2015: wounds in the geriatric population-salas

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WOUNDS IN THE GERIATRIC POPULATION

Adriana Salas, MSN, RN, CNS, ANP-BC

Ingrid Kruse, DPM

VA San Diego HealthcareSan Diego, CA

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Outline

WHY WOUNDS ARE IMPORTANT RISK FACTORSASSESSMENTSTANDARD WOUND MANAGEMENT REASSESSMENTADVANCED WOUND CARE

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Wounds are Common

ANY ULCER 12% of the population >65yrs 1

VENOUS STASIS ULCERS 1% of US population 2

PRESSURE ULCER 0.4 – 38%70% of pressure ulcers occur in the elderly 3,4,5

1. U.S. Census Bureau. Statistical abstract of the United States. 2012. http://www.census.gov/compendia/statab/2012/tables/12s0009.pdf. Accessed 9/15/14.2. Gillespie DL. Venus ulcer diagnosis, treatment, and prevention of recurrences. J Vasc Surg. 2010: 52:8S-14.3. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston VA: National Pressure Ulcer Advisory Panel; 2001. 4. https://www.soa.org/news-and-publications/newsroom/press-releases/society-of-actuaries/default.aspx 5. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington,DC: National

Pressure Advisory Panel; 2009.

http://www.census.gov/compendia/statab/2012/tables/12s0009.pdf.%20Accessed%209/15/14

https://www.soa.org/news-and-publications/newsroom/press-releases/society-of

https://www.soa.org/news-and-publications/newsroom/press-releases/society-of

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Wounds are Expensive

Foot infections are the most common reason for hospitalization in Diabetics

PRESSURE ULCER COST $43,180 - $151,500 per hospital stay $9.2 -$15.6 billion total U.S. cost 1,5

LEGAL COST2nd leading cause for litigation in long term care4 Medicare and Medicaid services stopped reimbursing acute care facilities for treatment of pressure ulcers in 2008

Diabetes Care 1998;21:2161-2177 and JAPMA 98:166,2008

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Morbidity

Physical decline Delayed rehabilitationInfectionAmputationDepressionFinancial burdenDeath

NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org

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Risk Factors

ModifiableTobaccoIncontinenceMalnutritionDiabetesHypertensionVascular Disease

Non-ModifiableSkinMuscleFatMobilityCognition

Assessment of Wounds

LocationStage/SizeBase TissueExudate

PerimeterPainInfectionOdor

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Venous Stasis Ulcers

TREATMENTCompression & ElevationPerforator LigationPhlebectomyStrippingSclerotherapyLaser Therapy

1. Falanga, V., Fujitani, R. M., Diaz, C., et al (1999), Systemic treatment of venous leg ulcers with high doses of pentoxifylline: efficacy in a randomized, placebo-controlled trial. Wound Repair and Regeneration, 7: 208–213. doi: 10.1046/j.1524-475X.1999.00208.x

2. Image: http://3.bp.blogspot.com/-ye1j4BSJ5VA/Ud9-93LC0qI/AAAAAAAABx8/IBDXEDmjhHA/s1600/Chronic+Ulcers+2.jpg

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Neuropathic/Diabetic Ulcer

TREATMENTPressure ReliefProper shoes

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Arterial UlcersSTUDIES: Ankle Brachial Index (ABI) Toe-Brachial Index (TBI) Segmental PressuresWaveform Analysis TCPO2, Angiogram 1

1. D Holtman, V Gahtan. Peripheral Arterial Perfusion: is it adequate for wound healing? Wounds. 2008: 20(8): 230-235.2. Image: http://www.angiologist.com/wp-content/uploads/2010/08/Rutherford_6.jpg

TREATMENT: Balloon angioplasty, stent, or bypass surgery1

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Pressure Ulcers

TREATMENT: Pressure relief Temperature controlMoisture control

1. Image: http://1.bp.blogspot.com/--f1gXWksxF0/TxUdgP8iwtI/AAAAAAAAA-I/O_4nc6O_CIU/s1600/IMG_0418.JPG

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Common Sites For Pressure Ulcers

http://img.docstoccdn.com/thumb/orig/41604968.png

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Stage I Pressure Ulcer: Non-blanchable Erythema


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Stage II Pressure Ulcer: Loss of Epidermis and Dermis


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Stage III Pressure Ulcer: Subcutaneous Fat Layer


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STAGE IV PRESSURE ULCER:

Exposed Bone, Tendon Or Muscle


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Unstageable: Full Thickness, Depth Unknown


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Deep Tissue Injury: Intact Skin Or Blister

1. Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stNPUAP agescategories/Pressure Ulcer Prevention Points. NPUAP.org

2. http://woundeducators.com/wp-content/uploads/2014/01/suspected-deep-tissue-injury.jpg

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Mechanical Debridement

http://www.curezone.org/upload/_N_Forums/Natural_Heali/Wound_Packed.jpg

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Enzymatic Debridement

http://in.hartmann.info/534.php

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Sharp Debridement

1.http://www.podiatry.com/images/desertfootsite/images/Debridement-1.jpg

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Wound Maceration

TREATMENTPaint wound edges with betadine, avoid occlusive dressings.

https://wocn.confex.com/wocn/2007AM/techprogram/images/2414-0.jpg

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Hypertrophic Granulation Tissue

• TREATMENT: non occlusive dressing, steroid cream low potency x 5-7 days, topical antibiotic, compression with foam dressings, Silver nitrate sticks.

