Download Wound Care Best Practice Guidelines

VITAS Healthcare Corporation
Wound Care
Best Practice Guidelines
Goal
To educate healthcare professionals on
effective wound care protocols, in order
to ensure optimal care for our
terminally ill patients.
Objectives
• Identify preventative measures
• Describe risk factors contributing to skin impairment
• Describe the parameters of wound assessment
including staging of wounds
• Describe wound types and tissues
• Describe care planning considerations and the
selection of appropriate interventions
Prevention
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Inspect skin
Moisture control
Proper positioning and transfer techniques
Nutrition
Avoid pressure on heels and bony prominences
Use of positioning devices
Monitor and document
Risk Assessment
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Alterations in mobility
Level of incontinence
Nutritional status
Alteration in sensation or response to discomfort
Co-morbid conditions
Medications that delay healing
Decreased blood flow to lower extremities when
ulceration is present
Contributing Factors
1
Friction
Immobility
Shear
Pressure
Ulcers
Pressure
Incontinence
Malnutrition
Assessment and Documentation
• Location
• Stage and Size
• Periwound
• Undermining
• Tunneling
• Exudate
• Color of wound bed
• Necrotic Tissue
• Granulation Tissue
• Effectiveness of Treatment
Assessment and Documentation
• Wound and Risk Assessment every visit
• Documentation on Wound Assessment Form every 7 days
when 1 or more pressure ulcer exists
• Physician assessment and documentation on
Physician Wounds Care Assessment tool
Pressure Ulcer Staging
Stage I
Stage II
Stage III
2
Stage IV
Care Planning
.
Overall strategy and scope of the
treatment plan depends on patient’s
condition, prognosis, and
reversibility of the wound.
Appropriate Goals
• Prevent complications or the
deterioration of an existing wound
• Prevent additional skin breakdown
• Minimize harmful effects of the wound
on the patient’s overall condition
• Promote wound healing
Interventions
Dressing considerations should include:
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Patient’s condition and prognosis
Caregiver ability
Ease and continuity of use
Ability to maintain moisture balance
Frequency of change
Pain Management
1) Medicate the resident prior to dressing
2)
1)
2)
3)
changes
Some treatment regimes may be
uncomfortable for the resident
Provide maintenance doses of medication
for those patients who have pain.
Adjuvant therapy may be appropriate
Consider non-medicinal approaches
Types of Wounds
• Pressure Ulcers
• Arterial Insufficiency
• Diabetic Ulcers
• Venous Insufficiency
• Surgical Wounds
• Tumors
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Palliative Wound Care
for the Imminent Patient
Think:
• Comfort
• Quality of Life
Treatment Choices:
• Keep Current Treatment
• Irrigation, Cover with DuoDERM Thin or
Bioclusive Dressing
• Irrigation, Silvadene, Cover with Gauze
(if infection is suspected)
Basic Elements of Wound Care
• Cleanse Debris from the
Wound
• Possible Debridement
• Absorb Excess Exudate
• Promote Granulation and
Epithelialization When
Appropriate
• Possibly Treat Infections
• Minimize Discomfort
Wet to Dry Dressings
Indicated for Mechanical Debridement ONLY
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Causes Injury to New Tissue Growth
Is Painful
Predisposes Wound to Infection
Becomes a Foreign Body
Delays Healing Time
Frequency
• Goal is to minimize
the frequency of
dressing change
• Daily dressing
changes increase
chances of infection
and disrupts the
healing of tissue
• Optimal wear time is
3-7 days
Decrease Frequency
of Dressing Changes
Interventions:
Patients At-Risk or Stage I
• Assess “Risk for Breakdown”
• Utilize skin creams and lotions
for dry skin
• Utilize barrier products as
needed to minimize irritation
from incontinence
• Reposition frequently
• Encourage fluids as tolerated
and appropriate
• Use pillows in bed for
positioning
Cleansing Wounds
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Remove Wound Debris
Sustain Moist Environment
Soften Necrotic Tissue
Debride the Wound
Reduce the Risk of
Bacterial Contamination
and Infection
• Reduce Odor
..
