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04/10/2013 Objectives: Identify the etiology of a wound State 4 different advance wound care products Colleen Drolshagen RN, CNS, CWOCN Cadence Health Central DuPage Hospital Winfield, IL List indications for each wound care product State an advantage and disadvantage for each wound care product Never use moistened 0.9 saline gauze in a wound. T_ F_ Dakin’s solution is often used to treat infected malodorous wounds. T_ F_ 3. It is best to stick with one type of dressing when treating a wound so the family and patient do not become confused. T_ F_ 4. Calcium Alginate dressing is an excellent choice for non-draining wounds. T_ F_ 5. Combining different types of products often leads to excellent outcomes. T_ F_ 6. Wash the wound well with hydrogen peroxide when using Santyl, an enzymatic debriding agent. T_ F_ 7. Graduated compression stockings are often a necessary adjunct in treating venous ulcers T_ F_ 8. Moisture associated dermatitis (MASD) may occur on periwound skin. T_ F_ 9. Off-loading is a key component for healing diabetic foot ulcers. T_ F_ 10. The goal for wound care is always healing. T_ F_ 1. 2. Pre-Test Treatment of Wounds Determine the etiology of the wound 1 04/10/2013 Determine Wound Etiology Arterial Ulcers 1. Arterial 2. Venous Tips of toes, foot calf, fingertips 3. Diabetic Well defined borders 4. Trauma/Surgical 5. Pressure Pale wound bed 6. Skin tears 7. Moisture Associated Dermatitis (MAD) Painful Sleeps with limb hanging down from bed ABI <.8= Lack of blood flow to the area Arterial ulcers treatment Improve blood flow Address pain Keep wound bed dry until blood flow is established Treatment choice may be Povidone-iodine (confirm pt is not allergic to iodine) Venous ulcers Located mid-calf (area covered by a sock) Poorly defined and jagged wound edges Wound bed ruddy, copious drainage Edema Hemosiderin staining Dry, scaly skin 2 04/10/2013 Venous ulcer treatment Diabetic Ulcers Address edema Absorb drainage Usually on the feet No pain compression Calloused wound edges Tubigrip stockings in sizes C-F Diabetic ulcer treatment Control blood glucose Establish blood flow Off-load Trauma/surgical wounds Treatment of traumatic/surgical wounds Control pain Manage exudate Provide moist wound healing principles Manage infection Control odor Protect periwound skin 3 04/10/2013 Pressure Ulcers A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Stage I Pressure Ulcer Stage III Pressure Ulcer Stage II pressure ulcer Stage IV Pressure Ulcer 4 04/10/2013 Unstageable Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. NPUAP 5 04/10/2013 Skin Tears At risk for skin tears Well moisturized skin Treatment of Skin Tears Minimize dressing changes to decrease risk of trauma to wound Most dressings can be left in place for up to 7 days Use foam, hydrogel, or non-adherent gauze (in that order) Moisture Associated Dermatitis (MASD (MASD): ): Moisture Associated (MAD) IrritationDermatitis and inflammation associated with exposure to stool of urine Often accompanied by erosion of the skin Sometimes accompanied by a secondary cutaneous infection (candidiasis) Etiology and pathology distinct from a pressure ulcer 6 04/10/2013 Protective Barrier Creams Urine on the skin Skin becomes alkaline Decrease barrier function Urea Ammonia Cavilon Extra Protective Further chemical damage Wound Care Treatment and Dressing Selections Baza antifungal barrier Transparent Film: Polyurethane or co-polymer that allows oxygen to pass through membrane. Smith & Nephew 3M Tegaderm Indicators: PartialPartialthickness wounds, Stage II-II pressure ulcers, superficial thermal injuries, donor sites and debridement Hydrocolloid Dressings: Hydrophilic Transparent Film Benefits: wound Disadvantages: inspection?, conformable, promotes autolytic debridement, and impermeable to bacteria. Also can be used as a secondary dressing May lead to maceration for periwound tissue, adhesive may be too aggressive, nonabsorptive and wound exudate may be mistaken for “pus” colloid particles bound together with polyurethane foam. Impermeable to bacteria and has moderate absorptive capabilities. DuoDERM By ConvaTec Comfeel by Coloplast Indications: Manage pressure ulcers, partial and full-thickness wounds. Mild exudating wounds, and wounds with necrosis or slough. Allow 1” border of intact skin when applying. 