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By Nataliya Lebedinskaya-RN,BSN,CWOCN

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  1. 2. <ul><li>SKIN LAYERS </li></ul><ul><li>Epidermis </li></ul><ul><li>Dermis </li></ul><ul><li>Subcutaneous </li></ul><ul><li>PARTIAL </li></ul><ul><li>THICKNESS WOUND : Injury not through dermis </li></ul><ul><li>FULL THICKNESS WOUND: Injury through all layers of skin </li></ul><ul><li>How thick is 2.075 mm? </li></ul><ul><li>A plastic ruler </li></ul><ul><li>A house key </li></ul><ul><li>A U.S. Nickel </li></ul>
  2. 5. On average*, a pressure ulcer 2.075 mm or deeper is classified at least as a Stage III. How thick is 2.075 mm? A plastic ruler A house key A U.S. Nickel
  3. 6. Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface
  4. 7. <ul><li>Compression of soft tissue leads to: </li></ul><ul><ul><li>Tissue anoxia </li></ul></ul><ul><ul><li>( hypoxia especially of such severity as to result in permanent damage ) </li></ul></ul><ul><ul><li>Cell death </li></ul></ul><ul><li>Deep tissue trauma can occur with relatively little superficial damage </li></ul><ul><ul><li>Difficult to discern the extent of tissue damage </li></ul></ul>“ Pressure Ulcers can develop within 24 hours of the insult or take as long as 5 days to present themselves” – Ratliff and Rodeheaver, 1999
  5. 8. <ul><li>Pressure is highest between the soft tissue and the bony prominence </li></ul><ul><li>Tissue injury starts at the bone/ tissue interface and extends outwards </li></ul>Accounts for the undermining commonly seen in pressure ulcers!
  6. 9. <ul><li>Sacrum – 36.0 Scapula – 2.4 </li></ul><ul><li>Heel – 30.3 Occiput – 1.3 </li></ul><ul><li>Ischium – 8.0 </li></ul><ul><li>Elbow – 6.9 </li></ul><ul><li>Malleolus – 6.1 </li></ul><ul><li>Trochanter – 5.1 </li></ul><ul><li>Knee – 3.0 </li></ul>
  7. 10. <ul><li>Staging </li></ul><ul><ul><li>For pressure ulcers ONLY </li></ul></ul><ul><ul><li>Describes only the level of tissue damage or loss </li></ul></ul><ul><ul><li>Does not describe levels of progression or healing </li></ul></ul>
  8. 11. <ul><li>Non-blancahble erythema of intact skin </li></ul><ul><li>May include: </li></ul><ul><li>-discoloration </li></ul><ul><li>-warmth/coolness </li></ul><ul><li>-edema </li></ul><ul><li>-change in tissue consistency </li></ul>
  9. 12. <ul><li>Partial thickness loss of dermis presents as a </li></ul><ul><ul><li>shallow open ulcer with red pink wound bed, without slough or bruising. </li></ul></ul><ul><ul><ul><li>open or intact blister </li></ul></ul></ul><ul><ul><ul><li>shiny or dry shallow ulcer </li></ul></ul></ul><ul><ul><li>May be painful </li></ul></ul>
  10. 13. <ul><li>Full-thickness skin loss </li></ul><ul><ul><li>Subcutaneous fat may be visible </li></ul></ul><ul><ul><li>May extend down to but not through underlying fascia </li></ul></ul><ul><ul><li>May be shallow or deep, with/without undermining or tunneling </li></ul></ul><ul><ul><li>Eschar and/or slough may be present but does not hide depth of tissue loss </li></ul></ul>
  11. 14. <ul><li>Full-thickness skin loss </li></ul><ul><ul><li>Extensive destruction of tissue, with visible or palpable muscle, bone, tendon </li></ul></ul><ul><ul><li>May include undermining / sinus tracts </li></ul></ul><ul><ul><li>May be shallow or deep </li></ul></ul><ul><ul><li>Slough or eschar may be present </li></ul></ul>
  12. 15. <ul><li>Full thickness tissue loss in which the base of the ulcer is covered with eschar or slough so that full extent of injury cannot be assessed. The stage cannot be determined </li></ul>
  13. 16. <ul><li>Purple or maroon area of intact skin, or blood-filled blister due to damage of underlying tissue from pressure or shear. May evolve into ulcer </li></ul>
  14. 17. <ul><li>Cannot reverse stage – a healing Stage 3 does not become a Stage 2. </li></ul>
  15. 18. <ul><li>Maintain Healthy SKIN </li></ul><ul><li>S urface </li></ul><ul><li>K eep Moving </li></ul><ul><li>I ncontinence Management </li></ul><ul><li>N utrition </li></ul>
  16. 19. <ul><li>If patient can be turned and has at least two intact turning surfaces, use a mattress overlay such as an air cushion or alternating pressure pad </li></ul><ul><li>If patient has breakdown on more than one surface, use a pressure reduction (low air loss) mattress </li></ul>
