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Wound ManagementWound Management
Pip RutherfordPip RutherfordNurse Practitioner Wound CareNurse Practitioner Wound Care
HawkeHawke’’s Bay DHBs Bay DHB
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ResourcesResources
ScenariosScenarios““woundwound””Film dressingFilm dressingFilm dressing 1 cm grid (Film dressing 1 cm grid (mmmmmm))Adhesive rulers (Adhesive rulers (mmmmmm))W/BW/BFelt Pens (Felt Pens (mmmmmm))Butchers paper Large post it (Butchers paper Large post it (mmmmmm))6 table packs with 4 copies of scenario and Sets of 6 table packs with 4 copies of scenario and Sets of dressings?dressings?
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Panel member Panel member ““volunteersvolunteers””
Ideally:Ideally:MedicalMedicalNursingNursingPodiatryPodiatry
Has anyHas any--one participated in:one participated in:Wound papersWound papersCourses on wound managementCourses on wound managementSpecial interest groups/journal clubsSpecial interest groups/journal clubs
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ContextContext
Primary care settingsPrimary care settingsClinical v Cost effectivenessClinical v Cost effectivenessTime constraints 15/60 appointmentsTime constraints 15/60 appointments““MarketingMarketing”” & & ““EvidenceEvidence””Tertiary study content on WMTertiary study content on WMResearch Research –– 10 year theory10 year theoryFocus on Focus on ““chronicchronic”” wounds wounds –– secondary closuresecondary closure
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ContentContent
Group work (15 minutes)Group work (15 minutes)A & P skinA & P skinDocumentationDocumentation
5 scenarios based on wound aetiology prevalence 5 scenarios based on wound aetiology prevalence (HHC) 30 minutes total(HHC) 30 minutes totalPresent backPresent backHealingHealingDressings Dressings Wound cleansingWound cleansingFeedback and panel reviewFeedback and panel review
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Dressings through the ages:Dressings through the ages:
Resins, balsam spicesResins, balsam spicesHerbsHerbsMudMudOilOilDungDungFresh meatFresh meatSalt and green pigmentSalt and green pigmentWillow leaves and dungWillow leaves and dungOpium and herbsOpium and herbsHoney/grease/lintHoney/grease/lintOnionOnionBoiling oilBoiling oil
Wine/wool/fig tree sapWine/wool/fig tree sapSponge and leavesSponge and leavesWoolWoolWild celeryWild celeryHoney and gheeHoney and gheeHerbs/cow urine/curd Herbs/cow urine/curd creamcreamHeavy metalsHeavy metalsFlour & oilFlour & oilDoves dungDoves dungInk (soot)Ink (soot)WineWine
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Discoveries in wound healingDiscoveries in wound healing
1960 1960 -- scabs impeded epithelial migrationscabs impeded epithelial migration1970s 1970s –– healing a dynamic phased processhealing a dynamic phased processDNA technology DNA technology –– able to study regulation of these able to study regulation of these phases on a molecular levelphases on a molecular levelNew cellular and biochemical events identified in New cellular and biochemical events identified in wound healingwound healingMoist wound healingMoist wound healingCytokines and proteases involvedCytokines and proteases involvedFive families of GF identifiedFive families of GF identified
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ActivityActivity
What is in your dressing cupboard/trolleyWhat is in your dressing cupboard/trolleyfor cleansing woundsfor cleansing woundsfor dressing woundsfor dressing wounds
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Skin ActivitySkin Activity
Adults have 2 mAdults have 2 m²² of skin which is:of skin which is:4.5 4.5 -- 5 kg in weight5 kg in weight0.5 mm 0.5 mm –– 4.0 mm depth4.0 mm depth
EveryEvery--one to draw a 1 cm square on the lateral one to draw a 1 cm square on the lateral aspect of your foreaspect of your fore--armarmIn groups In groups Name & QuantifyName & Quantify all the structures all the structures within this area to a depth of 2mm ( 5 minutes)within this area to a depth of 2mm ( 5 minutes)
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Skin ReviewSkin Review
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SkinSkin
300,000 Epidermal 300,000 Epidermal cellscells3.7 m nerves3.7 m nerves0.9 m blood vessels0.9 m blood vessels15 Sebaceous glands15 Sebaceous glands100 100 Sweat glands Sweat glands 3000 Sensory nerve 3000 Sensory nerve cells at end of nerve cells at end of nerve fibresfibres
200 Nerve endings to record pain2 Sensory apparatus for cold12 Sensory apparatus for heat25 Sensory apparatus for pressure10 Hairs
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Self assessmentSelf assessment
Compare your 1 cm square with others in your Compare your 1 cm square with others in your group.group.How accurate were youHow accurate were youDid you allow for curvature of the arm?Did you allow for curvature of the arm?Do you visually assess wound size at work?Do you visually assess wound size at work?How else could you measure a wound?How else could you measure a wound?
