1 Wound Management in the Elderly Stephanie Yates, MSN, ANP, ANP-BC, CWOCN Nurse Practitioner/CNS Duke University Medical Center Durham, NC
2 Skin Condition Key quality indicator To the family To the regulators To other healthcare providers
3 Cost of Skin Breakdown To the facility To the healthcare system To the patient
4 Documentation Absolutely important Assessment Reassessment Follow-up care Aspects of care that can t be changed Supportive measures nutrition, consults, rehab Physician communication
5 Alterations in Skin Integrity among Geriatric Population Pressure Ulcers Skin Tears Lower Extremity Ulcers Venous Arterial Neuropathic Incontinence-related Skin Breakdown
6 Assessing Risk for Skin Breakdown Risk Assessment Tools Braden Scale Score Norton Score Policy to define when risk assessment is repeated Interventions/Protocol to address risk elements
7 Support Surfaces Old Terms - Pressure Reduction and Pressure Relief New term Pressure Redistribution The ability of a support surface to distribute load over the contact areas of the human body..
8 Support Surfaces Components air, foam, fluid, gel, etc. Features alternating pressure, air fluidized, low air loss, multi-zoned Categories active or reactive, powered or not, overlay or mattress Regardless of support surface, patients will always need to be turned.
9 Types of support surfaces
10 What about bacteria in wounds?
11 Bacterial Levels in the Wound Contamination bacteria present on surface Colonization bacteria attach to tissue and multiply Infection bacteria invade healthy tissue and overwhelm immune defenses
12 Assessing for Infection Inflammation vs Infection Watch for changing in drainage, fever, local pain, signs of sepsis (hypotension, ^ pulse rate, ^ respirations) Localized pain may be only sign of infection with immunocompromised patient Look for infection when blood glucose elevated with no explanation
13 Criteria for identifying infection in chronic wounds Increased exudate Cellulitis and inflammation Surface discoloration (yellow/green) Increased odor Wound Infection Friable granulation tissue (bleeds easily) Abscess formation Non-healing wound Increased pain/tenderness Superficial pocketing of wound base Wound deterioration or dehiscence (Falanga, 1997)
14 Infection Colony counts > 10 5 per gram of tissue Prolongs the inflammatory phase Destroys surrounding tissue Retards epithelialization and collagen deposition Interrupts the wound healing cascade
15 Infection IFFE - Induration, Fever, Erythema, Edema When and how to culture Cleanse wound with saline, press with swab in 1 cm square area to express fresh exudate Follow-up on cultures Antibiotics - topical vs. systemic
16 Swab culture techniques Levine technique Clean wound prior to culture Moisten swab with saline Rotate swab over a 1 cm square area with sufficient pressure to express fluid from wound tissue Has been correlated to tissue biopsy results (Best Practice) 1 cm square (Levine, 1976)
17 What about wound cleansing?
18 Which wounds need cleansing? Dirty wounds wounds caused by bites, trauma with foreign objects or debris Infected wounds Debate over clean granulating wounds post surgical wounds, leg ulcers, other chronic wounds
19 Avoid Antiseptics Povidone Iodine (Betadine) Use solution only 1% or 10% is acceptable Hydrogen peroxide damages healing wounds, do NOT use in deep wounds no safe dilution Sodium hypochlorite Dakin s solution safe dilution is.025% (not.25% usually ordered) Acetic Acid no safe dilution
20 Characteristics of safe wound cleansers ph balanced Non-cytotoxic Long shelf life
21 Examples of safe wound cleansers Normal Saline Commercially available wound cleansers not the same as skin cleansers Smith & Nephew Dermal Wound Cleanser Bard Biolex Wound Cleanser ConvaTec Saf-clens Medline Skintegrity Etc..
22 Necrotic Wounds Consider whirlpool or pulse lavage for cleaning May use harsh agents if healing is not the objective may help with odor control Dakin s solution
23 Debridement Options Sharp debridement scalpel or scissors Mechanical debridement wet-to-dry dressings and whirlpool/pulse lavage Chemical debridement enzymatic agents Autolytic debridement occlusive dressing allows body to debride itself
24 Principles of Topical Therapy Debride non-viable tissue Treat infection Gently pack open space Manage drainage Maintain moist wound surface Protect from trauma Insulate maintain body temperature
25 Factors to consider Filler needed or just a cover dressing? Amount of drainage expected? Occlusion needed? Adhesive safe or not? Cost/frequency of change/availability? Goal desired?
