Vohra Wound ManagementVohra Wound Management

Ameet Vohra MD, CWSAmeet Vohra MD, CWS

Medical DirectorMedical Director

IntroductionIntroduction

• Who are we?Who are we?

-Physician group, focus is long term -Physician group, focus is long term carecare

• What does the program provide for What does the program provide for the facility? the facility?

-GRAND ROUNDS, Education, -GRAND ROUNDS, Education, ProtectionProtection

Benefits to the facilityBenefits to the facility

• Financial Savings / Increase RevenueFinancial Savings / Increase Revenue

• Liability ProtectionLiability Protection

• Education / CertificationEducation / Certification

• Compliance with State GuidelinesCompliance with State Guidelines

• Optimal Medical ManagementOptimal Medical Management

Outcomes DataOutcomes Data

• Fewer Infections: 46%Fewer Infections: 46%

• Fewer Amputations: 39%Fewer Amputations: 39%

• Fewer instances of gangrene: 42%Fewer instances of gangrene: 42%

• Fewer hospitalizations: 36%Fewer hospitalizations: 36%

Historical PerspectiveHistorical Perspective

• ““Dress” the wound – cover it up, hide Dress” the wound – cover it up, hide itit

• Hale was old English for “holy” & Hale was old English for “holy” & “heal”“heal”

• Hamlet : “it will but skin and film the Hamlet : “it will but skin and film the ulcerous place, whilst rank corruption ulcerous place, whilst rank corruption mining all within, infects unseen” mining all within, infects unseen”

Population Ageing Population Ageing

• >65 yrs will double by 2040>65 yrs will double by 2040

• >85 yrs will quadruple by 2040>85 yrs will quadruple by 2040

• Declining skin functions with ageDeclining skin functions with age

-barrier-barrier

-immune-immune

-healing-healing

• Increased MMPsIncreased MMPs

Key PointsKey Points

• Physician involvementPhysician involvement• DebridementDebridement• Deep tissue injuryDeep tissue injury• Skin failureSkin failure• Unavoidable – correct definitionUnavoidable – correct definition• Define etiologyDefine etiology• Individualize careIndividualize care• Pain – recognize, treat, documentPain – recognize, treat, document

Nursing Home StatisticsNursing Home Statistics

• 16,300 nursing homes nationwide16,300 nursing homes nationwide

• Approx. 1.5 million residentsApprox. 1.5 million residents

• Wound prevalence rate is 9%Wound prevalence rate is 9%

• 140,000 residents with wounds140,000 residents with wounds

• In-house prevalence rate is 0.8%In-house prevalence rate is 0.8%

Long Term Care Facility Long Term Care Facility TagsTags• F314 – Pressure Ulcers F314 – Pressure Ulcers

• F309 – End of Life / Pain ManagementF309 – End of Life / Pain Management

• F305 – Quality of LifeF305 – Quality of Life

• F385 – Physician InvolvementF385 – Physician Involvement

• F501 – Medical DirectorF501 – Medical Director

• F281 – Care meets professional standards F281 – Care meets professional standards RN not LPN for admission RN not LPN for admission

assessmentassessment

• F157 – Notification of ChangesF157 – Notification of Changes

Tags-continuedTags-continued

• F272 – Comprehensive AssessmentsF272 – Comprehensive Assessments

• F282 – MD Orders not implementedF282 – MD Orders not implemented

• F279 – Comprehensive care plansF279 – Comprehensive care plans

• F353 – Sufficient staffF353 – Sufficient staff

• F280 – Comprehensive care plan revisionF280 – Comprehensive care plan revision

- “clean ulcer should show evidence of - “clean ulcer should show evidence of healing within 2 - 4 weeks”healing within 2 - 4 weeks”

• F441 – Aseptic technique (change F441 – Aseptic technique (change gauze/gloves) gauze/gloves)

State SurveysState Surveys

• The future of surveys? The future of surveys? • New CMS guidance F314New CMS guidance F314• How to satisfy the stateHow to satisfy the state• The Initial Assessment: DTI / StagingThe Initial Assessment: DTI / Staging• What is an unavoidable ulcerWhat is an unavoidable ulcer• ““cms.internetstreaming.com”cms.internetstreaming.com”

