THE ARTS AND CRAFTS OF WOUND CARE Rebecca Mickel MSN, RN, CWON, CNE
■ Rate your comfort level with managing wounds in your care setting.
Tool kit essentials •Know what you are looking at •TIME principles •Nutrition •Pain management •Documentation essentials
Objectives Identify the etiology of wounds • Skin tears • Venous leg ulcers • Arterial ulcers • Pressure ulcers • Neuropathic ulcers
Identify common treatments and appropriate referrals Differentiate what specialty provides can do to heal a wound; • Certified wound ostomy continence nurse (CWOCN) • Vascular surgery • Physical therapy • Podiatry
COMMON ALTERATIONS IN SKIN INTEGRITIY
Skin tears ■ A skin tear is a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. A skin tear can be partial- thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underlying structures).
Carefully handling elderly patients with frail skin. Any harsh movement or pulling can create a skin tear. Research shows 25% of skin tears come from wheelchair injuries and another 25% from bumping into stationary objects Recommend that patients wear long sleeves and pants for added protection. Prevention Use paper tape or a non-adherent dressing on frail skin and gently remove it. Or use stockinette, gauze wrap, or any other similar type of wrap instead of tape to secure dressings and drains. Apply a moisturizing agent to dry skin to keep it adequately hydrated. Creams are better than lotions.
1. Gently cleanse the skin tear 2. Allow the area to air-dry or pat with saline or a nontoxic wound carefully to dry. cleanser. 4. Apply steri strips to hold flap in place •If no flap is present use a moist wound 3. Approximate the skin tear dressing, such as a hydrogel. Carefully flap/tissue, if present, as closely remove any product with an adhesive as possible backing to avoid further trauma. 6. Change dressings according to the manufacturer's 5. Secure non-adherent dressings recommendations. For example, with a gauze or tubular non- hydrogels are generally changed adhesive wrap. every day; hydrocolloids, weekly or as needed; and foams, weekly or as needed. 7. Educate the patient and family For information on one way to (and staff, if necessary) on how to describe skin tears in avoid skin tears in the future and documentation, see Classifying make sure prevention strategies Skin Tears. are initiated.
Venous leg ulcers ■ Caused by venous hypertension ■ Characterized by edema in the lower leg ■ Ulcers in lower leg or ankle ■ Often very wet wounds ■ Often has irregular edges ■ Hemosiderin staining in the gaiter area ■ Pulses palpable but may be faint Slachta (2006)
Common treatments Goal of wound care for venous ulcers is a balance of moisture and injury prevention ■ Elevating legs – Allow gravity to drain fluid back into circulation ■ Unna boot – An Unna boot is a compression dressing made of impregnated gauze around the leg and foot. It is often used to protect an ulcer or open wound. The compression works by muscle contractions when ambulating. ■ Compression wraps (2, 3 & 4 layers)
Arterial ulcers ■ Also called an ischemic ulcer, wound is due to arterial insufficiency to the tissue. ■ Skin may be pale, shiny, little to no hair growth ■ Thich ridged toe nails ■ Dependent rubor ■ Commonly occur around the toes ■ Wounds are often very painful ■ Dry wound bed Slachta (2006)
Common treatments ■ Reestablish blood flow to the limb ■ Wound care involves protecting the wound bed from further injury ■ Avoid debridement until blood flow is restored
Neuropathic ulcers (aka diabetic ulcers) ■ Also known as diabetic foot ulcers. Caused by pressure, friction, peripheral neuropathy and peripheral vascular disease. ■ Commonly located on the plantar surface of the feet: Metatarsal heads, great toe, and heels. ■ Sensory, motor and autonomic neuropathy typically impairs the feet and hands first then progresses up the extremity
Common treatments ■ Regulate blood sugars ■ Off load pressure ■ Debridement ■ Treat infection ■ Baranoski & Ayello (2016)
Pressure injuries ■ Pressure injuries develop when there is tissue ischemia from compression of the soft tissue. Prolonged tissue ischemia from pressure often caused tissue death. ■ Slachta (2006)
Pressure injury
