Hnatyszyn Assess and Manage DEC2018 FOR BOOK€¦ · present • Strip gauze, kerlix, alginate • Never pack a dressing you can not remove Principles of Local Wound Care Maintain

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Wound Care ©TCHP Education Consortium, November 2012, Revised Dec. 20181

Wound Assessment

Priorities for Wound Managementfrom Acute and Chronic Wounds. Bryant, Ruth A.

1. Control or eliminate causative factors

2. Provide systemic support to reduce existing cofactors

3. Apply topical therapy that will maintain a physiologic wound environment.

Priorities for Wound Management

1.Control / Eliminate the cause of the wound.• Pressure • Shear• Circulatory Impairment• Moisture• Friction


2. Provide System Support to reduce existing Co-factors• Tight glucose control• Increase oxygenation to tissue• Smoking cessation• Improve nutritional status and protein stores• Reduce edema• Reduce bio-burden/infection• Minimize steroid use


3. Apply topical therapy that will maintain a physiologic wound environment.

Goal is to create an environment the promotes wound healing and supports the body in healing itself.

What is a proper wound healing environment?

1. Adequate blood supply2. Appropriate moisture balance3. No direct pressure or irritation4. To be free from infection or heavy

bacterial colonization5. An ongoing plan of topical care that

changes along with the characteristics of the wound



1. Adequate Blood Supply2. Appropriate Moisture Balance

Too Dry

Increased cell dehydration and cell deathDecreased angiogenesisImpaired autolytic debridementDecreased re-epithelializationIncreased pain

Too Wet

Wash out many of necessary proteins and enzymes from wound bedMaceration of wound edges and peri-wound skinIncreased risk of infection

3. No direct pressure or irritation

4. Free of infection or bacterial colonization -

clean the wound“ Wound bio-burden has been confirmed as a factor in delayed wound healing and closure.”

Robson et al 1968

“ Proper cleansing of the wound is one of the most effective and most overlooked ways to keep the bacterial level down in a wound.” Brown Malloy 2005

5. Ongoing topical plan of care that changes as the wound evolves

Wounds are dynamic and topical care needs to be based on:Current wound assessment Level of moisture in wound bedCharacteristics of various wound care product

categories

Clinicians Role in Wound Healing

1. Patient Assessment2. Wound Assessment3. Understand Principles of Local

Wound Care4. Understand the Function of Wound

Care Product Categories




1. Complete Patient Assessment• Etiology of wound• Duration of wound• Co-morbidities

•Host infection/illness

• Smoking / Diabetes• Medications• Poor nutrition• Decreased perfusion• Pressure, Friction, Shear, etc…..


2. Wound Assessment• Location• Extent of tissue injury ( Thickness or Stage if Pressure Ulcer)• Dimensions• Characteristics of wound base• Exudate• Wound edges

• Including undermining or tunneling

• Peri-wound skin• S&S of infection• Pain

←Coccyx-Tailbone. 4 fused vertebrae below sacrum

← Sacrum –Triangular bone at the base

of the spine. It connects the last lumbar vertebrae with the coccyx

← Ischial tuberosityMarks the lateral boundary of the pelvic outlet. When sitting, the weight is frequently placed upon the ischial tuberosity

Trochanter →Head of the femur (Hip bone)

Iliac Crest →The crest of the ilium

Wound AssessmentLocation: Be as specific as possible

Wound AssessmentExtent of Injury ‐ thickness or stage

•Partial thickness vs Full thickness •Stage only if wound is a pressure ulcer

• All pressure ulcers

are wounds, but not all

wounds are pressure ulcers

Partial Thickness –tissue destruction through the epidermis extending into but not through the dermis.

Full Thickness –tissue destructionextending through the dermis, involving subcutaneous tissue & possibly bone & muscle.

Wound AssessmentDimensions ‐ only document what you actually measure

WidthLength

DepthUndermining/ tunneling



Wound AssessmentCharacteristics of Wound Base

NecroticEschar Slough

Wound AssessmentExudate

• Amount• scant, small, • heavy, copious

• Color• serous, serosanguenous• tan, yellow

• Odor• purulent, malodorous

Wound AssessmentWound Edges

Rolled wound edgesCalloused edges

Undermining Wound with tunnel or sinus tract

Macerated edge

Wound AssessmentPeri-Wound Skin

Wound AssessmentSigns and Symptoms of Infection

• Change in size (bigger)

• New breakdown

• Warmth

• Erythema / edema

• Increased exudate

• Odor

Wound AssessmentPain

• Wounds themselves are frequently painful.

