Debbie Theriot, MN, APRN, CWCN Ochsner Health Systems New Orleans, LA Full patient history Initiating event and wound duration Previous treatments and their outcomes Diabetes control and prior complications Medical conditions that interfere with wound healing Medications that may interfere with wound healing Underlying pathophysiology 1
Psychosocial barriers to wound healing Severity of pain Nutritional status Lifestyle/Environment Obesity Tobacco/Alcohol abuse Impaired mobility Inadequate social network, caregiver support Size Satellite ulcer Sinus tract Undermining Dead space Fluctuance Wound edges Indistinct Epiboly Hyperkeratosis Fibrotic 2
Peripheral tissue Pitting/non-pitting edema Crepitus Induration Maceration Abscess Exudate Serous, serosanguineous, sanguineous, seropurulent, purulent Wound bed tissue Desirable Epithelialization Granulation Friable Undesirable Hypergranulation Avascular Yellow slough Fibrin Black eschar Dessicated 3
Occur when the normal reparative process is interrupted Wound > 6 weeks old If a patient s wound does not respond to therapy after 6 weeks, consider a biopsy and culture of the wound Rule out systemic (DM, PVD, ESRD, etc.) and local (malignancy, topical and/or oral steroids, biofilms, etc.) factors Anatomic Location Below the knee (usually arterial, venous, diabetic or pressure ulcer) Bony prominences (usually pressure-related) Moist areas (usually due to moisture-associated skin damage) Extent of tissue injury (assess after wound debridement) Stage/Category: A pressure ulcer is localized to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear Partial-thickness vs. full-thickness: Used to describe the extent of injury for all wounds except pressure ulcers 4
Stage I Non-blanchable redness of intact skin usually over a bony prominence Discoloration of the skin, warmth, edema, hardness or pain may also be present Darkly pigmented skin may not have visible blanching Stage II Partial thickness skin loss or blister Loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough May also present as intact or open/ruptured serum-filled blister International NPUAP/EPUAP npuap.org Stage III Full thickness skin loss (fat visible) Bone, tendon or muscle are not exposed May have some slough, and include undermining/tunneling Stage IV Full thickness tissue loss (muscle/tendon/bone visible) Slough or eschar may be present Often includes undermining/tunneling International NPUAP/EPUAP npuap.org 5
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Unstageable/Unclassified Full thickness skin or tissue loss-depth unknown Depth is obscured by slough (yellow, tan, gray, green or brown) and/or eschar(tan, brown or black) in the wound bed Cannot stage until clean, but usually a Stage III or IV. Stable (dry, adherent, intact without erythemaor fluctuance) escharon the heels serves as the body s natural (biological) cover and should not be removed International NPUAP/EPUAP npuap.org 8
Suspected Deep Tissue Injury Depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear May be difficult to detect in individuals with dark skin tones Evolution may include a thin blister over a dark wound bed May further evolve and become covered by thin eschar International NPUAP/EPUAP npuap.org 9
Friction: Mechanical force exerted on skin that is dragged across any surface Rough red skin Superficial wound Observation of how the skin moves across a surface Shear: Interaction of both gravity and friction against the surface of the skin Occurs when layers of the skin rub against each other Also can occur when the skin remains stationary and the underlying tissue moves, stretches and angulatesor tears the underlying capillaries and blood vessels causing tissue damage Deep undermining wound Observation of how tissue rubs against tissue 10
Intervention Lower head of bed to less than 30 degrees (unless medically contraindicated) Moisturize the skin (avoiding massage) Avoid dragging the body when moving the patient (use of draw sheets) Consider an overhead trapeze Injury to the skin by repeated or sustained exposure to moisture Intertriginous dermatitis Incontinence-associated skin dermatitis Periwound moisture-associated dermatitis Peristomal moisture-associated dermatits 11
Inflammation in skin-to-skin or skin-to-device related to perspiration, friction and bacterial/fungal bioburden Characteristics include erythema, itching, maceration, erosion and odor. Possible stellate lesions Assess and treat the cause 12
Caustic Moisture Damage: Stool/Urine Inflammation of the skin that occurs when urine or stool comes into contact with perineal/perigenitalareas, inner thighs, buttocks or adjacent skin folds Assess and treat the cause Protective moisture barrier Absorptive pads Topical and/or oral antifungals 13
Caused by ischemia Usually on distal part of the leg (between toes, tips of toes, dorsal foot, phalangeal head, lateral malleolus) Usually painful, small punched-out ulcers Skin may feel cool or cold Wound base often pink in color, may have necrotic tissue Pulses are reduced or absent Thin, smooth, shiny, dry skin Hair loss on foot and leg History of claudication/rest pain Dependent rubor Pain is severe and increased with elevation 14
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Vascular studies to confirm arterial insufficiency Avoid constrictive garments Avoid compression Avoid exposure to extreme temperatures Moisturize extremities Select dressings that promote moist wound healing Vascular surgery consult Consists of slowly dying tissue related to the obstruction of one or more arteries Tissue is hard, shriveled and dry Check pulses (ABIs) Hx of arterial insufficiency/microemboli Address causative factors (circulation/infection) Manage co-morbidities (diabetes, renal insufficiency) If wet or gas gangrene is suspected, consider ID consult R/O osteomyelitis 16
