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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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.
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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.

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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.

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Skin Anatomy
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Skin Functions

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

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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

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Two Major Types of Wounds

• Stasis Ulcers
• Pressure Ulcers

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Venous Stasis Ulcers

• Caused by venous hypertension
• Obstruction Preventing Outflow
• Valvular Incompetence Allowing Backflow
• Muscle Pump Flow

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Venous Stasis Ulcers

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

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Venous Stasis Ulcers

• Palpable pulse
• Edema
• Distributed around the ankle
• Weeping lesions
• Hyperpigmented

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Venous Stasis Ulcers
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Arterial Leg Ulcers

• Absence of palpable pulse
• Dry wound
• Absence of hair
• Atrophy below the level of occlusion
• Pain upon elevation
• Borders well defined

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Arterial Leg Ulcers
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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

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Treatment of Stasis Ulcers

• Treat any potential wound infections
• Assess nutrition implement supplements as
  needed

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Nutrition Supplements

• Increase caloric intake
• Vitamin A
• Vitamin C
• Vitamin E
• Zinc

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Treatment of Stasis Ulcers

• Compression therapy
• Support Hose
• Orthotic devices
• Sequential compression devices

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Treatment of Stasis Ulcers

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

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Pressure Ulcers

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

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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

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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

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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

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Prevention of Pressure Ulcers

• Systematic skin assessments
• Pressure relief and reduction
• Positioning
• Address incontinence
• Nutritional Deficit
• Activity Deficit

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Pressure Points
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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

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Stage One
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Treatment Stage One

• Vigilant positioning and pressure reduction
• Avoid positioning over trochanters relieve
  pressure on heels, elbows and cartilage of the
  ear

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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

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Stage 2

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

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Stage 2
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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

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Treatment Stage 2

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

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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

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Stage 3

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

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Stage 3
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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

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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

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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

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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.

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Stage 4
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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

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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

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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

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Eschar
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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

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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

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Eschar
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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

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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

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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

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Other Treatments

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

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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.

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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.

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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.

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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.

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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

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Dressings

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

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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.

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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

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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.

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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.

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Dressings

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

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Dressings

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

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Dressing selection grid
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Documentation

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

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Additional charting tips

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

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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

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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.

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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

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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

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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

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