  17. 20. <ul><li>Patient must still be repositioned to promote pulmonary, renal, and vascular function along with protecting skin integrity </li></ul><ul><li>Head of bed no higher than 30 degrees, unless pt is eating, to prevent shearing. If possible get pt up to cushioned sit for meals </li></ul><ul><li>No more than 2 items between patient and surface - any more will alter pressure-reducing ability of surface </li></ul><ul><li>MUST FLOAT HEELS!!!!!! </li></ul>
  18. 21. <ul><li>Avoid HOB elevation above 30 degrees </li></ul><ul><li>Use lifting device for transfer/transport. </li></ul><ul><li>Consider trapeze to help patients with </li></ul><ul><li>self-transfer </li></ul>
  19. 22. <ul><li>Chair Bound Patients </li></ul><ul><li>Limit chair sitting to an hour or reposition every hour. </li></ul><ul><li>Encourage patients to shift weight every 20 minutes if able. </li></ul><ul><li>Sit in upright position </li></ul><ul><ul><li>Use pillow behind back if needed </li></ul></ul><ul><li>Pressure reduction/relief devices do not replace repositioning </li></ul>
  20. 23. <ul><li>Correct Cause of Incontinence if possible </li></ul><ul><ul><li>Offer frequent or timed toileting </li></ul></ul><ul><ul><li>Keep toilet aids within easy reach </li></ul></ul><ul><ul><li>Rule out possible UTI </li></ul></ul><ul><ul><li>Check for fecal impaction </li></ul></ul><ul><ul><ul><li>Frequent cause of fecal/urinary incontinence </li></ul></ul></ul><ul><ul><ul><li>Correct diet </li></ul></ul></ul><ul><ul><ul><li>Initiate measures to normalize stool frequency/ consistency </li></ul></ul></ul>
  21. 24. <ul><li>Contain or Absorb Incontinence </li></ul><ul><li>Use absorptive under pads to wick moisture away from the skin. </li></ul><ul><li>Limit use of adult incontinence garments (AKA diapers) to: </li></ul><ul><ul><ul><li>Specific patient request </li></ul></ul></ul><ul><ul><ul><li>Incontinent patients while ambulating </li></ul></ul></ul><ul><li>Check absorptive pads and diapers frequently for soiling. </li></ul><ul><li>Use breathable under pads if on specialty bed. </li></ul>
  22. 25. <ul><li>URINE </li></ul><ul><li>Water saturates skin, increases risk of friction and erosion </li></ul><ul><li>Ammonia raises pH, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes </li></ul>
  23. 26. <ul><li>STOOL </li></ul><ul><li>Fecal enzymes damage skin, promote erosion, worse in high volume diarrhea </li></ul><ul><li>GI Bacteria may be pathogenic </li></ul><ul><li>Water overhydrates the skin </li></ul>
  24. 27. <ul><li>CLEANSE – routine daily cleansing for everyone </li></ul><ul><li>MOISTURIZE – cleanse and moisturize after each major incontinent episode </li></ul><ul><li>PROTECT – apply moisture barrier for significant urine/stool/double incontinence </li></ul>
  25. 29. <ul><li>Protein and Calories </li></ul><ul><li>Multivitamin </li></ul><ul><li>Vitamin C </li></ul><ul><li>Zinc </li></ul><ul><li>Hydration </li></ul><ul><li>Dietician consult of course! </li></ul>
  26. 30. <ul><li>Purpose – </li></ul><ul><li>Immediately and accurately identify patients at risk for developing pressure ulcers </li></ul><ul><ul><li>Early intervention for pressure ulcer prevention </li></ul></ul><ul><ul><li>Target resources appropriately </li></ul></ul>
  27. 31. <ul><li>Sensory Perception </li></ul><ul><ul><li>The ability of the patient to sense pressure on the surface of the body </li></ul></ul><ul><li>Moisture </li></ul><ul><ul><li>Increases friability of skin </li></ul></ul><ul><ul><li>Increases the risk of skin breakdown by 5 times </li></ul></ul><ul><li>Physical Activity </li></ul><ul><ul><li>Frequency and duration that an individual ambulates </li></ul></ul><ul><ul><li>Not the type/amount of assistance the individual requires to ambulate. </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Ability to change & control body position in bed </li></ul></ul>
  28. 32. <ul><li>5. Nutritional Intake </li></ul><ul><li>6. Friction & Shear </li></ul><ul><ul><li>Friction </li></ul></ul><ul><ul><ul><li>Force that resists motion between two surfaces </li></ul></ul></ul><ul><ul><ul><li>Damages protective outer layer of skin promoting skin ulceration </li></ul></ul></ul><ul><ul><ul><li>Occurs when a patient is dragged across bed sheets </li></ul></ul></ul><ul><ul><li>Shear </li></ul></ul><ul><ul><ul><li>Mechanical force parallel to an area </li></ul></ul></ul><ul><ul><ul><li>Results from sliding and relative displacement of two opposing forces </li></ul></ul></ul><ul><ul><ul><li>Major contributors to the stage, size, and shape of pressure ulcers </li></ul></ul></ul>