What will trigger a CitationWhat will trigger a Citation

• Facility failure (protocols)Facility failure (protocols)• Failure to implement preventive careFailure to implement preventive care• Failure to diagnose earlyFailure to diagnose early• Failure to treat aggressivelyFailure to treat aggressively• Infection of wound – level 3 citationInfection of wound – level 3 citation• Delay in treatment (esp. nec. inf. Wound)Delay in treatment (esp. nec. inf. Wound)• Failure to implement orders Failure to implement orders • Failure to explain / document skin Failure to explain / document skin

deteriorationdeterioration• Failure to individualize managementFailure to individualize management

Unavoidable UlcerUnavoidable Ulcer

• If correct risk stratification & preventionIf correct risk stratification & prevention

• If detected at St 1, treated, & re-If detected at St 1, treated, & re-assessedassessed

• ““In-spite of early diagnosis, aggressive In-spite of early diagnosis, aggressive treatment & appropriate f/u, wound has treatment & appropriate f/u, wound has deteriorated. It is therefore deteriorated. It is therefore unavoidable.” DR ………unavoidable.” DR ………

• If etiology is not pressure If etiology is not pressure

Pro-active SolutionsPro-active Solutions

• Deep Tissue Injury: understand, Deep Tissue Injury: understand, recognize, document, treat (esp. heels)recognize, document, treat (esp. heels)

• Multi-specialty, interdisciplinary team Multi-specialty, interdisciplinary team headed by physicianheaded by physician

• Modern protocols, complete formularyModern protocols, complete formulary• Identify other etiologies – get DopplerIdentify other etiologies – get Doppler• Educate all the staffEducate all the staff• Get initial skin assessment rightGet initial skin assessment right

Systematic ApproachSystematic Approach

• Identify risk factors, individualize Identify risk factors, individualize interventions with interdisciplinary teaminterventions with interdisciplinary team

• Monitor daily, diagnose early, treat Monitor daily, diagnose early, treat aggressively, follow-up, re-assessaggressively, follow-up, re-assess

• Report deterioration / treatment failure Report deterioration / treatment failure to physician earlyto physician early

• Debridement non-viable tissue Debridement non-viable tissue “enhances wound healing”“enhances wound healing”

Litigation Recent Litigation Recent SettlementsSettlements• Florida (1998) $43 millionFlorida (1998) $43 million• Texas (1997) $92 millionTexas (1997) $92 million• Texas (1997) $83 millionTexas (1997) $83 million• Texas (2002) $3.8 millionTexas (2002) $3.8 million• Alabama (1993) $65 millionAlabama (1993) $65 million

21% claims > $500,000: median 21% claims > $500,000: median =$250,000=$250,000

Litigation – Perceptual Litigation – Perceptual IssuesIssues

• CommunicationCommunication

- understand and value family - understand and value family perspectiveperspective

- multidisciplinary communication- multidisciplinary communication

- involve family early- involve family early

- communicate regularly- communicate regularly

- document all communication- document all communication

Litigation – Standard of CareLitigation – Standard of Care

• Address failure to prevent / diagnoseAddress failure to prevent / diagnose

• Establish Realistic GoalsEstablish Realistic Goals

• Regular follow-upRegular follow-up

• Exceed Standard of Care Exceed Standard of Care

• Demonstrate the quality of care Demonstrate the quality of care delivereddelivered

• Document to defendDocument to defend

Litigation - RisingLitigation - Rising

• More informed consumersMore informed consumers• Blatant advertisingBlatant advertising• Earlier hospital / Rehab center dischargesEarlier hospital / Rehab center discharges• Precedent of generous settlementsPrecedent of generous settlements• Inadequately trained cliniciansInadequately trained clinicians• Sympathetic juries perceive wounds as Sympathetic juries perceive wounds as

indicators of poor careindicators of poor care

Wounds now second leading cause of litigationWounds now second leading cause of litigation

Damage Control Damage Control

• Early identification of skin deterioration Early identification of skin deterioration • Early contact with the responsible partyEarly contact with the responsible party -Explain why it happened-Explain why it happened -Explain plan of action-Explain plan of action -Explain realistic objectives-Explain realistic objectives -Encourage meeting wound care -Encourage meeting wound care SpecialistSpecialist

Medical Factors in Law Medical Factors in Law Suit Suit • Low risk patientLow risk patient

