Chronic wounds

Thin films

Cheap, self-adhesive, semi-occlusive, aid autolytic debridement

Thin film products

Opsite, tegaderm

Foam products

Polymem, Flexzan, Mitraflex, Allevyn

Arterial insuff. characteristics

usually has a pale granulated base, uniform round wound, thin and shiny skin

Venous insuff. characteristics

usually has slough, irregular borders, lots of drainage, hemosiderin stain, wet appearance

Location of venous insuff.

usually medial or anterior ankle, medial lower legs

Basement membrane of the dermis

where new cells are born, cells mature and are pushed out to the epidermis

Wound exam and eval

*C-color: describe the wound bed • %granulation, % slough,% necrosis, % bone, etc *O-odor: musty, foul, sweet (pseudomonas) *D-drainage: amount, color, texture *E-extent : measure the wound *S-surrounding skin :describe the perimeter, surrounding skin

Stage I pressure sore

"non-blanchable erythema"

Alginates

"seaweed", calcium alginate or synthetic, non-occlusive, absorb lots of drainage

Big picture of the wound during eval

*What is the etiology? *What has been tried before? *What medications are being taken? *Is cellulitis present, and is the patient on antibiotics? *Is the patient going to be able/willing to be compliant with your plan of care? *What allergies does the patient have?

Absorptive dressings (use on wounds that are too wet)

*alginates *foams *gauze

Basic questions to ask when first deciding on a dressing:

- Are there any signs/symptoms of infection • Do not use and occlusive dressing on an infected wound - How much drainage is present - Debridement needed vs maintain a healthy wound

Wound vac

- Can use topicals under both - instills solutions into wounds -Black vs white vs silver foam -Fenestrated dressings for body cavities

Proliferative phase of wound healing

- granulation tissue*, epidermal migration. Stuck here = hypergranulation/chronic wound.

Silvadene

-An old stand-by, can be used on lots of wounds -Contraindicated on young children/babies -Use with caution on patients with decreased renal or hepatic function -Nice antibacterial and antifungal -Can be covered with gauze or used without dressing

Gauze

-Cheap, absorbant, non-occlusive, but stick to granulation

Deep tissue injury

-Describes the deep purplish discoloration seen on patients when a severe insult has occurred, but the tissue is not opened (epidermis is intact). -DO NOT make the mistake of staging this as a stage I!! It's almost always deeper. -Recommendations are to term it deep tissue injury, an unstageable wound.

Sharp debridement

-Forceps, scissors, scalpel (must have order!!! and experience to do this independently

Inflammatory phase of wound healing

-Hemostasis, rush of platelets, macrophages/etc WBCs. -Drugs that decrease inflammation interfere. -Get stuck here = chronic wound

Cleaning a wound

-If it is necrotic or "dirty", clean it -Slough, eschar, odor, worrisome drainage - If it is clean, maintain it appropriately

Treatment of venous insuff. ulcer

-Most important part is COMPRESSION (if possible). -Good local wound care -Unna's boots* are effective if pt is ambulatory -Layer compression wraps provide more consistent compression in many professionals' opinions -Sequential compression pumps (ie lymphedema)

Treatment of Neuropathic wounds

-Must remove the shear!! Patients must be placed in total contact casts, custom boots, custom insoles, etc or become NWB for these wounds to heal. -Pt compliance is a must. -Shave the perimeter callous to enable the epithelial cells to migrate over the granulation. -Good local wound care, moist not wet! -Good control of blood sugars.

If wound is too dry, add dressings with moisture

-Occlusive or semi-occlusive dressings (never occlude an infected wound!!!!) -Topicals

Arterial Insufficiency Ulcer

-Occur on the lower leg or foot -Round wound with sharply demarcated edges -Usually have a pale, red base

Enzymatic debridement

-Ointments applied to dissolve eschar

Regrainex

-PDGF, approved by FDA only for "diabetic" ulcers -Applied with damp-dry saline dressing -Use on clean wounds only! -Expensive!!!!!!!!! -Use sparingly and refrigerate.

Pressure sore

-Prolonged pressure, usually over bony prominences, but can be any area of body. -Can happen in as little as 15-30 minutes on bony areas under direct pressure (heels, ischial tuberosity) -Are thought to originate deeply and then expand outward. -Weight-shifts and pressure-reducing surfaces are used to prevent them.