  29. 33. <ul><li>Skin sticks to surface </li></ul><ul><li>Deeper tissues move in opposite direction </li></ul><ul><li>Capillaries kink </li></ul><ul><li>Local ischemia </li></ul>
  30. 34. <ul><li>Assessment is useless without interventions to decrease the risks </li></ul>
  31. 35. <ul><li>Braden score 18 or less </li></ul><ul><li>Current or history of pressure ulcer </li></ul><ul><li>Life expectancy of 6 months or less </li></ul><ul><li>Incontinence with transfer or ambulation difficulty regardless of Braden score </li></ul>
  32. 36. <ul><li>Choose intervention(s) from </li></ul><ul><li>all 4 categories of </li></ul><ul><li>the SKIN pneumonic </li></ul>
  33. 37. <ul><li>Instruct Caregiver </li></ul><ul><ul><li>Keep linens/pads smooth to prevent bunching of fabric under </li></ul></ul><ul><ul><li>Avoid more than 2 layers of linen between patient and specialty mattress (including pads and diapers) </li></ul></ul><ul><ul><li>Float heels </li></ul></ul><ul><ul><li>Keep surface inflated according to manufacture’s instructions </li></ul></ul>
  34. 38. <ul><li>Instruct Patient and Caregiver </li></ul><ul><ul><li>Reposition q 2 hours in bed, every hour in chair. </li></ul></ul><ul><ul><li>WC bound: shift weight every 20 minutes. </li></ul></ul><ul><ul><li>Avoid prolonged pressure to bony prominences </li></ul></ul><ul><ul><li>HOB no more than 30 degrees </li></ul></ul>
  35. 39. <ul><li>Instruct Caregiver: </li></ul><ul><ul><li>Keep pt clean and dry </li></ul></ul><ul><ul><li>Check diapers at least every 2 hours </li></ul></ul><ul><ul><li>Use moisture barrier to peri-area with every diaper change </li></ul></ul><ul><ul><li>Incontinent product use </li></ul></ul><ul><ul><li>(skin barriers, pads, undergarments, catheters) </li></ul></ul>
  36. 40. <ul><li>Instruct Patient and Caregiver </li></ul><ul><ul><li>Monitor intake </li></ul></ul><ul><ul><li>Balanced diet </li></ul></ul><ul><ul><li>Monitor weight weekly </li></ul></ul><ul><ul><li>Eat 5 fruits or vegetables daily </li></ul></ul><ul><ul><li>Incorporate foods rich in Vitamin C </li></ul></ul>
  37. 41. <ul><li>Scenario: </li></ul><ul><ul><li>Mrs. C. is 80 years old. She was recently hospitalized for pneumonia. She lives with her daughter who is her primary caregiver. She has a history of a sacral pressure ulcer which is healed. She is incontinent of urine and wears diapers. She walks with a walker but requires assistance also . </li></ul></ul>
  38. 42. <ul><li>Verbalizes symptoms of exacerbation/complications, when to report and actions to take through education r/t </li></ul><ul><li>Avoid bunching of linens. Float heels in bed. Change position q 2 hrs in bed and q 1 hr in chair. Wash peri-area with soap & water and apply moisture barrier with each diaper change. Increase calories, protein and vitamins in diet. </li></ul>
  39. 43. <ul><li>All Braden scores are not created equal </li></ul><ul><li>Care Plan to deficits in each area </li></ul>
  40. 46. <ul><li>Skin Disorders </li></ul><ul><li>Herpes </li></ul><ul><li>Yeast </li></ul><ul><li>Scabies </li></ul><ul><li>Corns </li></ul><ul><li>Calluses (hyperkeratotic area) </li></ul><ul><li>Papillomas (skin tags) </li></ul><ul><li>Keratinous cysts </li></ul><ul><li>Warts </li></ul><ul><li>Keloids </li></ul><ul><li>Seborrheic keratoses </li></ul><ul><li>Actinic keratoses </li></ul><ul><li>Common acquired nevus (moles) </li></ul><ul><li>Fungal infections </li></ul>
  41. 47. <ul><li>Fungal or yeast rash : </li></ul><ul><li>Solid rash with multiple satellite lesions </li></ul><ul><li>Grows on warm, moist skin </li></ul><ul><li>Decrease moisture by using dry cloth or gauze in folds (InterDry Ag) </li></ul><ul><li>Treat rash </li></ul>
  42. 50. <ul><li>Friction : Sanding away of the surface layer of the skin. More common when skin is fragile or macerated </li></ul><ul><li>Maceration : Tissue is water logged </li></ul>
  43. 52. <ul><li>Skin tears. </li></ul><ul><li>Drag/pull across the bed sheets, etc. especially if patient is being moved incorrectly </li></ul>
  44. 55. <ul><li>Contact dermatitis </li></ul><ul><li>Enzymes, etc. </li></ul>
  45. 57. <ul><li>Denuded : Skin has been stripped by enzymes from incontinence or wound drainage </li></ul><ul><li>Very painful and very wet </li></ul><ul><li>Excoriated: Scratch marks </li></ul>
  46. 59. <ul><li>VASCULAR </li></ul><ul><li>WOUNDS </li></ul><ul><li>Etiology related to poor arterial and/or venous blood flow </li></ul><ul><li>Usually appear in lower extremities </li></ul>
