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Wound Assessment and Dressing Selection. Noreen Campbell RN BScN MA IIWCC Lt CSW TCS Systems North Saanich, BC, Canada . Wound Healing Process. Maturation/Remodeling Day 21 - 2 years. Epithelialisation. Proliferation Day 4-21. Kane. Inflammation Day 1-4. Hemostasis immediate. - PowerPoint PPT Presentation
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Wound Assessment and Dressing
SelectionNoreen Campbell RN BScN MA IIWCC Lt CSW
TCS SystemsNorth Saanich, BC, Canada
Wound Healing Process
Hemostasisimmediate
InflammationDay 1-4
ProliferationDay 4-21
Epithelialisation
Maturation/RemodelingDay 21 - 2 years
Kane
Homeostasis – first 24 hours
‘Meat’
Inflammation 1-4 days
‘Mess’
Proliferation day 4 - 21
‘Full’
Fibrin, Collagen Bridge to Skin• Yellow, caramel like surface, pain• Granulation peeking, epithelial starting
6
Epithelialization
‘Baby skin’
Maturation/Remodeling up to 2 years
Well healed scar – always a scar…weaker tensile strength
• Normal• Hypertrophic
– With incision• Keloid
– Extends to normal tissue ‘stronger’
Potential for HealingIndividual assessment
Wound
Care
10
Tissue depth? Probe…
Infection• Heat• Redness• Swollen• Pain
– Not with neuropathy
– Blood Sugars elevated
11CULTURE
Cochrane Review 2011 water for cleansing
Infection: Assess Clean Wound • Wound
Cleansing– Potable tap
water– Saline– Boiled
cooled water• Mild soap
– Dove no dye or perfume
Wound Imperatives and Antimicrobials
Product Function Cost * CDA 020114Promogran Prisma is above with silver
MMP bindingON the wound “let it dance with the wound”
Promogran 28 sq cm $23.95 123 sq cm $55.95Prisma 28 sq cm $26.95
Iodosorb cadexomer iodine
Cochrane level support red. Infection, promote healing, but pain reports may limituse
Ointment $21.95 10 GmPaste $58.95not recommended
Inadine povidone iodine
Non-adherent sheets 9.5x9.5cm $2.30
Silver dressings Support of efficacy lacking Expensive 4x4” $18.95
Honey dressings Support of efficacy lacking Expensive $24.95 50gm
Canadian Diabestes Association Store – [email protected]
Eschar: risk infection and delay healingStable
• Black• Dry• Hard
Wet• Drainage• Marbling• Breakdown
Iodosorb + cast padding Inadine PHD
Autoamputation?
Debride
Debride Unstable Eschar• Drainage• Fluctuance
• Iodine produce will become paler with release of iodine
Debridement Advantage DisadvantageSurgical Fast Surgery, expensive,
pain, non-selectiveConservative Sharp Bedside, pain, Scope of practice
Skill Maggot Selective, disinfect
wound, stimulate healing
Ordering process, $120 treatment, dressing change 48 hours
Enzyme (Santyl) Selective $90-120 tube, weeks
Mechanical Wet to dry Saline Compresses Irrigation Shower
Non-selective Pain (wet to dry)Labour - compresses
Autolytic (natural) Moisture (gel)
Natural, selective Slow
16
MDT 4 days
17
What type of debridement?
18
92yo anesthetic riskTrauma scooter accidentInner thigh
Differentiation: drainage or allergy?
• Contact Dermatitis– pattern
• Sensitivity– Localized to
wound and product
• Drainage– Direction of
pooling
Blister: drain if risk expansion
20
Edge: Undermined, rolled edge
Packing – think ‘wicking’.
Dressing: think ‘Band Aid’‘protect, absorb, hold layers’
Function Product CostProtection Surface protection
Silicon (7 days) severe pain or fragile
Mepitel $11.50 4”x7”
Inadine (antimicrobial+) Inadine $2.30 4”x4”
Jelonet (petrolatum mesh) 10cmx40cm $3.50Tin 10 cm x 7M $36.00
Adaptic non-adherent $3.75 3”x8” 3pkg
Absorb Alginates – lowest absorb., sticks if insufficient exudate
Hydrocolloid Minimal exudate containment and hold
Do not recommend
There are no standards for stating performance of dressings (i.e. absorption). Standard for approval ONLY safety not efficacy.
Function Product CostFoam Rated high exudate but
generally <5ml 4”x4” protection layer built into dressing
Fragile skinAdhesive border strength varies and can damage skin, change when drainage at border
Mepilex 3”x3” $3.75Allevyn Gentle 3x3 $3.95Tegaderm 3.5”x3.5” $4.59**do not recommend unless dressing one week
Acrylic poor expensive Do not recommend
Absorbent Dressing
Classic Pads- incontinent pad 17x20cm can hold 750ml (stay dry)
10x20cm 3 $1.95Ultra 17x40cm 2 $3.00Classic super 50 $33.00
Gauze – chronic wound or > 48 hours Clean not Sterile
poor absorption Adequate cover dry gangrene
2x2” 200 $1.954x4” 200 $6.50Non-sterile clean package
Cast padding Holds dressings padding Protouch 17 rolls $17.59Single roll $1.50
Function Product CostTape – peal factor is tension to remove, adhesive is ability to hold
Fragile skin may strip or tear.
*consider skin strength**how many dressings***how frequentOrder of peal factorTranspore (3M) +++Kind Removal (3M) ++Mepitac silicon +
Transpore $1.65 roll
Kind Removal silicon roll $6.95
Mepitac silicon $11.50
Stockinet - TubiFastRoll or meter*
Blue normal limb adultYellow larger
Blue 10M $16.95*Yellow 10M $10M $23.75
Tubigrip elastic Size determines pressure – straight may constrict limb
Skin barriers If you need these the products are not appropriate
Steroids Good for immediate skin reactions i.e venous excema