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8/24/17
1
NavigatingtheTreacherousWatersofWoundCare
Overcomingfearandemotion
• Peoplefeargoingintodeeperoceanwaterforfearofsharkbites• Realityis,mostsharkbitesoccurinwadingwaterdepth• Thelikelihoodofasharkbitepalesincomparisontodeathincarcrashesorevenlighteningstrikes• Ifwelookatthedatawegetabetterperspective
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SurfingInjuryRisk
• 2009AmericanJournalofSportsMedicine• Surfingissaferthansoccer
OvercomeEmotionandTradition
• WoundtreatmentsshouldbebasedonEvidenceandData• It’sdifficulttoovercome• “We’vealwaysdoneitthatway”• “Myaunthadawoundlikethatanditworkedforthem”• ”That’swhatthedoctorintheHospitalperscribed”
Pillarsofasuccessfulwoundcareprogram
• Properequipmentandsupplies• Currentwoundpracticesbasedonuptodateclinicalevidence• Welldefinedandorgainzed woundcareteam
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Getridofthecause90%
• Comparetoswimmerjuststarting…....doesnotneedtofocusonspecialtysuits.
• Drivenbyconditionofwoundbedandsurroundingtissue.• Treatmentsmayoptimizedtocreateanoptimalhealingenvironment,inaneconomicalway.• Agivenwoundmayhaveseveralappropriatetreatmentoptions• Treatmentshouldbechangedinnon-healingwoundafter2-4weeksifnoknowncauseforhealingdelay
WoundTreatmentOptions
MoisturedonatingMoistureabsorbingEnzymaticHemostaticAntimicrobial
CavityfillingStimulatorySubstrateprovidingArtificialmembranes
BasicTreatmentCatagories
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• Ifyouhavenecrotictissue—Debrideit• Ifitistoowet—Absorbit• Ifitistoodry—Moistenit• Ifthereisacavity—Fillit• Ifthereisinfection—Killit• Ifthereisbleeding—Stopit• Ifthereisodor—Eliminateit
TreatmentDecisions
• Necrotictissueremoval:collagenase• Absorptive:alginates,foams,andhydrofibers• Moisturedonating:hydrogels• Cavityfilling:packings(iodaform),gauze,alginates,andsilicones• Antimicrobials:Silvers(alginatesandgels),Antibiotics,PHMB,• Coagulants:Hemabate,QuickClot,andclottingpowders• Odorreducing:Carbonbased,charcol,andDakins
ExamplesofVariousCatagories
• Whenpossibleasingletreatmentisbest• Multipleproductsincreasescost.• Manytreatmentscanbechangedeveryotherdayorless (everythreedays,threetimesperweek,orevenweekly)• Nursingtimeispartoftreatmentcost
FrequencyofTreatment
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Autolytic:Slowest,usesbodiesownenzymestoslowlyeatawaynecrotictissue• Mechanical:Physicalremovalofnecrotictissue,ie wet-to-dry,pulselevage,whirlpool,ect…• Enzymatic:Chemicalenzymesthatdebrideawaynecrotictissueoveraperiodofdaystoweeks.• Surgical/Sharpdebridement
DebridementOptions
• Removalofnecrotictissuewithacuretteorblade.• Welldocumentedeffectivenessinhealingandpreventionofinfection.• Removalofsenescentcellsinthepresenceoflittlevisibleslough• Repeatedproceedures necessarytoachieveoptimaleffect.• Preformedbyatrainedclinician(PhysicianortrainedNursePractitioner).• Reducestheneedforexpensiveenzymatics
SurgicalSharpDebridement
• Collegenase (Santyl)• Obtainedfrombacteria• Selectivedebridementoftissuetypes• Viewedasworkingfromwoundbaseup
• Avoidusewithheavymetals• Whenpossible,quickerremovalofnecrosiscanbeachievedviasurgicaldebridement
CurrentEnzymaticDebridingAgents
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InhibitionofSantyl
• Antibiotics:Over-usemayleadtoresistantbugs• Silver:Bacteriostatic,noknownresistance,notanantibiotic,thereforenoresistancedevelops,butpatientsensitivitycan• Avoidtreatingculturesofbiofilm
Antimicrobials
• Pressurewillstopmostbleeding,don’trub• SilverNitratecautery• Monsel’sSoln.• QuickClot
BleedingWounds
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• Avoidculturesinwellhealingwoundswithoutsignsofinfection• Goldstandardistissuebiopsyafterremovalofnecrotictissueandslough• Lavinetechniquewhenbiopsynotpossible• Biopsyshouldbeperformedbytrainedclinician.
