*smith&nephew WOUND ASSESSMENT PROF. DR. HARIKRISHNA K.R.NAIR S.I.S KMN MD(UKM) FRCPI ICW (GERMANY)OSH(NIOSH) OHD(DOSH) CMIA(MAL) FCWCS Post Grad in Wound Healing & Tissue Repair (Cardiff, UK) CHM(USA) ESWT (Austria , Germany) FMSWCP WOUND CARE UNIT, DEPT OF INTERNAL MEDICINE, KUALA LUMPUR HOSPITAL ADJUNCT PROFESSOR, IMS, BHU, INDIA ADJUNCT RESEARCH ASSOC. PROFESSOR, PERDANA UNIVERSITY
KUALA LUMPUR HOSPITAL *smith&nephew
*smith&nephew Different etiology of wound Diabetic Foot Ulcer Pressure Ulcer Minor burn Burn Venous Leg Ulcer Trauma Dehiscence
*smith&nephew Chronic Wound Healing Phases Haemostasis Minutes Inflammation Days Proliferation Weeks Remodeling Year +
General assessment: *smith&nephew The general assessment is to identify and eliminate any underlying causes or contributing factors which may impede the wound healing process; the causes include: • Age (extremes of age ) • Diseases or co morbidities (e.g. diabetes mellitus , renal impairment ) • Medication (steroids , chemotherapy ) • Obesity • Nutrition (refer to chapter on nutrition) • Impaired blood supply (refer to chapter on arterial and venous ulcers ) • Lifestyle (smoking , alcohol)
Assessment of patient *smith&nephew Comprehensive Assessment Psychosocial Health Age Multidisplinary approach Nutritional status - Protein Complicating condition - Vitamins - Vascular problem Medications - Diabetic - Smoking - Immunosuppressive Wound Etiology Pain / Comfort - Pressure / trauma Hygiene - Shearing / friction Stress
*smith&nephew Local assessment is an ongoing process and should include: • A review of the wound history (How, What, When, Where, Who) • Assessment of the physical wound characteristics • location, size, base/depth • presence of pain • condition of the wound bed
Wound Appearance - THE COLOUR *smith&nephew MODEL • It is necessary to have a method to appraise the types of wound without having to resort to specialised histologists for each and every wound. • The colour method is used to identify and prioritise the treatment objectives in wounds and is also used in research. • In the early 80s, Lars Hellgrens, a Sweden dermatologist, was the first to claim that wounds could be categorised according to the colour of the wound surface.
*smith&nephew Wound Appearance - THE COLOUR MODEL Pink - Epitheliazation Red - Granulation Black - Necrotic Yellow - Slough
Triangle of Wound Assessment
*smith&nephew Triangle of Wound Assessment Dowsett C et al. Triangle of Wound Assessment Made Easy. Wounds International 2015
*smith&nephew Triangle of Wound Assessment – Wound bed Dowsett C et al. Triangle of Wound Assessment Made Easy. Wounds International 2015
*smith&nephew WOUND BED PREPARATION Debridement Bacterial Balance Exudate Management Dr. Gary Sibbald, et al ‘Preparing the wound bed for healing – debridement, bacterial balance & moisture balance’ Ostomy/ wound management 2000, 46(1)
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TIME – THE CLINICAL ASPECTS
*smith&nephew * T.I.M.E. - Principles of Wound Bed Assessment and Preparation:
*smith&nephew TIME *+ - Principles of Wound Bed Preparation
*smith&nephew Triangle of Wound Assessment – Wound edge Dowsett C et al. Triangle of Wound Assessment Made Easy. Wounds International 2015
*smith&nephew Triangle of Wound Assessment – Periwound skin Dowsett C et al. Triangle of Wound Assessment Made Easy. Wounds International 2015
*smith&nephew Migration for healthy skin Option to use these both.. One here, one at the end of slides as closing? https://incem.rwth-aachen.de/beneficiaries.html
*smith&nephew Triangle of Wound Assessment – Management plan Dowsett C et al. Triangle of Wound Assessment Made Easy. Wounds International 2015
Clinical Appearance: *smith&nephew Stage 3 pressure ulcer Site – sacral region Pink – Epithelial tissue Size 12 x 8 x 1 cm Red – granulation tissue Black – necrotic tissue Exudate – moderate (purulent) with odour Yellow - slough Edges - undermining
Advancing epidermal margin *smith&nephew (epithelialisation)
T IME (T = Reflects Tissue Viability) *smith&nephew Viable (granulation, epithelialising) • Non viable (necrotic, slough, eschar) • How does non viable tissue impede healing? • Prolongs inflammation • Impedes epithelialisation Antibiotics don’t penetrate to the wound environment • Dressings are unable to effect the wound millieu • Medium for bacteria growth • Goals in treating tissue in chronic wounds • Clear away dead or necrotic tissue – debridement • Always ensure adequate tissue oxygenation for angiogenesis and granulation process
T issue Non Viable: Necrosis, *smith&nephew Eschar,Slough
*smith&nephew T Debridement Debridement is not a single event - an “initial phase” and a “maintenance phase”. Debridement is an ongoing process. V. Falanga, 2000
Method of Debridement *smith&nephew T (Removal)? Surgical / scalpel? Mechanical? Hydro surgery debridement machine (eg. Versajet) Enzymatic? Autolytic? Biological? Combination? Surgical debridement is gold standard of care, once ischemia is excluded. (Wagner 1984, Knowles 1997, Laing 1994, Steed 1996,, Levin 1996).
