Wound Care 101 - capanet.org · dressing removal as the most painful part of dressing procedure and that gauze is most likely to cause pain Newer products were less likely to cause

CAPA Conference 2015

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Wound Care 101

Heather Grady, MPA, PA-C

CAPA Conference

October 10, 2015

Wound Classification

Etiology¹

Surgical/non-surgical

Acute and chronic

Depth¹

Superficial, partial-thickness, and full-thickness

Pressure ulcer staging

Comparison of superficial, partial-thickness and full-thickness

wounds

EPIDERMIS

DERMIS

SUBCUTANEOUS

MUSCLEBONE

Superficial woundInvolves only the epidermis

Partial-thickness woundAffects the epidermis,and may extend into thedermis but not through it

Full thickness woundExtends through thedermis into tissuesbeneath; adipose tissue,muscle, or bone maybe exposed


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Wound Assessment Model1

WoundAssessment

Wound BedAssess for

necrotic andgranulationtissue, fibrin

slough,epithelium,

exudate, odor

Surrounding Skin

Assess for color, moisture, supplenessSize

Measureand/ortrace

woundarea.

Measuredepth

Wound Edges

Assess forundermining andconditions ofmargins

Wound Bed

Necrotic tissue – Eschar– Dry, black or brownish devitalized tissue2

Slough – Formed when a collection of deadcellular debris accumulates on the woundsurface2

– Yellow or yellow-white, due to the large amounts ofleukocytes present

Granulation tissue – Indicator of normal healingin full thickness wound2

– Bright red in color

Epithelialization – newly formed epithelial cellsthat have a translucent appearance2

– Usually whitish-pink or pinky-purple in color

Eschar

Slough

GranulationTissue


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Wound progression from slough to granulation tissue

Granulation tissue and epithelialized tissue

Documentation –

Quantify the estimatedpercentage of tissueinvolved (e.g. woundcontains ± 50%granulation tissue, ±25% necrotic tissue and± 25% fibrin slough)1

Granulation Tissue2

Healthy GranulationTissue

Unhealthy GranulationTissue

Bright Red Dark red/blushdiscoloration or pale

Moist Dehydrated

Shiny Dull

Does not bleed easily Bleeds easily - fragile

Exudate2,3

Exudate Type Color Consistency Descriptor Significance

Serous Clear Thin watery Clear fluid absence of blood,pus debris

Normalinflammatory/proliferativephases of healing

Sanguinous Red Thin watery Bloody, composed entirely ofblood

Indicates new vessel growthor disruption

Serosanguinous Light red/pink Thin watery Blood mixed with clear fluid Normalinflammatory/proliferativephases of healing

Seropurulent Cloudy yellow Thin watery Pus mixed with watery fluid May be first signs of woundinfection or autolyticdebridement

Purulent/Pus Yellow/green Thick, opaque Pus, cloudy, viscous oftenmalodorous

Indicates wound infection


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Criteria for IndentifyingWound Infection2,4

Surfacediscoloration –

yellow/green hues

Increased odor

Superficialpocketing orbridging ofwound base

Wounddeterioration or

dehiscenceNon-Healing wound

Increaseddiscomfort and

tenderness

Abscessformation

Friable granulationtissue –

bleeds easily

Cellulitis andInflammation

Increasedexudate

WoundInfection

Wound Infection

Factors Increasing theRisk of Infection2,5

Reduced perfusion

Large wound area/depth

Chronicity

Necrotic tissue

Foreign bodies

Metabolic disorders – diabetes mellitus

Alcohol abuse/smoking

Corticosteroid medications


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Antibiotics

Systemic antimicrobial therapy should beused when active infection can’t bemanaged with local therapy2

