Wound Care for Hospitalists NANCY FOX RN BN IIWCC SHEILA MOFFATT RN BN IIWCC ETN
Disclaimer The presenters wish to inform all participants that they have not received any support from a commercial party directly or indirectly related to the subject of this presentation.
Objectives Describe the principles of wound management Discuss the factors that affect wound healing Identify the components of a wound assessment Review local antimicrobial treatment options Case discussion
Case AB Female 56 yrs old stepped on a nail which penetrated the mid plantar aspect of her right foot. At 2 weeks post injury, she visited family doctor; received tetanus vaccine and Keflex for a week. At 4 weeks, the injury had developed into an ulcer. Her heel was noted to be boggy with a large build-up of callous. Her heel has become more tender (9/10). She cannot stand on the heel due to the pain. What else do you want to know about your patient? What do you want to know about the wound? Moffatt, NSHA
Assessment Patient overall health, co-morbidities, medications Causative factors that may impact wound healing Environmental and system challenges Wound assess to determine the extent of injury, history Is the wound healing? Stalled? Fox NSHA
Location + MEASURE M Measure E Exudate A Appearance S Suffering U Undermining R Reevaluate E Edge Sibbald RG, Orsted HL, Coutts P, et al 2006 Fox NSHA
Appearance of Wound Fox NSHA Fox NSHA Fox NSHA Fox NSHA
Underlying/deeper structures Fox NSHA Fox NSHA Moffatt NSHA
Undermining Internal wound area undermining, tunnels, sinus tracts Fox NSHA Moffatt NSHA
Periwound induration, inflammation, maceration Fox NSHA Moffatt NSHA Moffatt NSHA
Edge HEALTHY Distinct, outline clearly visible, attached, even with wound base Gradual decline from edge to wound bed UNHEALTHY Not attached to wound base Not attached to base, rolled under, thickened Fibrotic, scarred or hyperkeratotic Moffatt, NSHA Moffatt NSHA
What s the goal? Identify goals based on healability of wounds Nutritional status Bloodwork albumin, pre-albumin, hemoglobin, HbA1c, CRP, WBCs Diagnostic tests
Diagnostics Wound Culture Ankle Brachial Index Toe pressures Transcutaneous oxygen tension (TcpO 2 ) Xray Bone Scan CT MRI
Cleansing/Debridement Cleansing NS, PHMB Autolytic - hydrocolloid, intersite gel, Mechanical - wet to dry, irrigation Chemical - Dakins, Santyl Surgical - sharp conservative, deep surgical Biologic-Maggots Moffatt NSHA
Biofilm Biofilms are structured aggregates of bacterial cells that are wrapped in self-produced extracellular polymeric substances (EPS). They cannot be seen with the naked eye. Biofilm consists of a network of bacteria and fungi locked in a thick slimy barrier of sugars and proteins. They begin to form within minutes to hours of skin breakdown. Biofilm outer wrap protects the micro-organisms from external threats making them resistant to standard treatment. The organisms within the biofilm cannot be tested using a normal wound culture methods. Biofilms are present in 60%-90% of chronic wounds and have the potential to delay healing. Biofilm formation provides increased resistance to environmental stresses. It can reduce the effectiveness of the host immune system and tolerance to antibiotics. Biofilm develop by: 1. Planktonic cells attach to the surface of the wound 2. Create microcolonies with EPS cover 3. Mature and disperse to new sites. Pseudomonas A. is an example of this formation. Toyofuku, M., Inaba,T., Kiyokawa, T., Obana, N., Yawata, Y & Nomura, N. (2015) Environmental factors that shape biofilm formation, Bioscience, Biotechnology, and Biochemistry, DOI: 10.1080/09168451.2015.1058701 http://dx.doi.org/10.1080/09168451.2015.1058701
Bacterial Balance Contamination Colonization Local/superficial Infection (critical colonization) Spreading/deep infection Systemic infection Contamination -no signs & symptoms Colonization Critical Colonization N E R D S Infection S T O N E E S
NERDS- at least 3 of the following to be superficial infection N-Non-healing wound E-Exudate R-Red and bleeding D-Debris S-Smell NERDS and STONES, by R. G. Sibbald, K. Woo, and E. A Ayello, 2007, Wounds UK, 3(2),pp. 25 46. Moffatt NSHA
STONEES- at least 3 of the following to be considered deep and surrounding tissue infection S-Size increasing T-Temperature (> 3 degree change between 2 mirror- image sites) O-(os) probe to or exposed bone N-New or satellite area E-Exudate E-Erythema/ Edema S-Smell Moffatt NSHA NERDS and STONES, by R. G. Sibbald, K. Woo, and E. A Ayello, 2007, Wounds UK, 3(2),pp. 25 46.
