Increasing Understanding of Wound Prevention and Management BC Farnham, MSW, MBA; Debbie Favel, RN, MSN, CHPN; Dr. Denise Green; Sheryl Matney, MS; Jenny Gilley Carpenter, LPN.; Karina Lemos, RN.; Elizabeth R. Pugh, LBSW. - PowerPoint PPT Presentation

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Increasing Understanding of Wound Prevention and Management BC Farnham, MSW, MBA; Debbie Favel, RN, MSN, CHPN; Dr. Denise Green; Sheryl Matney, MS; Jenny Gilley Carpenter, LPN.; Karina Lemos, RN.; Elizabeth R. Pugh, LBSW.

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Title: Increasing Understanding of Wound Prevention and Management BC Farnham, MSW, MBA; Debbie Favel, RN, MSN, CHPN; Dr. Denise Green; Sheryl Matney, MS; Jenny Gilley Carpenter, LPN.; Karina Lemos, RN.; Elizabeth R. Pugh, LBSW.


1
Increasing Understanding of Wound Prevention
and ManagementBC Farnham, MSW, MBA Debbie
Favel, RN, MSN, CHPN Dr. Denise Green Sheryl
Matney, MS Jenny Gilley Carpenter, LPN. Karina
Lemos, RN. Elizabeth R. Pugh, LBSW.
This program is made possible through a
collaborative community-education partnership
between The Consortium for Advancements in Health
Human Services, Inc. and the presenting agency.
The primary goal of this effort is to increase
public awareness and access to hospice care,
through the provision of community-based
education. Contact Hours are awarded to
professionals who complete this program by The
Consortium for Advancements in Health Human
Services, Inc.
2
Important Information
  • This education program for healthcare
    professionals was developed by The Consortium for
    Advancements in Health and Human Services, Inc.
    (CAHHS) and is facilitated by the presenting
    agency via a community education partnership
    agreement. CAHHS is a private corporation and is
    solely responsible for the development,
    implementation and evaluation of its educational
    programs. There is no fee associated with
    receiving contact hours for participating in this
    program titled, Increasing Understanding of Wound
    Prevention and Management. However, participants
    wishing to receive contact hours must offer a
    signature on the sign-in sheet, attend the entire
    program and complete a program evaluation form.
  • The Consortium for Advancements in Health and
    Human Services, Inc. is an approved provider of
    continuing nursing education by the Alabama State
    Nurses Association, an accredited approver by the
    American Nurses Credentialing Center's Commission
    on Accreditation. The Consortium for
    Advancements in Health Human Services, Inc., is
    approved as a provider of continuing education
    in Social Work by the Alabama Board of Social
    Work Examiners, 0356, Expiration
    Date 10/31/2014.
  • The course listed above was completed on / /
    and is approved for 1.0 CEUs. Approval number
    79003637. To claim these CEUs, log into your CE
    Center account at www.ccmcertification.org
  • In most states, boards providing oversight for
    nursing and social work recognize contact hours
    awarded by organizations who are approved by
    another state's board as a provider of continuing
    education.  If you have questions about
    acceptance of contact hours awarded by our
    organization, please contact your specific state
    board to determine its requirements. Provider
    status will be listed on your certificate.
  • CAHHS does not offer free replacement
    certificates to participants. In the event that
    CAHHS elects to provide a replacement
    certificate, there will be a 20.00
    administrative fee charged to the individual who
    requests it.

3
Learning Objective(s)
  • Increase understanding of the causal agents
    associated with various types of wounds.
  • Increase understanding of the treatment options
    specific to various types of wounds.

4
Skin Anatomy
5
Skin Functions
  • PROTECTION (largest organ of the body)
  • Protects against infection
  • Protects from UV sun exposure
  • Temperature regulation
  • Prevents loss of fluids and electrolytes

6
Who Is at Risk for Skin Breakdown?
  • Elderly
  • Terminal Disease
  • Impaired Mobility
  • Incontinence
  • Impaired Nutritional Status, Inadequate Fluid
    Intake
  • Altered Level of Consciousness
  • Diabetic Patients

7
Two Major Types of Wounds
  • Stasis Ulcers
  • Pressure Ulcers

8
Venous Stasis Ulcers
  • Caused by venous hypertension
  • Obstruction Preventing Outflow
  • Valvular Incompetence Allowing Backflow
  • Muscle Pump Flow

9
Venous Stasis Ulcers
  • 70 of chronic lower extremity ulcers
  • 600,000 cases annually in the United States
  • Recurrence rate is up to 90

