Disclosures for Tarik Alam. Wound Bed Preparation. Wound Prognosis. Session Objectives. Debridement 4/26/2015

Transcription

1 Disclosures for Tarik Alam Challenges in Managing Bioburden and Devitalized Tissue Tarik Alam RN, BScN, ET, MClSc(WH) Enterostomal Therapy Nurse Clinical Affairs Manager for Hollister Limited Adjunct Clinical Professor, Faculty of Health Sciences, School of Physical Therapy, University of Western Ontario Course Lecturer, 2 nd Year Nursing, Dawson College, Montreal Session Objectives Wound Bed Preparation List signs of superficial and deep wound infection Describe the 5 types of antimicrobial/antibacterial dressings available Choose a dressing based on form and function Treat the cause Debridement Chronic Wound Local wound care Control infection & inflammation Patient-centered concerns Moisture balance Edge Effect Sibbald RG, Orsted HL, Coutts PM, Keast DH. Best Practice Recommendations for Preparing the wound bed: Update Wound Care Canada 4(1): Wound Prognosis Healable wound: Medical condition and health care system support adherence to an optimal plan Non-healable wound: Patient does not have the capacity to heal e.g. untreatable arterial disease Maintenance wound: Patient choices not conducive to wound healing or the health care system cannot provide optimal treatment Debridement Eschar (dead leathery tissue) and slough (define it): pro-inflammatory effect Culture media for bacterial proliferation Removal of biofilm (protective layer for bacteria) Norton L, Coutts P, Sibbald RG. Choosing between a healable, non-healable and maintenance wound (2011). Rehab Magazine. 1

2 Contraindications to Debridement Non-healable wound Uncontrolled pain Risk of uncontrolled bleeding Immunosuppression Other barriers Inadequate skill level Lack of resources Types of Debridement Surgical sharp Conservative sharp Enzymatic Autolytic Mechanical Biological Conservative Sharp Debridement Moisture Balance NERDS and STONEES Pneumonic developed to assist clinicians in the identification of a chronic wound infection Helps clinicians distinguish between superficial and deep wound infection NERDS Superficial Wound Infection Treat with Topical Antimicrobials Non-healing Exudate Red and bleeding granulation tissue Debris Smell 2

3 STONEES Deep Wound Infection Treat Systemically +/- Topical Antimicrobials Size Temperature Os (exposed bone) New areas of tissue breakdown Exudate Edema, erythema Smell Upper & Lower Wound Infection Checklist Woo KY, Alam T, Marin J. Topical antimicrobial toolkit for wound infection. Surg Technol Int. Upper & Lower Wound Infection Checklist NERDS STONEES XXXX Woo KY, Alam T, Marin J. Topical antimicrobial toolkit for wound infection. Surg Technol Int. Biofilm Formation Edge Effect (Adjuvant Therapies) Used when underlying cause has been addressed and patient s overall health has been optimized May include treatments such as: Dressings (microenvironment) Treatments (Electrical stimulation, ultrasound) 3

4 Wound Healing meets Wound Dressing Form and Function Dressing Choice 1st Question Form - What it s made of Materials, ingredients, format Function - What it does Absorb, hydrate, maintain, protect, control cells or chemicals FLAT or DEEP FLAT DEEP FLAT PACKING Ovington L, Peirce B. Wound dressings: Form, function, feasibility, and facts. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: A clinical source book for healthcare professionals. 3 rd Ed HMP Communications, Wayne, PA Dressing Choice 2nd Question Dressing Choice 3rd Question LEVEL of WOUND FLUID DRY / MINIMAL MODERATE HEAVY MOISTURE DONATING ABSORPTIVE ABSORPTIVE IS WOUND INFECTED? YES NO ANTIMICROBIAL / ANTIBACTERIAL NON ANTIMICROBIAL / ANTIBACTERIAL Variety of forms and vehicles available Minimal systemic absorption (ionic silver dressings) Ionized silver (Ag + ) has potent antimicrobial property Ag 0 has anti-inflammatory property Silver Ionization requires aqueous environment Indications of cytotoxic effect on host cells, specifically fibroblasts and keratinocytes May cause burning and pain (dressings with high silver concentration) Indications of cytotoxic effect on host cells, specifically fibroblasts and keratinocytes Available as a solution (e.g. to paint non-healing dry wound) Cadexomer iodine releases iodine in controlled, prolonged period Small molecules may allow penetration into biofilms Iodine Thyroid function should be monitored related to increased serum iodine levels, especially for prolonged use, large vascular wounds, and patients with uncontrolled thyroid disease Cadexomer iodine can harden when dried up Use with caution in inflammatory type wounds (iodine is pro-inflammatory) 4

5 Honey Polyhexamethylene Biguanide (PHMB) May help promote autolytic debridement May reduce inflammation and wound pain Increase in wound drainage due to osmotic effect (may cause periwound skin maceration) Decreased effectiveness with high volume of exudate (diluting effect) Variety of forms available Gauze dressings and instillation solution containing PHMB can be used with negative pressure wound therapy Gauze format has limited absorptive capacity Certain gauze format is loosely woven and it may adhere to wound base and/or leave behind gauze fragments May help neutralize odor Contains antioxidants Not appropriate for dry necrotic wounds High tensile strength material for packing Available as dressings (foam, packing strips/ropes, rolls) and cleansing solutions Methylene Blue & Gentian Violet High absorbency Versatile (may be placed flat onto a wound or packed into a cavity) Physically binds harmful endotoxins and pulls bacteria-laden exudate up and away from wound Compatible for use with enzymatic debridement agents and growth factors Not appropriate for dry wounds Some dressings require moistening Small amounts of methylene blue and gentian violet may leach out of the dressing, but it is not cytotoxic Key Take Away Points Use a systematic approach to wound management (Wound Bed Preparation) Differentiate between superficial & deep infection Choose a dressing based on form and function 5