wound care - handout
TRANSCRIPT
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Pharmacists & wounds
Carmen GeorgeClinical Nursing Specialist Services
Role of the pharmacist
Dispenser(Shop keeper)AssessorAdvisor?ClinicianReferrer?????????
Overview of how wounds heal
2 stages of wound healing
HaemostasisVasoconstriction responseresponsePlatelet responseBiochemical response
Tissue repairInflammationReconstructionmaturation
Wound healing physiology
Inflammation 0- 3 daysCapillaries contract & thrombose to facilitate haemostasisIschaemia in wound causes release of histamine causing vasodilation of surrounding tissuesMore blood to surrounding tissue causing swelling heatMore blood to surrounding tissue causing swelling, heat, erythema and discomfortPolymorphs & macrophages arrive to wound to provide a defence response
Reconstruction 2- 24 daysMaturation 24- 365 days
Wound healing physiology
Inflammation 0- 3 daysReconstruction 2- 24 days
Polymorphs kill pathogens and macrophages digest bacteria and debris. cleaning up the woundMacrophages also stimulate fibroblasts to produce collagenNew vascular network is built by the process ofNew vascular network is built by the process of angiogenesis-new capillary development can be seen in granulation tissueEpithelial cell migration occurs from wound edges and from hair follicles etc. Mitosis thickens epitheliumWound contraction occurs simultaneously within this period
Maturation 24- 365 days
Wound healing physiology
Inflammation 0- 3 daysReconstruction 2- 24 daysMaturation 24- 365 days
Remodelling phaseRemodelling phaseTensile strength of wound is increasedDecreased vascularityScar size decreases
This model is acute wound healing as opposed to chronic wound healing
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No person no wound
A holistic assessment of the client should be undertaken in conjunction with a wound assessment, to not only determine why the wound is present but to also uncover anywound is present but to also uncover any factors that will retard healing
K.Carville
What characteristics of the patient and their wound should be included in a comprehensive woundcomprehensive wound assessment?
Wound Assessment
Type of woundType of healingTissue lossClinical appearance
Measurement DimensionsExudateSurrounding skinpp
Location PainWound Infection
Type of Healing
Primary intentionSecondary IntentionDelayed Primary Intention
Type of Wound
Surgical incisionTraumatic-abrasion, laceration, penetrating, contusion, skin tearsBurns-minor, majorLower limb ulcers-vasculitic ulcer, diabetic ulcer, venous, arterial neuropathic etcPressure ulcer
Tissue loss
Superficial-epidermisPartial-epidermis and dermisFull-Epidermis, dermis and subcutaneous tissue
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Clinical Appearance
EpithelialisingGranulatingContractingSloughgEscharAngiogenesis
Location
Documented as a point of referenceIdentifies problems associated with accessEase of dressing procedureg pHighly movable partProne to friction and shear
Measurement Dimensions
Point of referenceCan be repeatedObjectiveLengthDepthDepthVolume replacementUnderminingTracts
Exudate
AmountColourViscosityColourOdourType
Surrounding Skin
Does it need protecting?MacerationOedemaErythemaDenudedLesionsReactions to tapes or dressings
Pain
May need addressing prior to procedureMay indicate infectionMay be related to wound practices or products
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Wound Infection
Growth of an organism in a wound with associated tissue reactionInfection delays wound healingIdentify patients at risk ie those with predisposing conditions
Extra information required usually for
Skin tearsLower limb ulcersPressure ulcers
Skin Tears Lower Leg Assessments
Presence or absence of dorsalis pedis and posterior tibial pulses Ankle and calf measurementsNeurological sensitivity to touch and painABPI
Pressure Ulcer AssessmentStage 1
Observable pressure-related alterations of intact skin whose indicators as compared to the adjacent or opposite area in the body mayarea in the body may include changes in one or more of the following: Skin temperature,tissue consistency and/or sensation
Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers AWMA 2001
Stage 2
Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as anpresents clinically as an abrasion, blister, or shallow crater
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Stage 3
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer y gpresents clinically as a deep crater with or without undermining of adjacent tissue
Stage 4
Full thickness skin loss involving with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures eg tendon or joint capsule. j pUndermining and sinus tracts may also be associated with Stage 4 pressure ulcers.
