Wound Management Capital Health Network Practice Nurses 20 Feb 2018

Transcription

1 Wound Management Capital Health Network Practice Nurses 20 Feb 2018 ) MNP Judith Barker RN; NP; STN; B Hlth Sc (Nurs); MN (NP) Nurse Practitioner Wound Management Rehabilitation, Aged & Community Care Adjunct Associate Professor- University of Canberra

2 Objectives Wound incidence/prevelence Wound Management in the ACT Acute and chronic wounds seen in community Stages of wound healing Factors that facilitate or delay healing TIME Which dressing to use? Case studies Role of the practice nurse

3 Incidence Population Risk factors Age group Cost & resources Hospital days

4 Wounds seen in the community Trauma Skin tears Lower limb ulceration Pressure injuries Burns Skin cancers Surgical wounds Skin infections

5 Wound Management in the ACT Community Community nursing home visits 5 health centres Link team after hour community nursing service Walk in centres nurse led General practice Podiatry private/public High risk foot clinic OPD clinics private/public Private nursing care agencies Residential Aged Care Facilities Pharmacy

6 Community Care Tuggeranong Health Centre 5 Health Centres nurses/allied health Private Phillip nursing Health Centre agencies nurses/allied health/carers General Practitioner Nurse Practitioner (NP) Clinic Residential Aged Care City Facilities Health Centre Other health care sectors Belconnen Health Centre nurses/allied health/carers

7 Tier Two Referral to CNC Wound Management/NP Wound Clinics Multidisciplinary focus Assessment/diagnosis Treatment plan Evaluation General Practitioner Nurses/allied health/other Specialists

8 venous mixed Timely Accessible service Wound Assessment Tertiary referral Diagnostics investigations Treatment plan Multidispinary/ referrals venous BCC

9 Principles of Wound Management Define aetiology Control factors influencing healing Select appropriate dressing or device Plan for maintenance

10 The Skin

11 Factors Factors influencing wound healing Systemic factors Age Nutrition BMI Vitamin and trace element deficiencies - vitamin C, vitamin A, zinc Drugs steroids, chemotherapy, immunosuppression Systemic disease diabetes, jaundice, malignancy Hypoxia Blood Supply Infection Foreign Bodies Smoking Pain Psychological factors

12 Factors influencing healing Local factors Trauma/pressure Wrong dressing Wound temperature Wound ph Moisture balance Topical infection Foreign body Wound management practices

13 Physiology of wound healing Acute wounds Haemostasis Inflammation Reconstruction Maturation Primary Intention Secondary intention Skin grafts/flaps Chronic wounds

14 Principles of Wound Healing Haemostasis Production of the fibrin clot Platelets release a cocktail of cytokines Characterised by redness, heat, pain and swelling Initiated after trauma for up to 24 hrs Initiates the healing process by stabilising the wound through platelet activity that stops bleeding & triggers the immune response The fibrin matrix becomes the scaffold rapid restoration of a temporary barrier to the external environment

15 Principles of Wound Healing Inflammatory Stage Within minutes of the initial injury, neutrophils, monocytes and macrophages are on the scene to control bacterial growth and remove dead tissue Neutrophils often kill healthy host cells Characteristic red color and warmth is caused by the capillary blood system increasing circulation & laying foundation for epithelial growth

16 Growth factors Growth factors refer to a wide range of proteins that mediate and regulate wound healing processes throughout the healing trajectory Proteases matrixmetalloproteases (MMP) promote physiological wound debridement & facilitate cellular migration & re-modelling in healing wounds MMP have been found in high levels in chronic wound fluid degrade extracellular matrix, growth factors & cytokines necessary for healing Increased MMP activity & prolonged inflammatory responses in a wound are due to increased bacterial colonisation, repeated trauma & ischaemia

17 Principles of Wound Healing Proliferation Stage Begins within 24 hours of the initial injury and may continue for up to 21 days It is characterized by three events: Granulation Collagen synthesis Epithelialisation

18 Principles of Wound Healing Granulation Formation of new capillaries Granulation tissue is the red tissue that bleeds easily Friable Hypergranulation

19 Principles of Wound Healing Collagen Synthesis Creates a support matrix for the new tissue that provides it with its strength Oxygen, iron, vitamin C, zinc, magnesium & protein are vital for collagen synthesis This stage is the actual rebuilding and is influenced by the overall patient condition of the wound bed

20 Principles of Wound Healing Epithelialisation Formation of an epithelial layer that seals and protects the wound from bacteria and fluid loss It is essential to have a moist environment to foster growth of this layer It is a very fragile layer that can be easily destroyed with aggressive wound irrigation or cleansing of the involved area

21 Principles of Wound Healing Maturation Final stage of wound healing Tissue remodeling Begins around day 21 and may continue for up to 2 years Collagen synthesis continues with eventual closure of the wound and increase in tensile strength Tensile strength reaches only about 80% of preinjury strength

22 Acute vs Chronic Acute High mitogenic activity Low levels proinflammatory cytokines Decrease protease activity Mitotically competent cells Chronic Stunned & Stuck in the inflammatory stage High levels of proinflammatory cytokines Increase protease activity Decreased mitogenic activity & senescent cells Premature ageing of cells impairs proliferation and their response to growth factors