  47. 60. <ul><li>DIABETIC WOUNDS </li></ul><ul><ul><li>Neuropathic ulcer usually on soles of the feet </li></ul></ul><ul><ul><li>Typically heavy callus rim due to repetitive trauma </li></ul></ul><ul><ul><li>Lack of sensation due to neuropathy </li></ul></ul>
  48. 61. <ul><li>Impaired blood flow causing tissue ischemia </li></ul><ul><li>Most commonly due to smoking and atherosclerosis </li></ul><ul><li>Ulcers result from trauma </li></ul>
  49. 62. <ul><li>Pain with leg elevation, decreased pain when leg dependent </li></ul><ul><li>Feet pale when elevated, very red when dependent </li></ul><ul><li>Cool to touch and decrease/absent pedal pulses </li></ul><ul><li>Little or no leg/toe hair present </li></ul>
  50. 63. <ul><li>Wounds have punched out appearance </li></ul><ul><li>Wound bed pale, mostly dry </li></ul><ul><li>Tend to occur in distal part of leg in areas exposed to repetitive trauma or pressure </li></ul><ul><li>Usually small and deep, necrosis common </li></ul><ul><li>Edema NOT common; if present, pt has both venous and arterial disease </li></ul>
  51. 64. <ul><li>Classic arterial wound </li></ul><ul><li>Note dependent rubor </li></ul>
  52. 65. <ul><li>Ischemic changes 65 yr old female, non-bypassable, refuses to quit smoking </li></ul><ul><li>One week later. Amputation 3 weeks later </li></ul>
  53. 66. <ul><li>Arterial wounds due to trauma and neuropathy due to alcohol abuse </li></ul>
  54. 67. <ul><li>Arterial ulcer at the metatarsal head </li></ul>
  55. 68. <ul><li>First priority is to improve tissue perfusion </li></ul><ul><li>-Revascularization surgery is key to successful management </li></ul><ul><li>-No tobacco </li></ul><ul><li>No debridement in dry, uninfected necrotic wounds until ischemia resolved </li></ul>
  56. 69. <ul><li>Also called venous stasis ulcers </li></ul><ul><li>About 70% of all chronic leg ulcers </li></ul><ul><li>60% will recur </li></ul>
  57. 70. <ul><li>Inadequate calf muscle pump which causes </li></ul><ul><li>Distension of the veins which pulls valves apart resulting in elevated </li></ul><ul><li>Pressure causing capillaries to leak </li></ul><ul><li>Resulting in edema </li></ul><ul><li>Changes in the tissues make them more susceptible to trauma and ulceration </li></ul>
  58. 71. <ul><li>Risk factors include </li></ul><ul><li>-DVT </li></ul><ul><li>-Obesity </li></ul><ul><li>-Pregnancy </li></ul><ul><li>-Prolonged standing </li></ul><ul><li>-Aging </li></ul><ul><li>-Previous surgery or trauma to leg </li></ul>
  59. 72. <ul><li>Clinical Findings: </li></ul><ul><li>-30-40% are superior to the medial malleolus and remainder primarily on lower 1/3 of calf </li></ul><ul><li>-Wound bed is flat, irregularly shaped </li></ul><ul><li>-Moderate to heavy exudate depending on amount of edema </li></ul>
  60. 73. <ul><li>Clinical Findings </li></ul><ul><li>-Surrounding skin with edema, hyperpigmentation </li></ul><ul><li>-Pain most often when leg is dependent, pain decreases with leg elevation </li></ul>
  61. 76. <ul><li>Edema - leg looks like up-side down bottle. </li></ul><ul><li>Red in color. </li></ul><ul><li>Painful. </li></ul>
  62. 77. <ul><li>Irregular shape. </li></ul><ul><li>Clear or serosanguineous fluid. </li></ul>
  63. 78. <ul><li>Brown-black hue to periwound skin from RBC breakdown. </li></ul><ul><li>Shallow. </li></ul><ul><li>Gaiter area of leg. </li></ul>
  64. 79. <ul><li>Venous stasis ulcer with dermatitis </li></ul>
  65. 80. <ul><li>4+ edema </li></ul><ul><li>Ischemic </li></ul>
  66. 81. <ul><li>Improve venous return </li></ul><ul><li>-ligation of veins </li></ul><ul><li>-elevation of legs </li></ul><ul><li>COMPRESSION THERAPY </li></ul><ul><li>-eliminates capillary leakage </li></ul><ul><li>-reduces/eliminates edema </li></ul><ul><li>-Wounds will not heal without compression </li></ul>
  67. 82. <ul><li>Contraindications to compression: </li></ul><ul><li>-uncompensated CHF </li></ul><ul><li>-active thrombus </li></ul><ul><li>- ischemic disease of lower extremity </li></ul><ul><li>Generally not used in presence of active cellulitis until patient on antibiotics for 72 hours </li></ul>
  68. 83. <ul><li>Therapeutic Support Stockings </li></ul><ul><li>-wonderful if pt will wear them </li></ul><ul><li>-wait until ulcer is healed </li></ul><ul><li>-TEDs are NOT therapeutic for venous insufficiency </li></ul>
