Presented by : Mary Nametka,MSN,RN,CNS,CWS,CWCN,FACCWS,FNP- November 8, 2008 Dermatology Nurses Association Meeting McMinnville, Oregon

Transcription

1 Presented by : Mary Nametka,MSN,RN,CNS,CWS,CWCN,FACCWS,FNP- November 8, 2008 Dermatology Nurses Association Meeting McMinnville, Oregon

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3 If you don t understand skin then you can t really understand wounds. Dr Greg Raugi Implementation of best practice can t be achieved in isolation, because (wound) care is multidisciplinary. JWOCN Mary 2003

4 The real voyage of discovery is not in seeking new landscapes but in having new eyes Marcel Proust

5 Treating the Whole Patient, Not the Hole in the Patient Vicki Driver DPM 2004

6 Thoughts for today: Paradigms Lateral thinking Historical overview Future trends Demystifying Dressings Synergizing our practice- improving outcomes

7 Wound Care vs Tissue Viability Compliance vs Adherence vs Partnering Wound Care vs Chronic disease care Woundology vs Dermatology Wounds as leverage points Empiricism vs Evidence Based Practice Global Wound care

8 Epistemology & wound care Belief & truth-knowledge as subset Emipiricism, Rationalism, Constructivism The only thing I know for sure is that I don t know for sure Reconciling ways of knowing Evidence Based Practice Alternative evaluation endpoints

9 I am now convinced that the focus should be shifted from compliance to the goal of optimal treatment implementation. This web site is an elaboration and discussion of this idea. Dr Allan Showalter

10 Dressings- honey, grease & lint plasters Painting with ores- copper Adhesives & stitching Meat precursors to allografting Good vs Bad wounds

11 pound together fur-turpentine, pineturpentine, daisy, flour of Inninnu. Strain; mix in milk and beer in a small copper pan; spread on skin, bind on him and he shall recover. - ancient Mesopotamian Rx

12 Washing the wound Making plasters Bandaging the wound One of the earliest wound care products-beer

13 An extension of Egyptian medicine First to identify pressure ulcers Distinguished between fresh vs non-healing For an obstinate ulcer, sweet wine and a lot of patience should be enough Hippocratic collection

14 Warily must the surgeon take heed not to remove or interfere with Nature s balsam which healeth wounds. Nature has her own doctor in every limb; wherefore every surgeon should know it is not he, but Nature, who heals. Paracelsus 15 th century physician Empyema requires cold steel, not the folly of a physician Sir Wm Osler

15 Growth factors PDGF-ß, TGF-ß, EGF Metalloproteinases & TIMPs Mediate ECM degradation (what about bacterial exotoxins? Energy based interventions Inflammatory markers TNFα, (IL)-6 Marrow-derived stem (progenitor) cells

16 Non-diabetic Diabetic Epidermal cells are stained using flourescent antibodies to Protein Gene Product 9.5 (PGP9.5) permitting digital images of nerve fibers. Software generated analysis yields quantities of nerve fibers, including length & number of branch points as a potential non-invasive diagnostic tool Kennedy, W. (2002). The Laboratory of Willaim R. Kennedy, M.D. Retrieved May 20, 2005, from University of Minnesota Medical School, Department of Neurology Web site:

17 Images of human skin from normal (L) and diabetic (R) subjects. Epidermal nerves = green & yellow. basement membrane separating epidermis/ dermis & surrounding blood vessels= red Note the loss of ENFs in the diabetic subjects. Scale bars equal 100µm.

