wound management_pcn krisna

Wound Care

By

Ms. Krisna Muthusamy SRN.SCM.NICU.FP.FTC. BSC. MA

Penang Hospice

FUNGATING AND SMELLY

TUMOURS

Unsightly and smelly lesion are a severe blow to self

image

Malodorous wounds lead to social isolation

Ulcerated cutaneous metastases often cause severe

pain

Wound with Maggot

Fungating Wounds

Aims of managing fungating wound

Control / pain / exudates / odour

Prevent infection

Fewer dressing changes

Trauma-free dressing removal

Cosmetic acceptability

Improved quality of life

Principles of Management Palliative oncologic treatment brings temporary

control of malignant ulceration

Chemotherapy bring about regression of lesion

Radiotherapy control bleeding and achieve

healing

Toilet mastectomy may be indicated for massive

breast lesions

Symptomatic treatment

Cleansing the wound

irrigation with normal saline

do not use antiseptic cleansing solution or

hypochlorites---toxic to granulating tissue

Debridement

encrusted purulent materials use wet-dry dressing

purulent slough--xerogel e.g Debrisan

black,necrotic tissue--streptokinase/elase to necrotic

area

Symptomatic treatment --continued

Control odor

regular cleansing with disinfectant solution e.g

povidone iodine ,sodium hypochlorite or

1% chlorhexidine

metronidazole gel +oral Flagyl 200-400mg tds

charcoal dressing

maalox

yogurt

honey

Symptomatic treatment ----continued

Control Bleeding:

pressure

soak gauze in 1;1000 epinephrine and apply

sucralfate paste (crush 1 gm sucralfate tablet in

2- 3ml water -soluable gel)

haemostatic dressing /sponge (Kaltostat /gelform

silver nitrate

radiotherapy

Symptomatic treatment ---continued

Wound dressing

layer next to wound --sterile and non adherent

permeable for exudate

second layer absorbent

outer layer--charcoal to absorb odour

change dressing as required

soak dressing before removal

clean wound with saline irrigation

Symptomatic treatment--continued

Control Pain

Maalox} relieve burning sensatins

yogurt }

consider NSAIDs

Pressure Sores

Damage to the skin

as a result of

extrinic pressure and

shearing force

Pressure Sore

Contributing Factors

Pressure: decrease blood flow-->tissue anoxia-->

^ capillary permeability-->edema-->cell death

Shearing force

Friction

Moisture

Other factors

Immobility/obesity/age/sensory and motor deficit

general malnutrition/hypoproteinemia

vitamin C /zinc deficiency

cachexia/anaemia /peripheral vascular disease

chronic steroid therapy

immunosuppression / maceration of skin

improperly applied cast, bandages

folds /bed crumbs,/hard mattresses

restraints bed rail, chipped bed pans

Sites

Posture Sites

supine rim of ears, inner knee ,heel

lateral trochanter, lateral condyle

of knee, malleolus

sitting sacrum

semi recumbent outer ankle

Prevention

Appropriate mattress

egg-crate /water bed/air bed/ foam /clinitron bed

turning --2 hourly/ use pillow or wedge cushions

wheelchair cushion--shift weight every 15 minutes

elbow/heel pads

bed cradles

AVOID AIR RINGS

Aims

Maintain quality of life

Promote potential healing

Prevent further damage

Relieve pain and discomfort

Prevent infection

Control odour and exduate

Minimize bleeding

SKIN CARE

Inspect skin

keep skin dry

skin moisturized

avoid trauma

do not elevate patient >30% avoid sliding/shear

lift patient /no restraint/no bed rals

avoid over heating/vigorous massage

avoid alcohol or astringents on area under pressure

Nutrition /General care

Keep plasma albumin above 3gm/dl

haemoglobin above 10 gm /dl

supplements/ high protein

vitamin C

zinc

General measures

get patent out of bed/ mobility

avoid sitting for long period

active /passage range of motion exercises

Treatment Keep plasma albumin above 3gm/dl

haemoglobin above 10 gm /dl

supplements/ high protein

vitamin C

zinc

General measures

get patent out of bed/ mobility

avoid sitting for long period

active /passage range of motion exercises

Treatment by stages

Stage Appearance Management

1 blanch/erythema relief pressure

non blanch/red tegaderm change prn

skin intact

2 superficial skin loss omiderm dressing

3 blister /eschar omiderm dressing

do not open blisters

progress >4/52 debride

Treatment by stages—continued Stages Appearance Treatment

4 clean ulcer with relief pressure

granulomatous base povidone iodine /duoderm

calcium alginate dressing

honey, sugar-povidone iodine

packing

5 Infected ulcer pressure relief

grey slough surgical/enzymatic debridement

charcoal for odour

sugar-povidone iodine pack

Wet to dry dressing

systemic antibiotics

Choice of dressing according to stage Stage Dressing

Blanching vapour permeable adhesive

skin intact replace every 5-7 days

Superficial clean hydrocolloid (5-7 days )

Ulceration little exudates--hydrocolloid

subcutaneous heavy exudates--- alginate

Ulceration pack with hydrocolloid paste

debride--hydrocolloid dressing

Infected debridement-pack with alginate ribbon

cover with film dressing

Stomas and Fistulas

Definitions

Stoma:

A surgically created opening to divert feces / urine out of the body

Fistula

an abnormal passage between two internal organs or frnm an internal organ to the surface

Bowel Stoma

Location depend on the level of obstruction

Determines the character and volume of the

effluent

Ascending colon ----high volume, liquid stool

Transverse colon----loose/softy formed stool

Descending colon----loose to formed stool

Sigmoid colon--------formed stool

Small bowel-----------frequent watery tool

Stoma Care

Respect the patient’s established regimen for stomas

Be sure the skin is clean / dry before applying new

stoma appliances

Use only mild soap to clean around the stoma

Rinse the skin thoroughly to remove the soap

Pat the skin dry gently

Use special powder or ointment

Replace stoma bag promptly

Make sure it stoma bad fits properly

Supra Pubic Catheter

Special Consideration

Allergic dermatitis change different appliance

Effluent dermatitis stoma paste/cream

steroid cream/antifungal antibacterial

Don’t allow appliance to overfill

Trauma change pouch 4-7 days

Gas /odour activated charcoal/ avoid gas forming food

Diarrhoea anti diarrhea pills / diet

Constipation diet, enema laxative

Bleeding stoma powder, pressure, rule out tumour

Ileal conduits

Barrier cream to protect skin

Pouch should be odor- proof and have a drainage

valve to drain the urine

Swab the skin around the pouch with acidic solution

(1part vinegar to 1 part water)

Pour 1-2 oz of same solution in pouch, patient to lie

supine for ½ hour-----aid flushing inside the stoma

Empty the pouch

Routine care similar to bowel stoma

Nephrostomy Change dressing every other day preferably after the

shower

Clean the skin with an bactericidal soap then paint

with povidone iodine

Apply slit gauze around the nephrostomy tube, loop

the tube to avoid traction -- >place a large gauge pad

over the looped tubing.

Connect tubing to standard urine bag

Possible problems

blockage, dislodgement and purulent discharge

Cutaneous Fistulas

When possible apply a stoma bag

Clean the skin around the fistula with water

(no soap, antiseptics )

Use filler to create flat surface

Choose right size stoma bag

Control odor

Multiple fistulas, use absorbent pad and normal

Dressing

Protect surrounding skin

Recto-perineal fistula

Cancerous wound can heal