Wound Assessment & Treatment - PDF Free Download

Wound Assessment & Treatment Cathy Lyle Advanced Practice Nurse Providence Care, SMOL site LTC Physicians CME June 2011

Outline l Is it healing? l Will it heal? l What colour is it? l How wet is it? l Is it infected?

Canadian Association of Wound Care (CAWC)

Wound Measure l Size (cm) L x W x D Length greatest distance across in any direction Width greatest width at 90 degrees to length

Wound Measure l Size (cm) L x W x D Depth measure from deepest part of wound to top of wound margin

Wound Assessment Form Date Jan 13 Feb 10 Apr 4 Apr 18 May 2 Size (cm) 9 x 6 5 x 4.5 3 x 1.75 1 x 1.5 Closed Wound Base 80% black 20% black 100% granulation Periwound White Intact Intact intact Exudate Amt Large Mod large Small - moderate 100% granulation Small Exudate Purulent Serous Serous Serous Type Odour 1 (faint) No No No Stage X X 2 2 Pain No No No No

Measure Undermining l Undermining (cm) extent of wound unseen below the wound edges Probe distance from the edge of the wound with sterile Q tip Place thumb at Q-tip where it appears at edge of wound Record distance in cm. Use face of clock to record location with 12 o clock towards patient s head

What colour is it? l Black eschar l Yellow slough l Red granulation tissue l Pink epithelial tissue

Black Eschar l Black or brown l Soft or firm l Leather-like cap

Stage X

Hydrogel l Description: amorphous gel which hydrates granulation tissue and rehydrates dry eschar and slough liquefying the necrotic tissue for easy removal. l Indications: used on pressure ulcers (stage 2,3,4), partial- and full-thickness wounds, tunneling wounds, wound with minimal drainage, wounds with purulent drainage, and red, yellow, or black wounds.

Debridement l Removes dead tissue which is medium for bacteria growth l Reduces wound drainage and odour l Reveals true extent of wound can t determine true size until healthy wound bed is uncovered l Only for healable wounds

Types of Debridement l Autolytic body s own enzymes break down necrotic tissue moist wound environment helps pain free but slow contraindicated for infected wounds

Types of Debridement l Mechanical Gentle irrigation (syringe, 250 ml Normal Saline) Wet-to-dry dressings Be a Picker cut off dead tissue that you can lift from wound bed Painful Nonselective damages healthy tissue

Types of Debridement l Sharp Conservative at bedside by physician with scissors and scalpel need skill and a way to stop bleeding that may occur if wound debrided to healthy, bleeding base painful if debrided to bleeding base faster Surgical under anesthetic by surgeon fastest and most effective method

When to debride? l Debride only healable wounds There is a potential to heal There is adequate arterial perfusion The overall goal is healing

When to debride? l Do not debride when: Unknown wound origin Dry gangrene or ischemic wound Affected limb has no pulse or decreased perfusion Wound due to inflammatory or vasculitic process No necrotic tissue Treatment goal is wound maintenance

Hydrogel l hydrates granulation tissue and rehydrates dry eschar and slough, liquefying the necrotic tissue for easy removal l used on wounds with minimal drainage, wounds with purulent drainage, and red, yellow, or black wounds

Yellow - Slough l Creamy yellow or grey l Firmly attached to wound bed or l Loosely-attached strings of tissue

Red Granulation l Bright red, moist, shiny l Granular, bumpy l If bleeds easily (friable) may indicate infection l If darker red may indicate poor perfusion

Pink Epithelial l Whitish pink or pinky-purple l At first, seen as islands of white in midst of wound bed epithelial buds l Seen as ring of pink around rim of wound bed

Will it heal? l Treatment decisions based on heal-ability of wound l Not all chronic wounds heal l Healing potential influenced by cause of wound, underlying co-morbidities, patient s level of commitment to treatment plan

Wound Assessment Assess the whole patient not just the hole in the patient

What affects healing? l Low oxygen perfusion Smoking Chronic obstructive pulmonary disease, anemia Peripheral vascular disease, coronary artery disease, hypertension, diabetes, congestive heart disease

What affects healing? Malnutrition More calories and protein needed when healing Serum albumin (3.5-5 gm/dl) Prealbumin (20-40 mg/dl) Vitamin C, zinc, iron needed for collagen formation Vitamin A needed for epithelialization Dehydration Large amounts of wound drainage contribute