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Measurement that mattersMeasurement that matters
TracingTracingGridsGridsPhotosPhotosStick swabsStick swabs--rulerrulerCulture swabs (sinuses)Culture swabs (sinuses)FormulaFormulaRulers or tapesRulers or tapesStructured light or lasersStructured light or lasersVisitrakVisitrak
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Wound classifications:Wound classifications:
Depth Depth –– e.g. burne.g. burnHealing Phase 3 or 4 phases. E.g. traumaHealing Phase 3 or 4 phases. E.g. traumaHealing method e.g. primary Healing method e.g. primary -- secondarysecondaryAcute, Chronic, Delayed, Acute, Chronic, Delayed, Aetiology e.g. venous, arterialAetiology e.g. venous, arterialSurgical Surgical –– NonNon--surgicalsurgical
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Source: Keith HardingMonash University Post Graduate Wound Care
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Healing timesHealing times
Standard is 21 days most woundsStandard is 21 days most woundsAcute wounds 10 daysAcute wounds 10 daysTime and size dependentTime and size dependentNeed to see significant progressNeed to see significant progress
If no progress after 3 weeks you should be doing some If no progress after 3 weeks you should be doing some investigationsinvestigations
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Slow HealingSlow Healing
Bacterial balance (deep or superficial)Bacterial balance (deep or superficial)Needs DebridementNeeds DebridementForeign bodyForeign bodyPoor moisture balancePoor moisture balancePoor vascular supplyPoor vascular supplyHypoxia (smoking)Hypoxia (smoking)Underlying aetiologyUnderlying aetiology
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TIME framework for wound TIME framework for wound assessment & documentationassessment & documentation
Tissue viability/managementTissue viability/managementInflammation and infectionInflammation and infectionMoisture BalanceMoisture BalanceEpithelial (edge) advancementEpithelial (edge) advancement
Reference:Reference:EWMA position document (Paris 2004 Congress)EWMA position document (Paris 2004 Congress)
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Tissue ManagementTissue Management
Is the tissue alive? (often determined by colour)Is the tissue alive? (often determined by colour)Is there eschar? Is there eschar? –– dry leathery, blackdry leathery, blackIs there necrotic tissue? Is there necrotic tissue? -- increases bacterial increases bacterial burdenburdenDefective matrix Defective matrix Cell debrisCell debris
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Inflammation & InfectionInflammation & Infection
Place in healing curve is importantPlace in healing curve is importantDifferentiate between inflammation and Differentiate between inflammation and infectioninfectionBacterial influence depends on: quantity, Bacterial influence depends on: quantity, virulence, host reactionvirulence, host reactionTemperatureTemperatureOdourOdour
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Moisture BalanceMoisture Balance
Exudate is blood without the red cells or platelets. Has Exudate is blood without the red cells or platelets. Has nutrient, energy, and transport propertiesnutrient, energy, and transport propertiesIncreased exudate heralds infection (increased capillary Increased exudate heralds infection (increased capillary permeability)permeability)Exudate type, amount, colourExudate type, amount, colourToo wet (if wound stuck in inflammatory stage) Too wet (if wound stuck in inflammatory stage) Maceration, increased microMaceration, increased micro--organisms, pain, irritant organisms, pain, irritant dermatitisdermatitisToo dry (delays healing, increases pain, slows cell Too dry (delays healing, increases pain, slows cell migration migration
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Epithelialisation & EdgeEpithelialisation & Edge
What does the edge look like?What does the edge look like?Steep, shallow, epithelialized e.g. in fistulaSteep, shallow, epithelialized e.g. in fistula
Advancing or retreating?Advancing or retreating?Undermining?Undermining?Altered cell migrationAltered cell migrationAbnormal e.g. malignantAbnormal e.g. malignant
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Case StudiesCase Studies
TraumaTraumaBurnBurnDiabetic UlcerDiabetic UlcerChronic non healing ulcerChronic non healing ulcerInfected woundInfected woundAbrasion from motor bike accidentAbrasion from motor bike accident