18 Watchful Waiting Moist wound healing Advanced Wound Care Active Wound Care-Whole Person Care

19 Creates & maintains moist wound environment Promotes wound healing Provides thermal insulation Provides mechanical protection Requires infrequent changing Safe to use, nontoxic, nonsensitizing, hypoallergenic, non-inflammatory (gauze) Free from particulate contaminants Allows removal w/o pain or trauma (gauze) Capable of absorbing excess exudate Allows wound monitoring Allows gaseous exchange Conformable Impermeable to microorganisms Acceptable to the patient, easy to use & cost effective Grey, Jones & Harding p.248

20 30% Administration 60% Labor 10% Supplies

21 Not such a mystery-if it s wet- use an aborptive dry- add moisture open- control bioburden swollen- consider compression not clean- debridement neuropathic- offload!! + all above painful- pain mgmt

22 There are over 2,000 types of wound care dressings on the market. It helps to focus on the categories of wound dressings, versus specific brand names We will discuss 7 main categories: Alginates Hydrocolloids Foams Hydrogels Composites Films Miscellaneous

23 Biodegradable dressings derived from brown algae s Very absorbent, ideal for draining wounds Guluronic acid (hard) : mannuronic (soft) Must be used in combination with secondary dressings

24 ALGINATES ALGINATES INDICATIONS INDICATIONS ADVANTAGES ADVANTAGES DISADVANTAGES DISADVANTAGES APPLICATION APPLICATION Partial and Full Thickness Partial and Full wounds Thickness Deep wounds or tunneling wounds Deep or tunneling Wounds woundswith moderate Wounds to with heavy moderate drainage to Infected heavy drainage and noninfected Infected and wounds noninfected Moist, wounds red and yellow Moist, wounds red and yellow wounds Absorb up to 20x their weight Absorb up to 20x their Form weight a gel in the wound Form to a gel maintain the moist wound wound to maintain bed Autolytic moist wound debridement bed Fills Autolytic in dead debridement space Easy Fills to in apply dead and space remove Easy to apply and Hemostatic remove Hemostatic Not for wounds with Not light for wounds exudate or with dry eschar light exudate Can or dehydrate dry eschar wound Can dehydrate Require wound abed secondary Require a dressing secondary dressing Primary dressing Primary dressing Apply Dressing Apply Dressing

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26 Adherent, opaque, gas impermeable and absorbent dressings Good for wounds with low drainage Lowers infectgion risk- pmns,-ph Can be left in place for up to 7 days Can cause hypergranulation

27 HYDROCOLLOIDS HYDROCOLLOIDS INDICATIONS INDICATIONS ADVANTAGES ADVANTAGES DISADVANTAGES DISADVANTAGES APPLICATION APPLICATION Pressure Ulcers Partial Pressure and full Ulcers thickness Partial and full wounds thickness Necrotic woundsor slough Necrotic filled or wounds slough filled Wounds woundswith light Wounds to moderate with drainage light to moderate drainage Are impermeable to bacteria Are impermeable and other to contaminants bacteria and other Autolytic contaminants debridement Self Autolytic adhesive debridement and mold well Self adhesive and mold Provide well slight to moderate Provide absorption slight to Minimize moderate skin absorption trauma and Minimize disruption skin of trauma healing and disruption of If transparent, healing allow wound If transparent, observation allow Do wound not require observation secondary Do not require dressings secondary dressings Are not recommended Are not for recom- wounds mended with for heavy wounds exudate, with sinus heavy tracts, exudate, or infections; sinus tracts, or wounds infections; rounded wounds bysur- rounded skinby Can fragile be opaque, skin fragile making Can be wound opaque, assessment making wound difficult assessment May difficult be dislodged if the May wound be dislodged produces if the wound heavy exudate produces heavy Provide exudate an occlusive Provide an property occlusive that limits property gas that exchange limits gas between exchange the wound between andthe environment wound and May environment curl at edges May curl at edges Primary or secondary Primary or dressing secondary Comes dressing as wafers, pastes, Comes and as wafers, powders pastes, and powders Apply Dressing Apply Dressing

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29 Polyurethane dressing, highly conformable and permeable Nonadherent and absorbent May require additional dressing