  69. 84. <ul><li>Compression Wraps </li></ul><ul><li>-Unna’s boot </li></ul><ul><li>-Profore </li></ul><ul><li>- Coban 2-layer compression system </li></ul><ul><li>-Tubigrip </li></ul><ul><li>-CircAid / </li></ul><ul><li>Farrow wrap </li></ul><ul><li>-Pneumatic pumps </li></ul><ul><li>-NO ACE BANDAGES </li></ul>
  70. 85. <ul><li>Proper compression </li></ul><ul><li>Improper </li></ul><ul><li>compression </li></ul>
  71. 86. <ul><li>More improperly wrapped compression </li></ul>
  72. 87. <ul><li>Slow healing venous ulcer </li></ul><ul><li>Ulcer after 1 week of compression and wound care </li></ul>
  73. 88. <ul><li>Severe lymphedema with ulcerations </li></ul><ul><li>After compression </li></ul>
  74. 89. <ul><li>Diabetic neuropathy leads to </li></ul><ul><li>-diminished sensation causing undetected trauma </li></ul><ul><li>-decreased perspiration causing dry cracked skin </li></ul><ul><li>-muscle/ligament/bone atrophy resulting in structural changes in foot causing increased and repetitive pressure </li></ul>
  75. 90. <ul><li>Breakdown occurs in areas exposed to painless, repetitive trauma from friction or pressure </li></ul><ul><li>Most common on plantar aspect of foot </li></ul><ul><li>Sometimes at heel, tops of toes, between toes </li></ul>
  76. 91. <ul><li>Reduce or eliminate pressure and trauma </li></ul><ul><li>by offloading foot </li></ul><ul><li>-pressure relief for heel ulcers </li></ul><ul><li>-modify footwear to avoid pressure </li></ul><ul><li>Control diabetes </li></ul>
  77. 94. <ul><li>Infected diabetic ulcers with communicating sinus tracts </li></ul>
  78. 95. <ul><li>Idiopathic neuropathy, ulceration post plantar wart removal </li></ul><ul><li>Same ulcer, failed graft from patient walking on wound </li></ul>
  79. 96. <ul><li>Toe amputation, partial take of skin graft </li></ul><ul><li>Healing with local care </li></ul>
  80. 97. <ul><li>Re-ulceration in two months from non-compliance with shoewear </li></ul>
  81. 99. <ul><li>Location </li></ul><ul><li>Measurements in centimeters </li></ul><ul><li>width x length x depth </li></ul><ul><li>Any tunneling/undermining </li></ul><ul><li>Color of wound bed </li></ul><ul><li>Condition of surrounding tissue/skin </li></ul><ul><li>Drainage, odor, pain </li></ul>
  82. 100. MEASURING WOUNDS Use a single-use measuring guide.
  83. 102. Across longest and widest areas. Which is length? 12:00 6:00 3:00 9:00 Which is width?
  84. 103. <ul><li>Use a cotton tip applicator </li></ul><ul><li>Place tip in deepest part of wound </li></ul><ul><li>Mark skin level with finger </li></ul><ul><li>Measure length from applicator tip to level marked with finger </li></ul>
  85. 104. <ul><li>Definition </li></ul><ul><li>Tissue destruction to underlying intact skin along wound edges. </li></ul><ul><li>Measuring </li></ul><ul><li>Use cotton tip applicator. </li></ul><ul><li>Mark distance between tip and wound edge. </li></ul><ul><li>Indicate extent of undermining and location by using clock face. </li></ul>
  86. 105. <ul><li>Definition </li></ul><ul><li>A measurable tract extending from the wound bed. </li></ul><ul><li>Measuring </li></ul><ul><li>Use cotton tip applicator. </li></ul><ul><li>Mark length between tip and wound edge. </li></ul><ul><li>Indicate location by using clock face. </li></ul>
  87. 107. <ul><li>Serous is a clear, water plasma. </li></ul><ul><li>Sanguineous indicates fresh bleeding. </li></ul><ul><li>Serosanguineous is a pale, more watery drainage than sanguineous drainage. </li></ul><ul><li>Purulent is a thick, yellow, green, or brown drainage. </li></ul>
  88. 108. <ul><li>Foul smelling – expected in the presence of eschar or slough, and/or infected wounds. </li></ul><ul><li>Mild – may be associated with wound care products. </li></ul>
  89. 109. <ul><li>Think of color </li></ul><ul><li>Red – usually indicates granulation tissue. </li></ul><ul><li>Yellow – slough – soft necrotic tissue </li></ul><ul><li>Black – Eschar – firm/hard necrotic tissue </li></ul>
  90. 110. <ul><li>Unable to stage pressure ulcer with eschar </li></ul><ul><li>May or may not debride wound eschar depending on location </li></ul>
  91. 112. <ul><li>Describe the appearance of skin immediately surrounding the wound. </li></ul><ul><li>Measure and document the size of each characteristic </li></ul>
  92. 113. <ul><li>Redness of the skin due to capillary congestion. </li></ul><ul><li>Common cause – unrelieved pressure </li></ul>
  93. 114. <ul><li>Abnormal firmness of tissue with a definite margin. Marked by loss of elasticity and pliability. Cause is usually infection. </li></ul>
