Slide 1. Slide 2 Disclosures. Slide 3 Objectives. Karen Rogge Miller, RN, BS, WCC Wound and Ostomy Clinician

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1 Slide 1 Karen Rogge Miller, RN, BS, WCC Wound and Ostomy Clinician Slide 2 Disclosures Wound and Ostomy RN at St. Vincent Healthcare and Billings Clinic, Billings, MT Former employee of KCI, a division of Acelity Not a paid speaker No other disclosures Slide 3 Objectives Wound documentation basics Assess and measure Documentation Differentiate between wound types Wound bed preparation Dress that wound Plan of care Atypical wounds

2 Slide 4 Wound Documentation If it isn t documented it didn t happen!! Protect from litigious action Wound type or description Anatomical location Measure Wound bed Structures visible Plan of care Outpatient cares (WCC, HH) Operating room for surgical intervention Slide 5 Wound Documentation Measuring Length ruler based linear method Head (12 o clock) to toe (6 o clock) Width Side to side Depth Greatest depth to surface of skin Tunneling Face of the clock Undermining Face of the clock Slide 6

3 Slide 7 Tunneling and Undermining Slide 8 Wound Documentation Size: Measurements of the wound Length From edge to edge, the longest measurement of the wound Width From edge to edge, the widest measurement of the wound at right angles to the length Depth The deepest vertical measurement from the base of the wound to the level of the skin Undermining A destruction of tissue that occurs underneath the intact skin of the wound perimeter Sinus/Tunnel A channel that extends from any part of the wound and tracks into deeper tissue. Fistula An abnormal track connecting an organ to the skin surface, wound bed or to another organ. Slide 9 Wound Bed: The type of tissue or structure(s) observed within the wound Tissue damage noted but the skin is still intact Epithelialized tissue Covered completely with new epithelial tissue Hematoma Localized collection of blood Blister An elevation or separation of the epidermis tissue containing fluid Weepy skin Drainage but no obvious open areas noted Scab Superficial, dry crust Superficial pink, red

4 Slide 10 Clean, open pink/red area with non-measurable depth Friable Fragile tissue that may bleed easily Malignant Cancerous tissue Fungating tissue Cancerous or non cancerous rapidly growing tissue; appears cauliflower-like New tissue damage New damage due to pressure or trauma on an open wound bed; presents as dark purple, deep red or grey coloured tissue Hypergranulation Red, moist tissue raised above the level of the skin (proud flesh) Non-granulation tissue Moist, red (pale to bright) non-pebbled tissue Slide 11 Slough Granulation tissue Firm, red, moist, pebbled healthy tissue Dry or wet, loose or firmly attached, yellow to brown dead tissue Eschar dry, stable Firm, dry necrotic tissue with an absence of drainage, edema, erythema or fluctuance. It is black or brown in color and is attached to the wound edges and wound base Eschar soft, boggy Soft necrotic tissue which is black, brown, grey, or tan in color. It may be firmly or loosely attached to the wound edges and wound base; fluctuance and drainage may be present. Adipose Layer of yellow globular tissue where fat is stored Fascia Slide 12 Tendon Shiny white cord of fibrous connective tissue that connects muscle to bone Bone Hard, rigid white connective tissue Underlying tissue structure Structures such as cartilage, joints or ligaments Foreign body Objects such as mesh, hardware, suture(s) Fully callused Wound bed that is 100% covered with a callused tissue. Do not use this choice for a open wound with a callused edge. Epithelial islands Within an open wound bed, islands (small areas) of epithelial tissue proliferating and migrating from the center to the edge of the wound Biochemical wound product Residual/remaining biochemical wound care product in wound bed Not visible A portion or all of the open wound bed that cannot be visualized