• Wound worse due to wrong treatmentWound worse due to wrong treatment

• Inadequate physician involvementInadequate physician involvement

• Inadequate pain managementInadequate pain management

• Documentation conflict on transferDocumentation conflict on transfer

• AbandonmentAbandonment

• Infection missed causing worse outcomeInfection missed causing worse outcome

DefenseDefense

• Risk factors – documentRisk factors – document

• Skin failure – identifySkin failure – identify

• Peripheral vascular disease – Peripheral vascular disease – diagnosediagnose

• Diabetes – level of controlDiabetes – level of control

• Involve family early and regularlyInvolve family early and regularly

• Document family discussionsDocument family discussions

Anatomy of the SkinAnatomy of the Skin

• Largest Organ of the BodyLargest Organ of the Body

• Subject to injury and failureSubject to injury and failure

• Layers of the SkinLayers of the Skin– EpidermisEpidermis– DermisDermis– SubcutaneousSubcutaneous– Muscle and FasciaMuscle and Fascia

Skin FailureSkin Failure

• Diagnosis is based on the clinical Diagnosis is based on the clinical condition of the patient.condition of the patient.

• Diagnosis by the physician after a full Diagnosis by the physician after a full examination and review of medical examination and review of medical historyhistory

Supportive Factors in the Supportive Factors in the History:History:(skin failure)(skin failure)• Advanced ageAdvanced age• DehydrationDehydration• Advanced carcinomatous diseaseAdvanced carcinomatous disease• Protein malnutritionProtein malnutrition• Weight lossWeight loss• Hopsice/terminal condition (for any Hopsice/terminal condition (for any

reason) with life expectancy less than 6 reason) with life expectancy less than 6 monthsmonths

• Single/multi organ failureSingle/multi organ failure

Supportive Findings on ExamSupportive Findings on Exam(skin failure)(skin failure)

• Multiple wounds at various sites of the Multiple wounds at various sites of the bodybody

• No clear etiology for the woundNo clear etiology for the wound

• Multiple skin tears, areas of shear Multiple skin tears, areas of shear injuryinjury

• Frail, cachectic, poorly responsive Frail, cachectic, poorly responsive patientpatient

• Declining physical conditionDeclining physical condition

Pressure UlcerPressure Ulcer

• Localized injury to skin/underlying Localized injury to skin/underlying tissuetissue

• Usually over a bony prominenceUsually over a bony prominence

• Due to Pressure (combined with Due to Pressure (combined with shear and/or friction)shear and/or friction)

Stage I Pressure ulcerStage I Pressure ulcer

• Redness onlyRedness only

• Skin is intactSkin is intact

• Underlying damageUnderlying damage

may not be evidentmay not be evident

• Early recognition Early recognition

is keyis key

Stage II Pressure UlcerStage II Pressure Ulcer

• Broken SkinBroken Skin

• Involves epidermisInvolves epidermis

and/or dermisand/or dermis

Stage III Pressure UlcerStage III Pressure Ulcer

• More significant More significant

damage to skindamage to skin

• Involves epidermis,Involves epidermis,

dermis, and subcu-dermis, and subcu-

tanious tissuetanious tissue

Stage IV Pressure UlcerStage IV Pressure Ulcer

• Most severe Most severe

damage to skindamage to skin

• Involves all layersInvolves all layers

of skin down to of skin down to

muscle and fasciamuscle and fascia

Unstageable Pressure UlcerUnstageable Pressure Ulcer

• Can not visualizeCan not visualize

wound bedwound bed

• Number not assignedNumber not assigned

until full damage until full damage

is determinedis determined

Deep Tissue InjuryDeep Tissue Injury

• Change in temperatureChange in temperature

• Change in consistency: firm/boggy Change in consistency: firm/boggy (heels)(heels)

• Change in sensation: painChange in sensation: pain

• Bruising / purple discolorationBruising / purple discoloration

• Dark skin: difficultDark skin: difficult

Deep Tissue InjuryDeep Tissue Injury

• Etiology is PressureEtiology is Pressure

• Skin intact: tissue below affectedSkin intact: tissue below affected

• Appears as a deep bruise / maroon areaAppears as a deep bruise / maroon area

• May present as a blood-filled blisterMay present as a blood-filled blister

• Evolution to stage 3/4 may be rapid Evolution to stage 3/4 may be rapid despite optimal treatmentdespite optimal treatment

• Treatment: pain control and off-loadingTreatment: pain control and off-loading

When is it not a pressure When is it not a pressure ulcer?ulcer?