Selecting a method of *smith&nephew T debridement Debridement method Characteristic Autolytic Surgical Enzymatic Mechanical Speed 4 1 2 3 Tissue 3 2 1 4 selectivity Painful 1 4 2 3 wound Exudate 3 1 4 2 Infection 4 1 3 2 Cost 1 4 2 3 1 = most appropriate; 4 = least appropriate Table from Sibbald et al. 2000
*smith&nephew Autolytic Debridement Definition -The process by which the wound bed utilizes phagocytes and proteolytic enzymes to remove non- viable tissue This process can be promoted and enhanced by maintaining a moist wound environment.
*smith&nephew Autolytic debridement 1 2 After 2 days 3 After 4 days
*smith&nephew Autolytic Debridement – Hydrogel * As a selective type of debridement, autolysis removes only necrotic tissue
*smith&nephew MODE OF ACTION – HYDROGEL Contains: • Gently rehydrates dry necrotic tissue Cross-linked carboxymethylcellulose 2.3% • Provides moist Propylene Glycol USP 20.0% wound healing Purified Water environment 77.7 % • Softens necrotic tissue
*smith&nephew Surgical Debridement • Scalpel/Scissors • Curet • Laser • Hydrosurgery (Versajet) • Recommended for removal of thick, adherent eschar and devitalized tissue in large wounds • Not recommended in severely compromised patients • Analgesia/anesthesia may required
*smith&nephew Enzymatic Debridement • The use of topically applied enzymatic agents to stimulate the breakdown of non-viable tissue • Faster debridement process compared to Autolytic
*smith&nephew T I ME (I = Inflammation, Infection) • Persistent inflammation “wounds become stuck” • The bacterial continuum • What is infection? • How does infection differ between the acute and chronic wound? • What factors need to be considered?
*smith&nephew Assessing wound infection
*smith&nephew Clinical Presentation of local wound infection “Classic” signs & Symptoms “Secondary” signs & symptoms • Advancing erythema • Delayed healing • Fever • Change in color of wound bed • Warmth • Edema / swelling • Absent/ abnormal granulation tissue • Pain • or abnormal odor • Purulence • serous drainage • pain at wound site
*smith&nephew Every second counts! Infection E.coli divide every 20min, therefore a single organism divides into 512 daughter cells in 3hrs or 1,000,000 under 8 hrs
*smith&nephew TI M E(M = Moisture Imbalance) • Desiccation / Maceration • Composition of chronic wound fluid • Matching exudate volume with product absorbency for optimal moisture balance
*smith&nephew Optimal Moisture Balance Maceration Desiccation
*smith&nephew Exudate Management Chronic Wound Fluid Breakdown of Bacterial Edema Necrotic tissue Burden Debridement Compression Bioburden control
*smith&nephew Exudate Management None Low Moderate Heavy
*smith&nephew Material Conserve/ Fluid Control Donate Light Moderate High √ √ Films √ √ Sheet hydrogel √ √ Amorphous hydrogel √ √ Hydrocolloids √ √ √ Sheet foams √ √ Cavity foams √ √ Alginates √ √ Hydrofiber
*smith&nephew
*smith&nephew TIM E E = Edge of Wound • Non advancing wound edge = non healing wound • Undermining (critically colonised or infected) • Persisting inflammation • Non responsive cells REVIEW T/I/M Factors
*smith&nephew What if the epidermis fails to advance? Reconsider the principles of Wound Bed Preparation and the acronym TIME: • Has necrotic tissue been debrided? • Is there a well vascularised wound bed? • Has infection been put under control? • What is the status with inflammation? • To what level has moisture imbalance been corrected? • What dressings have been applied?
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