7 04/10/2013 Hydrogels: are water or glycerin-based amorphous gels, impregnated gauzes or sheet dressings. Maintain a moist wound Hydrocolloid Advantages: Conformable, wear time 3-7 days, comes in many shapes and sizes, moderate absorption, facilitates autolytic debridement, thermal insulation and pain reduction. Can be used to protect skin from frequent tape removal. environment. Disadvantages: Does not accommodate wounds with infections, tunnels, sinus tracts, or heavily draining wounds. May leave a residue and a distinctive odor upon removal. Dressings edges may curl. If opaque, unable to see wound bed. May cause hypergranulation tissue. Southwest Technology Elastogel Sytagenix Wound management Indications: Manage partial and full-thickness wounds, Stages II-IV, thermal injuries, radiation dermatitis, and wounds with necrosis and slough. Foam: Hydrophilic polyurethane/polymer or gel-coated foam, non-adherent, absorptive dressing Hydrogels Advantages: Non- adherent, rehydrates the wound bed, better alternative to saline gauze dressing, available as gels, sheets, strips and gauze. Aids in autolytic debridement. Disadvantages: May macerate periwound skin, daily dressing changes may be required, may need a secondary dressing, not recommended for heavy exudate Molnlycke Border Sacrum Smith and Nephew Alleyvn Foam Indications: Stage II-IV, partial and full- thickness wounds, moderate-heavy exudate, primary or secondary dressing. Also, one dressing of choice to treat hypergranulation tissue. Use of foam tip: Foams Advantages: adherent or nonadherent available, may be used under multi-layer compression wraps, conformable, available as sheets, pads, and cavity dressings. May stay on for up to 7 days. Disadvantages: not effective for wounds with dry eschar, may require a secondary dressing, may macerate periwound skin. Caution with use on infected wounds. adhesive border non-adhesive border Use 6x6 or 3x3 adhesive border for sacral, and coccyx pressure ulcers and skin tears Cut the 8x8 non-adhesive border to fit under trach plates or may use on skin tears with a secondary dressing to hold in place 8 04/10/2013 Calcium Alginate: Highly absorptive product derived from brown seaweed. ConvaTec Kaltostat Calcium Advantages: Alginate Absorbs Disadvantages: may 3M Tegagen Indications: Manage draining wounds with up to 20 times its weight, reduces frequency of dressing changes, conformable, easy to apply and remove, trauma free removal moderate to heavy exudate, partial and full-thickness wounds, tunneling, infected, and noninfected wounds, donor sites and assist with hemostasis. desiccate wound bed, some forms may leave fiber in the wound bed, contraindicated for dry eschar, full-thickness thermal injury, may require a second dressing to secure Collagens: major protein in the body, it stimulates cell migration, and formation of granulation tissue. Available in sheets, pads, particles, and gels. Smith and Nephew Biostep Medline Puracol Indications: partial and full-thickness wounds, infected and non-infected wounds, tunneling wounds, minimal to heavy exudate skin grafts and donor sites. Collagens Advantages: absorbent, maintains a moist healing environment, conforms easily, easy to apply and remove, change 17 days, daily if infection present Contact Layers: a single layer of woven net that acts a as lowadherent material when applied to the wound bed. This material allows wound exudate to be passed to a secondary dressing. Disadvantages: contraindicated for full-thickness thermal injury, presence of dry eschar, and those sensitive to collagen/bovine products. May require rehydration Requires a secondary dressing. Hollister Restore Molnlyke Healthcare Mepitel Indications: May be used as a primary dressing for partial and full-thickness wounds, minimal to heavy wound exudate, donor sites, and split-thickness grafts. 