10
Venous Stasis Ulcers
  • Palpable pulse
  • Edema
  • Distributed around the ankle
  • Weeping lesions
  • Hyperpigmented

11
Venous Stasis Ulcers
12
Arterial Leg Ulcers
  • Absence of palpable pulse
  • Dry wound
  • Absence of hair
  • Atrophy below the level of occlusion
  • Pain upon elevation
  • Borders well defined

13
Arterial Leg Ulcers
14
Treatment of Stasis Ulcers
  • Assess the entire patient
  • Systemic problems may impair wound healing
  • Assess wound
  • Size, depth, undermining
  • Appearance of the wound surface
  • Amount character of wound exudate
  • Status of periwound tissues

15
Treatment of Stasis Ulcers
  • Treat any potential wound infections
  • Assess nutrition implement supplements as
    needed

16
Nutrition Supplements
  • Increase caloric intake
  • Vitamin A
  • Vitamin C
  • Vitamin E
  • Zinc

17
Treatment of Stasis Ulcers
  • Compression therapy
  • Support Hose
  • Orthotic devices
  • Sequential compression devices

18
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19
Treatment of Stasis Ulcers
  • Provide a moist wound environment
  • Debridement of necrotic tissue, as appropriate
    based on patient condition
  • PREVENTION is the best treatment!

20
Pressure Ulcers
  • Caused by unrelieved pressure, usually to a soft
    tissue region overlying a bony prominence,
    resulting in damage to the underlying tissue.

21
Pressure Ulcers
  • Approximately 9 of hospitalized patients during
    the first 2 weeks of hospitalization
  • 3 of patients in surgical ICU
  • 5-8 of patients with neurologic impairment with
    a lifetime risk of 85 and mortality rate of 8
  • 28 of patients in long term care facilities

22
Pressure Ulcers
  • Increases nurses workload by 50
  • Adds 20,000 to hospital bill
  • Treatment of pressure ulcers in the United States
    is estimated to cost more than 1 billion annually

23
Prevention of Pressure Ulcers
  • Risk Assessment serve as a basis to identify
    measures that will alleviate, reduce, minimize
    the negative effects of identified risk factors
  • Braden Scale
  • Norton Scale

24
Prevention of Pressure Ulcers
  • Systematic skin assessments
  • Pressure relief and reduction
  • Positioning
  • Address incontinence
  • Nutritional Deficit
  • Activity Deficit

25
Pressure Points
26
Stage One
  • Pale, nonblanchable area of redness in lightly
    pigmented skin or persistent, red, blue or purple
    hues in darker skin types.
  • Skin intact
  • Pink/red skin that does not resolve when pressure
    is relieved

27
Stage One
28
Treatment Stage One
  • Vigilant positioning and pressure reduction
  • Avoid positioning over trochanters relieve
    pressure on heels, elbows and cartilage of the
    ear

29
Treatment Stage One
  • Prevent direct pressure on bony prominences
  • The wound will not heal without first stopping
    the insult
  • Skin Protectant apply to affected area, allow to
    dry. Reapply as daily and PRN.
  • OR
  • Transparent film dressing change every 5 days and
    as needed
  • OR
  • Hydrocellular foam dressing with good adherence,
    adds some cushioning.
  • Foam dressing may add to pressure directly over
    wound. You must first address pressure.
  • Pressure reduction mattress
  • APP
  • Low Airloss

30
Stage 2
  • Partial-thickness skin loss involving the dermis
    and/or the epidermis
  • Abrasion
  • Cracking
  • Blistering
  • Shallow crater appearance

31
Stage 2
32
Treatment Stage 2
  • Assess the entire patient
  • Systemic problems may impair wound healing
  • Assess wound
  • Size, depth, undermining
  • Appearance of the wound surface
  • Amount character of wound exudate
  • Status of periwound tissues

33
Treatment Stage 2
  • Treat any potential wound infections
  • Assess nutrition implement supplements as
    needed
  • Increase caloric intake
  • Vitamins A, C, E
  • Zinc

34
Treatment Stage 2
  • Cleanse with normal saline and 4x4s
  • No Drainage- apply hydrogel cover with composite
    boarder dressing change every 3 days and prn
  • Minimal drainage- Hydrocellular foam dressing
    change every 5 days and prn
  • Moderate drainage- hydrocolloid dressing change
    every 5 days and prn
  • Heavy drainage- Hydrocellular foam dressing
    change every 5 days and prn, may add algenate
    dressing if drainage is not well managed

35
Stage 3
  • Full-thickness skin loss involving damage or
    necrosis into subcutaneous fatty tissues or
    fascia. Appears as a deep crater.

