Chronic 2 - Unit 10 Wound Care

Nutrients for wound healing

Calories: prevent weight loss; 30-35 cal/kg/day Protein: for positive nitrogen balance to promote new cell development; 1.2-2g/kg/day Fluid: 30mL/kg/day; more is fluid loss through wound, drain, or NG... Vitamins/minerals Vit C helps make collagen, promotes healing, and helps build resistance to infection, essential for Iron absorption Vit A makes new skin cells Zinc promotes wound healing and improve immunity Iron necessary component of heme = carry oxygen

Yellow wounds

Caution Fibrin left over from the healing process usually appears as yellow slough or dead tissue in the wound base. This slough, or soft necrotic tissue, provides a medium for bacterial growth. Management: -Clean the wound and remove the yellow layer -Cover the wound with a moisture-retentive dressing (such as a hydrogel or foam dressing or a moist gauze dressing with or without a debriding enzme) -Consider hydrotherapy with whirlpool or pulsatile lavage (for debriding)

Partial thickness

Partial thickness involves the epidermis and extends into the dermis but not through it Heals by regeneration Re-epithelization

Wound care products

Primary Dressings Therapeutic or protective covering applied directly to the wound bed Secondary Dressings Serve as a therapeutic or protective function and secure the primary dressing

Indications for Hyperbaric Oxygenation

Primary therapy for carbon monoxide poisoning, and decompression sickness. Wound indications include crush injury, compartment syndrome, acute traumatic ischemia, necrotizing infections, chronic refractory osteomyelitis, radiation tissue damage, compromised skin grafts or flaps, diabetic lower extremity wounds, and select other problems.

Wound colors

Red, yellow, black

Supportive measures to enhance perfusion

warmth, hydration, blood volume, pain control, reduce edema

Alginate Dressing

*Applied To Fill Dead Space and Absorb exudate* Non adhesive and non occlusive Absorb serous fluid or exudate Primary dressing, requires a secondary cover Indications: full thickness, undermined or tunnel Moderate to heavy exudates Contaminated and infected wounds Odorous wounds with or without slough Absorb 20x their weight Not recommended for light exudates or dry eschar; can dehydrate a wound bed

Hydrogels

*Donate Fluid to the Wound Soothing and reduce pain, rehydrate the wound bed, facilitate autolytic debridement, fill in dead space, not recommended for wounds with heavy exudates* Sheets w/o adhesive borders may be changed daily Sheets w/adhesive borders can be change 3x/week Because of high water content, some cannot absorb large amounts of exudate Donates fluid to the wound Used as primary or secondary dressings Also used to manage partial and full thickness wounds, deep wounds, wounds with necrosis or slough, minor burns and tissue managed by radiation, necrotic and infected wounds Dehydrate easily if not covered, thus requires a secondary dressing May cause maceration (softening of tissue d/t soaking in fluid)

Hydrocolloid Dressing

*Duoderm, Tegasorb, Restore Moist healing environment allows clean wounds to granulate and necrotic wounds to debride autolytically* Occlusive or semi occlusive dressings Minimal to moderate exudates in partial and full thickness wounds May be used in combination with other dressing materials such as pastes, alginates Barrier to external fluids Conformable, absorptive May be used in combination with compression for venous ulcers May be left in place for up to 7 days... Not recommended for wounds with heavy exudates (this may dislodge the dressing), sinus tracts, or infections, wounds surrounded with fragile skin, or wounds with exposed tendon or bone

WOUND PICTURE

*W* -wound or ulcer location *O* -odor (assess before and during all dressing changes) *U* -ulcer category, stage (for pressure ulcer) and depth (partial thickness or full thickness) *N* -necrotic tissue *D* -dimension of wound (shape, length, width, depth: drainage, color, consistency and amount) *P* -pain (when it occurs, what relieves it, patient's description, patient's rating scale) *I* -induration, (surrounding tissue hard or soft) *C* -color of wound bed (red-yellow-black or combination) *T* -tunneling (record length and direction) *U* -undermining (record length and direction, using clock references to describe) *R* -redness or other discoloration in surrounding skin *E* -edge of skin loose or tightly adhered? Edges flat or rolled under

Focal assessment

-Data characterizes the status of the wound and surrounding skin -Anatomical location; for accurate description and may provide cues as to plan of care -Extent of tissue damage guides the selection of interventions (think partial/full thickness) -Percentage and type of tissue in wound base Distinguish viable tissue from non-viable (i.e.. 50% eschar, 50% granulation) The description indicates to what extent the wound is progressing toward healing... -Necrotic; nonviable, devitalized (dead tissue) -Eshcar; Black or brown necrotic devitalized tissue -Slough; soft, moist avascular (necrotic/devitalized) tissue → may be white, yellow, tan, or green, may be loose or firmly adherent -Granulation; Pink/red moist tissue comprised of new blood vessels, connective tissue, fibroblasts, and inflammatory cells.