26 Gauze Dressings Cheap Require frequent dressing changes to keep moist Use moist-to-moist instead of wet-to-dry for healing
27 Hydrocolloid Dressings Made of carboxymethylcellulose Surface is adhesive Forms a gel when drainage is absorbed Promotes autolytic debridement Use with caution in infected wounds
28 Hydrofibers Non-woven dressing used for absorption Wicks drainage vertically Used as a filler for draining wounds Requires a secondary dressing Absorbs more than an alginate
29 Calcium alginate dressings Derived from seaweed Used as a filler for moderately draining wounds Turns to a gel when in contact with wound fluid Requires a secondary dressing
30 Hydrogel Dressings Available in gel or sheet form Used to hydrate a dry wound Sheet can be used as primary dressing Gel can be used with gauze Promotes autolytic debridement Reduces frequency of dressing changes Watch for maceration
31 Foam Dressings Available as a filler or a cover dressing Available with or without adhesive Absorbs drainage but doesn t let the wound bed dry out Cushions and insulates May stick if too little drainage
32 Transparent Dressings Very thin polyurethane sheet with adhesive Impermeable to water and bacteria Allows slow evaporation Use in superficial wounds with little exudate Can be used over other dressings
33 Contact layer Woven or perforated polymer net that prevents adherence to wound bed Use in clean wounds Requires a secondary dressing Adaptic, Xeroform or Vaseline gauze Also silicone sheets, Wound Veil
34 Collagen dressings Available as sheets, particles, pads and rope Indicated for refractory wounds Collagen incorporated into wound as structure for healing Use in moist wounds Requires a secondary dressing
35 Composite dressings Combinations of two or more of the previously mentioned dressings Consider make-up and desired goals
36 Antimicrobial Dressings Used to treat wounds that have stalled when an increased bioburden may be the problem Used to treat wounds clinically known to be infected (in conjunction with systemic antibiotic therapy) Sometimes used for prevention in high risk patients
38 Silver Dressings Believed by many to provide an environment conducive to the preparation of the wound bed for healing by controlling the bio environment (bacteria) The evidence base is still in its infancy (really), but early reports point toward accelerated healing when other factors are corrected (i.e., malnutrition, necrotic tissue, etc.)
39 Silver Dressings Advantages: Physicians seem to like using silver in wound care Product may be left in the wound for an extended period of time without losing efficacy (5-7 days) Disadvantages: Cost (Product can range from $10-20 per unit) Discoloration from some products may alarm patients/ caregivers Products are often used incorrectly (changed too often) and have specific nuances
41 Cadexomer Ointment or Pads with Iodine (Iodosorb/Iodoflex) Iodine molecules encased in a protective matrix which breaks down as wound exudate is absorbed, allowing for a gradual release of iodine Absorbs exudate, contributes to the elimination of slough Very little in the literature to support this delivery system Advantages: ~ prescribers are familiar with iodine ~Can be left in wounds for several days Disadvantages: ~improperly used ~awareness of iodine toxicity and other contraindications are sometimes ignored
43 PHMB impregnated gauze Polyhexamethylene Biguanide (a compound similar to chlorhexidine) An antiseptic that has a broad range effectiveness against gram positive and gram negative microorganisms Prevents infection, no claims for treatment of infection
44 Sodium Hypochlorite Solution (Anasept) 0.057% sodium hypochlorite in an isotonic saline solution Clear amorphous isotonic hydrogel with 0.057% sodium hypochlorite maintain microbiocidal activity for at least 24 hours
45 Manuka Honey (Medihoney) Contains active Leptospermum honey from New Zealand Effective on hard-to-heal wounds and burns Helps to debride wounds and keep wound beds clean of necrotic tissue Indicated for diabetic foot ulcers, venous leg ulcers, arterial leg ulcers, pressure ulcers (I-IV), 1st and 2nd degree burns, donor sites, traumatic and surgical wounds
46 Negative Pressure Wound Therapy Once thought to be a second line therapy, is now considered by some to be a first line intervention. Advantages: seen to rapidly decrease wound dimensions in some patients and reduce costs in all care settings by reducing the overall number of dressings Anecdotal findings point to a reduction in wound infections Disadvantages: requires intensive staff education
47 Reassessment Few dressings can take a wound from beginning to healed. Reassess wound and adjust dressing regimen as needed. Policy on wound reassessment. Standardize wound measurement techniques or have same person measure weekly.
48 Guidelines for Care AHRQ (formerly AHCPR) guidelines are outdated and archived WOCN Society has guidelines for pressure ulcers and lower extremity ulcers AMDA published in 2008 and reaffirmed in NPUAP/EPUAP/PPPIA guideline
49 References 1. Baranoski, S. & Ayello, E.A. (eds.). (2011). Wound Care Essentials: Practice Principles (3 rd ed.). Philadelphia: Lippincott Williams & Wilkins. 2. Bryant, R.A. (ed.). (2012). Acute and Chronic Wounds: Current Management Concepts (4 th ed.). St. Louis: Mosby. 3. Hess, C.T. (2012). Clinical Guide to Skin & Wound Care (7 th ed.). Philadelphia: Lippincott Williams & Wilkins. 4. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
50 References 5. National Pressure Ulcer Advisory Panel website Information about using the Braden Scale for risk assessment Website for the WOCN Society; resource for guidelines Website for the American Medical Directors Association, resource for AMDA guidelines and online journal.
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