30 FOAMS FOAMS INDICATIONS INDICATIONS ADVANTAGES ADVANTAGES DISADVANTAGES DISADVANTAGES APPLICATION APPLICATION Partial and Full Thickness Partial and Full wounds Thickness with moderate, wounds with or heavy moderate, drainage or Provide heavy drainage absorption Provide and insulation absorption and Cover insulation packing in wounds Cover packing in (secondary wounds dressing) (secondary Around dressing) drainage tubes Around drainage tubes Nonadherent May Nonadherent repel contaminants May repel Easy contaminants to apply and remove Easy to apply and Absorb remove light to heavy amounts Absorb of light exudate to heavy May amounts be used of under exudate compression May be used under compression Are not effective for Are wounds not effective with dry for eschar wounds with May dry macerate eschar periwound May macerate skin if they periwound becomeskin if saturated they become May saturated require secondary May require dressing, secondary tape, or net dressing, tape, or net Primary and secondary Primary and dressing secondary Come dressing pad, sheet Come and in pillow pad, (cavity) sheet form and pillow (cavity) form Apply Dressing Apply Dressing

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32 Semitransparent, absorbent and nonadhesive; soothing Requires a secondary dressing Can cause maceration of surrounding tissues Good for wounds w minimal drainage

33 HYDROGELS HYDROGELS INDICATIONS INDICATIONS ADVANTAGES ADVANTAGES DISADVANTAGES DISADVANTAGES APPLICATION APPLICATION Partial and Full Thickness Partial and Full wounds Thickness Deep wounds Wounds Wounds Deep Wounds necrosis Wounds orwith slough necrosis or Minor slough Burns Tissue Minor Damaged Burns by Tissue Radiation Damaged Granulating by Radiation wounds Granulating wounds Are soothing and reduce Are soothing pain and Rehydrate reduce pain the wound bed Rehydrate the wound Autolytic bed debridement Fill Autolytic in dead space debridement Provide Fill in dead minimal space to moderate Provide absorption minimal to Applied moderate and absorption removed easily Applied from and the removed wound Can easily be used from when the wound infection Can be is used present when infection is present Not recommended Not for wounds recommended with for heavy wounds exudate with Some heavy require exudate secondary Some require dressing secondary Dehydrate dressingeasily if not Dehydrate coveredeasily Some if not may covered be difficult Some to may secure be Some difficult may to cause secure maceration Some may cause maceration Primary dressings Primary (amorphous dressings & impregnated (amorphous & gauzes) impregnated Secondary gauzes) dressings/sheets Secondary dressings/sheets Apply Dressing Apply Dressing

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35 Tend to be highly absorbent Will have a bacterial barrier Allow for moisture vapor permeability May require secondary dressing

36 COMPOSITES COMPOSITES FEATURES MUST INCLUDE Bacterial barrier Absorptive Bacterial barrier layer other than an alginate, foam, Absorptive hydrocolloid, layer other or hydrogel than an alginate, Semi-adherent foam, hydrocolloid, or non-adherent or hydrogel property for covering Semi-adherent the wound or non-adherent property for An adhesive the border wound An adhesive border INDICATIONS INDICATIONS ADVANTAGES ADVANTAGES DISADVANTAGES DISADVANTAGES APPLICATION APPLICATION Partial and full thickness Partial and full wounds thickness with minimal wounds to with heavy exudate minimal to heavy Granulating exudate wounds Granulating Slough wounds or moist eschar Slough or moist Mixed eschar wounds (eschar Mixed and wounds granulation) (eschar and granulation) Facilitates autolytic debridement Facilitates autolytic Allows debridement for exchange of moisture Allows for vapor exchange of Mold moisture well vapor May Mold be well used for infected May be wounds used for Easy infected to apply wounds and remove Easy to apply and Include remove an adhesive border Include an adhesive border Require a border of Require intact skin a border for anchoring of intact skin the for dressing anchoring the dressing Primary or secondary Primary or dressing secondary dressing Apply Dressing Apply Dressing

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38 Thin, transparent, semipermeable and nonabsorbent Good for superficial wounds with minimal drainage Can decrease shear Very adherent-may cause skin tears