– Fever

– Underlying deep structure infection

– Spreading cellulitis

Wound Basics

Standard of care is no longer wet-to-dry dressings

– This keeps wounds in a constantinflammatory state, slowing downwound healing6

With any wound, always takecare to protect the periwoundedges7

Don’t desiccate the wound bed

Dressing Basics

Type and amount of drainage dictates thetype of dressing used

If a wound is too dry, hydrate the woundwith gels

If a wound has too much drainage, usefoams to absorb the moisture6,7


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Film = Poly skin

Hydrogel = Duoderm gel

Hydrocolloid = Duoderm

Alginate = Aquacel, & Aquacel AG

Foam = Allyven foam – with and without adhesive

Specialty dressing– Mepitel – silicone contact layer

– Mepilex foam – silicone foam dressing – with and withoutadhesive border

– Polymem – foam dressing but with surfactant which cleanses thewound, does not absorb a lot of drainage

– Interdry AG – polyester cloth with silver impregnated in it, killsfungus and bacteria inside skin folds and wicks away moisture

– Anti-microbial – dressings with silver, Acticoat

Wound Margin &Surrounding skin

Prolonged exposureof the skin to woundexudates can result inskin maceration

Indicates– Wound dressing is not

being changedfrequently enough

– Dressing contains toohigh of water content

– The absorptive capacityof the dressing is notaligned to meet with theexuding fluid volume2


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Exceptions to the Rule

If the patient has decreased vascularity andyou want to keep the bacterial count down– Keep the wound dry and paint it with betadine

Eschar often can be usedas a physiologic dressing(especially with wounds on thefeet) and wound will heal underthe eschar7

Wound Pain

Surveys have shown that clinicians identifydressing removal as the most painful partof dressing procedure and that gauze ismost likely to cause pain

Newer products were less likely to causepain and skin trauma. These includehydrogels, alginates and siliconedressings2,8

Wounds and Nutrition

Protein is essential for the formation ofnew granulation tissue.

Severe protein malnutrition results in

– Slower wound healing

– Decreased immunocompetence

– Increased susceptibility to infection2,9


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Aging Population

Patient population is getting older and thedisease processes associated with thesepatients are increasing7

Medications and co-morbidities need to be takeninto account when addressing wound carebecause they can impede wound healing

Medications impact wound healing– ie. steroids, NSAIDs, anti-coagulation

Co-morbid diseases also affect healing– ie. COPD, DM, A-fib, pneumonia

Types of DressingsOld School of Thought

Wet-to-Dry dressings

– Gauze is inserted wet, covered with dry gauze and itdries out, then removed after adhering to surfacetissue6

– Typically intended for use in the debridement ofdevitalized tissue from a wound bed6 or to keep awound open that may have a small skin opening buttunnels more deeply

Types of DressingsNew Technology

NPWT - Negative pressure woundtherapy10

– Creates an environment thatpromotes wound healing bysecondary or tertiary intention(delayed primary) by:

Preparing the wound bed for closureReducing edemaPromoting granulation tissue formationand perfusionRemoving exudate and infectiousmaterial10

Advanced wound healing therapy


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Skin Tears

Skin Tears

Seen mostly in older patients – skin becomesthinner as we age

Address medications and co-morbidities

Surrounding edema will affect healing as well

Treatment

1. Stop bleeding

2. Attempt to approximate skin edges

3. Don’t cause additional trauma tosurrounding skin

4. Can take up to 4 weeks to heal7

Hemostasis

Achieving hemostasis can be hard,especially if patients are on anti-coagulants such as Coumadin or Plavix orif they are on steroids

May need products such as Surgicel orother agents that help prevent formation ofhematoma


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Approximating Skin Edges

If skin edges or skin flap remains, attempt toapproximateApply skin prep first (or Benzoin) to skin flap andintact skinHold in place with steri-strips, leaving a spacebetween each steri-strip to allow for drainageCover with silicone dressing (Mepitel) that helpsabsorb drainage and is less traumaticUse Telfa, covered with Kerlix or Cling andstockinette (great for use on extremities)7

Steri-Strip Wound

Types of Dressings

Silicone Dressings

– Does not adhere to skin

– Great on fragile, thin skin

– Used on skin tears


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Silicone Dressing

Additional Thoughts

Treat with antibiotic or antimicrobial ifconcerned about infection or contamination