• Identify pain level• Patient can verbalize degree

• Steps to minimize pain in the process

• Choose appropriate cleanser and method

• Protect peri-wound skin with sealants

• Moist packing, autolytic debridement

• Reduce inflammation and edema

• Medications as indicated (topical or oral)

• Choose dressings that minimize discomfort



Wound AssessmentPain

• Techniques to try to minimize pain• Allow patient to participate

• Remove dressing• Stop as needed during the procedure

• Moisten dried dressing before removal• Reduce frequency of dressing change• Distract the patient

Understand Principles of Local Wound Care

1. Cleanse wound2. Remove necrotic/non-viable tissue3. Prevent and manage infection4. Eliminate “dead space”5. Manage exudate6. Maintain appropriate moisture balance 7. Protect peri-wound skin from trauma, bacteria and

moisture.

Principles of Local Wound CareCleanse the Wound

Principles of Local Wound CareDebridement

(Remove Necrotic or Non‐Viable Tissue*)

•

*Unless the wound may be ischemic and the eschar is stable and dry.

Principles of Local Wound CarePrevent and Manage Infection

Principles of Local Wound CareManage the Exudate

• Drainage on intact skin causes - Maceration and break down - Supports growth of bacteria- Increases risk of infection



Principles of Local Wound CareEliminate the “Dead Space”

• Lightly pack tunnels and undermining

• Use saline moistened packing to fit the space and moisture content present

• Strip gauze, kerlix, **alginate• **Never pack a dressing you can not remove

Principles of Local Wound CareMaintain a Moist Wound Bed

• Choose dressing that match the current wound presentation• Add moisture? Absorb excess exudate?

• Moist but not wet wound bed – takes practice and the plan must change as the wound changes.

• Protect from trauma, bacteria, cold

• Dressings that meet the wound requirements and don’t need to be changed every shift or every day are best.

• Wounds are like crock-pots – taking off the lid slows the process.

“Wet to Dry” vs “Moist Gauze Packing”Goal:

Non-selective debridement

oBarely moistened gauze ispacked into wound with drygauze over.oOnce packing has dried outcompletely, it is removed quickly in an effort to remove necrotic tissue that has adhered to the packing.oRemoves necrotic tissue as well

as any new granulation tissue.

Goal:

Maintain moist wound bed

oSaline (and hydrogel) moistened gauze is packed into wound cavity to absorb wound exudate and maintain humidity at the tissue/packing interface.

Principles of Local Wound CareProtect Peri‐wound Skin

• Add sealant or barrier ointment to protect the edges from maceration and breakdown

• No Sting• Vaseline

Wound Treatments

Wound Dressing Product Categories



Best dressing for Wound at THIS time depends on Dressing Function

Dressing Categories

Each category has its own characteristics:

Cleanser

Hydrocolloid

Foam

Calcium Alginate/Hydrofiber

Hydrogel

Gauze

Impregnated Gauze

Enzymatic debridement agentAntimicrobial Dressings

Wound Cleansers

“ Wound bio-burden has been confirmed as a factor in delayed wound healing and closure.” Robson et al 1968

“ Proper cleansing of the wound is one of the most effective and most overlooked ways to keep the bacterial level down in a wound.” Brown Malloy 2005

Hydrocolloid

•Minimally absorptive so best for minimally draining wounds

•Aggressive adhesive; should not be used if frequent changes are required

•Will promote debridement

•Not for use on infected wounds• May “melt” into wound and have an odor. Does not

indicate infection

Foam •For moderate to heavilydraining wounds

•Will not stick to wound bed

•Should extend at least1 inch onto intact skin

Alginate/Hydrofiber

• Used on moist wounds with large amount of drainage.

• Dressing may not remain intact when wet so should not be used to pack tunnels.

• Must be rinsed out of wound bed before next dressing is placed



Hydrogel

Amorphous• Typically used on cavity type

wounds

• Moisture transfer properties assist with wound debridment.

• Requires secondary or cover dressing.

Sheet• Use for shallow wounds

• Is able to absorb but also keep wound bed moist.

Gauze

Comes in a variety of forms and sizes•Use “woven” gauze forpacking and filling space/cavity.

•Moist gauze will macerate

intact skin. Do not allow

moist gauze to overlap when

packing wound.

•Must loosely fill all nooks

and crannies of wound interior.

•Do not allow gauze packing todry out. May need Hydrogel to

keep packing moist.

Woven gauze; Kerlix wrap and 4x4

Iodosorb

Telfa

Impregnated GauzeMay be impregnated with

a variety of substances

to achieve a variety of healing goals.

Vaseline Gauze

Enzymatic Debriding Ointment

Collagenase:

It removes dead tissue so granulation tissue can start to grow.

Apply correctly: nickel thick layer of ointment

with dry cover dressing.