• Arterial (Doppler)Arterial (Doppler)

• VenousVenous

• DiabeticDiabetic

• TraumaticTraumatic

• InflammatoryInflammatory

Arterial UlcersArterial Ulcers

• Interruption or blockage of blood flowInterruption or blockage of blood flow

• Distal portion of the lower Extremity, Distal portion of the lower Extremity, ankle, top of foot, toesankle, top of foot, toes

• Wound bed dry and pale, minimal exudateWound bed dry and pale, minimal exudate

• Intermittent cluadication, decreased Intermittent cluadication, decreased pulses, pain on elevation, cool to touch, pulses, pain on elevation, cool to touch, decreased capillary refilldecreased capillary refill

• Critical ischemia = ulcer/gangrene + Critical ischemia = ulcer/gangrene + ankle systolic pressure < 60mmHgankle systolic pressure < 60mmHg

Neuropathic UlcersNeuropathic Ulcers

• Peripheral neuropathy from DiabetesPeripheral neuropathy from Diabetes

• Ball of foot over metatarsal heads, top Ball of foot over metatarsal heads, top of toesof toes

• Resembles arterial, frequently Resembles arterial, frequently infectedinfected

• Dx of DM required, with impaired Dx of DM required, with impaired sensation, may have Charcot sensation, may have Charcot deformity. deformity.

Venous UlcersVenous Ulcers

• Open layer of skin and or subcutaneous Open layer of skin and or subcutaneous tissuetissue

• Venous hypertension from compromised Venous hypertension from compromised valves, partial or complete venous valves, partial or complete venous obstruction, muscle pump failure (paralysis)obstruction, muscle pump failure (paralysis)

• Pretibial area Pretibial area • Wound bed moist and granulating, with Wound bed moist and granulating, with

minimal to copious exudate.minimal to copious exudate.• Pain in dependant position. Often recurring.Pain in dependant position. Often recurring.

Diabetes DemographicsDiabetes Demographics

• 2-6% annual risk foot ulceration2-6% annual risk foot ulceration

• 15-25% lifetime risk for foot ulcer15-25% lifetime risk for foot ulcer

• Diabetes prevalence in US is 7% Diabetes prevalence in US is 7%

• 20.8 million Americans with diabetes20.8 million Americans with diabetes

- expected to increase 60% over - expected to increase 60% over 22yrs22yrs

Impact of DiabetesImpact of Diabetes

• IncreasesIncreases

- healing timehealing time

- Infection, PhlegmonInfection, Phlegmon

- Inflammatory stateInflammatory state

Have low threshold Have low threshold for treating for treating infectioninfection

• DecreasesDecreases

- Cell migrationCell migration

- Skin contractionSkin contraction

- Lymphocyte Lymphocyte functionfunction

Monitor HbA1CMonitor HbA1C

Heel ulcers & Off-loading Heel ulcers & Off-loading ProtocolProtocol

• Bed bound patient: Use cradle/block Bed bound patient: Use cradle/block (sponge or waffle boot)(sponge or waffle boot)

• Patient in bed/chair: Use comfortable, Patient in bed/chair: Use comfortable, padded easy bootpadded easy boot

• Patient ambulatory: Use cradle/block Patient ambulatory: Use cradle/block (sponge)/waffle boot in bed, use (sponge)/waffle boot in bed, use multipodus boot in chair/whilst walkingmultipodus boot in chair/whilst walking

• Label boots: L and RLabel boots: L and R

When NOT to use Multipodus When NOT to use Multipodus bootboot

• Leg edemaLeg edema

• Leg ischemiaLeg ischemia

• ContracturesContractures

• AgitationAgitation

Modern Wound Modern Wound ManagementManagement• Debridement: Sharp / EnzymaticDebridement: Sharp / Enzymatic

• Control of Biofilm / bioburden Control of Biofilm / bioburden

• Culture when clinically infectedCulture when clinically infected

• Control exudate / odorControl exudate / odor

• Frequency of dressing changes: balanceFrequency of dressing changes: balance

• Moist wound bed healing Moist wound bed healing

- avoid wet-dry, dakens, peroxide, - avoid wet-dry, dakens, peroxide, - betadine (except - betadine (except <5% for <10 days)<5% for <10 days)

Vacuum TreatmentsVacuum Treatments

• Most effective in complex, deep Most effective in complex, deep woundswounds

• Use till ulcer base granularUse till ulcer base granular

• Re-eval Rx if no progress in 2- 4 Re-eval Rx if no progress in 2- 4 weeksweeks

• Effective via multiple modalitiesEffective via multiple modalities

• Becoming standard of careBecoming standard of care

Contra-IndicationsContra-Indications

• infectioninfection

• Necrotic tissueNecrotic tissue

• Fistula or exposed organ / vesselFistula or exposed organ / vessel

• IschemiaIschemia

• Non-complianceNon-compliance

• (other patient-specific impeding (other patient-specific impeding factor)factor)