Don’t apply a transparent dressing such asop-site

Once evaluated, leave area alone for 5days

May use xeroform as last resort

Complications

Skin flap doesn’t take

– Debride the area and treat as an open wound

Hematoma

– Evaluate if it needs to be evacuated


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Additional Dressings

Polymem – surfactant and glycerine dressingthat won’t stick to the wound– Can be left on for 7 days– Ok to shower with dressing in place– Good for contaminated wounds to keep the wound

clean

Ointments – apply antibiotic ointment ifconcerned about infection– Bacitracin ointment on the face– Triple antibiotic ointment on all other surfaces– Cover with Telfa, silicone dressing or Polymem

HematomasTo evacuate or not??

Need to really look at co-morbid diseases

Hematomas are a breedingground for bacteria;however, evacuating ahematoma leaves an openwound and bleeding maypersist if patient remains onanti-coagulant7

When not evacuating wound

Silicone or antibiotic silicone dressing can beused and it won’t disrupt the hematoma but stillallows for close monitoring

Cover the silicone dressing with a foam orpadded dressing to help protect the hematoma

Patients must be monitored very closely

It will take time for the hematoma to bereabsorbed


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Evacuation

If eschar is forming then the wound will needto be evacuated

If wound is evacuated, you must see thebase of the wound to fully evaluate it

Apply pressure if bleeding continues oncehematoma is evacuated

May need to use products such as coban toassist with applying pressure7

Additional Problems withHematomas

Older patients may have vascular insufficiencyadding to edema and decreased oxygenation tothe tissues causing stagnant blood– Especially seen in patient with renal failure and

vascular insufficiency7

Antibiotics– Don’t recommend antibiotics unless signs of infection

or contaminated process such as wound occurred indirt (think fungus or yeast)

– Suggest using Augmentin or Bactrim– Keflex is not a good option on soft tissue, especially on

lower extremity wounds

Diabetic Foot Ulcers


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Diabetic Ulcers

Never what they appear, always lookbenign

Usually associated with other underlyingdiseases that affect healing such as PVDand arterial disease

For this reason, must always assessvascularity leading to wounds

If there is no blood flow under wound, itWON’T heal

Assessing Diabetic Ulcers

Always do 3 view x-ray or MRI (especially offoot) to r/o osteomyelitis. If unable to get one ofthese imaging studies, get bone scan

Always probe wound

– The inflammatory processis usually delayedresulting in possibleundermining, tunneling,fluid collections or edema

Treatment of Diabetic Ulcers

Always evaluate shoes!

– Inside and out

– Look for dirt, foreign bodies, etc.

Perform neuro exam

Off-load foot. May need to add foam to shoes.

Limb salvage – Refer directly to a podiatrist if youdo not see signs of healing (partner with apodiatrist to help treat these types of wounds)

Wound may need to be incised and drained


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Treatment continued

Treat wound with antimicrobial agents

Hydrofiber, alginate or anti-microbial gels

Evaluate for proper management of DM

If you see signs/symptoms of infection,refer out to vascular surgeon, podiatry,Infectious Disease, etc.

If no evidence of infection, may treat for 3-4weeks before referring to podiatry

Types of Dressings

Hydrofiber– Highly absorbent dressing made of 100%

hydrocolloid. The hydrocolloid is spun into fibersthat make a soft, non-woven fleece-like dressingthat comes as a sheet or ribbon11

– Used as an alternate toalginate dressing. Thisdressing retains a highquantity of water withoutreleasing it, therebyforming a thickcomfortable gel11

Types of Dressings

Alginate

– A dressing made from seaweed,creating a gel form of dressing11

– Best used in moderate to highlyexudating wounds11


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Types of Dressings

Hydrogels– Comes as a sheet or a gel

– Sheets are used for shallow or low exudingwounds11

– Gels are used for cavities and are effectivefor desloughing and debriding wounds.Gels have a high water content which aidsthe rehydration of hard eschar andpromotes autolysis in necrotic wounds11

– To prevent possible maceration, a secondarybarrier film may be applied to peri-wound area11