36
Stage 3
37
Treatment Stage 3
  • Assess entire patient
  • Assess wound
  • Treat any potential wound infections
  • Assess nutrition implement supplements as
    needed
  • Increase caloric intake
  • Vitamins A, C, E
  • Zinc
  • Albumin levels are vital for wound healing

38
Treatment Stage 3
  • Clean, granulating wound bed (minimal drainage)
    apply hydrocellular foam dressing change every 5
    days and prn
  • Moderate to heavy drainage pack with alginate
    dressing cover with foam dressing change 3-5
    days and prn or composite border dressing change
    every 1-2 days and prn

39
Treatment-Stage 3 cont.
  • Tunneling present pack tunnel loosely to fill
    space
  • Minimal to no drainage gauze dressing
    impregnated with hyrogel
  • Moderate to heavy drainage alginate dressing
  • Cover as noted above
  • If infection present
  • Silver antimicrobial dressing cover with foam
    change every 3 days and prn
  • Oral (for example Keflex) or topical (crushed
    flagyl) may be appropriate

40
Stage 4
  • Full-thickness skin loss with extensive tissue
    involvement of underlying tissues. May involve
    necrosis and damage to muscles, bones, or
    supporting structures. Typically not as painful
    as Stage 3 due to nerve damage.

41
Stage 4
42
Treatment Stage 4
  • Assess the entire patient
  • Systemic problems may impair wound healing
  • Assess wound
  • Size, depth, undermining
  • Appearance of the wound surface
  • Amount character of wound exudate
  • Status of periwound tissues

43
Treatment Stage 4
  • Treat any potential wound infections
  • Assess nutrition implement supplements as
    needed
  • Increase caloric intake
  • Vitamins A, C, E
  • Zinc
  • Albumin levels are vital for wound healing

44
Treatment Stage 4
  • Same as stage 3
  • Debridement
  • Mechanical such as wet to dry. In a palliative
    care patient w/d dressings are generally
    ineffective and cause undo pain and damage to the
    wound bed
  • Enzymatic, discussed in a later slide
  • Irrigation

45
Eschar
46
Eschar
  • Black or brown necrotic, devitalized tissue
  • Can be loose or firmly attached, hard, soft,
    soggy
  • Cannot be staged until deepest viable tissue is
    exposed

47
Treatment - Eschar
  • Assess the whole patient.
  • What are the goals of treatment
  • Can the wound heal
  • Debridement Mechanical or Enzymatic
  • Surgical debridement by CWOC RN or MD

48
Eschar
49
Pain
  • Manage and control pain of patient
  • Medicate at least 30 minutes prior to dressing
    changes
  • Use topical anesthetics aerosolized morphine may
    be effective for painful wounds

50
Topical Debridement Agents
  • Enzymes (Santyl) digests denatured collagen in
    the slough to loosen necrotic tissue. Apply once
    daily.
  • Papain/Urea Combination (Panafil, Accuzyme)
    digests nonviable proteins. Apply once or twice
    daily

51
Treat Infection
  • Systemic antibiotic therapy for deep/surrounding
    tissue infection
  • Topical antibiotics may be sufficient for
    superficial infection
  • Silvadene
  • Triple Antibiotic Ointment
  • Always check for ALLERGIES

52
Other Treatments
  • REMOVE FOREIGN BODIES
  • WHIRLPOOL TREATMENT - Reserved for large,
    infected wounds
  • WOUND VAC Negative Pressure Wound Therapy
  • IRRIGATION 35ml syringe, 19gauge needle

53
Things to Remember
  • Once an ulcer is staged, it remains staged until
    healed.
  • When eschar is present, the ulcer cannot be
    properly staged until eschar sloughs.
  • Give vitamin and mineral supplements as tolerated
    for nutritional support.
  • Avoid using donut devices, which cause more
    pressure ulcers than prevent them.
  • Adhere to standard precautions for your
    protection and infection control.

54
Things to Remember
  • Living tissue requires moisture for transport of
    oxygen and nutrients
  • A dry environment is conducive to necrosis and
    eschar
  • Provide a moist (not wet) wound bed
  • Ulcer healing is delayed if there is bacterial
    burden within the wound bed.