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Each group to select Each group to select one scenarioone scenario
20 minutes to discuss and complete 20 minutes to discuss and complete assessmentassessment
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Each group present Each group present their casetheir case
5 minutes each5 minutes eachStick papers to wallStick papers to wall
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Scenario One: TraumaScenario One: Trauma
Microsoft Word Document
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ReviewReview
Full thickness skin tear with loss of flapFull thickness skin tear with loss of flapHealing stage: inflammatoryHealing stage: inflammatoryClassification secondary healingClassification secondary healingFactors delaying healing: venous flare, haematoma, necrotic Factors delaying healing: venous flare, haematoma, necrotic tissue, Investigations? Swab, L&S B/Ptissue, Investigations? Swab, L&S B/PDressings, hydrogel, to debride, Silver to reduce inflammatory Dressings, hydrogel, to debride, Silver to reduce inflammatory S/sS/sMedication Medication s/es/e ? Falls, bleeding? Falls, bleedingImmobilisation in past ? DVT with venous hypertensionImmobilisation in past ? DVT with venous hypertensionPt advice Pt advice –– work, potential S & S, expected healing, swelling, work, potential S & S, expected healing, swelling, ?ACC?ACCReferrals: Surgical, for debridement, SSG, Referrals: Surgical, for debridement, SSG,
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Scenario Two: BurnScenario Two: Burn
Microsoft Word Document
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ReviewReview
Healing stageHealing stageClassification Classification –– depth of burndepth of burnPossible factors delaying healingPossible factors delaying healingInvestigations and assessmentInvestigations and assessmentDressing rationale and choiceDressing rationale and choiceMedicationMedicationImmobilisationImmobilisationPt advice Pt advice ––potential problems. potential problems. Referrals, scar management, physio, plastics.Referrals, scar management, physio, plastics.
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Scenario Three: Diabetic FootScenario Three: Diabetic Foot
Microsoft Word Document
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ReviewReview
Healing stageHealing stageClassificationClassificationContributing factors delaying healingContributing factors delaying healingInvestigations and assessmentInvestigations and assessment
Neuropathic, vascular, biomechanical, glycaemic control, HT, Neuropathic, vascular, biomechanical, glycaemic control, HT, footwear, lifestyle. Depth of injury, FBfootwear, lifestyle. Depth of injury, FB
DressingsDressingsMedication, oral, IV, Medication, oral, IV, ImmobilisationImmobilisationPt advice Pt advice –– shoes, footshoes, foot--care, BGL monitoringcare, BGL monitoringReferrals Referrals –– orthotics, podiatry, dietician, DNS, orthotics, podiatry, dietician, DNS,
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What Not to WearWhat Not to Wear
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Scenario Four: Chronic Non HealingScenario Four: Chronic Non Healing
Microsoft Word Document
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ReviewReview
Healing stageHealing stageClassificationClassificationPossible factors delaying healingPossible factors delaying healingInvestigations, ABI, exclude malignancy, Investigations, ABI, exclude malignancy, Dressings and compression optionsDressings and compression optionsMedicationMedicationPt advice Pt advice –– work, potential S & S, work, potential S & S, ReferralsReferrals
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Scenario Five: AbrasionScenario Five: Abrasion
Microsoft Word Document
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Review AbrasionReview Abrasion
Healing stageHealing stageClassificationClassificationPossible factors delaying healingPossible factors delaying healingInvestigations Investigations Differential diagnosisDifferential diagnosisDressings Dressings MedicationMedicationPt advice Pt advice –– work, potential S & S, work, potential S & S, ReferralsReferrals
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Scenario Six: InfectedScenario Six: Infected
Microsoft Word Document
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Inflammation stage Inflammation stage …… or infected?or infected?
