WOUND CARE:IT’S ALL GREEK TO ME

BY CHERYL MARZOLI RN BHScN IIWCC

OBJECTIVES

• Provide a better understanding of wound care • How to: assess, provide interventions and document about wounds.

• Understanding moist wound healing • Discuss categories of dressing products, the use of the products, NPT (negative pressure therapy) and treatment of wounds.

WOUND

• DEFINITION: A wound is a bodily injury caused by physical means, with disruption of the normal continuity of structures. This can be identified as an acute or a chronic wound.

• ACUTE: Heals in approximately 2 weeks to 6 months • CHRONIC: Takes 6 months or more.

ACUTE WOUND

CHRONIC WOUND

PHASES OF WOUND HEALING

• Stages of wound healing: Hemostasis: immediate response Inflammation: 0-4 days Proliferation: 4-21 days Granulation (Epithelialization) :4-21 days Remodeling: up to 2 years * this is for acute wounds, chronic wounds fail to progress naturally

2 3 PHASE 1 4 GOAL HEMOSTASIS INFLAMMATION PROLIFERATION GRANULATION CONTRACTURE REMODELING PRINCIPLE WOUND CELL PLATELETS HOUSE BUILDING CONTRACTOR CAPPING OFF OFFENDING CONDUITS NEUTROPHILS MACROPHAGES LYMPHOCYTES ANGIOCYTES, NEUROCYTES FIBROBLASTS, KERATINOCYTES FIBROCYTES UNSKILLED LABORERS CLEAR THE SITE SUPERVISOR CELL SPECIFIC PREPARERS OF SITE PLUMBER, ELECTRICIAN FRAMERS ROOFERS/SIDERS REMODELERS *Krasner, et al

STAGES OF PRESSURE ULCERS

Stage 1: reddened skin Stage 2: blister (painful), shallow, pink ulcer Stage 3: through the dermis Stage 4: through to underlying structures (bone, tendons, etc.) Unable to stage: unable to visualize wound bed due to eschar/slough

Suspected Deep Tissue Injury (SDTI): purple localized area of discolored intact skin, boggy, warmer or cooler compared to adjacent tissues.

NOTE: NO reverse staging i.e. once a stage 3 always a stage 3, never changes to stage 2

STAGE ONE

•

Epidermis intact

•

Area reddened

• •

Does not disappear when pressure relieved No drainage

•

Reversible

STAGE TWO

STAGE THREE

STAGE FOUR

UNABLE TO STAGE

WHAT STAGE?

WHAT STAGE?

STAGING ALL OTHER WOUNDS NOT PRESSURE ULCERS

Classification is based on the 3 layers of skin Classify as superficial, partial or full thickness i.e. a burn can be partial thickness (second layer).

PARTIAL THICKNESS BURN

ASSESS THE PATIENT

1.Look at the whole patient not just the hole.

2. What are the patient’s concerns?

3. Is the wound new or old and how old?

4. Is this wound healable?

5. What are the patient’s co-morbidities?

6. How is the patients nutritional status 7. What medications if any could interfere with wound healing?

Probe the wound!!!!

Try and correct the causes that may delay wound healing

• Edema • Nutrition/Dietary consult • Alter medications • Glycemic control • Treat infection • OT/Physio consult

Documentation

• Slough * Location • Eschar * Size LxWxD • Granulation • Undermining • Erythema • Maceration • Exudate • Odor

Moist Wound Healing Motto…

If its wet……..DRY it!

If its dry………MOISTEN it!

If its irritated…SOOTHE it!

If its chronic…IRRITATE it!

If its palliative..COMFORT it!

Contamination, Colonization or Infection

Contamination: Bacteria-not attached to wound bed -are not replicating Colonization: - Bacteria are attached to the wound surface but are not replicating Infected: -Bacteria are invasive, replication and interfering with wound healing process -may lead to a “HOST RESPONSE” leading to systemic infection

SWABS

• Always take a swab from a newly cleaned wound.

• Cleanse with normal saline or sterile water • Take a swab by moving in a “Z” pattern over the wound and turning the swab at the same time • Punch biopsy (Physician only) • Do Not swab necrotic or slough tissue

Wound Cleansing

- Normal Saline or Sterile Water – Irrigate with 20-30 ml syringe – Use 18 angiocath – 4-6 inches above the wound – 5-15 PSI • **MMP’S( matrix metalloproteases)

ANTISEPTIC SOLUTIONS

• Acetic acid: pseudomonas • Proviodine: broad spectrum effectiveness • Hygeol: staph. and strep. • mechanical debridement • control odour • *acetic acid and hygeol are available through the pharmacy

Wound Care Products – Liquid barrier – Transparent films -non adherent dressings – Hydrocolloids -debriding agents – Gauze dressings -antiseptic – Hydrogels – Foam dressings – Absorptive dressings – Calcium alginate – Charcoal dressings – Silver coated dressings

LIQUID BARRIER

TRANSPARENT FILM

•

HYDROCOLLOID

GAUZE DRESSINGS

HYDROGEL

FOAM DRESSING

ABSORBENT DRESSINGS

CALCIUM ALGINATE

ODOUR CONTROL CHARCOAL DRESSINGS

ANTIMICROBIAL DRESSING

OTHER DRESSINGS

• Non adherent dressings • i.e.- mepital • Debriding agents-mesalt, iodosorb • Antiseptic- bactigras with a chlorhexidine base

BIOLOGIC DRESSINGS

BIOLOGIC DRESSINGS

NEGATIVE PRESSURE THERAPY

• WATCH FOR PRECAUTIONS AND CONTRAINDICATIONS WHEN ORDERING • MAKE SURE WOUND IS MEASURED ON INITIAL APPLICATION • IF NO CHANGE WITHIN 2-2I/2 WEEKS THEN DISCONTINUE • E-Z CARE IS A NEW NEGATIVE PRESSURE THERAPY

GOOD CANDIDATE FOR NEGATIVE PRESSURE

QUESTIONS

THANKYOU