55
Cleansing Agents
  • Cleanse wounds that are expected to heal with
    non-cytotoxic fluids(e.g. saline).
  • Cytotoxic fluids(e.g. povidine iodine, acetic
    acid, hydrogen peroxide, Dakin solution) will
    kill granulation tissue and greatly prolong
    healing time.
  • Dont clean a wound with any fluid you would not
    put in your eye if you want the wound to heal.

56
Tips for Odor Control
  • Odor may lead to patient isolation and poor
    quality of life
  • Double bag soiled dressing as appropriate away
    from patient area
  • Cleanse wound with wound cleanser and pat dry
  • Utilize silver antimicrobial dressings to
    decrease bacterial burden. Oral antibiotics may
    be efficacious.

57
Odor control cont.
  • Odor eliminators
  • Oil of wintergreen (aroma therapy)
  • Kitty litter, charcoal briquettes or coffe
    grounds open container placed in the corner of
    the room
  • Metronidazole paste (dry wound) or crushed tabs
    (wet wound) to the wound bed. Then cover wound
    with appropriate dressing
  • Charcoal based dressings may be the last line of
    defense for a fungating tumor

58
Dressings
  • Foams (lyofoam, Allevyn, generic brands like
    Medline).
  • Absorptive. May be used as primary dressing
    such as a bordered foam or a secondary dressing.

59
Dressings
  • Alginates
  • Works to desiccate an overly wet wound.
    Prevents maceration of surrounding skin from
    excess fluid is hemostatic and may reduce risk
    of infection.

60
Dressing
  • Hydrogels
  • Wound gels are excellent for helping to create or
    maintain a moist environment. Some Hydrogels
    provide absorption, desloughing and debriding
    capacities to necrotic and fibrotic tissue
  • Helps to provide and maintain a moist wound
    environment
  • Best for wounds with minimal to no exudate

61
Dressings
  • Hydrofiber
  • Absorptive textile fiber pad or ribbon for
    packing deep wounds. Covered with secondary
    dressing. Combines with wound exudate to form
    hydrophilic gel. Aquacel Ag contains 1.2 ionic
    silver with strong antimicrobial properties
    against even MRSA and VRE.

62
Dressings
  • Hydrocolloid wafers (DuoDerm).
  • Self-adhesive. Promotes autolysis,
    angiogenesis and granulation. Remains in place
    for 5-7 days. Often used to seal a wound that
    is otherwise clean in order to promote healing.
    Can also be used to seal any underlying dressing
    in order to maintain a moist environment in which
    the wound can heal. Note do not use an occlusive
    dressing if there is a substantial risk of
    infection.

63
Dressings
  • Thin films (OpSite, Tegaderm) for skin at risk
    or Stage one pressure ulcers.
  • Also to hold another type of absorbent
    dressing in place.

64
Dressings
  • Cotton gauze, used to cover the primary dressing.
    Rarely the appropriate dressing for a significant
    skin ulcer.

65
Dressing selection grid
66
Documentation
  1. Stage
  2. Location
  3. Size diameter, depth
  4. Appearance of wound and surrounding tissue
  5. Undermining, tunneling
  6. Drainage
  7. Pain level

67
Additional charting tips
  • CLOSED acronym
  • C color
  • L location
  • O odor
  • S stage and size
  • E exudate
  • D depth
  • wound pain

68
Documentation
  • Avascular necrotic, nonviable
  • Clean wound free of devitalized tissue,
    purulence, or debris
  • Dead Space a defect or cavity
  • Granulation pink/red tissue fills an open
    wound when it starts to heal has berry like
    surface

69
Documentation
  • Healing Synthesis of new tissue for repair of
    skin and soft tissue defects
  • Healing Ridge induration beneath the skin that
    extends 1 cm on each side of the wound. Becomes
    evident between 5 and 9 days of wounding,
    persists till about 15 days post wounding.

70
Documentation
  • Slough soft moist avascular tissue may be
    yellow, white, tan, or green may be loose or
    firmly attached
  • Tunneling (sinus tract) course or path of
    tissue destruction occurring in any direction
    from the wound

71
Documentation
  • Undermining area of tissue destruction under the
    intact skin along the periphery of a wound.
  • Common in shear injury
  • Involves significant portion of wound edge

72
DIDNT HEALFactors affecting Wound Healing
  • D Diabetes
  • I Infection
  • D Drugs
  • N Nutritional problems
  • T Tissue Necrosis
  • H Hypoxia
  • E Excessive tension on wound edges
  • A Another wound
  • L Low temperature

73
  • Questions/ Comments
  • Evaluation Certificate Process
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