Chronic Wound Care

Necrotic stage III decubitus ulcer with eschar picture? What is an eschar?

Eschar - dry, black or brown devitalized tissue (necrotic) that must be removed in order for the wound to properly heal; may be soft or firm

Stuck in what stages? Huge cause of what? w/ what

-"Stuck" in the inflammatory and/or proliferative phases of healing -Huge cause of morbidity: ≥ 2.5 million pressure ulcers annually in hospitalized patients w/ Financial implications

Moisture Balance: A moist wound environment promotes what? But a wound that is too wet will do what?

-A moist wound environment promotes: granulation, epithelialization, and autolytic wound debridement, HOWEVER... -A wound that is too wet will lead to maceration and tissue damage

Foams(Curafoam Plus, Sof-Foam Dressing, 3M Reston Self-Adhering Foam, Tielle hydropolymer dressing)????

-Absorbing pad - any wound shape -Highly absorbent -May be hydrophilic or hydrophobic -May require a secondary dressing to hold them in place -Wound VAC & Foam

ABI - Ankle Brachial Index administered when? Pt feet at what level? What is used to detect arterial signal? -Two blood pressure cuffs used? -ABI calculated for each side:

-Administered after at least 10 minutes of rest -Patient supine feet at the same level as the heart -Doppler probe used to detect arterial signal -Two blood pressure cuffs used: ---Proximal to the ankle to obtain ankle pressures ---Proximal to the antecubital crease for the brachial pressure -ABI calculated for each side: ---Ratio of the highest systolic blood pressure at the ankle (posterior tibial or dorsalis pedis arteries) divided by the highest brachial systolic blood pressure. ---ABI of 1 to 1.2 is considered normal since the pressure in the leg should be equivalent or slightly higher than the pressure in the arm

Wound Infection

-All wounds are colonized by bacteria! -True infection can delay wound healing -Swab cultures usually grow bacteria that are contaminating the surface of the wound -CDC recommends needle aspiration or wound bed biopsy for a definitive culture and sensitivity

Dressing Materials: choice of dressing depends on what? Common types?

-Choice of dressing depends on: Amount of wound exudate, Shape & location of wound -Common Types: Alginates & hydrofibers, Hydrocolloids & hydrogels, Foams, Enzymatic agents

Barrier Creams form a what between what? Uses for what? (4)

-Creams/ointments that form a barrier between the skin and the environment -Uses: 1. For stage I decubitus ulcers 2. For skin protection in incontinent patients 3. For skin protection in immobile patients 4. For protection of intact skin surrounding open wounds

Alginates (AlgiDerm, AlgiSite, Dermastat)????

-Derived from seaweed -Twisted rope or pads à forms a soft gel which conforms to the shape of the wound -Highly absorbent -Easy to remove -Usually require secondary dressing

Stage III Pressure Ulcers what is it? Tx?

-Full thickness skin damage extending into the subcutaneous tissue -Treatment: Pressure reduction; Skin protection and cleanliness; Maintain moisture balance; Remove necrotic tissue (I had a pressure ulcer in Stage 3 after I FT the Sub and tried to protect myself by cleaning but stayed moist and necrotic)

Stage IV Pressure Ulcers what is it? Tx?

-Full thickness skin damage with damage extending to muscle and/or bone -Treatment: Pressure reduction; Skin protection and cleanliness; Maintain moisture balance; Remove necrotic tissue (I had a pressure ulcer in stage 4 after I FT and had a BM. I tried to protect myself by getting clean but stayed moist and necrotic)

Advanced Technologies include what? (4)

-Growth Factors: Oasis (Healthpoint) nRegranex (J&J) -Cellular skin equivalents: Apligraf (Organogenesis); Dermagraft (Smith and Nephew) -Acellular matrix materials -Wound VAC (KCI)

Wound Vac is what? (4)

-Negative pressure wound therapy -Intermittent and continuous -Regulates pressure at the wound site -Promote granulation tissue formation

Symptoms of Wound Infection??

-No healing despite optimal care for 2-4 wks. -Purulent drainage -Cellulitis of surrounding skin -Increased pain -Systemic symptoms - fever, leukocytosis, etc -Increased warmth of the wound

Stage I Pressure Ulcers sx? Treatment?

-Nonblanchable erythema of skin -Discoloration, warmth/cold, edema, hardness of dark skin -Treatment: Pressure reduction; Skin protection & cleanliness (I had a pressure ulcer in stage 1 with DEW who's Hard with NE and tried to Prevent it by staying clean)

Hydrocolloids & Hydrogels(DuoDerm, ExuDerm, OriDerm, Tegasorb)????

-Occlusive or semi-occlusive dressings -Contain gelatin, pectin, and other -Provides a moist healing environment -Hydrocolloids - Don't require 2ndary dressing -Low exudate wounds only because of high water content -Hydrocolloids are not recommend for infected wounds

Stage II Pressure Ulcers what is it? Tx?