What affects healing? l Age Skin thins, higher risk for trauma Slower inflammatory response Healing takes longer

What affects healing? l Other chronic diseases Rheumatoid arthritis, renal failure, cancer Immunocompromised patients (unable to mount adequate inflammatory response) l Medication and treatments Radiation, chemotherapy disrupts cell formation Anti-inflammatory meds (NSAIDS) suppresses inflammatory response

What affects healing? l Psycho-physiological stress Includes pain and noise Stimulates sympathetic nervous system vasoconstriction l Local factors Foreign bodies l packing left in or causing too much pressure l sutures

What affects healing? l Patient s expectations and level of commitment to treatment What is important to patient? What is patient s goal? Healing or maintenance How does patient want to spend time?

Is it healable? l Yes, wound has good potential to heal, treatment goal is to close wound proceed with best practices in wound care l No, wound will probably not close poor potential for healing, treatment goal is to maintain condition of wound focus on promoting client function and comfort with wounds (living with wounds)

Periwound Assessment l Intact normal epithelial skin l Macerated/excoriated wet, white opaque skin l Induration feels firmer than surrounding tissue l Erythema bright red, blanches or doesn t l Callus thick, dry epidermis l Dehydrated dry, flaky with fissure, cracks

Tissue Injury from Moisture l Wet skin becomes soft and macerated more prone to breaking down with pressure/friction more prone to bacteria and yeast infection l Incontinent patients 5X more likely to have skin breakdown l Where damage occurs? perineal area, skin folds, around wounds

Moisture Prevention & Treatment l Protect periwound skin No Sting barrier film Zinc oxide, vaseline Cover wound edges (picture frame) - hydrocolloid (Tegasorb) Use products that wick drainage away from periwound (foams cut to fit wound bed size)

Product Categories l Gauze l Films l Hydrocolloids l Calcium Alginates l Hydrofibres l Foams l Silver Impregnated l Cadexomer Iodine

Gauze l Minimal absorbency small to mod draining wounds l Wear time: dependent on amount of exudate, usually daily l Does not promote a moist wound environment l Painful (#1 painful dressing)

Transparent Film l Adhesive, semipermeable, waterproof and impermeable to bacteria and contaminants, permits water vapour to cross the barrier l For wounds with little or no exudate, wounds with necrotic tissue or slough, can be used in high friction areas l Wear time: 7 days

Hydrocolloid l Impermeable to bacteria & other contaminants, moist wound healing environment, promoting granulation and/or autolytic debridement, self-adhesive and mold well. l For wounds with light to moderate exudate l Wear time: up to 7 days (usually 3-5)

Acrylic l Transparent, breathable membrane that allows vapour to transfer out l Exudate solutes remain, colouring dressing l Change in 21 days or when dressing leaks

Calcium Alginate l Derived from brown seaweed, interacts with wound exudate to form a soft gel that maintains a moist healing environment l Used for wounds with moderate to heavy drainage, can absorb up to 20 times it s weight l Requires secondary dressing; can be used in combination with hydrocolloid or foam to increase wear time

Hydrofibre l Man-made fibrous dressing (100% pure carboxymethylcellulose), interacts with wound exudate to form soft gel that maintains a moist healing environment, can absorb up to 30 times its weight. l For wounds with moderate heavy drainage l Requires secondary dressing; can be used in combination with hydrocolloid or foam to increase wear time

Foam l non-linting absorbent dressings that vary in thickness l have a non-adherent layer allowing for nontraumatic removal l provide a moist environment and thermal insulation. l moderate to large draining wounds

Preventing Tape/Adhesive Damage l Protect periwound skin No Sting barrier film Picture frame wound hydrocolloid (Tegasorb) l Remove adhesive carefully Alcohol dissolves adhesive bond Clear film removal technique

Managing Bacterial Burden l Proven effectiveness in wound healing l Inflammation is helpful in acute wound healing Induces vasodilatation and increases blood flow Brings antibodies and phagocytic cells to remove wound debris, microorganisms, foreign debris, Usual signs are pain, redness, swelling, increased temperature, purulent drainage