9 04/10/2013 Contact Layer Advantages: May be Disadvantages: Not applied with topical medications, fillers, or gauze dressings. Protects trauma of wound bed upon dressing changes. May be used in negative pressure wound therapy to decrease pain and trauma to wound bed recommended for stage I pressure ulcers, tunneling wounds, dehydrated or eschar covered wounds, or wounds draining viscous exudate. Usually requires a secondary dressing Gauze Dressings: available in many forms, woven and nonwoven, impregnated, and nonadherent Kendall Kerlix Roll Medline gauze sponge Indications: (vary with individual gauze products) Wounds requiring debridement, packing, management of tunneling, tracts or dead space, surgical incisions, thermal injury, partial and full-thickness wounds, and pressure ulcers. Gauze Advantages:Dressings can be used Disadvantages: May on infected wounds with topical medication, conformable and effective as a packing agent, easy to apply, available in many sizes and shapes, may have absorptive and wicking action, and provide mechanical debridement. Saline gauze dressings Moist to moist Wet to dry interfere with wound healing if not changed often enough or changed too often, fibers may shed and adhere to wound bed, more likely to cause pain if not removed properly, may not be the most effective moist wound healing therapy Impregnated Gauze Dressings Hypertonic Saline (Mesalt) Petroleum (Vaseline gauze) Anti-microbial (Kerlix AMD) 10 04/10/2013 Antimicrobial Dressings may contain silver, methylene blue, iodine, or active Leptospermum honey Medihoney made from the manuka plant in New Zealand Sterile honey that provide an acidic environment for wound helaing Assists to debride wounds “Jump starts” a stalled wound Smith and Nephew Aticoat Hollister Hydroferra Blue Smith and Nephew Iodof Derma Sciences Medihoney Indications: For use in draining, infected, or Can be used on infected wounds Can be left in place up to 7 days Confirm pt is not allergic to honey Colloid nonhealing wounds. May manage various types of acute and chronic wounds including thermal injury, diabetic, pressure, and vascular ulcers Paste Antimicrobial Dressings Advantages: Provides a Disadvantages: May broad range of antimicrobial or antibacterial activity. Can reduce or prevent infection. Can “kick start” the wound healing process. cause staining in wound and on intact skin. May cause stinging sensation. Must remove silver dressing for a magnetic resonance imaging (MRI) testing. Development of resistant organisms? Drugs: prescription products that provoke a series of physiochemical events in the body that assists with wound healing Healthpoint Xenaderm Increase blood flow, improve epithelialization and aid in reduction of pain. Indications: Varies by product Negative pressure therapy: localized negative pressure that removes interstitial fluid, infectious material, and promotes granulation tissue formation. Healthpoint Regranex (becaplermin) Gel 0.01% KCI Wound V.A.C. Avoid silver and iodine products and apply ~ a nickel thick Smith and Nephew Renasys Go Blue Sky Versatile 1 Indications: Acute and chronic wounds, traumatic wounds, partial-thickness thermal injury, dehisced wounds, flaps ,grafts, enteric fistulas 11 04/10/2013 Negative Pressure Therapy Advantages: M-W-F Disadvantages: Needs dressing changes or every 48 hrs, decreases edema and bacterial colonization, encourages epithelial and cell migration special supplies and training, contraindicated for unexplored fistulas, necrotic tissue with eschar, wounds with malignancy, untreated osteomylitis, and over exposed organs or blood vessels. Can be painful with dressing removal. Nutrition Multivitamin Adequate calories Protein Zinc (if deficient) Nutrition Pre-albumin is the best