23 Chronic vs Acute

24 Principles of Wound Healing Normal Age Changes Decreased epidermal cell turnover Increased capillary fragility and reduced vascularisation Reduced oxygen flow to the area Altered nutrition and fluid intake Impaired immune response Reduced dermal and subcutaneous thickness

25 Skin Tears Initial treatment Moisture balance Protection of the wound & surrounding skin Dressing products - Silicone foam eg mepilex or allevyn gentle Protective tubular bandage

26 Risk factors Age Dependence Immobility History of skin tears Poor nutritional/hydration status Sensory & cognitive deficits Polypharmacy Co morbidities

27 Leg Ulcers Origin Arterial Venous Mixed Neuropathic

28 Aims of Treatment Determine aetiology Remove or treat cause Promote circulation Promote healing Prevent recurrence

29 Causes of Leg ulcers Vascular disorders Lymphatic disorders Haematological disorders Metabolic disorders Tumours Infections Trauma Allergic response

30 Venous Disease

31 ABPI value is calculated by dividing the higher systolic pressure in each leg by the higher systolic brachial pressure

32 Assessment of venous ulcers History of DVT Valvular incompetence Obesity Peripheral oedema - leaking Haemosiderin pigmentation Previous ulcers Dilated & tortuous superficial veins Location medial malleous, anterior to pretibial ulcer, lower 1/3 leg Uneven edges Ruddy granulation tissue No necrotic tissue Maceration & puritis of surrounding skin Foot pulses present

33 Management - Venous Compression therapy Wound/skin Care treat eczema Self examination Ambulation - exercise Nutrition weight loss Elevate legs Stop smoking Calf & foot exercises Moisturise Treat the aetiology Prevent recurrence support groups

34 Compression therapy

35 Arterial ulcers

36 Assessment of arterial ulcers Arteriosclerosis Advanced age Diabetes Hypertension Smoking Thin, shiny, dry skin Thickened nails Absence of hair growth Pallor Cool limb Location: toes, over phalangeal heads, side or sole of foot Deep punched out wound Necrotic tissue Deep pale base Pain at rest May have neuropathy Diminished or absent foot/limb pulses

37 Management - Arterial No compression Avoid mechanical/thermal trauma Daily inspection Foot wear Podiatry care Moisturises Relief from pressure of clothing/shoes Elevate head of bed Consult with vascular surgeon

38 High risk foot Diabetes Neurovascular disease Neuropathic diseases Congenital or other foot abnormalities

39 Diabetic foot examination D - deformity I - infection A - atrophic nails B - breakdown of skin E - oedema T - temperature I - ischaemia C - callosities S - skin colour

40 Foot examination cont Deformity - charcot s, claw toe, hammer toe Infection - crepitus, fluctuation, deep tenderness Atrophic nails - fungal infections and sub ungal ulcers Breakdown of skin - ulcers, fissures, blisters Ischaemia - pulses may be weak or absent Callosities - plantar surface, metatarsal heads Skin colour - red = charcot s - pale = ischaemia pink, with pain and absent pulses = ischaemia.

41 Alert! Remember diabetics may have micro or macro vascular disease or both Always be suspicious of infection Do not use occlusive dressings on foot wounds

42 Skin cancers

43 Surgical wounds

44 Infection Critical colonisation Local infection Topical infection Systemic infection Increased bacterial burden S & S include: Static healing Rolled edges Changes in granulation tissue Bright friable hypergranulation, pocketing, bridging of tissue, increased exudate and discomfort.

45 Dressings Which one to use?

46 TIME

47 CDE: colour, depth and volume of exudate Select the most appropriate dressing according to Wound bed tissue Colour Volume of exudate Depth of the wound Surrounding tissue

48 Ideal dressing Provide mechanical protection Protect against secondary infection Non adherent and easily removed without trauma Leave no foreign particles in the wound Remove excess exudate Be cost effective Offer effective pain relief Protects surrounding skin or peri wound

49 Generic dressings Impregnated mesh dressings Low adherent lightly absorbent pads Super absorber pads Protective film wipes Film sheets Foam and foam like absorbent dressings Hydrocolloid wafers and paste Hydrogel sheets and amorphous with or without additives. Calcium alginates Hydrofibre Hypertonic salt Cadexomer iodine Silver Medicated honey Zinc bandages.

50 Matching colour with product

51 Necrotic black - hydrate

52 Dry necrosis

53 Yellow/Sloughy Wet yellow - antimicrobial dressing Dry yellow - rehydrating dressing

54 Red/sloughy

55 Hypergranulation - antimicrobial

56 Pink/red - protect

57 Infection green - antimicrobial

58 Acute/trauma wounds

59

60 Wounds that fail to heal further investigations and assessment - multidisciplinary focus Infection Foreign body Diabetes DVT Arterial disease Lymphoedema Osteoarthritis Gout Rheumatoid arthritis Osteomylitis Atrophie blanche Vasculitis Pyoderma gangrenosum Neoplasm Blood dyscrasias

61 Case study Leg ulcer

62 Additional Resource For further information refer to the wound dressing guide via the following link. data/assets/pdf_file/0003/451767/book 2-wound-dressing-guide.pdf

63 Thank you Questions