5 Slide 13 Exudate Characteristics: appearance of the wound s exudate Serous Thin, clear, yellow Sanguineous Bloody Sero-sanguineous Combination of both serous and sanguineous exudate Purulent Thick, cloudy Other Exudate Amount: Wound drainage amount considered in relationship to the size of the wound Nil Small/scant Moderate Large/copious Odour: Unpleasant smell noted from wound after cleansing Slide 14 Wound Edge: The perimeter of the wound Diffuse Not well defined, indistinct, difficult to clearly define wound outline Demarcated Well defined, distinct, easy to clearly define wound outline Epithelializing New, pink to purple, shiny migrating tissue Attached Edge appears flush with wound bed or as a sloping edge Non-attached Edge appears as a cliff Rolled Epithelial wound edge of a cavity wound which rolls under Callused Hyperkeratosis, thickened layer of epidermis Scarred Fibrotic regenerated tissue following wound healing Slide 15 Periwound Skin: Surrounding area immediately adjacent to the wound edge Intact Unbroken skin Fragile Skin that is at risk for breakdown Dry Flaky skin Rash Temporary eruption on the skin-often raised, red, sometimes itchy Macerated Wet, white looking skin Erythema Redness of the skin; may be intense bright red to dark red Indurated Abnormal firmness of the tissues with palpable margins Increased warmth Increased warmth when compared to skin in adjacent area Excoriated/denuded Superficial loss of tissue Weepy Moist, draining areas Boggy Soft, spongy tissue Blister Elevation or separation of the epidermis containing fluid Tape tear Superficial skin loss due to tape Edema Interstitial collect of fluid Bruised Dark red purplish blue tissue that fades to yellow green grey depending on the skin colour Callused Hyperkeratosis, thickened layer of epidermis Erythema >2cm Redness of the skin; may be intense bright red to dark red Indurated >2cm Abnormal firmness of the tissues with palpable margins Increased warmth Increased warmth when compared to skin in adjacent area

6 Slide 16 Exudate Characteristics: appearance of the wound s exudate Serous Thin, clear, yellow Sanguineous Bloody Sero-sanguineous Combination of both serous and sanguineous exudate Purulent Thick, cloudy Other Exudate Amount: Wound drainage amount considered in relationship to the size of the wound Nil Small/scant Moderate Large/copious Odour: Unpleasant smell noted from wound after cleansing Slide 17 Wound Edge: The perimeter of the wound Diffuse Not well defined, indistinct, difficult to clearly define wound outline Demarcated Well defined, distinct, easy to clearly define wound outline Epithelializing New, pink to purple, shiny migrating tissue Attached Edge appears flush with wound bed or as a sloping edge Non-attached Edge appears as a cliff Rolled Epithelial wound edge of a cavity wound which rolls under Callused Hyperkeratosis, thickened layer of epidermis Scarred Fibrotic regenerated tissue following wound healing Slide 18 Periwound Skin: Surrounding area immediately adjacent to the wound edge Intact Unbroken skin Fragile Skin that is at risk for breakdown Dry Flaky skin Rash Temporary eruption on the skin-often raised, red, sometimes itchy Macerated Wet, white looking skin Erythema Redness of the skin; may be intense bright red to dark red Indurated Abnormal firmness of the tissues with palpable margins Increased warmth Increased warmth when compared to skin in adjacent area Excoriated/denuded Superficial loss of tissue Weepy Moist, draining areas Boggy Soft, spongy tissue Blister Elevation or separation of the epidermis containing fluid Tape tear Superficial skin loss due to tape Edema - Interstitial collect of fluid Callused Hyperkeratosis, thickened layer of epidermis Erythema >2cm Redness of the skin; may be intense bright red to dark red Indurated >2cm Abnormal firmness of the tissues with palpable margins Increased warmth Increased warmth when compared to skin in adjacent area

7 Slide 19 Wound Types Pressure Injuries Surgical Dehisced and non-dehisced Incision management Acute and Traumatic Wounds High impact traumatic - MVC Gunshot, blasts Venous Leg Ulcers Diabetic Foot Ulcers Arterial Ulcers Burns Slide 20 Pressure Injury Wound formerly known as Pressure Ulcer NPUAP changed name in 2016 Stage 1,2,3,4 Unstagable Deep Tissue Injury Slide 21 Stage 1 Pressure Injury Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in dark pigmented skin

8 Slide 22 Stage 2 Pressure Injury Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Slide 23 Stage 3 Pressure Injury Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Slide 24 Stage 4 Pressure Injury Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur.

