THE ARTS AND CRAFTS OF WOUND CARE Rebecca Mickel MSN, RN, CWON, - - PowerPoint PPT Presentation

THE ARTS AND CRAFTS OF WOUND CARE

Rebecca Mickel MSN, RN, CWON, CNE

■ Rate your comfort level with managing wounds in your care setting.

• Know what you are looking at
• TIME principles
• Nutrition
• Pain management
• Documentation essentials

Tool kit essentials

Objectives

• Skin tears
• Venous leg ulcers
• Arterial ulcers
• Pressure ulcers
• Neuropathic ulcers

Identify the etiology of wounds

Differentiate what specialty provides can do to heal a wound;

• Certified wound ostomy continence nurse (CWOCN)
• Vascular surgery
• Physical therapy
• Podiatry

Identify common treatments and appropriate referrals

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)

• r full-thickness (separation
• f both the epidermis and

dermis from underlying structures).

Prevention

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. 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

with saline or a nontoxic wound cleanser.

• 2. Allow the area to air-dry or pat

carefully to dry.

• 3. Approximate the skin tear

flap/tissue, if present, as closely as possible

• 4. Apply steri strips to hold flap in

place

• If no flap is present use a moist wound

dressing, such as a hydrogel. Carefully remove any product with an adhesive backing to avoid further trauma.

• 5. Secure non-adherent dressings

with a gauze or tubular non- adhesive wrap.

• 6. Change dressings according to

the manufacturer's

• recommendations. For example,

hydrogels are generally changed every day; hydrocolloids, weekly or as needed; and foams, weekly or as needed.

• 7. Educate the patient and family

(and staff, if necessary) on how to avoid skin tears in the future and make sure prevention strategies are initiated. For information on one way to describe skin tears in documentation, see Classifying Skin Tears.

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

Tissue

Baranoski, S. & Ayello, E. (2016) Debridement: Low frequency non contact ultrasonic (MIST), Debridement wipes Larvae, Autolytic (medi-honey, hydrogels) Enzymatic (collagenase), Sharp debridement, Chemical (antiseptic, silver, Dakin’s), Negative Pressure Wound therapy Cleaning Use a non cytotoxic agent: Normal saline, wound cleaner. AVOID HARSE WOUND CLEANSER No hydrogen peroxide Undiluted betadine

Time concept

Infection

Bacterial Balance 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

Moisture balance Balance moisture and exudates. 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

Edge

Protect the edge of the 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 ■ Characteristics of the wound: ■ Include – Location – Length, width, depth, – Stage, classification, category – Exudate quality and amount – Tissue type – Pain ■ Local wound dressing selection ■ Nutrition status ■ Pressure redistribution ■ Regular assessments (weekly) ■ Oasis-C, MDS 3.0

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

Diabetic ulcer

■ Measure ■ Clean ■ Protect edge ■ Decide to either absorb or donate moisture ■ Absorb= use a product with silver to decrease bacterial load ■ Donate= hydrogel, hydro fiber use a product with silver to decrease bacterial load ■ Off load pressure! ■ Adequate nutrition ■ Maintain blood sugar within optimal levels

NOW HOW DO YOU FEEL ABOUT WOUND CARE?

References

MacLellan L., Gardner G., and Gardner A. (2002). Designing the future in would care: the role

• f the nurse practitioner. Primary intention 10(3), 97-112.

Lablanc K., Baranoski, S., Christenson, D., Langemo, D., Edwards, K., Holloway, S. et. al (2015). The art of dressing selection: A consensus statement on skin tears and best practice. Advances in skin and wound care (29) 1, 32-46. LeBlanc K, Baranoski S. International Skin Tear Advisory Panel: A tool kit to aid in the prevention, assessment and treatment of skin tears using a simplified classification system. Advances in Skin & Wound Care. 2013;26(10): 459-478. Wound care made incredible easy (3rd ed.). Edited by: Slachta, P. (2016). Wolters Kluwer: Philadelphia Wound care essentials: Principles (4th ed.) Edited by: Baranoski, S. & Ayello, E, (2016). Wolters Kluwer. New York: New York.