Unable to stage pressure ulcers
Factors affecting wound healingDiabetes Anaemia SmokingVascularityAutoimmune diseases eg IBD,RA,ImmobilityInfectionMedicationsNutritional StatusMalignancy
External factors affecting wound healing
Availability of ProductsMedical Officers OrdersNursing Knowledge and skill? Pharmacists' knowledge of product performance
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Types of products
No such thing as the ‘ideal dressing’ ie one dressing wont do for all types of wounds.What are you trying to achieve?Short term objectivesShort term objectivesLonger term objectives
Refer to appropriate clinicianNursing, medical, hospital, clinic
Principles of wound management
Define/identify the aetiologyIdentify and if possible control or eliminate factors that can impair or effect wound healingSet long term and short term objectivesImplement a management plan/regimeReview and evaluate management regime regularlyPlan for wound healing maintenance
Why dress a wound??
To create an environment conducive to healingTo promote comfortTo protect the wound and surrounding tissueTo reduce pain by excluding
To control and prevent odourTo contain drainageTo immobilise an injured body partTo apply compression for p y g
air from nerve endingsTo maintain temperature in the woundTo control and prevent haemorrhage
pp y phaemorrhage or venous stasisTo prevent and manage clinical infection in woundsTo decrease distress for client and carers by covering the wound.
K Carville 2005
Ideal Dressing
Removes excess exudateMaintains a moist wound healing environmentAllows gaseous exchange if appropriateProvides thermal insulation
Does not cause sensitivity or allergic reactionProtects against mechanical traumaAllows removal without traumatising the new tissue
of woundProvides barrier to pathogensDoes not promote infectionDoes not shed fibres or leak out toxic substances
Is easy to applyIs comfortable to wearIs adaptable to body partsDoes not interfere with body functionIs cost effective
K Carville 2005
Types of dressings
Natural fibre dry dressings-gauze, combine, lint, linenNon adherent dry or film coated dressings island dressings eg Telfa, Melolin, MeloliteTulle Gras eg Jelonet, Adaptic,CuticerinTulle Gras with antiseptics eg bactigras, InadineSemi permeable Film dressings eg Opsite, Tegaderm
Types of dressings
Foam dressings eg Biatain, Hydrasorb, Polymem, Allevyn, Lyofoam. Sheets or cavityCalcium Alginate dressings eg Kaltostat, Sorbsan, Algoderm, Algisite M. Sheets or ropeHydrocolloids eg Duoderm Comfeel, Cutinova Hydro (sheets, powder & pastes)Hydrogels eg Intrasite, Comfeel Purilon Duoderm. Tube,sheets, impregnated dressings
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Types of Dressings
Hydrofibres- Aquacel. Sheets and fillerMultilayer Absorbent dressings eg Alione, CombidermCharcoal dressings eg Carbonet, Carboflex, Actisorb PlusHypertonic Saline Inpregnated dressings eg Curasalt, Meslat, HypergelC d I di d iCadexomer Iodine dressingsInteractive wet dressings eg TenderwetSilicone dressings eg Mepitel, MepilexSilver dressings eg Acticoat, aquacel Ag, Polymem Silver etcCeramic wound treatment devices egCerdakCapillary wicking dressings eg VacutexHoney eg medihoney, B Naturals, L Mesitran
Modern Wound DressingsAbsorbent exudate managers
Leg Ulcer managementCompression bandaging
Absorbent Wound Fillers
Autolytic Debriders Antibacterial
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Anti infective silver dressings Sophisticated products available in Australia
Silver at the chemists? New Ideas ?
Wound Bed PreparationWhat does this mean?Basically preparing the
wound for healing
Includes debridement, exudate managementinfection control, and
Usually referring to chronic wounds that have stalled in the healing process
,conversion of static wounds to active wounds
Readings and Resources
AWMA 2000 Standards for Wound ManagementAWMA 2001 Clinical Practice Guidelines for the prediction and Prevention of Pressure UlcersCarville K. 2005 Wound Care Manual(5th edition). Silver Chain WASilver Chain. WAwww.worldwidewounds.orgSAWMA www.sawma.org.auAWMA www.awma.org.au