Common treatments ■ Offload pressure ■ Debride denatures tissue ■ Treat infections ■ Provide optimal wound healing environment
TIME concept T issue Debridement: Cleaning Low frequency non contact Use a non cytotoxic agent: Normal saline, wound cleaner. ultrasonic (MIST), Debridement wipes AVOID HARSE WOUND CLEANSER Larvae, No hydrogen peroxide Autolytic (medi-honey, hydrogels) Undiluted betadine Enzymatic (collagenase), Sharp debridement, Chemical (antiseptic, silver, Dakin’s), Negative Pressure Wound therapy Baranoski, S. & Ayello, E. (2016)
Time concept Bacterial Balance I nfection Disrupt the Biofilm in non healing wounds, debridement & antimicrobial dressing Persistent inflammation Prevent growth of microorganism, nanocrystalline silver Baranoski, S. & Ayello, E. (2016)
TIME concept Moisture balance Balance moisture and exudates. M oisture Provide moisture when wound bed is dry, absorb when wound bed is too moist. Select a dressing that will absorb exudates while maintaining a moist wound bed Baranoski, S. & Ayello, E. (2016)
Time concept Protect the edge of the E dge wound from exudates, tension, sheering forces Baranoski, S. & Ayello, E. (2016)
Who does what? Certified wound ostomy continence nurse (CWOCN) Vascular surgery Physical therapy Podiatry
TOOL KIT ESSENTIALS Cleansing agent Reducing bacterial load Wound filler Absorption Protection
There are a number of product lines available Avoid brand loyalty, base your decision on products that can be used in a variety of situations
Cleaning with a non cytotoxic agent ■ A Cochran meta analysis examined the effect of normal saline vs. tap water and found there was no difference. ■ If the wound has exudate and necrotic tissue a commercially available wound cleaner should be considered. ■ There are a number of agents available for use. Ex. Shur-Clens, Biolex, SAF-Clens, cara clenz, Dermal wound cleanser, Puri-Dlens, Restore
Reducing biofilm & necrotic tissue ■ Debridement – Autolytic – Mechanical debridement: Pulse lavage – Biological – Enzymatic
Wound filler ■ Moist gauze ■ Hydrofiber ■ Calcium alginate ■ Foams These products also come with silver imbedded
Absorption ■ Need to allow room for absorption of exudates
Protect wound edge
Protect ■ Protect for pulling on the wound edges
Nutrition ■ Nutrition screening for adequate nutrition ■ For optimal wound healing promote positive nitrogen balance – Offer high protein supplements – Include arginine ■ Hydrate – Encourage adequate fluid intake – Consider additional fluid if s/sx of dehydration, fever, vomiting, diarrhea, perfuse sweating or excessive fluid drainage ■ Vitamins and minerals – Provide a balance diet and a supplemental multivitamin if deficiency is suspected
Pain management ■ Pain is a very individual experience ■ Tissue ischemia will cause pain ■ What you already know about pain assessment and treatment apples to wound care ■ Consider local pain management: – Lidocaine gel for local – Warm solutions to body temperature – Use a gentle hand when cleaning: Shower off old dressing – Meditation – Laughter – Acupuncture – Distraction – Music – Magnets
Documentation essentials ■ History of the wound ■ Local wound dressing selection ■ Characteristics of the wound: ■ Nutrition status ■ Include ■ Pressure redistribution – Location ■ Regular assessments (weekly) – Length, width, depth, – Stage, classification, category ■ Oasis-C, MDS 3.0 – Exudate quality and amount – Tissue type – Pain
Case study with pictures of common wounds/problem wounds and practice the development of a plan.
Skin tear ■ Measure ■ Clean ■ Protect edge ■ Decide to either absorb or donate moisture ■ Absorb= hydrofiber ■ Donate= hydrogel sheet ■ Protect = moist gauze, abd, gauze wrap
Venous ulcer ■ Measure ■ Clean ■ Protect edge ■ Decide to either absorb or donate moisture ■ Absorb=sheet foam ■ Gauze wraps ■ Compression and/or elevate leg ■ If does not respond to treatment refer to wound care and continue plan until seen
Arterial ■ Measure ■ Clean ■ Protect from damage ■ Refer to vascular surgery
Pressure injury ■ Measure ■ Clean ■ Protect edge ■ Decide to either absorb or donate moisture ■ Absorb=sheet foam, hydrocolloid ■ Donate= hydrogel sheet ■ Off load pressure ■ Adequate nutrition
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