9 Slide 25 Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Slide 26 References Pressure Injuries can be confusing and difficult to differentiate between stages. NPUAP National Pressure Ulcer Advisory Panel Medline University Apples to Ulcers Documents/ViewDocument.aspx?AddToLog=1&Docum entid=1525 Slide 27 Deep Tissue Injury A deep tissue injury is a full thickness pressure ulcer (injury down to deeper structures under the skin) although it initially appears as a superficial purple/maroon discoloration over a bony prominence or a blood-filled blister.

10 Slide 28 Skin Tears A partial or complete separation of the outer skin layers from the inner tissue. In younger people, whose skin is more flexible, thicker, and less fragile, tearing is most often the result of an accident, particularly when shearing or friction forces are involved. 3 Categories 1 no flap loss 2 partial flap loss 3 complete flap loss Slide 29 Incontinence Associated Dermatitis (IAD) IAD Perirectal May have fungal componinet (yeast) Often confused with Pressure Injury May lead to Pressure Injury Epidermal stripping and damage caused by urine and stool Barrier Ointments to protect skin from further damage 29 Slide 30 Understanding the difference between IAD and Pressure Injury

11 Slide Slide 32 INTERTRIGINOUS DERMATITIS Intertriginous Dermatitis is the redness between skin folds Breast Pannus Groin Common in obese patients May have fungal component 32 Slide 33 Surgical Wounds Dehisced and non-dehisced Secondary intention healing If dehisced, can be susceptible to infection Incision line management NPWT with contact layer over incision line Specialty NPTi dressing systems

12 Slide 34 Slide 35 Acute and Traumatic Wounds High impact Extensive tissue damage, may include bone Interstitial edema Skin damage denuded, abrasion (MVC) Difficult to manage dressings Epithelial damage External fixation Highly exudating Increased risk of infection Require multiple surgeries Slide 36

13 Slide 37 Venous Leg Ulcers Shallow wound that occurs when the leg veins can t return blood back toward the heart the way they should, due to venous insufficiency. These ulcers usually form on the sides of the lower leg, above the ankle and below the calf. Often have an arterial mixed component Painful Difficult to manage drainage, edema NEED Vascular studies DO NOT compress without ABI Edema management is a must!! Often difficult for older patients to apply edema wear (non-compliance) andkfj Slide 38 Slide 39 Arterial Ulcers Arterial skin ulcers are less common than venous skin ulcers. They happen when arterterial disease is present (sometimes in combination with venous disease). These ulcers tend to be extremely painful. They are usually on the toes and feet. NEED ARTERIAL STUDIES BEFORE ANY COMPRESSION Wounds will not heal without blood flow Require Interventional Radiology or surgical intervention

14 Slide 40 Slide 41 Diabetic Foot Ulcer Neuropathic Ulcer Diabetic ulcers are the most common foot injuries leading to lower extremity amputation Often recalcitrant to treatment and are associated with serious medical complications such as osteomyelitis and lower limb amputation. Diabetic foot ulcers are associated with decreased quality of life. Increase mortality rate by 35% Insulin management program is key Compliance issues High cost of equipment shoes, offloading boot High risk of infection Slide 42

15 Slide 43 Burns Burns are categorized by severe damage to your body's tissues caused by heat, chemicals, electricity, sunlight, or radiation. Refer to burn specialist Not just a skin issue Airway, volume shift, hypovolemic and septic shock, infection Require surgical intervention Dressing changes under anesthesia make difficult to manage unless a burn unit Skin grafting, skin substitutes, advanced wound dressings Slide 44 Let s come back in 15 minutes Slide 45 Dress That Wound