Inflammatory healing stageInflammatory healing stageErythemaErythemaHeatHeatOedemaOedemaDiscomfortDiscomfortFunctional disturbanceFunctional disturbance
Infection signs & symptomsInfection signs & symptomsCellulitisCellulitisRaised temperatureRaised temperatureIncreased exudateIncreased exudatePusPusLymphangitisLymphangitisOdourOdourIncreased painIncreased painWound deteriorationWound deteriorationDeep Deep ““meatymeaty”” granulation, granulation, bleeding easilybleeding easily
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ReviewReview
Healing stageHealing stageClassification Classification –– deep compartment or superficial deep compartment or superficial Possible factors delaying healingPossible factors delaying healingInvestigations,Investigations,Differential diagnosis: Pyoderma gangrenosum, ? Tape injury, ? Differential diagnosis: Pyoderma gangrenosum, ? Tape injury, ? Suture reactionSuture reactionDressings, silver, absorbent, silicone, foamDressings, silver, absorbent, silicone, foamMedication, IV pathway: cephazolin IV Oral Medication, IV pathway: cephazolin IV Oral clinadamycinclinadamycinIf Pyoderma: steroids If Pyoderma: steroids MobilisationMobilisationPt advice Pt advice –– work, potential S & S, elevation, tissue loss, pain.work, potential S & S, elevation, tissue loss, pain.ReferralsReferrals
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Infection in Chronic wounds:Infection in Chronic wounds:
No single bacterial group worseNo single bacterial group worseHighly colonized wounds still healHighly colonized wounds still healStatistical significance if >4 groupsStatistical significance if >4 groupsSwab or biopsy?Swab or biopsy?Technique (whole surface, Technique (whole surface, zigzig--zagzag, rotating), rotating)Moisten swab if dry woundMoisten swab if dry wound
ReferenceReference WA trial WA trial TrengoveTrengove et alet al……(1995)(1995)
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Superficial InfectionSuperficial Infection
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DeepDeep compartment infectioncompartment infection
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Managing InfectionManaging Infection
Ignore Swabs unless host reactionIgnore Swabs unless host reactionDeep compartment infectionDeep compartment infection
Oral antibioticsOral antibioticsIV antibioticsIV antibiotics
Superficial infectionSuperficial infectionSilverSilverCadexomer IodineCadexomer IodineHoney (UMF)Honey (UMF)
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Reflection: Did you documentReflection: Did you document……
Wound sizeWound sizeCharacteristicsCharacteristicsExudateExudatePainPainHealing stageHealing stageHealing typeHealing typeIntervention/investigation /managementIntervention/investigation /managementPatient perspectivePatient perspective
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Wound cleansingWound cleansing
Rationale: to remove inflammatory contaminants from Rationale: to remove inflammatory contaminants from wound bedwound bedCauses some traumaCauses some trauma
MechanicalMechanicalChemicalChemical
Surfactants: break bonds between contaminants and Surfactants: break bonds between contaminants and wound surface. (strength of action = strength of wound surface. (strength of action = strength of toxicity)toxicity)
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CleansingCleansing
Saline or waterSaline or waterWarmedWarmedIrrigatedIrrigated-- psipsi research ongoingresearch ongoing