39 TRANSPARENT FILMS TRANSPARENT FILMS INDICATIONS INDICATIONS ADVANTAGES ADVANTAGES DISADVANTAGES DISADVANTAGES APPLICATION APPLICATION Prevent and manage Prevent Stage and I pressure manage ulcers Stage I Partial pressure thickness ulcers wounds Partial with thickness little or wounds no exudate with little Wounds or no exudate with necrotic Wounds tissue with or slough necrotic tissue or slough Retain moisture Are Retain impermeable moistureto bacteria Are impermeable and other to contaminants bacteria and other Autolytic contaminants debridement Allow Autolytic woundebridement observation Allow wound Do observation not require secondary Do not require dressings secondary dressings May not be recommended May not be for infected recommended woundsfor Not infected for wounds wounds with Not moderate for wounds to heavy with drainage moderate to Not heavy drainage recommended Not for use recommended on fragile for skin use on fragile Require skin a border of Require intact skin a border for adhesive of intact edge skin of for dressing adhesive edge of May dressing be difficult to apply May and be difficult handle to May apply dislodge and handle in high May friction dislodge in areas high friction areas Primary or secondary Primary or dressing secondary dressing Apply Dressing Apply Dressing

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41 Hydrofibers Manuka Honey - Medihoney Carbon impregnated dressings Absorbent dressings Hyaluronic acid impregnated dressings Small Intestinal Submucosa dressings Oxidized Regenerated Cellulose/Collagen matrix dressings

42 Hydrofiber Oasis Exudry

43 Debriding Agents: Papain Urea*off mkt Collagenase Antimicrobials: Cadexomer iodine gel Nanocrystaline silver dressings Silver gel Growth Factors: Becaplermin Antifungals Skin Substitutes/Tissue Engineering Anti-inflammatory agents

44 Critical Colonization, Bacterial Synergy, Quorum Sensing, Exotoxins

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47 ~Alginates (absorptive) ~Foams (absorptive) ~Hydrogels (donate moisture) ~Hydrocolloids (conserve moisture) ~Films (conserve moisture) ~Debriders (enzymatic clean up) ~Application (atraumatic)

48 Human Tissue Equivalents Growth Factors MIST Ultraviolet C Electrical Stimulation MIRA-monochromatic infrared

49 Ennis WJ, Foremann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Manage. 2005;51(8): Kavros SJ, Miller JL, Hanna SW. Treatment of ischemic wounds with noncontact, low-frequency ultrasound: the Mayo Clinic experience, Adv Skin Wound Care. 2007;20(4): ML-66057_E Effec. Date: 1/28/08

50 Acoustic Pressure Wound Therapy Staphylococcus aureus Control* (2 minutes, 30 seconds of treatment with saline) MIST Therapy* (2 minutes, 30 seconds of treatment with MIST) Wagner SA, Kavros SJ, Vetter EA, Cockerill FR. The effect of mist ultra-sound transport technology on common bacterial wound pathogens. Abstract. Presented at Symposium on Advanced Wound Care, * SEM (scanning electron microscopy) ML-66057_E Effec. Date: 1/28/08

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55 Professional Organizations WOCN,AAWC,ACCWS, WHS Wound care Journals OW-M, Advances, WOCN, Wounds Websites- Advancing the Practice WOCN guidelines Certified Wound Care Specialists Solutions Algorithms NIH guideline

56 Systemic, Global Assessment Think Derm Consensus Statements/guidelines/EBP ABI/ PAE Familiarity w basic compression strategies Familiarity w the 7 dressing categories Debridement Pain management Offloading Swab culture technique Think Quality of Life

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58 It s ~really all about applying dressings ~not possible to achieve better outcomes & still reduce costs ~too complicated for non-specialists ~not a part of what I do- I don t have time And ~gauze is fine, the new stuff wastes money ~Dakin s is non-toxic in wounds

59 5/06/04

60 5/19/04

61 06/01/04

62 04/05/05 2/5/08 still closed

63 07/08/04

64 10/25/05

65 10/25/05

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73 Stronger integration Derm perspective Develop shared knowledge domains Telemedicine Referral network creating your own interdisciplinary team

74 Implementation of best practice can t be achieved in isolation, because (wound) care is multidisciplinary. The environment exerts a powerful set of influences on the adoption of best practice. JWOCN, May 2003