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.
1Increasing 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.
2Important 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.
3Learning 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.
4Skin Anatomy
5Skin Functions
- PROTECTION (largest organ of the body)
- Protects against infection
- Protects from UV sun exposure
- Temperature regulation
- Prevents loss of fluids and electrolytes
6Who Is at Risk for Skin Breakdown?
- Elderly
- Terminal Disease
- Impaired Mobility
- Incontinence
- Impaired Nutritional Status, Inadequate Fluid
Intake - Altered Level of Consciousness
- Diabetic Patients
7Two Major Types of Wounds
- Stasis Ulcers
- Pressure Ulcers
8Venous Stasis Ulcers
- Caused by venous hypertension
- Obstruction Preventing Outflow
- Valvular Incompetence Allowing Backflow
- Muscle Pump Flow
9Venous Stasis Ulcers
- 70 of chronic lower extremity ulcers
- 600,000 cases annually in the United States
- Recurrence rate is up to 90
10Venous Stasis Ulcers
- Palpable pulse
- Edema
- Distributed around the ankle
- Weeping lesions
- Hyperpigmented
11Venous Stasis Ulcers
12Arterial Leg Ulcers
- Absence of palpable pulse
- Dry wound
- Absence of hair
- Atrophy below the level of occlusion
- Pain upon elevation
- Borders well defined
13Arterial Leg Ulcers
14Treatment 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
15Treatment of Stasis Ulcers
- Treat any potential wound infections
- Assess nutrition implement supplements as
needed
16Nutrition Supplements
- Increase caloric intake
- Vitamin A
- Vitamin C
- Vitamin E
- Zinc
17Treatment of Stasis Ulcers
- Compression therapy
- Support Hose
- Orthotic devices
- Sequential compression devices
18(No Transcript)
19Treatment of Stasis Ulcers
- Provide a moist wound environment
- Debridement of necrotic tissue, as appropriate
based on patient condition - PREVENTION is the best treatment!
20Pressure Ulcers
- Caused by unrelieved pressure, usually to a soft
tissue region overlying a bony prominence,
resulting in damage to the underlying tissue.
21Pressure 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
22Pressure 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
23Prevention 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
24Prevention of Pressure Ulcers
- Systematic skin assessments
- Pressure relief and reduction
- Positioning
- Address incontinence
- Nutritional Deficit
- Activity Deficit
25Pressure Points
26Stage 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
27Stage One
28Treatment Stage One
- Vigilant positioning and pressure reduction
- Avoid positioning over trochanters relieve
pressure on heels, elbows and cartilage of the
ear
29Treatment 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
30Stage 2
- Partial-thickness skin loss involving the dermis
and/or the epidermis - Abrasion
- Cracking
- Blistering
- Shallow crater appearance
31Stage 2
32Treatment 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
33Treatment Stage 2
- Treat any potential wound infections
- Assess nutrition implement supplements as
needed - Increase caloric intake
- Vitamins A, C, E
- Zinc
34Treatment 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
35Stage 3
- Full-thickness skin loss involving damage or
necrosis into subcutaneous fatty tissues or
fascia. Appears as a deep crater.
36Stage 3
37Treatment 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
38Treatment 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
39Treatment-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
40Stage 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.
41Stage 4
42Treatment 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
43Treatment 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
44Treatment 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
45Eschar
46Eschar
- Black or brown necrotic, devitalized tissue
- Can be loose or firmly attached, hard, soft,
soggy - Cannot be staged until deepest viable tissue is
exposed
47Treatment - 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
48Eschar
49Pain
- 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
50Topical 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
51Treat 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
52Other Treatments
- REMOVE FOREIGN BODIES
- WHIRLPOOL TREATMENT - Reserved for large,
infected wounds - WOUND VAC Negative Pressure Wound Therapy
- IRRIGATION 35ml syringe, 19gauge needle
53Things 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.
54Things 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.
55Cleansing 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.
56Tips 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.
57Odor 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
58Dressings
- Foams (lyofoam, Allevyn, generic brands like
Medline). - Absorptive. May be used as primary dressing
such as a bordered foam or a secondary dressing.
59Dressings
- Alginates
- Works to desiccate an overly wet wound.
Prevents maceration of surrounding skin from
excess fluid is hemostatic and may reduce risk
of infection.
60Dressing
- 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
61Dressings
- 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.
62Dressings
- 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.
63Dressings
- Thin films (OpSite, Tegaderm) for skin at risk
or Stage one pressure ulcers. - Also to hold another type of absorbent
dressing in place.
64Dressings
- Cotton gauze, used to cover the primary dressing.
Rarely the appropriate dressing for a significant
skin ulcer.
65Dressing selection grid
66Documentation
- Stage
- Location
- Size diameter, depth
- Appearance of wound and surrounding tissue
- Undermining, tunneling
- Drainage
- Pain level
67Additional charting tips
- CLOSED acronym
- C color
- L location
- O odor
- S stage and size
- E exudate
- D depth
- wound pain
68Documentation
- 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
69Documentation
- 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.
70Documentation
- 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
71Documentation
- 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
72DIDNT 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