jeanne lowe phd, rn, cwcn va hsr&d center of excellence
TRANSCRIPT
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Jeanne Lowe PhD, RN, CWCN
VA HSR&D Center of Excellence
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Objectives:
•Describe skin function and structure
•Discuss normal phases of healing
•Identify factors that can interfere with normal healing
•Describe basics of wound assessment
•Discuss different categories of wound dressings
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Functions of the SkinProtectionThermoregulationSensationMetabolism Communication
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EpidermisDermis
Subcutaneous Fat
Muscle
Bone
Skin Structure
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Factors Contributing to Impaired Skin IntegrityCirculationNutritionCondition of the
EpidermisAllergiesInfections
Systemic DiseasesTraumaExcessive ExposureMechanical Forces
FrictionShearingPressure
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Phases of Wound HealingHemostasis and Inflammation
Platelets releasevasoactive substance
causing permeabilityenzymes that attract
leukocytesgrowth hormones that
influence fibroblastsWound develops
erythema and edema
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Phases of Wound HealingWound “clean up”
Neutrophils arrivePhagocytosis
Macrophages appear within 3-4 daysPhagocytosisRelease of enzymes
that trigger fibroblast response
Stimulate angiogenesis
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Wound RepairRegeneration of injured cells by cells of same type
(i.e. Epidermis, bone)
Replacement by fibrous tissue (fibroplasia, scar formation)
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Fibroplasia (Proliferation)Occurs within the granulation tissue
framework (new blood vessels and loose collagen)
Proliferation of fibroblasts at site of injuryGrowth factorsCytokines
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Surgical WoundIntentional injury that disrupts blood vessels and
causes clotting and cascade of events that leads to wound closure within 2 to 4 weeks
History of Surgery 18th Century surgeons were
apprentices of barbers and
butchers
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Primary Closure
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Patient Risk Factors for Post-Surgical Wound Complications
ObesityDiabetesImmunosuppressionCardiovascular diseaseSmokingCancerPrevious surgeryMalnutrition
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Surgical Wounds: Complications
HemorrhageHematomasInfectionDehiscenceEviscerationFistula
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Incision Healing TimeEpithelial resurfacing complete at 2-3 days
No tensile strength, but impenetrable to bacteria
“Healing ridge” 5-9 daysLack of ridge = interventions to reduce incisional strain
Most dehiscences occur 5-8 days post-op, and about half are associated with infection
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Incision Care Cover with dry sterile dressing 24 to 48
hours, then open to airGently wash between sutures/staples to
remove crustsReport persistent pain, bleeding,
erythema, wound edge separation or cloudy drainage
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Wound Closure Aids
Steri-stripMontgomery strapsMedical StaplesSutures
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Steri-Strips
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Montgomery Straps
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Medical Staples
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Suture/Staple RemovalUsually removed 7-10 days post-opIncisions over areas with tension up to two
weeksIf concerned about incision dehiscence:
Remove every other oneSteri-strip
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Wound DehiscenceFascial or Cutaneous
disruptionHeavy bacterial loadLong time-lapse since
woundingCrushed or ischemic
tissue – severe contused avulsion injury
Sustained high-level steroid therapy
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Secondary Intention(includes chronic wounds)
Large tissue defectMore inflammationMore granulation tissueWound contraction - myofibroblasts
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Factors Inhibiting Wound HealingMedication
Cortisone, and epinephrineMalnutrition
Protein & caloriesVitamin & mineral deficits
Zinc, Vitamin A, Vitamin C, Vitamin EDehydrationEdemaPerfusionChronic illness & other conditions
i.e. diabetes, CHF, immobility
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Principles of Wound CareKeep wound moist
Manage drainage
Fill deep wounds
Control bacterial load
Protect wound from trauma
Assess healing
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Keep Wounds Moist Select dressings that maintain moisture.
Minimize time that wounds are open to air.
Add moisture to wound bed?
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Maceration makes skin more fragile.
Excessive drainage requires nursing time.
Manage Drainage
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Fill Dead SpaceFill wound with
dressing
Be careful not to over-fill (no rocks)
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Control Bacterial LoadTake time to wash or
irrigate wounds to decrease bacterial load.
No need to scrub!
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Protect From TraumaBe gentle to skin
Use non-stick dressings
Minimize tape
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But . . .
Remember to protect yourself from splash
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AssessKnow what is under
the dressing
Know typical healing pattern
Size matters
Document
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Document findingsLocation
Size (length / width / depth)
Wound base
Drainage
Surrounding skin
Systemic infection
What we’re doing
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Wound Documentation:Wound Base Descriptors
Granulation tissueRed, cobblestone/beefy.Only in full thickness
wounds
Epithelial tissueRegrowth of epidermisPink or pearly Smooth, shiny
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Wound Documentation:Wound Base Descriptors
SloughNecrotic/avascular tissue.Moist.Can be white, yellow, tan, or
green.
EscharNecrotic/avascular.Black or brownHard or soft.Often leathery adherent tissue.
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Wound Healing BasicsWounds do best in moist environment
not too wet, not too dryLoosely pack when needed
tight packing → injury to wound bed.Protect peri-wound skin
No Sting BarrierCleanse/irrigate before assessmentPre-medicate for pain prior to dressing changesIf culture is needed
cleanse wound thoroughly prior to swabbing swab in area of granulation/viable tissue if present. Never culture dressing!