Wound assessments

-Exudate: clear, sanguineous, serosanguinous, purulent, yellow, tan, green -Odor: absent, faint, moderate, strong (assess after the wound has been cleaned) -Wound margins: Newly formed epithelium along the wound edge commonly flat and pale pink to lavender in color (termed the edge effect) indicates healing -Periwound area: Gives clues to the effectiveness of treatment. Look at color (erythema, white, blue), texture (moist, dry, indurated, boggy, macerated), and skin temp -Wound pain: can indicate infection or deterioration as well as inappropriate treatment choices

Effects of Hyperbaric Oxygen in Wound Healing

-Increased capacity of blood to carry and deliver oxygen to tissues. -Increased oxygen at the wound site has an angiogenic effect promoting neovascularization and healing. -Antibiotic activity is synergistically improved (especially the aminoglycosides) and leukocyte function is improved. -Vasoconstriction which is helpful in managing edema related to traumatic wounding or crush injuries.

Venous stasis ulcer

-Most common type of lower leg ulcer and are a symptom of underlying venous disease -Many are long standing with a duration of over a year -Must aid in venous return to the heart -Common complaints of venous insufficiency include swelling, discomfort, and heaviness of the legs. -Trauma is frequently reported as the initial cause of ulceration -Typically these ulcers are not painful and when mild discomfort is present, it is usually relieved by leg elevation

Hyperbaric oxygenation Precautions

-Only cotton linens/bedding and clothes. -No petroleum based products. -No cosmetics, hairspray, deodorant. -Due to increased pressure don't let pt hold breath. -Check blood glucose before and after treatment, can cause hypoglycemia. -Potential for hypertension and hyperthermia

Measuring wounds

-The length is longest distance across the open area of the wound - regardless of orientation. (Some facilities use the clock orientation - check hospital policy.) -The width is the longest distance across the wound at a right angle to the length.

Wound culture swap

1) Inspect and irrigate with normal saline 2) Rotate a sterile swab along all areas of the wound as shown including the sides and base of the wound, using the 10-point coverage system. 3) Don't use pus to culture. 4) Don't swab over hard eschar. Use sterile Ca Alginate or rayon swab, do not use cotton swab.

Tunneling vs Undermining

A tunnel is a channel that extends from any part of the wound through the subcutaneous tissue or muscle Undermining is tissue destruction that occurs under intact skin around the wound perimeter

Foam dressing

Absorption dressing *Minimal to heavy exudate, packing material, primary dressing for absorption and insulation, secondary dressing for wounds with packing, not effective for wounds with dry eschar* Provide a moist environment and thermal insulation Minimal to heavy exudate Partial and full thickness wounds Infected wounds May be used to provide additional absorption around drainage tubes Nonadherent forms protect surrounding skin Conform to shape around angular body contours May be used under compression venous ulcers Not effective for wounds with dry eschar

Obesity: Rhabdomyolysis

According to one study, a morbidly obese patient undergoing a surgical procedure lasting more than 5 hours can generate enough pressure on skeletal muscles to produce ischemia and infarction leading to rhabdomyolysis.

Cigarettes and wound healing

Adequate perfusion and oxygenation is a necessity; highest need for O2 is the inflammatory phase Cigarette smoking is particularly damaging (effects both) Byproducts = nicotine (vasoconstrictor & potentiates platelet aggregation), Carbon Monoxide (competes w/O2→lowers saturation), hydrogen cyanide (interferes with cellular transport of oxygen) Studies indicate a higher incidence of wound infection, dehiscence, and delayed healing among smokers

Transparent film

Adhesive, waterproof and impermeable to bacteria and contaminants. Has no absorbent capacity. Semipermeable to oxygen. Used as prophylaxis for high risk intact skin, superficial wounds with minimal or no exudates, autolysis Can leave on up to 7 days Functions as protection; prophylaxis on high risk intact skin, eschar covered wounds when autolysis is indicated Secondary dressing Skin tears (cautiously) Protect and promote autolysis Allow visualization

Obesity and wound healing

BMI of 40 = severe obesity, BMI of 40-49.9 = morbid obesity, >50 BMI = super Adipose tissue is poorly vascularized, resulting in suboptimal tissue perfusion and insufficient oxygenation = poor wound healing. As a result, infection, seroma formation, anastomotic leaks and wound dehiscence are more common among this population.

Chronic Wounds

Chronic wounds generally fail to heal within 3 months and are generally caused by an underlying pathologic process. Again, the time frame is only part of the data to determine if the wound is chronic Chronic wounds such as pressure ulcers, vascular ulcers, and neuropathic wounds behave much differently and may be extremely slow to heal

Whirlpool

Commonly used to remove bacteria and debris from the surface of large wounds. Additional benefits include softening and loosening of adherent necrotic tissue and cleansing and removal of wound exudates. Whirlpool and lavage for debridement not for cleaning - will disturb good tissue. Mechanical debridement

Unstaged ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar. Until enough slough and/or eschar is removed to expose the base of the wound, the depth and stage cannot be determined. Deep Tissue Injury damage begins in the muscle and progresses to the epidermis ...damage of underlying soft tissue from pressure and/or shear...