BiofilmBiofilm

• Layer of non-viable matterLayer of non-viable matter

• Harbors bacteria that exist synergisticallyHarbors bacteria that exist synergistically

• Impenetrable topically and systemicallyImpenetrable topically and systemically

• Curettage/Debridement effective in Curettage/Debridement effective in

disrupting and removing filmdisrupting and removing film

BioburdenBioburden

• Quantity of bacteria at wound bedQuantity of bacteria at wound bed

• Contamination-Colonization- Contamination-Colonization- CRITICAL CRITICAL

BIOBURDEN-BIOBURDEN- Infection Infection

• Critical bioburden- early diagnosis Critical bioburden- early diagnosis

essentialessential

Diagnosis of Critical Diagnosis of Critical BioburdenBioburden

• Pale granulation tissuePale granulation tissue

• Increase in odor/exudate/erythemaIncrease in odor/exudate/erythema

• Increase in pain and size of ulcerIncrease in pain and size of ulcer

• Failure to improveFailure to improve

• NO pus/cellulitisNO pus/cellulitis

Treatment OptionsTreatment Options

• Debridement/curettage Debridement/curettage

• Silver Silver

• Antibiotics Antibiotics

Debridement/CurettageDebridement/Curettage

• Remove infection risk, biofilm, Remove infection risk, biofilm, bioburdenbioburden

• Remove non-viable tissueRemove non-viable tissue

• Debridement options:Debridement options:

-Sharp (infection & pain control)-Sharp (infection & pain control)

-Enzymatic-Enzymatic

-Autolytic-Autolytic

-Mechanical-Mechanical

The Role of SilverThe Role of Silver

• Topical Non-antibiotic antibacterialTopical Non-antibiotic antibacterial

• Long history of safety and efficacyLong history of safety and efficacy

• Effective against bacteria, viruses, fungiEffective against bacteria, viruses, fungi

• No resistance development (not an No resistance development (not an antibiotic)antibiotic)

• Topical form, minimal systemic Topical form, minimal systemic absorptionabsorption

• 2 weeks therapy approx.2 weeks therapy approx.

When to CultureWhen to Culture

• Abscess fluidAbscess fluid

• Infection not responding to treatmentInfection not responding to treatment

• Must have cellulitis/pusMust have cellulitis/pus

• Suspect resistant organismSuspect resistant organism

• Wound failing to progress after 4-6 weeks Wound failing to progress after 4-6 weeks

Control of ExudateControl of Exudate

• Goal = moist environmentGoal = moist environment

• Individualize treatments, BiD to 1/5 Individualize treatments, BiD to 1/5 daysdays

• Frequent dressing- control exudate Frequent dressing- control exudate better but interferes with healing and better but interferes with healing and local immune response.local immune response.

• Key to success = Balance + Key to success = Balance + IndividualizeIndividualize

AvoidAvoid

• Wet to dry (mechanical debridement) from US civil Wet to dry (mechanical debridement) from US civil

warwar

• Dakens solution, Hydrogen peroxideDakens solution, Hydrogen peroxide

• Betadine (except < 5% for< 10 days)Betadine (except < 5% for< 10 days)

• Drying out wound bed (except gangrene)Drying out wound bed (except gangrene)

• Expensive unwarranted therapiesExpensive unwarranted therapies

• Wound care centers Wound care centers

Individualized CareIndividualized Care

1.1. Holistic approachHolistic approach2.2. Identify risk factorsIdentify risk factors3.3. Realistic objectivesRealistic objectives4.4. Select optimal wound dressingsSelect optimal wound dressings5.5. Depart from established Depart from established

protocols/algorithm protocols/algorithm 6.6. Nutritional supplementationNutritional supplementation7.7. Pain evaluation Pain evaluation

Daily Nursing AssessmentDaily Nursing Assessment

• Look for:Look for: 1) evidence of infection1) evidence of infection 2) change in size2) change in size 3) appearance of bone3) appearance of bone 4) change in exudate/odor/pain4) change in exudate/odor/pain 5) increase in pain5) increase in pain• Report wound deterioration to physicianReport wound deterioration to physician

Pain AssessmentPain Assessment

• Affected by anxiety, neuropathy, Affected by anxiety, neuropathy, timetime

• Get full historyGet full history

• Validate patients painValidate patients pain

• Whatever & whenever patient says it Whatever & whenever patient says it isis

• DocumentDocument

Pain InterventionPain Intervention

• Address inflammation, infection, Address inflammation, infection, edemaedema

• Use non-adherent dressingUse non-adherent dressing

• Protect surrounding skinProtect surrounding skin

• Pre-medicate systemically when Pre-medicate systemically when dressings painfuldressings painful

