Venous. Arterial. Neuropathic (e.g. diabetic foot ulcer) Describe Wound Types & Stages of. Pressure Ulcers. Identify Phases of Healing & Wound Care

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1 A dressing the situation at hand Describe Wound Types & Stages of Pressure Ulcers Identify Phases of Healing & Wound Care Goals Clarify Referral Protocol Lacerations- The goal is nearest to complete approximation of wound edges to prevent cosmetic blemish and infection. Use of suturing or steri strips recommended. Avulsions and abrasions- The goal is to ensure a moist wound bed that is free of debris in order to prevent infection. Venous Arterial Neuropathic (e.g. diabetic foot ulcer) Due to venous insufficiency Moderate to heavy drainage Usually on the medial aspect of the leg or malleolar area Beefy red Jagged irregular edges Minimal to moderate pain Treat with compression 1

2 Complete or partial arterial blockage may lead to tissue necrosis and / or ulceration. Usually on toes and lateral malleolus Pulselessness of the extremity Dry pale wound bed Painful Cool or Cold skin Treat by restoring blood flow or amputation Diabetic with neuropathy Toes, heel, bony prominences on foot Low to moderate drainage Usually infected Treat infection 2

3 Lymphedema is a condition of localized fluid retention caused by a compromised lymphatic system. Can be primary or secondary (e.g. post surgical or radiation treatment affecting lymph nodes). Danger comes from persistent risk of developing an uncontrolled infection in the affected limb. Treat with compression- ABI MUST BE MEASURED PRIOR The Ankle Brachial Index (ABI) is the ratio of the B/P in the lower legs to the B/P in the arms. Compared to the arm, lower B/P in the leg is an indication of blocked arteries. Measured using an 8 MHz Doppler attachment and B/P cuff. Calculated by dividing systolic B/P at the ankle by systolic B/P in the arms. Not accurate in a diabetic- Need a TBI (toe brachial index) ABI < or = 0.5 Refer to vascular specialist (compression therapy contraindicated) ABI = Consider referral to vascular specialist. Intermittent claudicant indicating peripheral arterial occlusive disease (compression therapy contraindicated) ABI = Mild peripheral arterial occlusive disease (with caution- consider lighter compression) ABI = > 1.0 Safe for compression therapy but proceed with caution in diabetics. (full compression) ABI = > 1.3 Consider referral to vascular specialist (compression therapy contraindicated) A Toe Brachial Index or TBI is performed when the ABI or Ankle Brachial Index is abnormally high due to plaque and calcification of the arteries in the leg Caused by atherosclerosis and is most often found in diabetic patients. The abnormally high ABI is >1.3. 3

4 A pressure ulcer is any ulcer caused by unrelieved pressure Usually over a bony prominence that results in damage to underlying tissue Only pressure ulcers are staged, otherwise wounds are categorized as partial or full thickness wounds (e.g. lacerations, avulsions, abrasions). DTI Stage I Non-blanchable erythema of intact skin (vs. reactive hyperemia). The rush of blood to clear away byproducts of ischemia 4

5 Stage II Partial thickness skin loss involving epidermis and/or dermis. Clear fluid filled blister Stage III Full thickness skin loss involving subcutaneous tissue, but not through underlying fascia. May present with necrotic tissue. Stage IV Full thickness skin loss involving muscle, bone, tendon Unable to stage Full thickness tissue loss but cannot discern the type of tissue at the base of the wound due to presence of necrotic tissue Suspected Deep tissue Injury Purple or Maroon areas of discolored intact skin due to deeper underlying damage 5

6 Moist Wound Healing Identify & Eliminate Infection Obliterate Dead Space Remove necrotic tissue Absorb Excess Exudate Thermal insulation Protect Healing Wound Homeostasis/Inflammation (occurs within seconds to 5 days) u2 Proliferation (occurs 4-24 days) u3 Maturation Stage (occurs 21 days to 2 years) u1 Slough: Soft necrotic tissue made up of fibrin. This serves as a medium for bacterial growth. Dressing of choice reduces bio-burden-silver, medical honey then either hydrocolloid, hydrofibers, regular pads to absorb. Exudate causes maceration diluting wound healing factors Bacterial toxins in the exudate may inhibit healing Unless created in O.R., all wounds contaminated/ colonized/ infected Wound cleansing removes necrotic tissue Debridement is needed. Autolytic the body heals itself (e.g. occlusive dressings) Mechanical using gauzes (e.g. wet to dry) Enzymatic chemical enzymes (e.g. collagenase) Sharps scalpel, laser, surgery Bio-surgical maggots, leeches 6

7 Slide 32 u1 u2 u3 Remodeling of tissue Increase tensile strength (scar tissue is only 80% as strong as normal skin) user1, 4/7/2012 Immediate response to injury begins the cascade of healing Fibrin-platelet matrix to control hemorrhage and release growth factors Histamine, kinins, serotonin cause vasodilation Cytokins and growth factors attract granulocytes to wound Neutrophils destroy debris and bacteria by phagocitisis Characteristics are edema, erythematic, heat and pain user1, 4/7/2012 Angiogenesis: Regeneration of blood vessels Granulation: Fibroblasts secrete collagen and fills the wound with connective tissue (needs an adequate supply of nutrients and blood) Contraction: Contracts the wound edges Epithiliazation: Covers with epithelium user1, 4/7/2012

8 Granulation: wound begins to heal with pink granulation tissue covers the wound bed which becomes thicker and appears beefy red. Continue to fill dead space until healed with dressing of choice: hydrogel, hydrofiber or calcium alginate. Chronic wounds- For lower extremity ulceration not healing after 3 weeks, referral should be made to either out-patient wound care clinics or to homecare if client is unable to attend appointments due to being homebound. Pressure wounds If client is homebound, a referral for RN and either PT/OT is beneficial. Neuropathic ulcers- A referral to podiatry is needed to ensure appropriate debridement and address prevention including footwear. Fungating wounds- Physician referral is mandatory to address malignant nature of wound and underlying cancer. A team approach is always best for the client Special thanks to Jessica Fogarty WCC RN at Sutter Medical Center for her guidance Boateng J, Matthews KH,, Stevens H, Eccleston GM. (2008) Wound Healing Dressings and Drug Delivery Systems: A Review. Journal of Pharmaceutical Sciences, 97, Calliano C & Holton SJ. (2007) Fighting the Triple Threat of Lower Extremity Ulcers. Nursing2007, 37(3), Cullum N, Nelson EA, Fletcher AW, Sheldon TA. (2001) Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD DOI: / CD Ndip A, Ebah L, Mbak A (2012) Neuropathic diabetic foot ulcers evidence-to-practice. International Journal of General Medicine, 5, Treiman GS, Copland A, McNamara RM, Yellin AE, Schneider PA, Treiman RL. (2001) Factors influencing ulcer healing in patients with combined arterial and venous insufficiency. Journal of Vascular Surgery, 33(6),