Bulb syringe = low Bulb syringe = low psipsi12ml syringe 22 g needle =13 12ml syringe 22 g needle =13 psipsi12 ml syringe 19h needle = 20 12 ml syringe 19h needle = 20 psipsi
Clean surrounding skinClean surrounding skinClean wounds before swabs for MC&SClean wounds before swabs for MC&S
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AntisepticsAntiseptics
Non selectiveNon selectiveKills Kills ““good bacteriagood bacteria”” replaced with harmful replaced with harmful speciesspeciesHost hypersensitivityHost hypersensitivityDeaths recordedDeaths recordedUrgent research neededUrgent research needed
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Sodium Chloride 0.9%Sodium Chloride 0.9%
Is isotonicIs isotonicCost effectiveCost effectiveDoes not harm living tissueDoes not harm living tissue
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Irrigated Warmed Tap Irrigated Warmed Tap WaterWater
No difference in infection rates or wound No difference in infection rates or wound size between saline/water groupssize between saline/water groupsWater not analyzed in researchWater not analyzed in researchCosts lessCosts lessSmall sample sizeSmall sample size
Griffiths, Fernandez, Griffiths, Fernandez, UssiaUssia (2001) JWC(2001) JWC
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Water Water vsvs SalineSaline
Can cause pain and tissue damage, Can cause pain and tissue damage, RBCsRBCs burst when in contact with waterburst when in contact with waterTap water purity importantTap water purity importantOsmosis effects crossing cell membraneOsmosis effects crossing cell membraneTap, Boiled, Distilled?Tap, Boiled, Distilled?Sodium Chloride 0,9% can be slightly acid due to Sodium Chloride 0,9% can be slightly acid due to absorbing carbon dioxideabsorbing carbon dioxide
Lawrence, (1997) JWCLawrence, (1997) JWC
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ChlorhexidineChlorhexidine GluconateGluconate
Kills gram Kills gram ––veve and gram +and gram +veveLow toxicity to granulationLow toxicity to granulationSystemic absorption rareSystemic absorption rareGood for disinfecting instrumentsGood for disinfecting instrumentsNot isotonicNot isotonicEffect reduced/inactivated by soap, blood, Effect reduced/inactivated by soap, blood, organic material, povidineorganic material, povidine--iodineiodineCan be contaminated by PseudomonasCan be contaminated by Pseudomonas
Source K Carville 2001Source K Carville 2001
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ChlorhexidineChlorhexidine GluconateGluconate & & cetrimidecetrimide ((SavlonSavlon))
Effective with gram Effective with gram ––iveive & +& +veveCan clean wound debrisCan clean wound debrisGood for equipment, surfaces etcGood for equipment, surfaces etcVery toxic to fibroblastsVery toxic to fibroblastsSame disadvantages as Same disadvantages as ChlorhexidineChlorhexidineSevere skin irritation can occurSevere skin irritation can occur
Source K Carville 2001Source K Carville 2001
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Hydrogen PeroxideHydrogen Peroxide
Mechanical debridement (bubbling)Mechanical debridement (bubbling)OO²² mmay kill anaerobic bacteriaay kill anaerobic bacteriaCan lift new epitheliumCan lift new epitheliumCytotoxic to fibroblastsCytotoxic to fibroblastsEmbolus riskEmbolus riskCan dissolve clots and cause bleedingCan dissolve clots and cause bleeding
Source K Carville 2001Source K Carville 2001
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Acetic Acid 0.5%Acetic Acid 0.5%