1. Sephen-Haynes, J., Hampton S. Achieing effective outcomes in patients with over granulation: wound care alliance UK. www.wcauk.org/downloads/booklet_overgranulation.pdf retr9eved 9/23/14

2. Image:https://woundcare-today.com/news/special-report/wound-care-today-special-report-overgranulation

http://www.wcauk.org/downloads/booklet_overgranulation.pdf%20retr9eved%209/23/14

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Peri-wound Yeast Infection

Treatment: topical or oral antifungal1. image: http://www.oley.org/lifeline/TubetalkMA07.html 2. http://www.monarchlabs.com/mdtdressings

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Wound Infection

• SIGNS/SYMPTOMS: induration, redness, warmth, purulent discharge, increased pain, fever, leukocytosis, elevated CRP

• STUDIES: MRI, bone biopsy, bone culture

• TREATMENT: topical, oral or intravenous antibiotics

http://healthh.com/wp-content/uploads/2014/06/diabetic-foot-ulcer-pictures-3.jpg

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Wound Odor

TREATMENT:

• Dressing with activated charcoal

• Metronidazole 0.75% gel

• Frequent dressing changes

• Dakins Solution

Image: http://s.hswstatic.com/gif/smelly-feet-1200x800.jpg

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Reassessment

MEASUREMENTS: – Pressure Ulcer Scale for Healing (PUSH) tool 1

– Bates-Jensen Wound Assessment Tool (BWAT) 2

PICTURES: Obtain consent per facility protocol

FREQUENCY: Daily until a working dressing change is established, then at least weekly

www.npuap.org Pressure Ulcer Scale for Healing (PUSH) PUSH Tool 3.0 http://www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf

http://www.npuap.org/

Sheehan et al. Diabetes Care 2003;26:1879-1882. 28

Wound Healing Prediction

• New Wounds that do not become 50 % smaller in 4 weeks will likely fail to heal and turn into a Chronic Wound!

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The Chronic Wound

• “Non-healing Wound”• “Stalled Wound”• “Problem Wound”

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The Chronic Wound

1.Infection – Biofilm, Osteomyelitis2.Hypoxia – Edema, Vascular disease, Nicotine3.Poorly controlled Diabetes, Malnutrition4.Trauma – Too much Pressure!!

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Chronic Wound

All risk factors addressed and corrected But wound still not healing :

Consider using Advanced Wound Care

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Advanced Wound Care Technologies

1. Negative Pressure Wound Therapy 2. Growth Factors: Regranex 3. Bioengineered Skin Substitutes: Apligraf, Dermagraft, Grafix 4. Extracellular Matrix :Oasis, Integra 33

Negative-Pressure Wound Therapy (Wound Vac)

Introduced in the US in 1997

produced faster wound-healing and faster granulation tissue formation than

standard wound careArmstrong et al:Lancet366:1704,2205

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Negative Pressure Wound Therapy , KCI

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Growth Factors: Regranex

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Bioengineered Skin Substitutes Products with living cells as functional skin

equivalents Recruitment of stem cells Production of growth factors Stimulation of angiogenesis

Re-epithelialization: Substrate for keratinocyte migration

Modification of inflammatory processes: Recruitment of neutrophils, prevention of biofilms

Mansbridge J. J Biomater Sci Polymer Edn 2008;19:955-968.40

Apligraf®

Organogenesis

Living bi-layered dermal-epidermal skin substitute Dermal layer: fibroblasts in bovine type I collagen Epidermal layer: keratinocytes Cells from human neonatal foreskin tissue FDA-approved for venous leg ulcers, diabetic ulcers Shipped overnight, viable for 2-3 days

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Dermagraft®

Shire

Bioengineered Dermal substitute Fibroblasts seeded on a bio-absorbable mesh Cells derived from human neonatal foreskin

tissue FDA-approved for diabetic ulcers Preserved at -70°C with 6-month shelf-life

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Dermagraft® Apligraf®

Bioengineered Skin Substitutes

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GrafixOsiris

• Cryopreserved Placental Membrane• Contains extracellular matrix rich in

collagen, growth factors, stem cells, epithelial cells

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Dermagraft

• Leg ulcer for over 1 year's duration

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Dermagraft

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Surgical Debridement

• In case of an abscess, incision and drainage is ESSENTIAL with debridement of all abscessed tissue.

Consensus Development Conference on Diabetic FootCare, 1999,Boston,MASSDiabetes Care, 1999:22:1354-60 49

Summary

1.Diagnose and correct reversible risk factors2.Manage wound bed 3.Assess healing after 4 weeks of standard

wound care4. If healing<50% consider Advanced Wound

Therapies

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Questions????

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2015: wounds in the geriatric population-salas

Health & Medicine