WoundCultures
• CalciumAlginate(maxorb)• Hydrofibers(aquacel)• Iodaform• SilvasorbCavity• Hydrogelimpregnatedgauze
CavityFilling
• CollegenDressings(Fibercol,Puracol,Cellerate)• GrowthFactors(Regranex,Oasis)• Trypsincontainingagents(Xenoderm,Granulex)
StimulatoryAgents
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• Apligraf• SkinGrafts• SkinFlaps
Tissuedressings
• Onrareoccasionsthesetreatmentsmaystillbeappropriate.• Wet-to-dry• Dakin’sSolution• Betadine,Iodine,ect…
OlderTreatmentstoAvoid
• Woundbedconditiondrivestreatmentchoice.• Removalofnecrotictissuepreventsinfection,reducesbioburden,andstimulatesnewgrowth• Singleproductuse,withattentiontocostincrucialintodaysenvironment• Re-evaluatewoundsfrequentlyandconsiderchangesif2-4weekspasswithoutimprovement
DressingSelectionSummary
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TheWoundCareDreamTeam
Sailboatstory
• Intrototeammembers:eduardo,Megan….(woundcareteam)• Intortoboat:MakuMaki(rightequipment)• IntrotoCaptain:NedWebster(effectiveleadership)• Identificationofgoal:GettothefloridaKeys(clearlyidentifiedpurpose)• Problems:stormontheHorizon.(Unexpectedresults)• Innovation:formationofideasandsolutions• Solution:fixingthesails:(solutiontocorrectresuts)• Unpacking:(AfterActionReview)
• LargestOrganoftheBody• Subjecttoinjuryandfailure• LayersoftheSkin– Epidermis– Dermis– Subcutaneous–MuscleandFascia
AnatomyofSkin
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• PressureUlcers• ArterialUlcers• VenousUlcers• DiabeticNeuropathicUlcers• SurgicalWounds--Dehisance
TypesofWounds
• Stageone=Redness• Stagetwo=Damagetoepidermisandordermis,butnotsubcutaneous.• Stagethree=Damagedownintothesubcutaneoustissue,butnottomuscleandfascia• Stagefour=DamagethroughSubcutaneoustolevelofmuscleandfascia
PressureUlcers
• Rednessonly• Skinisintact• Underlyingdamagemaynotbeevident• Earlyrecognitioniskey
StageIPressureUlcer
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• BrokenSkin• Involvesepidermisand/ordermis
Nosloughornecrosispresent
StageIIPressureUlcer
• Moresignificantdamagetoskin• Involvesepidermis,dermis,andsubcu-tanious tissue
StageIIIPressureUlcer
• Mostseveredamagetoskin• Involvesalllayersofskindowntomuscleandfascia
StageIVPressureUlcer
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• Cannotvisulizewoundbed• Numbernotassigneduntilfulldamageisdetermined
UnstageablePressureUlcer
• Nonpressurerelated,interruptionorblockageofbloodflow• DistalportionofthelowerExtremity,ankle,topoffoot,toes• Woundbeddryandpale,minimalexudate• Intermittentcluadication,decreasedpulses,painonelevation,cooltotouch,decreasedcapillaryrefill
ArterialUlcers
}Openlayerofskinandorsubcutaneoustissue} Venoushypertensionfromcompromisedvalves,partialorcompletevenousobstruction,musclepumpfailure(paralysis)
} Pretibialarea}Woundbedmoistandgranulating,withminimaltocopiousexudate.} Painindependant position.Oftenrecurring.
VenousUlcers
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• PeripheralneuropathyfromDiabetes• Balloffootovermetatarsalheads,topoftoes• Resemblesarterial,frequentlyinfected• Dx ofDMrequired,withimpairedsensation,mayhaveCharcotdeformity.
NeuropathicUlcers
• TypicalPostsurgicalwoundsshouldbeclean,wellapproximated,andlittletonodrainage• Ifearlyonabreakdownoccurs,notifythesurgeonascontinuedcaremaystillbewithintheglobalperiod• Signsofconcern:non-healing,increasederythema,increasedorpusdrainage,woundseparation,increasedpain
SurgicalWounds