Effective against pseudomonas Effective against pseudomonas aeruginosaaeruginosaToxic to fibroblastsToxic to fibroblastsNot isotonicNot isotonicPainfulPainfulMay irritate surrounding skinMay irritate surrounding skin
Source K Carville 2001Source K Carville 2001
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PovidinePovidine--IodineIodineEffective gram Effective gram ––veve & +& +veve, spores, fungi, , spores, fungi, viruses, protozoaviruses, protozoaMultiple preparations, lotions creams etc Multiple preparations, lotions creams etc Inactivated by body fluidsInactivated by body fluids5% concentration causes cessation of 5% concentration causes cessation of blood flowblood flowToxic to fibroblastsToxic to fibroblastsSkin reactionSkin reactionSystemic absorption in deep wounds Systemic absorption in deep wounds ––cardiovascular, renal, liver toxicity and cardiovascular, renal, liver toxicity and nephropathynephropathy
Source K Carville 2001Source K Carville 2001
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Sodium hypochloriteSodium hypochloriteGood for surfaces, toilets, etcGood for surfaces, toilets, etcInactivated by body fluids, pus, organic matterInactivated by body fluids, pus, organic matterToxic to fibroblastsToxic to fibroblastsPrevents collagen synthesisPrevents collagen synthesisPermanently occludes microcirculationPermanently occludes microcirculationIrritant to skin,Irritant to skin,Causes local oedemaCauses local oedemaDissolves clots, causes bleedingDissolves clots, causes bleedingAbsolutely unsafe on woundsAbsolutely unsafe on wounds
Source K Carville 2001Source K Carville 2001
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Weak Consensus on Antiseptics Weak Consensus on Antiseptics (Paris)(Paris)
Chronic ulcersChronic ulcers (no (no RTCsRTCs to support)to support)Pressure areasPressure areas (only if near orifices) otherwise (only if near orifices) otherwise Diabetic footDiabetic foot 30/60 if exposed bone or single 30/60 if exposed bone or single bacterial speciesbacterial speciesAcute woundsAcute wounds
(no (no RCTsRCTs to support) often advised, ? duration and to support) often advised, ? duration and application. application. ☺☺ in contaminated trauma and post surgery. in contaminated trauma and post surgery.
Infected woundsInfected wounds (no evidence, no standard definition (no evidence, no standard definition of infection) is appealing in practiceof infection) is appealing in practiceBurnsBurns ☺☺ as initial cleanser onlyas initial cleanser only
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Wound Infection Institute Wound Infection Institute (Budapest)(Budapest)
ResistanceResistanceInIn--vitrovitro--, in, in--vivo, invivo, in--situsituSubSub--therapeutic levelstherapeutic levelsToxicityToxicityPenetration of antimicrobials & effectsPenetration of antimicrobials & effectsEvidence lacking for antimicrobial and antiseptic agentsEvidence lacking for antimicrobial and antiseptic agentsAllergy Allergy vsvs Skin sensitivitySkin sensitivityClaims, mixed messages, overuse, costClaims, mixed messages, overuse, cost
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Aggressive Aggressive debridement and debridement and
careful cleansing are careful cleansing are the best form of wound the best form of wound
disinfectiondisinfection
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Which Dressings to Which Dressings to Use?Use?
ThinkThink……what do you want this what do you want this dressing to do?dressing to do?