Managing Bacterial Burden l In chronic wounds infected with persistent microbial burden, the inflammatory response is prolonged and actually releases enzymes and cell mediators that harm the tissue host l Thrombosis and vasoconstriction lead to tissue hypoxia promotes bacterial proliferation

Managing Bacterial Burden l Chronic wounds may become stuck in the inflammatory phase excessive drainage, increased slough on wound bed usually due to presence of bacteria, fungi, viruses in wound bed

Bacterial Burden Continuum Contamination Colonization Local infection Systemic infection Critical colonization

Managing Bacterial Burden l Local infection Pain Redness in periwound tissue Swelling in periwound tissue (induration) Increased temperature Purulent drainage Foul odour vs l Critical colonization Delayed healing Increased exudate Discolored granulation tissue friable, exuberant New areas of breakdown or slough on wound Foul odour New pain

Superficial Increased Bacterial Burden NERDS N nonhealing wound E exudative wound R red and bleeding wound D debris in the wound S smell from the wound Reference: Sibbald, Woo, Ayello, Increased Bacterial Burden and Infection: The Story of NERDS and STONES, Advances in Skin & Wound Care, October 2006

Deep Compartment Infection STONES S size is bigger T temperature increased O os (probes to or exposed bone) N new areas of breakdown E exudate, erythema, edema S smell Reference: Sibbald, Woo, Ayello, Increased Bacterial Burden and Infection: The Story of NERDS and STONES, Advances in Skin & Wound Care, October 2006

Managing Bacterial Burden l Clean the wound Cleansing and irrigation with normal saline or sterile water to remove exudate and surface debris Irrigate with syringe (20 30 cc) plus angiocath (18-20 gauge) Debride necrotic tissue l Use topical antimicrobial agents

Managing Bacterial Burden l Nanocrystalline silver has antiinflammatory and antimicrobial effect Effective against broad range gram positive and negative bacteria, aerobes, anerobes, fungi, yeast, viruses Affects bacteria DNA, enzymes, cell membranes Low possibility of developing resistance Minimum inhibitory concentration (20-40 ug/ml)

Managing Bacterial Burden l Nanocrystalline silver has antiinflammatory and antimicrobial effect Actisorb Silver (Johnson & Johnson) Silvercell (Johnson & Johnson) Aquacell Silver (Convatec) Acticoat Silver (Smith & Nephew) Acticoat 7 Silver (Smith & Nephew)

Cadexomer Iodine l combines iodine and a modified starch in the form of a gel or a pad in order to reduce bacterial load l time-released antimicrobial l change when the colour changes from brown to a yellow-grey

Other Antimicrobial Dressings l Mesalt (hypertonic saline gauze) l Medihoney (hospital grade manuka honey) l 10% Povidone-Iodine (Betadine)

Staging Pressure Ulcers l National Pressure Ulcer Advisory Panel (NPUAP) l 4 stages of tissue injury l Stage X

Stage 1 l Persistent redness as a result of inflammation response l Skin intact l Very painful l Blanch test normally turns white with pressure l Usually repairs itself when pressure removed

Stage 1

Stage 2 l Skin is open l Partial thickness injury (epidermis, dermis) l Very superficial (blister, abrasion, shallow crater) l Heals in a few days with moist wound healing products if pressure relieved l Exception: if moisture is the cause of skin breakdown

Stage 2

Stage 3 l Full skin thickness is damaged and into subcutaneous tissue

Stage 3

Stage 4 l Damage extends through subcutaneous tissue to the muscles, bones, tendons, joints l Undermining may occur

Stage 4

Stage X l Stage X unable to stage, wound covered with slough or eschar

Stage X

Negative Pressure Wound Therapy: VAC l Description: Noninvasive active therapy using localized negative pressure. It removes excess interstitial fluid, decreases edema and bacterial colonization, increases blood supply and granular tissue formation, and enhances epithelial and cell migration. l Indications: Granular draining wounds; fullthickness wounds; venous, arterial, diabetic, and pressure ulcers; surgical wounds; flap and grafts; and acute traumatic wounds.

Negative Pressure Wound Therapy: VAC l Contraindications: necrotic tissue, enteric fistulas, untreated infection or osteomyelitis, malignancy l Change indicator: dressings are change M-W-F for most wounds, leave on for 5 days for graft. l Wear Time: dependent on goal of therapy