Moisture Balance and Exudate Moffatt NSHA Moffatt NSHA
Case AB What factors are you going to base your wound care decisions on? Moffatt NSHA
Wound Care Decisions Wound assessment (periwound skin, exudate,) Wound history Dressing interactions Patient/caregiver needs ease of use Cost-effectiveness/affordable Matching the attributes of the specific dressing with the needs of the wound There is no one perfect dressing! Moffatt NSHA
Antimicrobials Antimicrobials is an umbrella term used to group antibiotics and antiseptics Generally broad spectrum with effectiveness against VRE, MRSA Use preventatively for patients at high risk for wound infection Generally effective for 3 days The choice of antimicrobial is based on: bacterial bioburden volume of exudate type of tissue in the wound bed wound size, depth, tunneling and/or undermining Moffatt NSHA
Iodine based Topical antimicrobial Slow release iodine Effective in de-sloughing (Iodosorb) Avoid in patients with known or suspected iodine sensitivity, thyroid or renal disorders
Silver Anti-inflammatory properties Antimicrobial effectiveness against pseudomonas, MRSA, VRE Saline can inactivate certain silver dressings (Acticoat) Do not use silver products in combination with oil based products such as petrolatum or paraffin Do not use silver products during MRI examination or radiation therapy Antimicrobial effectiveness for up to 7 days
Honey 100% medical grade Manuka honey dressings Antimicrobial effect due to low ph (3.2-4.5) and high osmolarity Assists in debridement Helps manage moisture balance for low exudating wounds Available in several forms i.e. gel, colloid and alginate
Methylene blue and gentian violet A foam dressing containing two components, methylene blue and gentian violet Broad-spectrum antibacterial protection including yeast Assists in autolytic debridement Resolution of epibole and flattening of wound edges Non-cytotoxic Hydrofera Blue Classic hydration may be required Hydrofera Blue Ready No hydration required, Up to 7-day wear time
Polyhexamethylene Biguanide (PHMB) Dressings are impregnated with PHMB, a powerful yet safe antiseptic Broad-spectrum effectiveness provides protection against gram negative, gram positive, and fungi/yeast microorganisms including MRSA and VRE
Polyhexamethylene Biguanide (PHMB) Wound Irrigation Prontosan contains unique ingredients that have a double effect on the wound bed to create a wound environment optimal for healing. Betaine a gentle effective surfactant to penetrate, clean and remove wound debris and biofilm. Polyhexanide (PHMB) a powerful antimicrobial agent that can reduce bioburden. Cleansing, decontamination and moisturizing of acute and chronic skin wounds, superficial and partial thickness burns.
Case AB Social: lives alone in low income apartment. There are 3 flights of stairs to her apartment. Comorbidities: HTN, GERD, IDDM x 15 years, non-smoker, weakness in LE, obesity (220 lb s), diabetic neuropathy, retinopathy, CKD, hypothyroidism, asthma Bloodwork: HbA1c-13, fasting glucose 10.2, Hgb-87, WBC-13, CRP-77.17 Medications: Novolin 40 ac breakfast and Novolin 25 ac supper, Rosuvastatin, Lasix, Metformin, Pregabalin Diagnostic Tests: ABI: RT 1.0/LT 1.03; Toe Pressures-R 0.60/ L 0.63 Moffatt NSHA
Case CL 59 year old obese male patient admitted with an AECOPD and CHF. Mobility is poor. PMH: CAD with NSTEMI in 2011, COPD, CHF, DM2, CKD, GERD, HTN, DLP, PVD, Chronic stasis dermatitis, bilateral lower leg edema with recurrent cellulitis and venous ulceration, OSA Medications: Pantoprozole, Rasuvastatin, Ranitidine, Metoprolol, Furosemide, Atrovent, Ventolin and Symbicort inhalers, Ferrous sulfate with addition of Prednisone antibiotics. Bloodwork: albumin 24 and Hgb 123. Social: Lives with his wife and 2 sons in an apartment; currently unemployed on disability; non-adherent with compression therapy Diagnostic tests: ABIs L 0.85/R 0.81 March 2/17 Moffatt NSHA
CL March 15/17 Moffatt NSHA March 23/17 Moffatt NSHA
Resources www.woundcarecanada.ca CLWK wound product information sheets https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/ Diagnostic Tests to Determine Vascular Supply Appendix I (page 123-125) http://rnao.ca/sites/rnaoca/files/assessment_and_management_of_foot_ulcers_for_people_with_diabetes_second_ed ition1.pdf
References 1. Sibbald, R. G., Woo, K., and Ayello, E. A (2007)NERDS and STONES. Wounds UK, 3(2),pp. 25 46. 2. Sibbald, RG., Goodman, L Woo, K., Krasner, D., Smart, H., Tariq, G., Ayello, E., Burrel, R., Keast, H., Mayer, D., Norton, L. and Salcido, R.(2011). Special Considerations for Wound Bed Preparation 2011: An Update. Advances in Skin and Wound. 24(9);415-436. 3. Toyofuku, M., Inaba,T., Kiyokawa, T., Obana, N., Yawata, Y & Nomura, N. (2015) Environmental factors that shape biofilm formation, Bioscience, Biotechnology, and Biochemistry, DOI: 10.1080/09168451.2015.1058701 http://dx.doi.org/10.1080/09168451.2015.1058701 4. Orsted, H., Keast, DH., Forest-Lalande, L., Kuhnke, JL., O Sullivan-Drombolis, D., Jin, S., Haley, J.,and Evans, R.(2017) Foundations of Best Practice for Skin and Wound Management; Recommendations for the Prevention and Management of Wounds. Wounds Canada p 1-73 5. Sibbald, R.G., Elliott, J. A., Ayello, E. A. and Somayaji, R. (2015). Optimizing the Moisture Management Tightrope with Wound Bed Preparation. Advances in Skin and Wound Care, 28(10), p. 468. 6. Orsted, H. (2017) Using the Wound Prevention and Management Cycle to Create a Professional Development Process. Wound Care Canada. 15(1); p8-12.