indicator of nutritional adequacy. Normal Prealbumin: 16 to 35 mg/dl Increased Prealbumin: Alcohol abuse, corticosteroids Decrease Prealbumin: Zinc deficiency, inflammation Infection Increase pain Wound healing stalled Increased drainage Increase odor Increase WBCs Erythema notes on periwound skin Culturing a Wound Prior to culturing the wound: 1. Remove old dressing 2. Cleanse wound with normal saline or commercial wound cleanser to remove old drainage 3. Obtain culturette to perform wound culture 4. When culturing the wound, apply sufficient pressure and perform a 10-point sweep across the wound bed to cause tissue fluid to be expressed (It is the bacteria in the tissue fluid that is desired for culture) If the wound has any tunneling or undermining, obtain an anaerobic culture as well 5. Example of 10-Point Sweep 12 04/10/2013 Malodorous wounds The most important step in determining dressing selection for those patients with chronic non-healing wounds is: Goal is to decrease the anaerobic activity Topical and oral metronidazole A. Cost of the product B. Identifying wound etiology Medihoney Silver ¼ Strength Dakin’s (protect periwound skin with a moisture barrier) In the patient with a highly exudating wound, which category of dressing wound be most appropriate? A. Transparent dressings B. Hydrocolloids C. Collagens D. Alginates In conclusion remember every wounds is C. Preference of the wound clinician D. Availability of the product Avoid the use of enzymatic deriding agents and hydrogen peroxide when utilizing dressings containing silver. True False Questions Unique Ever changing Dynamic Each wound should be assessed accordingly and your treatment will change as the wound changes 13 04/10/2013 References Bryant, R, Nix, D. Acute & Chronic Wounds, Current Management Concepts. 2007 Gray, Mikel, et al. Moisture-Associated Skin Damage: Overview and Pathophysiology, JWOCN, May/June, 2011 Hess, C.T. Clinical Guide: Wound Care 6th ed. Springhouse Pa.: Springhouse Corp.,2008 Thank You 14 From the Crow’s Nest: Topical Wound Care and Dressing Selection Colleen Drolshagen RN, CNS, CWOCN I. Identification of wound etiology. a.Pressure b. arterial c. venous d. diabetes e. skin tears f. moisture associated dermatitis II. Advance wound care products 1. Foam 2. Calcium alginate 3. Contact Layer 4. Antimicrobial dressings 5. Other IV.Indications A. Foam 1. Indications: Stage II-IV, partial and full-thickness wounds, moderate-heavy exudate, primary or secondary dressing. Also, one dressing of choice to treat hypergranulation tissue. B. Calcium Alginate } Indications: Manage draining wounds with moderate to heavy exudate, partial and full-thickness wounds, tunneling, infected, and noninfected wounds, donor sites and assist with hemostasis. C. Contact Layer } Indications: May be used as a primary dressing for partial and full-thickness wounds, minimal to heavy wound exudate, donor sites, and split-thickness grafts. D. Antimicrobial dressings } Indications: For use in draining, infected, or nonhealing wounds. May manage various types of acute and chronic wounds including thermal injury, diabetic, pressure, and vascular ulcers E. Others Pre-test 1. Never use moistened 0.9 saline gauze in a wound. T_ F_ 2. Dakin’s solution is often used to treat infected malodorous wounds. T_ F_ 3. It is best to stick with one type of dressing when treating a wound so the family and patient do not become confused. T_ F_ 4. Calcium Alginate dressing is an excellent choice for nondraining wounds. T_ F_ 5. Combining different types of products often leads to excellent outcomes. T_ F_ 6. Wash the wound well with hydrogen peroxide when using Santyl, an enzynmatic debriding agent. T_ F_ 7. Graduated compression stockings are often a necessary adjunct in treating venous ulcers T_ F_ 8. Moisture associated dermatitis (MASD) may occur on periwound skin. T_ F_ 9. Off-loading is a key component for healing diabetic foot ulcers. T_ F_ 10. The goal for wound care is always healing. T_ F_