Recalcitrant Wounds

Biofilm can develop and nothing can impregnate itkeeping wound in the inflammatory stage

Wound will need sharpdebridement

Evolving field – Lab inTexas will tailor treatmentbased on tissue specimen,genetics, bloodwork andlocation of wound

Pressure Ulcers


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Pressure Ulcers

Currently classified into 4 stages– Discussions to change classification to suspected

deep tissue injury

Stage 1 and Stage 2– More from shearing and friction

Stage 3 and Stage 4– Deep tissue injury

Suspect deep tissue injury if darkred/purple/maroon, hard/bony surface, won’tblanche

Staging System

Should be used as an admission diagnosissystem only2,7

Not designed to capture changes thatoccur during the healing process

Changes in the wound status should bedocumented as area and depthassessment, not “reverse staging”2,7

Pressure UlcersStage 1 and 2

Early stages may start to evolve

Will start to look diffuse with edges notwell defined. Pink edges, purple area mayopen up and evolve to an open woundstage ulcer

Stage 1 Stage 2


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Treatment of Pressure UlcersStage 1 and 2

Always off-load

Observe frequently

Silicone products will off-load and absorbsdrainage

– Some wounds may heal with silicone alone

May also use hydrocolloids (DuoDerm) orFoam dressings

Types of Dressings

Hydrocolloids

– Waterproof, occlusive dressing that consists of amixture of pectin, gelatine, sodiumcarboxymethylcellulose and elastomers11

- Creates an environmentthat encouragesautolysis to debridewounds that aresloughing or necrotic11

Types of Dressings

Foams– Dressing produced from polyurethane - soft,

open cell sheets11

– These are non-adherent and can absorb largeamounts of exudate11

– Also available impregnated with charcoal(attracts and traps bacteria and odor) and withwaterproof backing11

Silver dressing– Dressing impregnated with Silver – anti-microbial

dressing

– Used to treat infected wounds


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Considerations with Treatment

What is the causative agent of the ulcer?

Nutritional status?– May need to add Ensure, Megace or tube feedings

Hydration?– Is the patient dehydrated?

UTI?

Frequent pneumonia?

Local care is needed to heal wound but must also findthe underlying cause and address it2,7

There may be a short term cause such as a fracture butif there is no short term cause, need to find the reasonfor the ulcer

Pressure UlcersStage 3, Stage 4 and Unstageable

Stage 3 Stage 4

Unstageable


Clean wound bed– Surgical debridement– Autolytic debridement (hydrocolloids)– Transparent dressings (op-sites) – soften up eschar

to allow for debridement later– Medical grade honey, if no bee allergy (Manuka

Honey - Medline)– Hypertonic solution/pad can be used for sloughing

wound – will withdraw fluid and debride wound– If odorous, use ¼ strength Dakin’s solution on gauze.

This will improve odor and debrides. Use for about 3-4 days


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Autolytic Debridement

Results in little to nopain or wound trauma

However, it is a slowermethod of debridement

May be contraindicatedif there is a highbacterial burden in thewound2


Always protect periwound skin with ointment(moisture retentive) to protect healthy skin frommaceration caused by excessive drainage

– Calmoseptine or A&D ointment

Apply ointment under foam or ABD pad that willallow the drainage to be soaked up

Can use fiber type fillers such as alginate orhydrofiber to fill dead space

Stage 4 Pressure UlcerWhen to treat with wound vac vs flap?

Evaluate overall physical and mental health,including life expectancy

Previous hospitalizations, operations, orulcerations

Diet and recent weight changes

Bowel habits and continence status

Presence of spasticity or flexion contractures

Tobacco, alcohol, and recreational drug use7


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Stage 4 Pressure UlcerWhen to treat with wound vac vs flap?