Goals & Treatment Guidelines
• Dry to Minimal Exudate
• Moderate Exudate
• Copious Exudate
Interventions
Stage I
GOALS:
TREATMENTS:
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Preferred agents (dry skin)
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Maintain skin integrity
Skin to remain clean and
odor free
Protect and moisturize skin
• Aloe Vesta skin cream
Preferred agents (at risk for
breakdown due to
incontinence/pressure)
• Aloe Vesta protective
ointment
• Dermarite Perigaurd
barrier ointment
Interventions
Stage II, III, IV
Dry to Minimal Exudate
GOALS:
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Minimize dressing changes
Maintain moist environment
Prevent infection
Prevent additional skin
breakdown
TREATMENTS:
Preferred agents:
• Hydrofiber (Aquacel)
• Viscopaste
• Hydrocolloid (DuoDERM
Extra Thin)
Follow product guidelines for
frequency of dressing change
Interventions
Stage II, III, IV
Moderate Exudate
GOALS:
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Minimize dressing changes
Maintain moist environment
Prevent infection
Prevent additional skin
breakdown
TREATMENTS:
Preferred Agents:
• Hydrofiber (Aquacel)
• Hydrocolloid (DuoDERM
Signal)
Follow product guidelines for
frequency of dressing change
Interventions
Stage II, III, IV
Copious Exudate
GOALS:
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Minimize dressing changes
Manage Exudate
Prevent infection
Prevent additional skin
breakdown
TREATMENTS:
Preferred Agents:
• Hydrofiber (Aquacel)
• Hydrocolloid (DuoDERM
Signal)
Follow product guidelines for
frequency of dressing change
Interventions
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Necrotic Tissue in Ulcer Bed
Fungating Lesions
Infected Wounds
Skin Tears
Gangrenous Wounds
Diabetic Ulcers
Interventions
Necrotic Tissue in Ulcer Bed
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Mechanical Debridement
Autolytic Debridement
Sharp or Surgical Debridement*
Enzymatic or Biochemical Debridement*
Biological Debridement*
*Requires Approval
Interventions
Necrotic Tissue in Ulcer Bed
• Prior to debridement interventions, assess
whether it will enhance wound healing or
promote infection or cause undue pain.
• Do NOT institute aggressive debridement if
the patient is within days/week of death, or if
the eschar is stable, dry, non-draining, and
wound is not infected.
• For Intact black heel – relieve pressure – no
dressing or debridement – if opens then refer
to necrotic treatments.
Interventions
Fungating Lesion
Goals:
• Removal of exudate
• Odor control
• Pain control
Non-Pharmacological measures to
control odor include:
• Oil of Wintergreen
• Charcoal briquettes or Coffee
grounds
• Dryer Sheets
Treatments:
Preferred Agents
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Non-Adherent Gauze Dressing
(Telfa)
Zinc Oxide Paste (Viscopaste)
Activated Charcoal Dressing
(Carboflex)
Atropine solution may be used
to control bleeding
Metrogel cream can be used to
control odor
Interventions
Infected Wounds
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Diagnosis of wound infection:
• Swab Cultures not
recommended
• Based on clinical signs (fever,
increased pain, friable
granulation tissue, foul odor)
Tissue culture or biopsy is not
optimal for the hospice patient.
Treatments:
Preferred agents:
• Hydrofiber (Aquacel Ag)
• Silvadene ointment and
non-sterile gauze
DO NOT USE:
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Providine Iodine
Iodophor
Dakin’s solution
Hydrogen peroxide
Acetic Acid
Interventions
Skin Tears
Goals:
Treatments:
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Preferred Agents:
• Non-Sterile Gauze
• Transparent Film
(Opsite)
Prevent infection
Healing
Prevent further injury
Minimize dressing change
frequency
Interventions
Ischemic
(Gangrenous)
Wounds
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Venous Stasis or
Diabetic Ulcers
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Draining wounds
– Cover with Telfa or gauze
and wrap with Kerlix
No drainage
– Cover with gauze and
Kerlix
Change QD and PRN
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Draining wounds
– Cover with Telfa or
Adaptic with a Kerlix
wrap changed QD
– Cleanse with normal
saline using bulb
syringe
Non-draining wounds
– Cover with gauze and
wrap with Kerlix
– Apply tape to the Kerlix
to prevent further injury
to surrounding skin
– Change QD
Support Surfaces
Comfort and Shear
Reduction Products:
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Pillows
Heel/Elbow Protectors
Foot Cradles
Sheepskin Pads
DO NOT USE DONUT
TYPE DEVICES IN
WHEELCHAIRS
Support Surfaces
Multiple Pressure Points (greater than 2 turning surfaces)
• Standard Mattress
• 3-4” Eggcrate Overlay on Standard Bed
• Gel Mattress Overlay
• Wheelchair Foam Pad
• Wheelchair Gel Pad
Multiple Pressure Points (fewer than 2 turning surfaces)
• Static Air Mattress
• Alternating Pressure Pad and Pump
• Low Air Loss Mattress (requires approval)
In Summary….
• Determine the plan of care based on the
patient’s characteristics
• Evaluate the wound status every visit
and at a minimum of weekly
• Evaluate the effectiveness of the
treatment regime
• Try to provide consistent wound care
among all caregivers
• Completely document status of wound
Thank you
Together, we can make a
difference!