chronic wounds

enzymatic debridement

-collagenase (Santyl) ointment -dnu with silver containing agents -alt to sharp debridement for patients with CI

drug agent used for debridement

-collagenase (Santyl) ointment -used for debridement by digesting collagen fibers -can be used in infected wound -used for pressure sores, diabetic foot, and venous ulcers -clean wound with saturated saline gauze pad to gently remove any debride and then apply to wound once daily

venous ulcer treatment

-compression therapy is standard of care -reduce edema -keep legs elevated: 30 mins TID-QID with their legs at heart level -wound dressings: use alginates, hydrofibers, foams

composites

-covaderm, stratasorb -contain at least 2 diff products in a combo of layers -one layer is semi permeable to reduce bacteria -all in one dressing

stage 3 & 4 treatment

-debride necrotic tissue -irrigation of pressure wounds with normal saline -chose most appropriate dressing based on how wet the ulcer is

diabetic foot ulcer treatment

-debridement: sharp recommended -moist wound care -pressure off-loading -elevate foot -diabetic footwear -non-removable casts

compression therapy

-elastic: bandage, stockings -rigid: pasta gauge (unna) boot -TED hose not recommended for compression therapy-not enough pressure

hydrogels

-elasto-gel -99% water or glycerin, available in sheets, gels, or gauzes -give moisture to dry wounds, consider for wounds with little exudate

pressure ulcer stage 3

-full thickness tissue loss -subcutaneous fat may be seen only -healing time=1-3 months

pressure ulcer prevention

-have skin inspected regularly -moisturize to keep skin hydrated: lanolin not recommended, baza cream( zinc oxide and miconazole), aloe vesta ointment (mineral oil, petrolatum, aloe, miconazole ) -do not use foam rings or donuts-do not adequately distribute pressure

risk factors for pressure ulcers

-incontinence -poor nutrition -poor perfusion -older age -smoker -mental status alteration

drug agent for diabetic foot ulcers

-Becaplermin (Regranex 0.01%) -adjunctive treatment -recombinant human platelet-derived growth factor -used in diabetic foot ulcers to promote new cell and blood vessel growth -apply once daily and cover with saline moistened dressing -very expensive -risks: cancer

alignates

-Curasorb, calcium alginate -forms gel with exudate and provides moist environment -good for moderate and heavy exudate -change daily, packing agent, used in infected wounds

hydrocolloids

-DuoDERM CGF -absorb exudate over a period of time and prevent evaporation of skin moisture -dressing(combo of moisture from wound and dressing) may smell bad but wound may not be infected -change 3x per week but may be left on for up to 7 days

hydrofibers

-aquacel -form a soft gel upon contact with moisture -absorb 3x more moisture than alginate -used for wounds that produce heavy exudate

medications for venous ulcers

-aspirin -MOA: inhibits platelet aggregation -used in combo with compression therapy -dose: 325 mg PO daily

autolytic debridement

-body's natural process of removing dead tissue -slow process

pressure ulcer aka decubitus ulcers

-caused by reduced blood flow to an area -considered a preventable condition -most common over bony areas

stages of wound healing

-inflammation: inflammatory cells enter and cause redness, warmth and swelling -proliferation: new blood vessels and collagen develop, new epidermis formed -maturation: remodeling occurs ( can take up to 2 years)

other forms of debridement

-larval -surgical -mechanical

venous ulcers

-may have problems with valves in veins -damage from previous blood clot -cause: muscles in lower leg pump blood back to the heart become weak resulting in venous hypertension -have a lot of exudate bc of leg edema

wound dressings

-moisturize while removing excess wound fluid (exudate) -non-toxic/allergenic -protect from further trauma, including on removal -prevent bacteria from entering the wound -insulating -allow gas exchange -comfortable -infrequent changes -low cost

pressure ulcer stage 4

-most severe stage -full thickness skin loss -exposed bone, tendon, or muscle -healing time=12-24 months

diabetic foot ulcers risk factors

-neuropathy -peripheral arterial disease -dry cracked skin -reduction in blood flow to the foot

most common chronic wounds

-non-healing surgical wound -pressure ulcer -diabetic foot ulcers -venous ulcers

patient-specific risk factors for wound healing

-older patients -thin skin -comorbidities -nutritional deficiencies (weight extremes) -poor vasculature (smokers, atherosclerosis)

pressure ulcer stage 2

-partial loss of dermis -ulcer is shallow with red-pink wound bed -blister may present, no sloughing -healing time=1-3 weeks -treatment: occulusive/semipermeable, hydrocolloid, aliginates or foam (if heavy exudate)

diabetic foot ulcer prevention

-regular foot exams -inspect feet daily -protective footwear

venous ulcer prevention

-regular use of compression stockings -walking -leg elevation

sharp debridement

-scapel or scissors used -acute, done in physician's office

pressure ulcer stage 1

-skin is still intact-red -redness is not blanchable -healing time=1-3 days -treatment: transparent film, saline moistened gauze, hydrocolloid, hydrogel

flims

-tegaderm, polyskin -polyurethane with an adhesive on one side -patients can visualize the wound -need to be changed once a week

gauze

-telfa -most common, need to be changed everyday -used for wet to dry dressings

local risk factors for wound healing

-too much pressure -dryness -too much moisture -repeated trauma -fluid retention -infection -skin necrosis

best way to manage wounds

TIME method

agents that should not be used

cytotoxic agents impair wound healing -povidone iodine, hydrogen peroxide, acetic acid

E

edge of wound -keep the wound edges healthy to promote wound closure

foams

good for wounds with exudate

I

infection or inflammation -prevent or treat infection, minimize inflammation

M

moisture balance -dont want scab to form because it delays re-epithelization, but also don't want too much moisture

preferred wound cleaning agent

normal saline 0.9%

T

tissue management -debridement to remove necrotic tissue and enhance wound healing