  94. 115. <ul><li>Softening of tissues by soaking in fluids. Dissolving connective tissue components causing degenerative changes. </li></ul><ul><li>Causes: wound drainage, contact with stool and/or urine. </li></ul>
  95. 116. <ul><li>Loss of superficial epidermis. </li></ul><ul><li>Common causes: unrecognized or treated maceration, tape on fragile skin </li></ul>
  96. 117. <ul><li>Discoloration: An increase or decrease in pigmentation not consistent with surrounding skin; may be purple, brown, etc. Commonly seen with venous ulcers. </li></ul><ul><li>Edema: Presence of abnormally large amounts of fluid in the interstitial space. Seen with venous ulcers. </li></ul>
  97. 118. <ul><li>Firm, thickened area of tissue usually seen on the diabetic foot from repeated pressure or shear. </li></ul>
  98. 120. <ul><li>Wound Healing and Barriers </li></ul><ul><li>Principles of wound management </li></ul><ul><li>Dressing Selection guidelines </li></ul>
  99. 121. <ul><li>Only two ways to heal – </li></ul><ul><li>Regeneration – partial thickness wound or </li></ul><ul><li>Granulation – full thickness wound </li></ul><ul><li>(Proliferation, remodeling) </li></ul>WOUND HEALING
  100. 122. <ul><li>Injury not through dermis </li></ul><ul><li>Inflammatory phase </li></ul><ul><li>Epithelialization </li></ul><ul><li>Re-establishment of normal skin </li></ul>PARTIAL THICKNESS WOUND
  101. 123. <ul><li>Injury through all layers of skin </li></ul><ul><li>Inflammatory phase </li></ul><ul><li>Proliferation phase </li></ul><ul><li>Contraction </li></ul><ul><li>Epithelialization </li></ul><ul><li>Maturation </li></ul>FULL THICKNESS WOUND
  102. 124. <ul><li>Inflammatory phase </li></ul><ul><li>Starts with surgery or injury – lasts 3-4 days </li></ul><ul><li>fragile bond </li></ul><ul><li>The four cardinal signs of inflammation, as described by the Roman physician and science writer Celsius, are: </li></ul><ul><li>Rubor - redness </li></ul><ul><li>Tumor - swelling </li></ul><ul><li>Calor - heat </li></ul><ul><li>Dolor - pain </li></ul>STAGES OF WOUND HEALING
  103. 129. <ul><li>To heal wounds, our bodies use a large collection of cell types, proteins, and molecules. </li></ul><ul><li>Photo: Dennis Kunkel Microscopy, Inc. </li></ul>
  104. 130. <ul><li>PROLIFERATION/RECONSTRUCTION/ </li></ul><ul><li>CONTRACTION </li></ul><ul><li>As per Merriam-Webster: proliferation is to grow by rapid production of new parts, cells, buds, or offspring </li></ul><ul><li>lasts 4-21 days – pink granulation tissue, collagen </li></ul>STAGES OF WOUND HEALING
  105. 132. <ul><li>REMODELING </li></ul><ul><li>Can last up to 2 years </li></ul><ul><li>80% </li></ul><ul><ul><li>60% </li></ul></ul><ul><ul><ul><li>40% </li></ul></ul></ul><ul><ul><ul><ul><li>20% </li></ul></ul></ul></ul>STAGES OF WOUND HEALING
  106. 133. <ul><li>PRIORITIES </li></ul><ul><li>-Correct Etiology </li></ul><ul><li>-Provide Systemic Support </li></ul><ul><li>-Use appropriate therapy </li></ul><ul><li>GOAL </li></ul><ul><li>-Healing </li></ul><ul><li>-Maintenance </li></ul>BASIC WOUND MANAGEMENT
  107. 134. <ul><ul><ul><ul><ul><li>MONITOR RESPONSE </li></ul></ul></ul></ul></ul><ul><li>-Expect improvement in 2-4 weeks </li></ul><ul><li>-Change regimen if maceration or increased depth due to increased exudate </li></ul><ul><li>-Failure to improve most commonly due to systemic factors – reassess and correct </li></ul>
  108. 135. <ul><li>DIDN’T HEAL : </li></ul><ul><li>= Diabetes </li></ul><ul><li>= Infection </li></ul><ul><li>= Drugs </li></ul><ul><li>= Nutrition </li></ul><ul><li>= Tissue necrosis </li></ul>FACTORS THAT AFFECT WOUND HEALING DIDN'T
  109. 136. <ul><li>= Hypoxia </li></ul><ul><li>= Excessive tension on wound edges </li></ul><ul><li>= Another wound </li></ul><ul><li>= Low temperature </li></ul>HEAL
  111. 139. <ul><li>Keep wound clean, warm, dark, moist, protected </li></ul>VERY BASIC PRINCIPLE
  112. 140. <ul><li>Remove necrotic tissue (slough, eschar) </li></ul><ul><li>Treat infection </li></ul><ul><li>Fill dead space </li></ul><ul><li>Maintain moist wound environment </li></ul><ul><li>Protect from infection/trauma/cold </li></ul>UNIVERSAL PRINCIPLES OF WOUND CARE
  113. 141. <ul><li>Debridement essential for infected wounds </li></ul><ul><li>Critical first step when healing is goal </li></ul>REMOVE NECROTIC TISSUE
  114. 142. <ul><li>Surgical </li></ul><ul><li>Fastest way to a clean wound </li></ul>DEBRIDMENT CAN BE...