Autolytic debridement

-Pt's body does the work *The most selective

Hyperbaric oxygen

-Special pressure chambers used - 1.5 to 3 times normal atmospheric pressure -Used for gas gangrene, osteomyelitis* most often -Medicare will cover if standard wound care has not been effective and wound demonstrates progress with HBO

Pressure relieving surface

-Supposed to prevent capillary closing pressure, therefore allowing blood to continue to perfuse tissues *Clinitron beds (air fluidized beds) -Does not completely prevent capillary closing, so still requires wt-shifts or turning *Low air loss mattresses *Wheelchair cushions

Neuropathic wounds

-True "diabetic" wounds -People with diabetes can have any type of wound. -Classify them carefully. -A pressure sore on a person with diabetes is still a pressure wound. -Diabetic neuropathic wounds occur typically on the bony prominences of the plantar surface of the foot, especially the met heads, but can also occur on other surfaces of the foot. -Typically round with large amounts of callous built up around the perimeter. -Can also happen in anyone with neuropathy, not just diabetics

Management of skin tears

-Try to save the flap if possible -Moist wound care for open wound, possibly just a topical for category 1's. Polymems work great. -If flap dies or you cannot unroll, will need to be debrided.

Mechanical debridment

-Use gauze to wipe -Wet-dry dressing

Gauze

-Use on dirty wounds, wounds with heavy exudate, use to pack tunnels/tracts/undermining, use on wounds that have to be changed daily

Venous insufficiency ulcer

-Usually occur on the ankle, with medial ankle being the most common area, but can occur anywhere on the lower leg -Typically are shallow wounds with significant slough and irregular borders, minimal pain -Can be present for years without significant change

Signs of arterial insufficiency ucler

-Usually painful, especially with elevation or gait (claudication) -ABI less than 0.8 -Rubor of dependency*, thin shiny skin, no hair, cold extremity (poikilothermia)

Signs of venous insufficiency ulcer

-Waxy, thick skin, edema -The entire leg can be oozing serous fluid in severe cases, with dozens of small open ulcers, or can be one large ulcer with eschar/slough

Exception to adding moisture to dry wound

-stable heel ulcers -dry gangrene

Topical antibiotic ointments

Is ok for shallow wounds

Biological debridement

Maggots

Debridement

Removal of non-viable tissue *eschar* or slough/non-viable tissue *it slows granulation and reepithelialization, and harbors microorganisms

Foams

Semi-occlusive, can be self-adhesive, aid autolytic debridement, gentle on skin, absorb significant drainage

Dakin's solution

Sodium hypochlorite, used to saturate gauze/packing; can be used for grossly necrotic/infected wounds, NOT for wounds with significant amounts of granulation tissue. Full strength Dakins (0.5%) is best for infection; half strength (0.25%) is better for suspected colonization.

Alginate products

Sorbsan, Kaltostat, Aquacel

Location of arterial insuff.

anywhere on foot

Foams

Use on generally clean wounds, but can handle more drainage than films can.

Thin films

Use on wounds that are generally clean, have minimal drainage, and the dressing can be left in place for a few days

Alginates

Use under a semi-occlusive dressing for added drainage control

Topical skin preps

Usually come as a wipe-on or spray to prevent tape stripping of skin or maceration of wound edges

Stage II pressure sore

a blister or shallow crater, not into the subcutaneous

Stage IV pressure sore

a deep wound involving muscle, bone, etc.

Undermining

a shelf at perimeter of wound; skin is growing and wound remains under skin

Stage III pressure sore

a wound through the dermis into the subcut, but not into muscle or bone

Chlorpactin

again, chlorine is the active ingredient; harsh on granulation, like Dakins. (0.4% or 0.2%)

Remodeling phase of wound healing

collagen remodeling, wound will never be more than 80% of pre-injury strength

Unstageable pressure sore

eschar or slough on bed

Tracts

long thin openings in wound, "dead-ends"

Topical barrier creams

skin protectants

Topical Xenaderm/Calmoseptine

thick ointments, very versatile for barrier (incontinence) or shallow wound healing (now have generic "allanderm")

Full thickness wound

through the dermis