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
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
Incidence Population Risk factors Age group Cost & resources Hospital days
Wounds seen in the community Trauma Skin tears Lower limb ulceration Pressure injuries Burns Skin cancers Surgical wounds Skin infections
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
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
Tier Two Referral to CNC Wound Management/NP Wound Clinics Multidisciplinary focus Assessment/diagnosis Treatment plan Evaluation General Practitioner Nurses/allied health/other Specialists
venous mixed Timely Accessible service Wound Assessment Tertiary referral Diagnostics investigations Treatment plan Multidispinary/ referrals venous BCC
Principles of Wound Management Define aetiology Control factors influencing healing Select appropriate dressing or device Plan for maintenance
The Skin
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
Factors influencing healing Local factors Trauma/pressure Wrong dressing Wound temperature Wound ph Moisture balance Topical infection Foreign body Wound management practices
Physiology of wound healing Acute wounds Haemostasis Inflammation Reconstruction Maturation Primary Intention Secondary intention Skin grafts/flaps Chronic wounds
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
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
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
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
Principles of Wound Healing Granulation Formation of new capillaries Granulation tissue is the red tissue that bleeds easily Friable Hypergranulation
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
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
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
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
Chronic vs Acute
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
Skin Tears Initial treatment Moisture balance Protection of the wound & surrounding skin Dressing products - Silicone foam eg mepilex or allevyn gentle Protective tubular bandage
Risk factors Age Dependence Immobility History of skin tears Poor nutritional/hydration status Sensory & cognitive deficits Polypharmacy Co morbidities
Leg Ulcers Origin Arterial Venous Mixed Neuropathic
Aims of Treatment Determine aetiology Remove or treat cause Promote circulation Promote healing Prevent recurrence
Causes of Leg ulcers Vascular disorders Lymphatic disorders Haematological disorders Metabolic disorders Tumours Infections Trauma Allergic response
Venous Disease
ABPI value is calculated by dividing the higher systolic pressure in each leg by the higher systolic brachial pressure
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
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
Compression therapy
Arterial ulcers
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
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
High risk foot Diabetes Neurovascular disease Neuropathic diseases Congenital or other foot abnormalities
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
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.
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
Skin cancers
Surgical wounds
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.
Dressings Which one to use?
TIME
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
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
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.
Matching colour with product
Necrotic black - hydrate
Dry necrosis
Yellow/Sloughy Wet yellow - antimicrobial dressing Dry yellow - rehydrating dressing
Red/sloughy
Hypergranulation - antimicrobial
Pink/red - protect
Infection green - antimicrobial
Acute/trauma wounds
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
Case study Leg ulcer
Additional Resource For further information refer to the wound dressing guide via the following link. https://cms.qut.edu.au/ data/assets/pdf_file/0003/451767/book 2-wound-dressing-guide.pdf
Thank you Questions