  116. 144. <ul><li>Eschar on heel </li></ul><ul><li>After debridement </li></ul>
  117. 145. <ul><li>DO NOT debride dry stable eschar from heel wounds </li></ul>ALWAYS EXCEPTIONS...
  118. 146. <ul><li>Apply to wound daily per manufacturer’s instructions </li></ul>ENZYMATIC
  119. 147. <ul><li>Slow, but less painful, less expensive </li></ul>AUTOLITIC
  120. 149. <ul><li>with the use of Dakin’s </li></ul><ul><li>with the use of wet to dry gauze dressings. Wet gauze sticks to wound bed. When it dries, pull it off to remove dead tissue. Do not moisten dried gauze. VERY PAINFUL </li></ul>CHEMICAL MECHANICAL
  121. 150. <ul><li>Medical grade maggots </li></ul><ul><li>Application of maggots </li></ul>BIOLOGICAL
  122. 151. <ul><li>Drainage from maggot therapy </li></ul><ul><li>Fat and happy maggots! </li></ul>
  123. 152. Historically <ul><li>Historically, maggots have been known for centuries to help heal wounds. Many military surgeons noted that soldiers whose wounds became infested with maggots did better --- and had a much lower mortality rate --- than did soldiers with similar wounds not infested. William Baer, at Johns Hopkins University in Baltimore, Maryland, was the first physician (an orthopedic surgeon, actually) in the U.S. to actively promote maggot therapy; his results were published posthumously by his colleagues in 1931. MDT was successfully and routinely performed by thousands of physicians until the mid-1940's, when its use was supplanted by the new antibiotics and surgical techniques that came out of World War II. Maggot therapy was occasionally used during the 1970's and 1980's, when antibiotics, surgery, and other modalities of modern medicine failed. In 1989, physicians at the Veterans Affairs Medical Center in Long Beach, CA, and at the University of California, Irvine, reasoned that if maggot therapy was effective enough to treat patients who otherwise would have lost limbs, despite modern surgical and antibiotic treatment, then we should be using maggot therapy BEFORE the wounds progress that far, and not only as a last resort </li></ul>
  124. 153. Natural History of Blow Flies <ul><li>Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. there are thousands of species of flies, each with its own habits and life cycle. We use Phaenicia sericata (green blow fly) larvae. </li></ul><ul><li>Medical Maggots are now produced by Monarch Labs and can be obtained by Licensed health care providers </li></ul><ul><li>Medicinal maggots have three actions: 1) they debride (clean) wounds by dissolving the dead (necrotic), infected tissue; 2) they disinfect the wound, by killing bacteria; and 3) they stimulate wound healing </li></ul>
  125. 155.       Eggs are off-white, and laid in clusters of 25-500. One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.