(Not what should I put on this wound)(Not what should I put on this wound)
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Insulate, be non toxic, moist environment
Reduce pain
Control & contain exudate
Promote autolytic debridement
Protect surrounding skin
Quality of life: comfort, conformability
Be a barrier to pathogens
Dressings should – Check with what you identified…
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Films
Alginates
Foams
Hydrogels
Hydrocolloids
Hydrofibre
Silver
Medicated
Paraffin Dressings
Cadexomer Iodine
Low adherent
Combination
Charcoal
Silicone
Dressings Dressings –– generic groupsgeneric groups
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Dressings that donate moistureDressings that donate moisture
HydrogelsHydrogelsClean wounds of debrisClean wounds of debrisSoften escharSoften escharRemove sloughRemove sloughFeels cool and reduces pain (but no thermal insulation is Feels cool and reduces pain (but no thermal insulation is provided)provided)Relatively impermeable to gasesRelatively impermeable to gasesRehydrate tissue but can also absorb some fluidRehydrate tissue but can also absorb some fluid
Consider using in sunburn, chickenConsider using in sunburn, chicken--pox, shingles, cracked pox, shingles, cracked nipples in breastfeeding nipples in breastfeeding
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Dressings to promote Dressings to promote granulationgranulation
Angiogenesis is faster in a hypoxic environmentAngiogenesis is faster in a hypoxic environmentHydrocolloidHydrocolloidHydrocolloid PasteHydrocolloid PasteOcclusive dressingsOcclusive dressings
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Dressings to Manage ExudateDressings to Manage Exudate
AlginatesAlginatesHard gel (more Hard gel (more guluronicguluronic acid in composition)acid in composition)Soft gel (more Soft gel (more mannuronicmannuronic acid in composition)acid in composition)
Foam sheets and cavity fillersFoam sheets and cavity fillersHydroactive (surfactant)Hydroactive (surfactant)Hydrofibre Hydrofibre ExudryExudrySome hydrogel sheetsSome hydrogel sheets
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Dressings to Encourage Dressings to Encourage EpithelialisationEpithelialisation
High oxygen concentrations are beneficial at High oxygen concentrations are beneficial at wound surface and tissue is very fragile wound surface and tissue is very fragile
ConsiderConsiderFilmsFilmsNon adherentNon adherentContact layersContact layersMepitel Mepitel
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Dressings to Debride SloughDressings to Debride Slough
Hydrogel (moisture donation)Hydrogel (moisture donation)HydrocolloidHydrocolloidCadexomer iodineCadexomer iodineAlginate if high exudateAlginate if high exudateHydrofibreHydrofibreEnzyme (new Enzyme (new clostridialclostridial collagenase)collagenase)
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Managing Moisture Managing Moisture Transpiration Rate (MTR)Transpiration Rate (MTR)
FilmsFilmsBacterial permeabilityBacterial permeabilityPain managementPain managementNon exuding woundsNon exuding woundsAbrasionsAbrasions
CombinationsCombinations
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Dressings to Manage Odour Dressings to Manage Odour
CharcoalCharcoalCharcoal plus absorptionCharcoal plus absorptionFlagylFlagyl gel*gel*Manuka HoneyManuka HoneyTea bagsTea bagsAroma therapy in palliative fungating wounds Aroma therapy in palliative fungating wounds (peppermint and tea tree oils in base cream (peppermint and tea tree oils in base cream Journal Journal
Wound care Vol 14 Nov 2005Wound care Vol 14 Nov 2005))
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Dressings to manage wound Dressings to manage wound pain/Allodyniapain/Allodynia
Arterial pain Arterial pain -- gravitygravityVenous pain Venous pain -- elevationelevationDressings Dressings –– adherence, granulation into spacesadherence, granulation into spacesSkin strippingSkin strippingSurfactant in dressingsSurfactant in dressingsSilicone sheetsSilicone sheetsWear timeWear time
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Topical Management for infectionTopical Management for infection
Cadexomer iodineCadexomer iodineAcetic acid 5%Acetic acid 5%Manuka honeyManuka honey-- gamma radiatedgamma radiatedBioBio--available silveravailable silverDebridementDebridementPeriPeri--anal skin careanal skin careAntibioticsAntibiotics
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WebsitesWebsites
http://http://www.ewma.orgwww.ewma.orghttp:// http:// www.nzwcs.org.nzwww.nzwcs.org.nzhttp:// http:// www.nzgg.org.nzwww.nzgg.org.nzhttp://http:// www.awma.com.auwww.awma.com.auhttp://http:// www.cawc.netwww.cawc.nethttp://http://www.joannabriggs.edu.auwww.joannabriggs.edu.au
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24
Panel QuestionsPanel Questions
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