Transcript SKIN ANATOMY - Amazon Web Services

WOUND CARE MANAGEMENT
“A Crash Course”
Alvyn “Joy” C. Halili, PT, CWS, FACCWS
Acute Therapies Manager
Certified Wound Care Specialist
Winter Haven Hospital
OBJECTIVES
• Determine Basics in Wound Healing
• Determine/Identify Current Methods in
Clinical Assessment
• Identify Interventions Appropriate for Wounds
Encountered
• Aid in Clinical Decision in Discharge Planning
or Continued Interventions
Contents
• Review of Skin Anatomy
• Review of Phases in Healing
• Review of the Clinical Team Approach in
Wound Healing
• Review SOAP for Commonly Encountered
Cases
REVIEW OF SKIN ANATOMY
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Epidermis
BMZ
Dermis
Sub-dermis
Stratum Corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basale/Germinativum
Basement Membrane Zone
DERMIS
DERMIS
REVIEW OF PHASES IN WOUND HEALING
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HEMOSTASIS
INFLAMMATORY
PROLIFERATIVE
REEPITHELIZATION
MATURATION/REMODELLING
ACUTE vs CHRONIC
• Acute
• Sequence of Healing is within the expected time
frame of physiologic healing
• Chronic
• Failed to proceed through an orderly and timely
process to produce anatomic and functional integrity,
or proceeded through the repair process without
establishing a sustained anatomic and functional
result
THE CLINICAL TEAM
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Direct
Physician, ARNP, PA
Surgeon, Podiatrist, Dermatologist, Pathologist
Infectious Disease (ID)
Pharmacist
Nurses (Enterostomal Nurse, WC Nurse)
Ancillary (PT, OT, Dietary, Orthotist, Prosthetist)
Wound Care Specialist
CASE SUMMARY
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Arterial Insufficiency/Ulcers
Venous Insufficiency/Ulcers
Lymphedema
Diabetic Ulcers
Infected/Critically Colonized Surgical Wounds
Pressure Ulcers
Traumatic Wounds
Burns
Atypical Wounds
S – Subjective
O – Objective
A – Assessment
P - Plan
Arterial Insufficiency
S – Subjective: Complains of significant levels of pain
O – Objective: ABI, Cardiac History
A – Assessment: distally located wounds, dry wounds,
well shaped wounds, no pulse, no hair, poor capillary
refill
P – Plan
- Keep it dry
- Vascular Studies
- Offloading – consider weight bearing restrictions
- No compression if studies significant for PAD
- Refer Vascular consult
Venous Insufficiency
S – Subjective: Complains of swelling, weeping,
reoccurring problem
O – Objective: ABI, Venous Doppler, Culture
A – Assessment: Irregularly Shaped Wounds, Ulcers
on Gaiter Area, Heavy Drainage,
P – Plan:
- Keep it dry
- Elevation
- Compression (35-45 mm Hg), Not Ted Hoses
- Consider UNNA Boot/Multilayer Compression
dressing
- Offloading – consider weight bearing restrictions
- No compression if studies significant for PAD
- Refer Vascular consult
- Dietary Consult
Lymphatic System
Like Venous
S – Subjective:
O – Objective: ABI, Venous Doppler, Culture
A – Assessment: Ulcers can be on Gaiter Area, Heavy
Drainage
P – Plan:
- Keep it dry
- Elevation
- Offloading – consider weight bearing restrictions
- No compression if studies significant for PAD
- Dietary Consult
- Lymphedema Specialist (MLD,Compression,
exercises)
Diabetic
S – Subjective: Complains of pain or no pain at all due
to neuropathy
O – Objective: ABI, Hgb A1c, Prealbumin
A – Assessment: distally located wounds, Located on
distally weight bearing areas, Charcot Foot Dse
P – Plan
- Keep it dry
- Vascular Studies
- Offloading – consider weight bearing restrictions
- No compression if studies significant for PAD
- Refer to Podiatrist > Refer to Orthotist
- Refer Vascular consult/Surgical Consult
- Refer to Infectious Disease
Surgical Wounds
S – Subjective: Variable, Pain, Fever, Dehiscence
O – Objective: Prealbumin, Tissue biopsy, Culture and
Sensitivity
A – Assessment: Determine presence of devitalized
tissue
P – Plan
- Optimal moisture
- Surgical Consult – Surgeon’s protocol/preference
- Refer to Infectious Disease
- Dietary Consult
NECROTIZING FASCIITIS
PRESSURE ULCER (PU)
Definition:
A pressure ulcer is localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, or
pressure in combination with shear and/or friction. A number of
contributing or confounding factors are also associated with
pressure ulcers; the significance of these factors is yet to be
elucidated.