16 Slide 46 Sometimes turns into What Not To Wear Slide 47 Where to Start Maintain Optimal Healing Enviroment Prevent and Manage Infection Maintain Appropriate Level of Moisture Eliminate Dead Space Control Odor Manage drainage Manage Pain Protect Wound and Peri Wound Area Slide 48 Prevent and Manage Infection Appropriate dressing change frequency Antimicrobial dressings Debridement Silver dressings Foam Alginate Contact layers

17 Slide 49 Moisture Management Absorbent dressings for moist and exudating wounds Moist dressings for dry wounds Advanced wound care modalities NPWT Foam Alginate Contact layer Slide 50 Eliminate Dead Space Pack wound to address all aspects Tunnels and undermining DON T STUFF THE TURKEY!!!! Alginate rope Packing strips NPWT Slide 51 Manage Drainage and Control Odor Absorbent dressings Charcoal dressings Antimicrobial Acetic Acid Hypochlorous solution Vashe NPWT

18 Slide 52 Pain Management Protect tissue and structures Tendon, ligament, bone, deep muscle tissue Pre-medicate with appropriate analgesia Contact layer Lidocaine Advanced Wound Care dressings to minimize frequency Antimicrobial NPWT Slide 53 Protect Periwound and Wound Periwound maceration Absorbent wound dressings Skin prep No sting cyanoacrylate Marathon Epidermal stripping Damage caused by frequent dressing changes Sting free adhesive remover Wound location Over movable joint Bridge off if NPWT Protect from friction Slide 54 Compression Other Treatments Multi-layer compression wraps Edema wear Skin substitutes Amniotic Bovine, porcine Shark cartilage HBO UV light and Ultrasound

19 Slide 55 Atypical Wounds Not typical, present as common or complex wounds Difficult to heal Using incorrect treatment modality Require further testing and evaluation Biopsy Dermatology consult Infectious Disease qjkdjgfio Slide 56 Necrotizing Fasciitis Necrotizing fasciitis is an infection caused by bacteria. It can destroy skin, fat, and the tissue covering the muscles within a very short time. The disease sometimes is called flesh-eating bacteria. When it occurs on the genitals, it is called Fournier gangrene. Necrotizing fasciitis is very rare but serious. Requires multiple surgical debridements to remove infected tissue Slide 57 Pyoderma Gangrenosum Condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs. When they occur, they can lead to chronic wounds. Ulcers usually initially look like small bug bites or papules, and they progress to larger ulcers. Though the wounds rarely lead to death, they can cause pain and scarring Long-term steroid use to treat, leads to other complications wound and systemic

20 Slide 58 Calcifilaxis AKA -calcific uremic arteriolopathy (CUA), is a syndrome of calcification of the blood vessels, blood clots, and skin necrosis. It is seen mostly in patients with stage 5 chronic kidney disease, but can occur in the absence of kidney failure. It results in chronic non-healing wounds and can be fatal. Calciphylaxis is a rare but serious disease, believed to affect 1-4% of all dialysis patients Moisture, pain and odor management Normally do not debride Slide 59 Wound Care is a Multidisciplinary Approach STARTS WITH - Primary Caregiver RN, LPN, CNA Wound Care Primary Provider Specialty Provider Plastics, CV Surgeon, General Surgery PT/OT Respiratory Social Worker/Care Manager Dietitian Outpatient Wound Care Center Slide 60 And Remember We treat the WHOLE patient.not just the HOLE in the patient

21 Slide 61 References Ruth A Bryant, Denise P. Nix Acute and Chronic Wounds, Current Management Concepts 4th Edition. Mosby Inc.; National Pressure Ulcer Advisory Panel Updated Staging System. NUAP

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