Full thickness

Full thickness wounds extend through the dermis into tissues beneath and may expose adipose tissue, muscle, or bone Heals by contracting and scar tissue

Red wounds

Healing When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed. As this layer thickens, it becomes beefy red Management: -Cover the wound, keep it moist and clean, and protect it from trauma -Use a transparent dressing (such as Tegaderm or Opsite) over a gauze dressing moistened with normal saline solution -OR- Use hydrogel, foam, or hydrocolloid dressing to insulate and protect the wound

Obesity: hyperglycemia

Hyperglycemia r/t stress = ↑ glucose levels = impaired immunity, inhibition of the inflammatory response, and interference with collagen synthesis in addition to the probable impaired perfusion/oxygenation of microvascular changes Insulin infusion may be more effective post-op than oral or injected route. Initially post-op care for patients undergoing major surgery (w or w/o diabetes) is glycemic control w/insulin gtt Remember bacteria need glucose to create the energy to replicate...

Obesity: surgery time

Increased risk for surgical wound infection d/t site of surgery (abdomen), procedure lasting > 2 hours, ≥ 3 co-morbidities (consider any size patient that meets these criteria at risk). Operation times of as little as 2½ hours have been shown to cause deep tissue injury or pressure ulcer

Other factors impacting wound healing

Medications: -Chemotherapeutic agents (due to the impact on rapidly dividing cells) -Anti-inflammatory medication (Corticosteroids suppress inflammation and delay epithelization NSAIDs are linked to delayed wound healing Age: All processes of the body is slowed due to aging. Two significant concerns is diminished inflammatory response and increase probability of microvascular disease (with or w/o conditions which directly effect vessel wall/capillary bed integrity Stress: Both psychologic and physiologic ↑ corticosteroid level compromises immune function, sympathetic stimulation → vasoconstriction Immunosuppression: Any disease process or medication that suppresses the immune system can alter healing. Primarily due to impairment of the inflammatory process End result is delayed wound healing and increased susceptibility to infection Miscellaneous: Any systemic condition that affects health status negatively affects wound healing Renal or Hepatic dz., Blood abnormalities (think blood cells for oxygen or inflammation response) Hypothermia, adverse wound pH

Foam "bandaid"

Some have an adhesive border Used for: Autolytic debridement Insulation Packing cavities Absorption: Light to moderate Moisture retentive Optimize epithelialization Protection Can be used for "off loading" to reduce pressure on wound

Stage 3 and 4 ulcers

Stage 3 Pressure Ulcer: Full thickness tissue loss. Subcutaneous Fat may be visible, but bone, tendon, or muscle is not exposed. Slough, undermining and tunneling may be present. Stage 4 Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough of eschar may be present on some parts of the wound bed. It often includes undermining and tunneling. It is important to remember there is no reverse staging of pressure ulcers. Once a stage 4 ulcer, remains a stage 4 but documented as healed; muscles is lost, subcutaneous fat and dermis is never replaced.

Xeroform Impregnated Gauze

Sterile, fine mesh gauze impregnated with 3% Bismuth Tribromophenate (Xeroform) and USP Petrolatum Non-adherent to wound site and helps maintain a moist wound environment 3% Bismuth Tribromophenate (Xeroform) provides deodorizing and bacteriostatic action INDICATIONS: Minimally draining wounds, Surgical incisions, Lacerations, Donor sites, Burns

Black wounds

Tissue death Black, the least healthy wound color, signals necrosis. Dead avascular tissue (known as eschar) slows healing and provides a site for microorganisms to proliferate *Management* Debride the wound as ordered: -Enzyme product such as Accuzyme or Panafil -Conservative sharp debridement -Hydrotherapy with whirlpool or pulsatile lavage Do not debride, keep clean and dry: -Wounds with inadequate blood supply -Uninfected hell ulcers -Assess for infection: localized edema or indurations and accompanied by warmth

Factors that impair wound healing

Tissue perfusion/oxygenation Nutrition Infection vs. Inflammation Diabetes Obesity Medications Age Stress Immunosuppression Any systemic condition (disease, malignancy, sepsis) Blood Abnormalities Wound "factors" (temp., edema, bacteria, pH)

Gauze dressing

Used as wound packing Adheres to wound tissue for nonselective debridement, labor intensive some may dry out Minimal to heaving absorption, packing, can be impregnated to deliver antimicrobials Partial and full thickness wounds, infected wounds, wounds with cavities or tracts No longer standard of care, causes pain, has poor antimicrobial properties, labor intensive, many times done incorrectly ( as you all discovered when practicing and demonstrating) This dressing is cheaper We are still seeing it used

Best way to classify wounds

Wound age -Wound depth-Wound color

Depth of tissue destruction

partial thickness or full thickness

Hyperbaric Therapy Protocols

• Remember oxygen is a drug and with it comes risks for toxicity • Calculations are involved to determine the atmosphere absolute (ATA) desired for the specific wound • Example: for radiation injury, 2.5 ATA x 90 minutes