Pressure ulcers should be closedsurgically if it does not respond to otherwound care (including vac treatment) andif there are no other contraindications tosurgery

When rapid closure is indicated

Some contraindications include tobaccouse, poor nutrition, infection,noncompliance, recent failed flap7

Local Rotation FasciocutaneousFlap

Cellulitis


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Cellulitis

Cellulitis is a spreading bacterial infectionof the skin and tissues beneath the skin

The bacteria usually responsible forcellulitis are Staphylococcus andStreptococcus, although many types ofbacteria can be the cause

Signs and symptoms include redness,tenderness, swelling, and warmth of theaffected area

Abscess

Abscess

Cellulitis/induration is not an indication forincision and drainage

Must have an area of palpable fluctuanceor imaging documenting deeper fluidcollection to perform I & D

Always mark border of erythema with apen or marker which allows assessment oftreatment with antibiotics and/or drainageof wound


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Abscesses

If patient thinks it is a spider bite, alwaysI&D, open wound and pack– Must be drained– Likely MRSA or Staph

Skin poppers– Iodasorb gel or Cadoximer Iodine for treatment– Easy for patient to do themselves and protects

against many organisms– Sustained released of orange fluid – placed on

wound bed and absorbs drainage– Comes in a tube that is applied to wounds by

patient– Ok to shower

MRSA

MRSAMethicillin-resistant Staphylococcus aureus

If an abscess is admitted to the hospital fortreatment, assume MRSA until provenotherwiseIf possible, place patient on isolationprecautionsTreatment includes IV antibiotics such asVancomycin and/or Rifampin and oralantibiotics such as Bactrim DSOnce diagnosed, suggest patients showerwith CHG (chlorhexidine gluconate) untilwounds resolve, and in the future at the firstsighting of any erythema to the skin


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Road Rash

Road Rash

Must be very diligent to scrub all debris fromwound within first 24 hours

– If debris is not removed, patient will get tattoo fromwound

Shower daily with CHG (ChlorhexadineGluconate) for 2 weeks

Apply Xeroform over the area then a gel pad

– This will absorb the fluid and is more comfortable forthe patient because it deters dressing from stickingand dressing changes will be less frequent

Other Wound Care

Dakins solution– Used for malodorous, soupy

wounds with stringy/yellowdebris

– Or used if you suspectpseudomonas (greenishappearance to wound ordrainage)

Non-healing wounds– Always need biopsy to r/o

SCC or other possibleinflammatory process


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NPWT(Wound VAC – Vacuum Assisted Closure)

Used for treatment ofopen wounds

Negative pressuretherapy

Controls edema andprovides support toincision/wound

Improves healing anddecreases treatmenttime10

Creates an environment thatpromotes wound healing10

Microstrain

Reduces edema

Promotes perfusion

Promotes granulation tissueformation

Cell mitosis/proliferation

Fibroblast migration

Macrostrain

Draws wound edges together

Removes exudate

Removes infectious materials

Types of Wounds10

ChronicAcuteTraumaticSubacuteDehisced WoundsPartial-Thickness BurnsUlcers (such asdiabetic, pressure,venous)Flaps and Grafts


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VAC Dressing Types10

V.A.C.

GranufoamDressing

Reticulated (open) porePolyurethane ideal for:Deep acute woundsTraumatic woundsDiabetic & Pressure ulcersDraining or dry woundsFlaps and grafts (with non-adherent)

V.A.C. White FoamDressings

Dense (higher tensile strength) open-pore Polyvinyl Alcohol ideal for:Tunneling/tracts/underminingPainful woundsWounds requiring controlled growth ofgranulation tissueSuperficial wounds

Reticulated (open) celled Polyurethane micro-bonded with silver to provide a protectivebarrier to reduce aerobic,gram-/+ bacteria, yeast and fungi.Ideal for:• Deep acute wounds• Traumatic wounds• Diabetic & Pressure ulcers• Draining or dry wounds• Flaps and grafts (with non-adherent)10

99.9% of pathogenseliminated Within thefirst 30 minutes

V.A.C.® DrapeEasy as…1…2…Blue

V.A.C. Canisters


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Contraindications10

Do not place foam dressings of the V.A.C.® TherapySystem directly in contact with exposed bloodvessels, anastomotic sites, organs, or nerves

Malignancy in the wound

Untreated osteomyelitis

Non-enteric and unexplored fistulas

Necrotic tissue with eschar present (afterdebridement V.A.C. Therapy may be used)

Sensitivity to silver

Warnings, Precautions and Safety Tips

Protect Vessels and Organs: All exposed orsuperficial vessels and organs in or around thewound must be completely covered andprotected prior to the administration of V.A.C.®

TherapyProtect Tendons, Ligaments and Nerves:Tendons, ligaments and nerves should beprotected to avoid direct contact with V.A.C.