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Product SelectionFrequency of change
Ease of procedure
Caregiver ability
Availability of products
Cost/reimbursement factors
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Dressing Purposes:To absorb drainageTo prevent contaminationTo prevent mechanical injury to the woundTo help maintain pressure to prevent
excessive bleedingTo provide a moist wound environmentTo provide comfort
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Alginates/Fiber Gelling Dressings Antimicrobials Collagen Contact Layers Foams Gauze & Impregnated Gauze Hydrocolloid Hydrogels (Amorphous) Skin Sealants Topical Debriders Negative Pressure Therapy Compression Therapy
Topical Wound Care Products
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Gauze Packing(Kerlix, Nu-gauze, 4 x 4s)
description - inexpensive, user dependent
indications - to fill deep defects to maintain moisture and absorb exudate, may be soaked with antibiotic solution
considerations - pack lightly, may cause surrounding wound maceration, may traumatize wound if allowed to dry
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Contact Layer Dressings (Greasy gauzes, N-terface, Adaptic, Xeroform, Mepitel)
description - nonadherent, prevents trauma and permits exudate to “pass through” pores of dressing for absorption by a secondary dressing, inexpensive
indications - superficial wounds with minimal to moderate exudate
contraindications - if goal is to “clean up” wound
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Hydrocolloids (Duoderm, Comfeel)
description - absorbs exudate, maintains moisture, insulates, protects from secondary infection, non-permeable
indications - or superficial wounds with minimal to moderate drainage
contraindications - infected woundsTypically changed every
3 - 5 days
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Polyurethane Foam (Mepilex,Biatain, LyoFoam)
description - nonadherent foam, absorbs exudate, insulates, variable protection from environmental contaminants (outer layer water proof or water-repellent)
indications - superficial weeping wounds, cover for deep (packed) wounds
leave on for 3 - 5 days or change when cover-layer is at least
50% saturated
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Hydrogels (solid gel sheets or amorphous gel)
description - nonadhesive, maintains moisture, protects wound and allows visualization, non-absorptive
indications - superficial wounds with minimal drainage; amorphous gel may be buttered on semi-dry red wound before applying moist dressing; good dressing for arterial ulcers
contraindications - heavily exudating wounds
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Alginates / Fiber Gel (Kaltostat, Sorbsan, Medifil, Aquacel)
description - applied to wound dry but forms gel with absorption of exudate
indications - heavily exudating wounds to allow daily or QOD dressing changes
contraindications - minimally exudating wounds (it will stick to wound and dehydrate)
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Moisture BarriersBarriers are products
that wick away moisture from skin
ContainZinc oxideDimethiconePetrolatumPolymer(i.e. SensiCare,
Proshield, Perineal wipes, No Sting)
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Compression Therapy(Profore, SurePress, Jobst, Isotoner)
description – Single or multi-layer compression bandage or stocking usually applied over primary dressing
indications – management and treatment of venous leg ulcers. Can be left on for up to one week.
contraindications – do not use on patients with ABI <0.8 or on diabetic patients with advanced small vessel disease
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Tapes and Adhesives
Consider gentleness to skin
Consider cost
Consider job to be done
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Clinical InterventionsMonitor skin at every visitEvaluate type of skin care practicesAssess patient and/or caregiver abilityMinimize exposure of skin to moisture from
incontinence, perspiration, or drainageEvaluate need for specialty mattresses or
seating cushionsAssess nutritional status
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Nutritional DeficitsDetermine barriers to the patient eating sufficient quantities of quality food
Nutritionist consult? Diabetes education?
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Moisture and incontinenceMinimize exposure to moisture and soilingUse briefs and underpads to wick away
moisture from skinTeach patients & caregivers to cleanse
skin at the time of soilingUrine & feces very caustic
Use barrier cream as necessary
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Pressure Ulcer PreventionAssess for risk factors: immobility,
moisture & incontinence, inadequate nutrition, impaired sensation or perception, decreased activity, exposure to friction & shear
Incorporate risk assessment into plan of care
Monitor patient’s skin at each visit
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Document Evaluation Is the skin intact? Is the wound healing? Did the interventions work or
not? If no progress at two-week assessment, time to
change interventions If yes, do you want to continue? If no, how do you want to revise? Does patient understand risk factors and wound care
plan?
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89-year-old male with hx of COPD with chronic steroid use. Uses 2 L O2 at home and smokes 1/2 pack cigarettes a day. Hx. Includes DM, depression, and prostate cancer.
Presents to your clinic with right forearm wound after scraping arm against wheelchair.
Case Studies
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49-year-old male with hx of IV heroin use. Smokes 2 packs cigarettes a day. Hx also includes Hep C, depression, and hypertension.
Presents to your clinic with fever, chills, and right lower limb wound that he has had for months.
Case Studies
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46 year-old female admitted to hospital for elective surgery to remove renal growth. Morbidly obese, uses 2 L O2 at home, smokes 2 packs a day. Hx includes DM, depression, sleep apnea. Rarely gets out of bed at home (able to walk w/ assistance to bathroom).
Suspected deep tissue injury to sacrum present on admission. Wound surgically debrided.
Warning . . .
Case Studies
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What do you see?
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Make sure there are no hidden surprises
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