area.

49
  • For MOIST WOUNDS
  • Foam Dressings, Acrylic Dressings
  • Examples Allevyn, Mepilex, Tegaderm foam, (Heel
    design) Tegaderm Absorbent, Acrylic.
  • Uses Partial to full thickness with heavy
    drainage or light drainage
  • Stage II-IV Wounds
  • Under compression wraps
  • Dermal and surgical wounds
  • Skin tears (Clear Acrylic dressings)

50
  • Foam Dressings
  • Advantages
  • Non adherent, trauma free removal
  • Comfortable
  • Good fluid management
  • Easy to apply and remove
  • Frequency of dressing changes dependant on
    drainage-up to 7 days
  • Multiple sizes

51
  • Foam dressings
  • Not for dry non-draining wounds
  • May macerate periwound area
  • May require secondary tape
  • Not all foams recommended for tunneling wounds.
  • Acrylic dressings only absorb a little drainage.
    (light drainage)

52
  • Other Dressings and
    Supplies
  • Calcium alginate- Is a filler for wound with
    depth. Can be used in infected wounds. Absorbs
    large amounts of fluid
  • Hydrogel- nice to use when wound is a little dry
    with some depth- provides a little moisture to
    the wound. Use in clean granulating wounds
  • Tegaderm Ag mesh- antimicrobial, can be used with
    wound fillers, packed into tunnels or undermined
    areas. Safe to use with saline. Effective for
    MRSA and VRE. Contains ionic silver.

53
  • Other dressings and supplies
  • Cavilon No sting Barrier film- Forms a protective
    film between the skin, urine feces or body fluids
  • Coban II- compression dressings- for venous
    ulcers. Usually stays on for 7 days
  • Xeroform Petolatum dressing- Impregnated with
    Bismuth- and vaseline-antibacterial.

54
Other
dressings Contact layers Mepetil- Silicone
Used to keep dressings from sticking to a
Can stay in a wound 7 days Adaptic-Gauze
inpregnated with petrolatum Can use directly
on a wound to prevent the secondary dressing
from sticking
55
WOUND VACS
56
Documentation
  • Plan is in place and that all interventions are
    being done
  • If patient/resident is refusing make sure that
    this is charted
  • Identify the at risk changes that may be
    happening that are out of your control

57
Documentation
  • Assure that all information is included not time
    for a check list charting.
  • Same time charting will stand better in the
    courts than charting after the fact so be aware
    of changes with your patient/resident and then
    make sure any variance for the plan of care is
    charted

58
Question
  • Thank you so much for taking the best care of the
    patients/residents entrusted in you care
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