Antimicrobial Dressings

• Use on highly contaminated or infected wounds; odorous wounds with minimal to heavy exudate.

MediHoney

Aquacel Ag

Many product have an anti-microbialOption; ie silver foam, silver hydrogel etc.

AMD strip gauze

Antimicrobial ProductsSilver Creams – Silver sulfadiazine

Alginates – Aquacel AgFoams VAC foams

Staph aureus

Honey OintmentAlginateHoneycolloid

Creates a hostileenvironmentCan’t declare itself as bactericidal

Iodine Cadexomer Iodine –IodosorbCreams, ointments, sprays

Staph aureus

Dakins (Sodium hypochlorite 0.25%)

Solutions Staph aureusPseudomonasE. Coli Enterococcus

Acetic Acid Solution Staph aureusPseudomonas

methylene blue and gentian violet

Foam – Hydrophera Blue Staph Aureus

Xeroform-(Bismuth Tribromophenate)

Impregnated gauze Board spectrum



Advanced wound care treatments

Advanced Wound Care Treatments

Advanced Wound Treatments

Negative Pressure Wound Therapy (NPWT)

Negative Pressure Wound TherapyDefinition by Wikipedia

• Negative-pressure wound therapy (NPWT):

• A therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns.

• The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump.

Wound VAC Therapy (KCI)

• 1995 - KCI (Kinetic Concepts Inc) was the first company to have a NPWT product cleared by the US Food and Drug Administration.

• In past years, several more companies have developed some type of NPWT.

• Both the VA Medical Center and HCMC use the Wound VAC Therapy by KCI.



Wound VAC Therapy (KCI)

• Promotes wound healing by applying a vacuum through a special sealed dressing.

• Vacuum suction draws out fluid from the wound and increases blood flow to the area.

• Draws wound edges together, remove infectious materials and actively promote granulation.

Indications for Use

• Acute and chronic wounds

• Traumatic wounds

• Partial thickness to full thickness burns

• Dehisced surgical wounds

• Diabetic ulcers

• Pressure ulcers

• Flaps and grafts

Examples of Wounds Examples of Wounds

Contraindications for Use

• Malignancy in the wound

• Untreated osteomyelitis

• Non-enteric and unexplored fistula

• Necrotic tissue with eschar present

• Do NOT place VAC dressing directly in contact with exposed blood vessels, organs or nerves.

• MRI

• HBO therapy

Warnings in using VAC therapy

• Bleeding/hemorrhage

• Protect vessels, organs and nerves

• Protect tendons and ligaments

• Infection

• SCI patients• Autonomic dysreflexia

• Foam placement

• Foam removal



Precautions of VAC Therapy

• Standard Precautions

• Keep VAC Therapy on 22 out of 24 hours/day

• Spinal Cord Injury

• Continuous vs Intermittent VAC thearpy

• Enteric Fistulas

• Protect periwound

Equipment

• Info VAC- hospital use

• Activac – home use

• TRAC pad

• Foam

• Drape

• Canisters

ULTA VAC

• Light weight. Weighs only 5.9 pounds

• Easy to use. Features a full-color intuitive touch screen controls for simplified navigation

• Simple. IV pole and bedside positioning capabilities

• Canister: 500cc

• Seal Check• Designed to help clinicians and patients identify and troubleshoot negative

pressure leaks

ActiVAC – home VAC therapy

• Light/ Small. Weighs only 2.4 pounds

• Discreet. Carrying case hides the tubing

• Informative. Alarm notifications

• Efficient. Easy, quick release 300 mL canister

• Simplified Touch Screen

• Seal Check• Designed to help clinicians and patients identify and troubleshoot negative

pressure leaks

Prevena Incisional Vac Different VAC foams

• VAC GranuFoam – black foam• Reticulated/open pore

• to help evenly distribute the negative pressure

• Hydrophic (repels moisture and enhances exudate removal)• Contracts wound• Assists with tissue granulation • Use non-adherent dressing under this for flaps, grafts



Different VAC foams

• VAC Vers-foam – white foam• High tensile strength• Hydrophillic – moisture retaining• Pre-moistened with sterile water (non-adherent property)• Controls rate of granulation tissue growth• Minimum pressure is 125mmHg due to density• Used for shallow and painful wounds• Used for undermining and tunneling

Different VAC foams

• VAC GranuFoam Silver foam• Same properties as the black foam• Micro-bonded metallic silver is uniformly distributed throughout the dressing• Provides an effective barrier to bacterial penetration.

• The protective silver ion reduces aerobic, gram-negative and gram-positive bacteria, and may help reduce infections in wounds.

Patient Outcomes Patient Outcomes

Dressing Application

• Pain management needs to be addressed!

