epn ii book 2 chapter 5,6

7/24/2019 EPN II Book 2 Chapter 5,6

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Chapter

5

After studying this chapter, student should be able to: Explaining wound

management related to neuropathic ulcers (focus: speaking skill)

Read the passage below carefully.

TREATMENTS AND WOUND CARE OF NEUROPATHIC ULCERS

Neuropathic ulcers form as a result of peripheral neuropathy, typically

in diabetic patients. Neuropathic ulcers also called diabetic foot ulcer. The wound

should be thoroughly debrided down to healthy, bleeding tissue. Often there

is infection underneath the superficial layer of necrotic tissue, even extending down

into the bone and bone marrow. Debridement allows for better assessment of the

ulcer and any underlying infections, as well as providing a better healing

environment. Ideally, the wound environment should be moist while healing, but also

allowed to breathe. The exact properties of the dressing should be matched to those

of the wound.One of the most essential components to effectively healing neuropathic ulcers

is to reduce pressure on the affected area. However, relieving pressure from the

wound needs to be balanced with keeping proper circulation to the extremities, so

excessive bed rest is not recommended. Contact casts can be used to decrease pressure

of the affected area while allowing the patient to remain ambulatory. Therapeutic

shoes are also available to serve the same purpose, but are typically used for

prevention or to avoid recurrence as opposed to during treatment.

If the ulcer does not resolve after more conservative measures, surgery to correct

deformities in the foot may be considered to remove excessive pressure.

A.

Principles Wound ManagementD Debride necrotic tissue

I Identify and treat infection

P Pack dead space lightly

A Absorb excess exudate

M Maintain a moist wound surface

O Open wound edges (heal from bottom up)

P Protect the healing wound from trauma and infection

Learning Objectives

ACTIVITY (at Home)


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I Insulate the wound bed

B.

Wound Bed Preparation

Wound assessment involves many parameters, but the following indices should be

included in continued documentation of wound healing: size (length, width,

depth), extent of tissue involvement (partial or full thickness; stage of pressure

ulcer), presence of undermining or tracts, anatomic location, type of tissue in base(viable or nonviable), color (red, yellow, black categories), exudate, edges,presence of foreign bodies, condition of surrounding skin, and duration2.

Photography is useful for documenting progress and should include a measuring

scale and date. Photograph the wound from the same distance each time to

properly frame and scale the wound. Debridement is a key component in wound

healing. It facilitates the removal of all foreign debris within a wound, thereby

promoting the formation of granulation tissue and allowing for definitive wound

closure. There are some debridement methods:

1. Surgical Method

Wound debris cut away by surgeon.

Usually requires operating room time.Best used in large areas of necrosis and extremely contaminated wounds.

Also used to prepare wounds for grafting or skin flaps.

Not recommended for malignant wounds

Fastest and most effective way to clean up a wound.

Good choice for diabetics with foot ulcers.

2. Enzymatic Method

Involves using enzymatic agents to breakdown necrotic debris.

Used on wounds prone to eschar formation and friction-type injuries.

Fast-acting and causes minimal damage to healthy tissue.

Requires prescription.

Good choice for home care patients who find it difficult to mobilize inorder to go to a clinic.

3. Autolytic Method

Do not use this method in the treatment of infected pressure ulcers

Uses bodys own enzymes to soften and breakdown the eschar.

Painless form of debridement.

Good choice for patients with low pain tolerance.

Slow method.

Requires close monitoring for infection.

Can be achieved with semi-occlusive or occlusive dressings or with the

addition

of water-based gel to wound bed.

Used for Stage 3 ulcers, venous ulcers, and traumatic ulcers with lighteschar.

Do not use on heavily exudating wounds.

If tissue autolysis is not apparent in 24 to72 hours, use another form of

debridement

4. Sharp Method

Similar to the surgical method in terms of employing a sharp instrument to

remove non-viable tissue, but should not reach blood.


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5. Mechanical Method

Physical removal of debris from a wound.

May be used in the management of surgical wounds and pressure,

ischemic, and venous leg ulcers.

Simplest form is wet-to-dry but this technique is time-intensive and costly,

and often causes bleeding and pain, with removal leading to wound

trauma.Other methods include irrigation, pulsatile lavage, and whirlpool therapy.Wound irrigation can be used to remove exudate that will remove the

exudate but not damage new tissue

6. Maggot Debridement (Bio-Debridement, Live Debridement)

Maggots ingest necrotic tissue.

C.

Dressing Selection

Apply appropriate topical therapy in keeping with the principles of wound

healing and in accordance with the manufacturers recommendations. The most

important factor in wound dressing selection is the ability ofthe dressing to keep

the ulcer tissue moist and the surrounding intact skin dry.Use a dressing that will keep the wound bed continuously moist.

Use clinical judgment to select a type of moist dressing suitable for the

wound.

Choose a dressing that keeps surrounding peri-wound skin dry while keeping

the wound bed moist.

Choose a dressing that controls exudates but does not desiccate the wound

bed.

Consider caregiver time when selecting dressings.

Eliminate wound dead space by loosely filling all cavities with dressing

material. Avoid overfilling.

Nutritional Therapies and Interventions

Wound Type Risk and Assessment Factors Nutritional Considerations

Neuropathic ulcers

(related to the loss of

protective sensation

(LOPS) in the feet and

legs as a result of a

primary neurological

condition, metabolic

disease process

(diabetes))

Loss of protective sensation

along with physical or

mechanical stress, such as

increased plantar pressure

Hyperglycemia

Glycemic control is

important for

preventing and

reducing the risk of

infection.

B12 supplements may

be beneficial in

neuropathy.


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Each member of a group should give the opinion related to the pictures,focused on wound management.

SPEAKING ACTIVITY (at Class)

1

2


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Chapter

6

After studying this chapter, student should be able to using a wound assessment

chart.

Look at the picture then fill into Wound Assessment Chart.

Learning Objectives

Learning Objectives

UMM HOSPITAL

WOUND ASSESSMENT CHART

Ward : 12AConsultant :Surname : Anggun M.Given names : MarshaDOB : 5/09/74Sex : Female

WOUND ASSESSMENT FORM

Date 8/2/2008Name Marsha Anggun M.

Wound site L calf

Wounddescription

granulated sloughy necrotic infected

Frequency ofdressing

bd tds daily 3rddaily

Antibiotics no yes oral IV

Surrounding

skin

healthy dry macerated inflamed

Exudate nil Small amt moderate heavy

Exudate type N/A serous haemoserous purulent

Odor present yes no

Debridement nil surgical Mechanical(wet to drydressings)

chemical Autolytic

Dressing

products

Non-adhesive dressing (NAD)

antimicrobial hydrating

Woundclosure

sutures clips open wound

Comments For review by vascular team on MondayWound intact-next dressing n two days

N/A : not applicable IV : intravenoustds : three times a day amt : amountbd : twice a dayL : left

epn ii book 2 chapter 5,6

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