• Document improvement/patient Document improvement/patient satisfactionsatisfaction

AllergensAllergens

• Common allergens: Balsam of Peru Common allergens: Balsam of Peru

(<37%), lanolin (<20%), Neomycin (<37%), lanolin (<20%), Neomycin

(<15%), Bacitracin, repeated use (<15%), Bacitracin, repeated use

benzocaine/EMLAbenzocaine/EMLA

• Under-diagnosed and under-considered Under-diagnosed and under-considered

• Latex allergyLatex allergy

Allergy InterventionAllergy Intervention

• Change agentChange agent

• Tacrolimus (Eladil)Tacrolimus (Eladil)

• Steroid creamSteroid cream

• NSAID creamNSAID cream

• Maintain high index of suspicianMaintain high index of suspician

• Wound that deteriorates/fails to Wound that deteriorates/fails to improve/increases in painimprove/increases in pain

Atypical WoundsAtypical Wounds

• Neoplasm- excisionNeoplasm- excision

• Vasculitic- anti-inflamatoryVasculitic- anti-inflamatory

• Pyoderma gangrenosum- immuno-therapy Pyoderma gangrenosum- immuno-therapy

• Vasculopathy - anticoagulationVasculopathy - anticoagulation

• Cryoglobulinemia – treat causeCryoglobulinemia – treat cause

Wound ChemistryWound Chemistry

• MMPsMMPs

• InterleukinsInterleukins

• Growth hormonesGrowth hormones

• Inhibitors and stimulators of Inhibitors and stimulators of angiogenesisangiogenesis

• Hyper-granulation Hyper-granulation

• Wound chem. abnormal in diabetic Wound chem. abnormal in diabetic ulcersulcers

Wound MicrobiologyWound Microbiology• Pepto streptococcusPepto streptococcus

• BacteroidesBacteroides

• Streptococcus spp.Streptococcus spp.

• ColiformsColiforms

• ClostridiumClostridium

• Staph aureus (high Staph aureus (high prevalence rate in non-prevalence rate in non-infected ulcers, 88%, has infected ulcers, 88%, has low incidence of infection low incidence of infection vs other microbes eg vs other microbes eg anaerobes. Staphs may anaerobes. Staphs may facilitate growth of more facilitate growth of more toxic microbes eg toxic microbes eg anaerobes.anaerobes.

• Pseudomonas AeroginosaPseudomonas Aeroginosa

• FusabacteriumFusabacterium

• Streptococcus pyogenesStreptococcus pyogenes

• P. AcnesP. Acnes

• PneumotellaPneumotella

• Evidence that several Evidence that several common colonizing common colonizing microbes actually facilitate microbes actually facilitate healing. healing.

• Future challenge = target Future challenge = target only deleterious only deleterious microorganisms.microorganisms.

Nutrition: ProteinNutrition: Protein

BaselineBaseline 1g / Kg / day1g / Kg / day

Skin / Tissue damageSkin / Tissue damage 1.5g / Kg / day1.5g / Kg / day

High stressHigh stress 2.0g / Kg / day2.0g / Kg / day

Nutrition: Vitamins & Nutrition: Vitamins & MineralsMinerals

BaselineBaseline 1 multi-vitamin / day1 multi-vitamin / day

Skin / Tissue damageSkin / Tissue damage 1 multi-vitamin / day1 multi-vitamin / day

++

Nutritional supplementsNutritional supplements

++

Individualize for VitC & Individualize for VitC & ZnSO4 supplementsZnSO4 supplements

High stress, History High stress, History Malnutrition / Diarrhea / Malnutrition / Diarrhea /

Highly exudative Highly exudative woundswounds

1 Multi-vitamin / day1 Multi-vitamin / day

VitC 500mg BiDVitC 500mg BiD

ZnSO4, 220mg QD ZnSO4, 220mg QD x14days x14days

The FutureThe Future

• Growth factorsGrowth factors

• Novel support surfacesNovel support surfaces

• New antimicrobial therapy New antimicrobial therapy

• Expanded physical therapy supportExpanded physical therapy support -Anadyne, Ultrasound, Pulse lavage, Electrostim, -Anadyne, Ultrasound, Pulse lavage, Electrostim,

UVUV

• MaggotsMaggots

• Skin GraftsSkin Grafts

Wound Care Wound Care DocumentationDocumentation

Acrobat Document