• Assess wound size and type• DO NOT reapply if there is bleeding or infection

• Clean wound with wound cleanser

• Protect edges with skin prep and hydrocolloid dressing

• Protect skin if needing to bridge trac pad away from wound

• Cut foam to size of wound• Careful to cut foam away from wound so pieces of foam don’t fall into wound

Dressing Application

• Place foam into wound• Indicate how many pieces of foam are in wound

• Create bridge

• Seal with VAC drape

• Cut 2 cm round hole for TRAC pad and attach pad

• Secure to canister

• Set negative pressure• Setting (75mmHg to 200mmHg)• Continuous vs Intermittent

• Power on VAC



Trouble Shooting

• Low Pressure/Leak Alarms• Check for kinks or clamps in tubing• Check seal around wound – reinforce with drape or Tegaderm• Check trac pad to make sure it is in place

• Monitor seal check to make sure it is in the green-• Therapy – Seal check

Advanced Modalities

• Total Contact Casting

• Arobella Ultrasonic debridement

• E-stim

• Skin Substitutes

• Platelet Rich Plasma Therapy – PRP

• HBO

Total Contact Casting

•Definition• Application of a NON-REMOVABLE plaster or fiberglass

cast to the lower extremity which allows continued ambulation while reducing plantar and forefoot pressure and trauma with the goal of ulcer healing

• Used for diabetic and neuropathic foot ulcers that are NOT infected

Total Contact Casting‐Transfers weight bearing to leg instead of foot

Benefits• Allows for healing while

ambulating• Forced compliance• Immobilization• Minimizes vertical and

shear stresses

Contraindications• Acute infection• Severe ischemia• Claustrophobia• Allergy to casting material• Excessive or fluctuating edema• Excessive drainage

ResultsOne study shows healing in 43 days vs 73 days

Arobella Ultrasound Wound Therapy Ultrasound Guided Debridement

•Definition• Low frequency ultrasonic energy

that is delivered to the wound surface and subdermal tissues resulting in selective debridement, bacterial killing and cellular stimulation via acoustic streaming.

• Example:• Arobella



Ultrasound Guided Debridement

•Benefits• Enhances tissue perfusion• Direct bacterial killing• Decreased bioburden via debridement• Stimulation of granulation via increased cellular

proliferation

•Concerns• Pain

• Topical lidocaine

Video of Arobella

• https://www.bing.com/videos/search?q=arobella+debridement+video&&view=detail&mid=0332E062DEBA1B27F05B0332E062DEBA1B27F05B&&FORM=VRDGAR

Electrical Stimulation Therapy

• Definition:• High voltage pulsed electrical current that

promotes microcirculation and healing of ischemic wounds and increase perfusion of periwound tissues.

• Electrical currents attract or repel ionized cells such as neutrophils, macrophages, fibroblasts or epidermal cells at the appropriate healing phase.

• Vasodilation and Angiogenesis – growing new vascular system.

• Create significant improvement in periwound oxygen

• Low voltage pulsed electrical current has proven to have an effect on gram + and gram – bacteria.

Skin Substitutes

Platelet Rich Plasma Therapy – PRP

• Growth Factors• Platelets release healing proteins called growth factors. • Growth factors accelerate tissue and wound healing.• Multiple studies are underway to help further refine the

treatment and demonstrate its efficacy.

HBO Therapy



Advanced ModalitiesPharmaceutical

•Oxygen• Hyperbaric Oxygen Therapy• Definition

• Inhaled 100% oxygen delivered to the patient completely enclosed in a pressurized environment

Hyperbaric Oxygen Therapy

Emergent Indications

• Decompression sickness• Gas embolism• Gas gangrene• Acute ischemia• Extreme anemia• Carbon monoxide• Cyanide (smoke inhalation)• Thermal burns

Elective Indications

• Radiation injury• Chronic osteomyelitis• Diabetic wounds• Problem wounds

Hyperbaric Oxygen Therapy

•Benefits•Growth factor stimulation•Decreased edema•Tissue hyperoxygenation•Enhanced WBC filling•Cellular proliferation•Neovascularization

Reference

• Acute and Chronic Wounds: Current Management Concepts, 4th Edition (2012), Ruth Bryant and Denise Nix.

Documents

Hnatyszyn Assess and Manage DEC2018 FOR BOOK€¦ · present • Strip gauze, kerlix, **alginate • **Never pack a dressing you can not remove Principles of Local Wound Care Maintain

Hnatyszyn Assess and Manage DEC2018 FOR BOOK€¦ · present • Strip gauze, kerlix, alginate • Never pack a dressing you can not remove Principles of Local Wound Care Maintain