Foam Dressings. These structures may becovered with natural tissue, meshed non-adherent material, or bio-engineered tissue tohelp minimize risk of desiccation or injury10

Warnings, Precautions and Safety Tips

V.A.C. Therapy On: Never leave a V.A.C. Dressing inplace without active V.A.C. Therapy for more than 2hours. If therapy is off for more than 2 hours, remove theold dressing and irrigate the wound. Either apply a newV.A.C. Dressing from an unopened sterile package andrestart V.A.C. Therapy; or apply an alternative dressingat the direction of the treating clinicianBleeding: With or without using V.A.C. Therapy, certainpatients are at high risk of bleeding complications1000 mL Canister: DO NOT USE the 1000 mL canister onpatients with a high risk of bleeding or on patients unable totolerate a large loss of fluid volume.MRI, X-Ray & HBO10


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Dressing Application

Target Pressure 125 mmHg(125-175 white foam)Continuous first 48 hrsIntermittent if tolerated

Dressing change every 48-72 hrs

Basic Dressing

Tunneling: White foam andGranuFoam

Target Pressure 125 mmHg(125-175 white foam)

ContinuousDressing change every 48-72 hrs


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Framing: Wounds with SmallOpenings

Target Pressure 125 mmHg(125-175 white foam)Continuous first 48 hrsIntermittent if tolerated

Dressing change every 48-72 hrs

Bridging

Final Thoughts

Wound assessment is as important astreating the wound itself

Type and amount of drainage now dictatesthe type of dressing used

Take care to protect the periwound area

Identifying and treating the underlyingcause aids in the overall management ofchronic and acute wounds


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Resources

KCI1.com

KCI Advantage Center1-800-275-4524

24/7!

Reps On-Call

Territory Manager

Service Consultants

References1. Van Rijswijk L. Wound assessment and documentation. In: Krasner DL, Rodeheaver GT, Sibbald

RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed.Wayne, Pa: HMP Communications; 2001:104.

2. Smith & Nephew. Wound Bed Preparation: A Guide to Advanced Wound Management

3. Mulder, GD. (1994) Quantifying wound fluids for the clinician and researcher. Ostomy/WoundManagement; 40(8):66-69.

4. Flanagan, M. (1997) Wound Management, Churchill Livingstone

5. Schultz, GS, Sibbald GR, Falanga, V, et al. (2003) Wound Bed Preparation: A systematicapproach to wound management. Wound Repair and Regeneration; 11(2): 1-28.

6. Ovington, LG. Hanging Wet-to-Dry Dressings Out to Dry. Advances in Skin & Wound Care. Vol15 No 2. March/April 2002:79-86.

7. P Milnes, WOCN. Personal Communication, August 13, 2013.

8. Moffatt, C, Franks, P, Hollinworth, H. (2002) Understanding wound pain and trauma: aninternationtal perspective. EWMA Position Document: Pain at Dressing Changes: 2-7

9. Mazzotta MY. (1994) Nutrition and wound healing. Journal of American Podiatry MedicalAssociation; 84: 456-462.

10. KCI Product Information. 1998-2013. http://www.kci1.com/KCI1/home

11. Pain Dictionary. (2009). Retrieved September 14, 2013, from http://less-pain.com/en/Pain-Dictionary

12. Mölnlycke Health Care. www.molnlycke.com

13. Medline Product Information. http://www.medline.com/

14. ConvaTec Product Information. http://convatec.com/

Documents

Wound Care 101 - capanet.org · dressing removal as the most painful part of dressing procedure and that gauze is most likely to cause pain Newer products were less likely to cause