Intact Skin
STAGES OF PRESSURE ULCERS
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STAGE I
STAGE II
STAGE III
STAGE IV
DEEP TISSUE INJURY(DTI)
UNSTAGEABLE
• Evolving Ulcer, Possible Stage III or IV
STAGE I
Stage I:
Intact skin with non-blanchable redness
of a localized area usually over a bony
prominence. Darkly pigmented skin may
not have visible blanching; its color may
differ from the surrounding area.
Further description:
The area may be painful, firm, soft,
warmer or cooler as compared to
adjacent tissue. Stage I may be difficult
to detect in individuals with dark skin
tones. May indicate "at risk" persons (a
heralding sign of risk)
STAGE I
Stage I:
Intact skin with non-blanchable redness
of a localized area usually over a bony
prominence. Darkly pigmented skin may
not have visible blanching; its color may
differ from the surrounding area.
Further description:
The area may be painful, firm, soft,
warmer or cooler as compared to
adjacent tissue. Stage I may be difficult
to detect in individuals with dark skin
tones. May indicate "at risk" persons (a
heralding sign of risk)
STAGE II
Stage II:
Partial thickness loss of dermis
presenting as a shallow open ulcer with
a red pink wound bed, without slough.
May also present as an intact or
open/ruptured serum-filled blister.
Further description:
Presents as a shiny or dry shallow ulcer
without slough or bruising.* This stage
should not be used to describe skin
tears, tape burns, perineal dermatitis,
maceration or excoriation.
*Bruising indicates suspected deep
tissue injury
STAGE III
Stage III:
Full thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon or muscle
are not exposed. Slough may be present
but does not obscure the depth of tissue
loss. May include undermining and
tunneling.
Further description:
The depth of a stage III pressure ulcer
varies by anatomical location. The bridge of
the nose, ear, occiput and malleolus do not
have subcutaneous tissue and stage III
ulcers can be shallow. In contrast, areas of
significant adiposity can develop extremely
deep stage III pressure ulcers. Bone/tendon
is not visible or directly palpable.
STAGE IV
Stage IV:
Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often
include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by
anatomical location. Stage IV ulcers can extend
into muscle and/or supporting structures (e.g.,
fascia, tendon or joint capsule) making
osteomyelitis possible. Exposed bone/tendon is
visible or directly palpable.
DEEP TISSUE INJURY
Suspected Deep Tissue Injury:
Purple or maroon localized area of
discolored intact skin or blood-filled
blister due to damage of underlying soft
tissue from pressure and/or shear. The
area may be preceded by tissue that is
painful, firm, mushy, boggy, warmer or
cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to
detect in individuals with dark skin tones.
Evolution may include a thin blister over a
dark wound bed. The wound may further
evolve and become covered by thin
eschar. Evolution may be rapid exposing
additional layers of tissue even with
optimal treatment.
UNSTAGEABLE
Unstageable:
Full thickness tissue loss in which the base of
the ulcer is covered by slough (yellow, tan,
gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed
to expose the base of the wound, the true
depth, and therefore stage, cannot be
determined. Stable (dry, adherent, intact
without erythema or fluctuance) eschar on
the heels serves as "the body's natural
(biological) cover" and should not be
removed.
WOUND MANAGEMENT
Does the patient have what it takes to heal?
Is there infection?
Is there mechanical stress?
Is there necrotic tissue?
Is there swelling, edema?
Is the patient diabetic?
Does the patient have peripheral arterial disease?
Does the patient need financial support?
Does the patient need nutritional support?
Is the drainage controlled?
Who is going to follow through?
What available resource do I have in this facility that I
can use?
ADVANCES IN WOUND CARE
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Debridement
Wet to Dry versus Active Dressings
NPWT (Negative Wound Pressure Therapy)
PLWS (Pulsatile Lavage with Suction)
Ultrasonic Debridement
References
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Clinical Guide: Skin and Wound Care (Clinical Guide: Skin & Wound Care) Cathy Thomas Hess
RN BSN CWOCN (Author)
www.npuap.org
Wound Care Essentials: Practice Principles Sharon Baranoski (Author), Elizabeth A.
Ayello (Author)
Acute and Chronic Wounds: Current Management Concepts, 4e Ruth Bryant (Author), Denise
Nix (Author)
www.about.com Heather Brannon, MD
Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses Carrie
Sussman (Editor), Barbara Bates-Jensen (Editor)