-Partial thickness skin damage involving the epidermis and may involve dermis -Treatment: Pressure reduction; Skin protection and cleanliness; Maintain moist wound environment (I had a pressure ulcer in stage 2 after I went to the PT with ED. I tried to protect and clean myself but stayed moist)

Factors that Delay Wound Healing Psychological factors? Other factors?

-Psychological factors: Stress, anxiety, depression, Motivation and compliance -Age, Weight, Smoking, Financial status, Local wound factors, Location, Edema impeding oxygen flow BASICALLY EVERYTHING!!!

Venous Ulcers typical location? Usually have what? Wound bed? Skin may be what?

-Typical location: medial lower leg, shiny -Usually have moderate to heavy exudate -Wound bed is usually shallow -Skin may be shiny or tight from edema

Arterial Ulcers typical locations? Wound appearance? Wound bed? May not heal without what?

-Typical locations: Between toes or on tips of toes; Around lateral malleolus; Over phalangeal heads -"Punched out" wound appearance -Pale wound bed -May not heal without revascularization

Diabetic Foot Ulcers typical locations? Usually what?

-Typical locations: On plantar aspect of foot; Over metatarsal heads; Under heel -Usually painless

Chronic vs. Acute Wounds wound debridement necessary for which? Which has significant necrotic burden?

-Wound debridement necessary in both -Chronic wounds have significant necrotic burden

Pressure Ulcers what are they?

-lesions caused by unrelieved pressure resulting in damage of the underlying tissues; usually located over bony prominences and staged according to the degree of tissue damage

Wound Debridement: Autolytic debridement vs Mechanical debridement vs enzymatic debridement? What are three other types?

1. Autolytic debridement: -Naturally occurring in all wounds -Macrophages & enzymes liquefy nonviable tissue 2. Mechanical debridement: -Wet-to-dry dressings -Pressurized irrigation -Whirlpool therapy 3. Enzymatic debridement: -Exogenous enzymes that are applied to the wound surface to dissolve and digest necrotic tissue -Collagenase or P:pain-urea 4. Sharp debridement 5. Surgical debridement 6. Biological debridement (Myiasis)

Enzymatic Agents involves what? (4)

1. Enzymes that dissolve & digest necrotic tissue 2. For eschar (hard & dry) and necrotic wounds 3. Papain - derivative of papaya fruit/plant 4. Requires secondary dressing

Wound Vac macrostrain vs microstrain?

1. Macrostrain - visible stretch that occurs with negative pressure -Draws wound edges together -Provides direct and complete wound bed contact -Evenly distributes negative pressure -Removes exudate and infectious materials 2. Microstrain - at cellular level, leads to cell stretch (increased mitosis and cell proliferation) -Reduces edema -Promotes perfusion -Promotes granulation tissue formation by facilitating cell migration and proliferation

Treatment Goals include what? (5)

1. Reduce and/or relieve pressure 2. Reduce friction and shear 3.Correct nutritional deficiencies 4. Increase mobility (where possible) 5. Provide a barrier from excess moisture (from stool or urine) (I PIC RR to get Treated)

Acute Wound Healing stages? (3) and days?

1.Inflammatory (0 - 6 days): Edema, erythema, heat, pain 2.Proliferative (4 - 24 days): Granulation tissue, red, beefy, shiny; Cells migrate from margins sealing wound (epithelialization) 3.Maturation (21 days - 24 months): Collagen reorganizes, remodels, gains tensile strength (I had an acute wound that was inflamed for 0-6 days with the Pro who's 4-24 and Mature for 21-24 months)

Unable to stage due to necrotic tissue?

BROWN UNSTAGEABLE

Slough definition? Necrotic stage III decubitus ulcer with slough picture?

Slough - dead cellular debris that collects on wound surface; must be removed for wound to granulate; may be firm or soft and stringy

Factors that Delay Wound Healing: Systemic diseases?

Systemic disease: Diabetes, Renal failure, COPD, Anemia, HF, HIV, Malignancy, Immunosuppression, Medications (Immunosuppressants, Steroids, Anticoagulants), Nutritional status (Dehydration, Vitamin deficiencies) (My wound was delayed by the system bc DR CAHH was here for a MMIN)

Key points?

nKnow the what happens during the 3 phases of wound healing (inflammatory, proliferation, maturation) n Know how to readily identify wound stages nKnow the difference between venous, arterial and diabetic ulcerations, why they occur, symptoms and how to diagnose them (table) nKnow the indications for the different types of wound dressings (Alignates, Hydrocolloids, Hydrogels, Foams, Enzymatic agents) nIndications for wound debridement nHow to identify wound infection