WOUND CARE:ITS ALL GREEK TO ME

BY CHERYL MARZOLI RN BHScN IIWCC

OBJECTIVES

Provide a better understanding of wound care How to: assess, provide interventions and document about wounds. Understanding moist wound healing Discuss categories of dressing products, the use of the products, NPT (negative pressure therapy) and treatment of wounds.

WOUND
DEFINITION: A wound is a bodily injury caused by physical means, with disruption of the normal continuity of structures. This can be identified as an acute or a chronic wound.
ACUTE: Heals in approximately 2 weeks to 6 months CHRONIC: Takes 6 months or more.

ACUTE WOUND

CHRONIC WOUND

PHASES OF WOUND HEALING

Stages of wound healing: Hemostasis: immediate response Inflammation: 0-4 days Proliferation: 4-21 days Granulation (Epithelialization) :4-21 days Remodeling: up to 2 years
* this is for acute wounds, chronic wounds fail to progress naturally

PHASE 1

GOAL HEMOSTASIS

PRINCIPLE WOUND CELL PLATELETS

HOUSE BUILDING CONTRACTOR CAPPING OFF OFFENDING CONDUITS

INFLAMMATION

NEUTROPHILS

UNSKILLED LABORERS CLEAR THE SITE

PROLIFERATION GRANULATION

MACROPHAGES LYMPHOCYTES

SUPERVISOR CELL SPECIFIC PREPARERS OF SITE PLUMBER, ELECTRICIAN FRAMERS ROOFERS/SIDERS

CONTRACTURE

ANGIOCYTES, NEUROCYTES FIBROBLASTS, KERATINOCYTES

REMODELING

FIBROCYTES

REMODELERS
*Krasner, et al

STAGES OF PRESSURE ULCERS

Stage Stage Stage Stage

reddened skin blister (painful), shallow, pink ulcer through the dermis through to underlying structures (bone, tendons, etc.) Unable to stage: unable to visualize wound bed due to eschar/slough

1: 2: 3: 4:

Suspected Deep Tissue Injury (SDTI): purple localized area of discolored intact skin, boggy, warmer or cooler compared to adjacent tissues.
NOTE: NO reverse staging i.e. once a stage 3 always a stage 3, never changes to stage 2

STAGE ONE

Epidermis intact Area reddened Does not disappear

when pressure relieved No drainage Reversible

STAGE TWO

STAGE THREE

STAGE FOUR

UNABLE TO STAGE

WHAT STAGE?

WHAT STAGE?

STAGING ALL OTHER WOUNDS NOT PRESSURE ULCERS

Classification is based on the 3 layers of skin Classify as superficial, partial or full thickness i.e. a burn can be partial thickness (second layer).

PARTIAL THICKNESS BURN

ASSESS THE PATIENT

1.Look at the whole patient not just the hole. 2. What are the patients concerns? 3. Is the wound new or old and how old? 4. Is this wound healable? 5. What are the patients co-morbidities? 6. How is the patients nutritional status 7. What medications if any could interfere with wound healing?

Probe the wound!!!!

Try and correct the causes that may delay wound healing

Edema Nutrition/Dietary consult Alter medications Glycemic control Treat infection OT/Physio consult

Documentation

Slough Eschar Granulation Undermining Erythema Maceration Exudate Odor

* Location * Size LxWxD

Moist Wound Healing Motto

If If If If If

its its its its its

wet..DRY it! dryMOISTEN it! irritatedSOOTHE it! chronicIRRITATE it! palliative..COMFORT it!

Contamination, Colonization or Infection

Contamination: Bacteria-not attached to wound bed -are not replicating Colonization: - Bacteria are attached to the wound surface but are not replicating Infected: -Bacteria are invasive, replication and interfering with wound healing process -may lead to a HOST RESPONSE leading to systemic infection

SWABS

Always take a swab from a newly cleaned wound. Cleanse with normal saline or sterile water Take a swab by moving in a Z pattern over the wound and turning the swab at the same time Punch biopsy (Physician only) Do Not swab necrotic or slough tissue

Wound Cleansing

- Normal Saline or Sterile Water

Irrigate with 20-30 ml syringe Use 18 angiocath 4-6 inches above the wound 5-15 PSI

**MMPS( matrix metalloproteases)

ANTISEPTIC SOLUTIONS

Acetic acid: pseudomonas Proviodine: broad spectrum effectiveness Hygeol: staph. and strep. mechanical debridement control odour *acetic acid and hygeol are available through the pharmacy

Wound Care Products

Liquid barrier Transparent films Hydrocolloids Gauze dressings Hydrogels Foam dressings Absorptive dressings Calcium alginate Charcoal dressings Silver coated dressings

-non adherent dressings -debriding agents -antiseptic

LIQUID BARRIER

TRANSPARENT FILM

HYDROCOLLOID

GAUZE DRESSINGS

HYDROGEL

FOAM DRESSING

ABSORBENT DRESSINGS

CALCIUM ALGINATE

ODOUR CONTROL CHARCOAL DRESSINGS

ANTIMICROBIAL DRESSING

OTHER DRESSINGS

Non adherent dressings i.e.- mepital Debriding agents-mesalt, iodosorb Antiseptic- bactigras with a chlorhexidine base

BIOLOGIC DRESSINGS

BIOLOGIC DRESSINGS

NEGATIVE PRESSURE THERAPY

WATCH FOR PRECAUTIONS AND CONTRAINDICATIONS WHEN ORDERING MAKE SURE WOUND IS MEASURED ON INITIAL APPLICATION IF NO CHANGE WITHIN 2-2I/2 WEEKS THEN DISCONTINUE E-Z CARE IS A NEW NEGATIVE PRESSURE THERAPY

GOOD CANDIDATE FOR NEGATIVE PRESSURE

QUESTIONS

THANKYOU