  126. 156. DAY 1 DAY 3 DAY 7
  127. 157. <ul><li>All wounds are contaminated </li></ul><ul><li>Culture if wound is infected. Routine culture of all wounds not necessary </li></ul><ul><li>Use Modified Swab technique </li></ul><ul><li>-cleanse with sterile saline </li></ul><ul><li>-swab one square centimeter of viable tissue x 5 seconds with enough force to produce exudate </li></ul>TREAT INFECTION
  128. 158. <ul><li>Systemic antibiotics if indicated </li></ul><ul><li>Topical treatments </li></ul><ul><li>-Dakins Solution: 0.025% is wound strength and is bactericidal to most bacteria found in wounds and non-cytotoxic. ¼ strength solution most often used </li></ul><ul><li>-Povidone-iodine: Use solution only, never scrub. Use 10% or less concentrated solution </li></ul>TREAT INFECTION
  129. 159. <ul><li>- Acetic acid: Toxic to Pseudomonas in 5% solution; this is also toxic to all cells needed for repair. 0.25% commonly used </li></ul><ul><li>Stop use of these products when wound is clean!!! </li></ul>TREAT INFECTION
  130. 160. <ul><li>Antibacterial Dressings </li></ul><ul><li>-Cadexomer iodine </li></ul><ul><li>-Sustained release silver dressings </li></ul><ul><li>-Polyhexamethylene Biguanide (AMD) </li></ul><ul><li>-Hypertonic </li></ul>TREAT INFECTION
  131. 161. <ul><li>Topical Antibiotics </li></ul><ul><li>-Polysporin/Neosporin: Staph aureus, E.Coli, Pseudomonas </li></ul><ul><li>-Silvadene: Pseudomonas, E.Coli, Staph aureus </li></ul><ul><li>-Bactroban (Mupirocin): MRSA </li></ul><ul><li>-Gentamicin: Pseudomonas, E.Coli, Staph aureus </li></ul>TREAT INFECTION
  132. 162. <ul><li>LIGHTLY pack wounds to allow for drainage </li></ul><ul><li>Over packing creates a plug and puts pressure on tissue </li></ul><ul><li>NO STUFFING! </li></ul>FILL DEAD SPACE
  133. 163. <ul><li>Choose a dressing based on volume of exudate </li></ul><ul><li>minimal exudate needs dressings that add or trap moisture </li></ul><ul><li>moderate exudate needs dressings that absorb without dehydrating </li></ul><ul><li>large amount exudate needs highly absorbent dressings </li></ul>MAINTAIN MOIST ENVIRONMENT
  134. 164. To add or maintain moisture : <ul><li>Damp gauze </li></ul><ul><li>Gels – Solosite, Curagel </li></ul><ul><li>+ Cover dressing to retain moisture </li></ul><ul><li>Transparent film – OpSite, Tegaderm </li></ul><ul><li>Non-adherent gauze – Adaptic, Vaseline gauze </li></ul>
  135. 165. <ul><li>Filler Dressings </li></ul><ul><li>-Calcium Alginate </li></ul><ul><li>-Hydrofiber </li></ul><ul><li>-Gauze </li></ul><ul><li>Cover Dressings </li></ul><ul><li>-Polyurethane Foam – Allevyn, Polymem </li></ul><ul><li>-ABD and other gauze </li></ul>To absorb exudate
  136. 166. <ul><li>Hydrocolloid – Duoderm, Tegasorb </li></ul><ul><li>Able to absorb minimal to moderate amount of exudate </li></ul><ul><li>Provides insulation and protection from bacterial invasion and trauma </li></ul><ul><li>Yellowish exudate and odor normal with removal </li></ul><ul><li>Change dressing 1-2 x week </li></ul>
  137. 167. <ul><li>Based on amount of drainage and presence of infection </li></ul><ul><li>Infected wounds need to be monitored daily </li></ul><ul><li>Heavily draining wounds may need to be changed 2-3 times a day </li></ul><ul><li>As drainage decreases, increase time between dressing changes </li></ul>DRESSING CHANGE FREQUENCY
  138. 168. <ul><li>Choose cover dressings that protect from the environment </li></ul><ul><li>-Transparent films, foams, waterproof tapes </li></ul><ul><li>-63 layers of gauze needed to protect from bacterial invasion </li></ul><ul><li>Protect wounds from re-injury </li></ul><ul><li>Decrease dressing frequency to prevent thermal shock </li></ul>PROTECT FROM INFECTION / TRAUMA / COLD
  139. 169. Shallow and Wet Shallow and Dry SHALLOW/SUPERFICIAL WOUNDS MODERATE – HEAVY EXUDATE Goals : Absorb exudates, maintain moist surface; support autolysis if necrotic tissue; protect and insulate Need : Absorptive cover dressing: Alginates, foam, gauze, hydrocolloid (if not too wet) SHALLOW/SUPERFICIAL WOUNDS MINIMAL OR NO EXUDATE Goal : Maintain or create moist surface; protect and insulate Need : Hydrating or moisture retentive cover dressing: Gels, hydrocolloids, transparent thin films, non-adherent gauze
  140. 171. SUMMARY
  141. 172. Deep and Wet Deep and Dry CAVITY WOUNDS MODERATE – HEAVY EXUDATE Goals : Fill dead space; absorb excess exudates; maintain moist wound surface; protect Need : Filler and cover dressing Fillers : alginates, gauze Cover : Gauze, ABD, transparent film, foam CAVITY WOUNDS MINIMAL OR NO EXUDATE Goals : Fill dead space; maintain moist wound; protect and insulate Need : Hydrating filler dressing; cover dressing Filler : Gel, damp gauze Cover : Gauze, ABD, transparent film, foam
  142. 173. Review of last session <ul><li>SKIN ACCRONYM </li></ul><ul><li>Surface </li></ul><ul><li>Keep moving </li></ul><ul><li>Incontinence management </li></ul><ul><li>Nutrition </li></ul>Keep moving Incontinence management Nutrition Surface
  143. 174. THANK YOU