If revascularization for limb salvage is considered Vascular imaging Duplex MRA CTA Angiogram Revascularizaition Vascular bypass Endovascular treatment Angioplasty Arthrectomy Stent If revascularization for limb salvage is not considered Wound Care Leave dry gangrenous tissue open to air and paint with betadine Separate necrotic toes with gauze, cotton, or foam dressing Avoid moistening gangrenous tissue to reduce bacterial growth If gangrene becomes wet, consider iodosorb or silvadene cream Antibiotics Adjunctive therapies Hyperbaric oxygen treatments for gas gangrene (along with surgical debridement) and/or osteomyelitis Consider consult with orthopedics 17
Wet Gangrene 18
Caused by ambulatory venous hypertension Usually above the malleolus(gaiter area) Usually has large, irregularly shaped ulcers with associated pain Ruddy,granular tissue Often drains moderate to large amounts of exudate Stasis dermatitis Superficial varicosities may be present Pulses/ABIs are normal Eczematous skin changes Scaling Pruritis Erythema Vesicles Lipodermatosclerosis Indurationrelated to fibrotic changes of the dermal and subcutaneous tissues (woody, brawny edema) Erythema related to inflammation Hyperpigmentation (hemosiderin staining) Bony ankylosis of the ankle joint related to immobility 19
Pre-EVLT vascular ultrasound Elevate the extremity Provide compression Moisturize extremities Select dressings that promote moist wound healing 20
Caused by neuropathic and vascular complications Located on pressure points of the foot Callous often surrounds ulcer Ulcers are usually small but may be large Surrounding skin is often extremely dry and cracked Insensate foot 21
Rule out vascular disease Optimize blood sugar level Aggressive debridement (if adequate blood flow) Redistribute pressure (offloading, orthotics) Exfoliate and moisturize feet Select dressings that promote moist wound healing 22
Grade 0: No ulcer in a high risk foot Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues Grade 2: Deep ulcer penetrating down to ligaments and muscle, but no bone involvement or abscess formation Grade 3: Deep ulcer with cellulitisor abscess formation, often with osteomyelitis Grade 4: Localize gangrene Grade 5: Extensive gangrene involving the whole foot 23
Location Arterial Venous Diabetic Pressure Usually distal Above malleolus Pressure areason foot Usually on bony prominence Size Small Smallto large Usuallysmall, may be large Small to large Shape Round Irregular Round Round,but may be irregular if large Depth Usually shallow Shallow Shallow to deep Shallow to deep Base Pale, may be necrotic Variable: increased exudate Variable: frequently necrotic, if infected Variable Margins Smooth Irregular Usually smooth Variable Surrounding skin Pale Pigmented Frequently calloused Variable Often occurs on upper extremities May have tissue loss, epidermal flap may be absent Usually painful 24
Moisturize extremities Select dressings that promote moist wound healing Select dressings that are non-adhesive or easy-to-remove Mechanical Ultrasound Sharp Autolytic Highly selective, yet natural process, where endogenous proteolytic enzymes break down devitalized tissue (Hydrophilic wound dressing, Medihoney) Enzymatic Collagenase Santyl 25
Moist saline gauze Mechanical debridement can damage granulation tissue on removal Fills dead space May dehydrate wound bed Permeable to fluid and bacteria Impregnated gauze Less adherent to wound bed or graft Keeps wound moist Not absorptive Hydrocolloid dressings Water-resistant protective barrier Minimally exudating wounds Softens and loses shape with heat and friction May increase risk for anaerobic infection Films Water-resistant Allows wound visualization May tear fragile skin on removal May cause maceration 26
Non-adherent contact layer Skin tears Donor grafts and sites Hydrogel wound fillers and gels Use on dry, sloughy wounds with low exudate levels Provides moist wound environment Autolytic debrider Can cause periwound maceration Soothing and pain relieving Foam dressings Minimal to heavy absorption of exudate Helps maintain moist wound environment Protects wound and periwound from trauma May macerate wound edge if dressing becomes saturated Calcium alginate Highly absorptive Fills dead space Can dehydrate wound bed Not appropriate for dry or eschar wounds 27
Hydrofibers Highly absorptive Fills dead space Can dehydrate the wound bed Collagen dressings Appropriate for chronic wounds Regulates microenvironment of wound bed No appropriate for necrotic or significantly infected wounds Hypertonic saline gel Supports autolytic debridement Absorbs large amounts of drainage May damage granulation tissue if drainage is minimal Contaminated/Colonized Minimal exudate Healthy granulation tissue Normal wound margin Healing wound 28
Critically Colonized Increased serous drainage Abnormal granulation tissue Possible tunneling Static, non-healing wound Infected Excessive odor Excessive exudate or purulent exudate Tunneling, erythema and warm skin Wound increasing in size 29
Becaplermin(Regranex) Biologic Skin Repair Therapy (Appligraf) Dermal Substitute (Dermagraft) Antimicrobial Dressing (Silver) Antimicrobial Ointment (Iodosorb) Bacteriostatic Dressing (Hydrofera Blue) Extracellular Matrix (Oasis) Enzymatic Debridement Ointment (Collagenase Santyl) Silicone Dressing (Mepitel) Is hydrophobic, which enhances exudate removal Has reticulated open-celled pores to help evenly distribute negative pressure across the wound Assists in granulation-tissue formation in wounds Aids in wound contraction 30
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