1 F314 Follow-up Clinical Training January 23, 2006 Presented by Jeri Lundgren, RN, CWS, CWCN Wound...

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F314 Follow-up Clinical TrainingF314 Follow-up Clinical TrainingJanuary 23, 2006January 23, 2006

Presented by

Jeri Lundgren, RN, CWS, CWCN Wound Care Consultant

Pathway Health Services

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Training ObjectivesTraining Objectives

Know what a comprehensive risk assessment should include

Discuss individualized turning and repositioning Understand the treatment for lower extremity

wounds Describe the causes of pressure ulcers Differentiate between pressure reduction verses

pressure relief Discuss the application of pulsatile lavage in

wound management

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Risk AssessmentRisk Assessment

Guidance states

“Although the requirements do not mandate any specific assessment tool, other than the RAI, validated instruments are available to assess risk for developing pressure ulcers”

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Risk Assessment ToolsRisk Assessment ToolsBRADEN SCALEBRADEN SCALE

Mobility Activity Sensory Perception Moisture Friction & Shear Nutrition

*Please note: Using the Braden scale requires obtaining permission atwww.bradenscale.com or (402) 551-8636

http://www.bradenscale.com/

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“Regardless of any resident’s total risk score, the clinicians responsibility for the resident’s care should review each risk factor and potential cause(s) individually”

“an overall risk score indicating the resident is not at high risk of developing pressure ulcers does not mean that existing risk factors or causes should be considered less important or addressed less vigorously than those factors or causes in the resident whose overall score indicates he or she is at a higher risk of developing a pressure ulcer.”

Risk Assessment ToolsRisk Assessment Tools

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Risk Assessment ToolsRisk Assessment Tools

A COMPREHENSIVE risk assessment should be done:

– Upon admission

– *Weekly for the first four weeks after admission*

– With a change of condition

– Quarterly

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Comprehensive Risk Comprehensive Risk AssessmentAssessment

Overall skin condition - including tissue tolerance

Medical diagnosis and co-morbidities Medications or Treatments Degree of Mobility Incontinence of Bowel and/or Bladder Scarring over bony prominences Contractures Bedfast or Chair-bound

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Cognitively impaired Resident choice Restraints Unrelieved pain Slouching in a chair Repeated hospitalizations or ER visits

with-in 6 months Nutrition and hydration

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The overall goal of the risk assessment is to ensure that individualized interventions are attempted to stabilize, reduce or remove the underlying risk factors

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Prevention Interventions:Prevention Interventions:Provide appropriate pressure reduction or reliefProvide appropriate pressure reduction or relief

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Prevention Interventions Prevention Interventions Choose appropriate pressure reducing Choose appropriate pressure reducing

surfaces while in bed and sittingsurfaces while in bed and sitting

Pressure Reduction: Is the reduction of interface pressure, not necessarily below capillary closure pressure

Pressure Relief: Is the reduction of interface pressure below capillary closure pressure

Capillary closing pressure is also individual to the resident

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Support SurfacesSupport Surfaces There is no standardize testing or requirements

for support surfaces There is no set mandate or recommendation as

to when a specific type of support surface should be used.

Guidance states:“Appropriate support surfaces or devices should be

chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation: for example, multiple ulcers, limited turning surfaces and ability to maintain position.”

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Support SurfacesSupport Surfaces Surveyors should consider the following

pressure redistribution issues:– Static devices (e.g., solid foam or gel

mattresses) may be indicated when a resident is at risk or delayed healing. A specialized reduction cushion or surface might be used to extend the time a resident is sitting in a chair; however, the cushion does not eliminate the necessity for periodic repositioning

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Support SurfacesSupport Surfaces pressure redistribution issues

continued:– Dynamic pressure reduction surfaces may be

helpful when:» The resident can’t assume a variety of positions

without bearing weight on a pressure ulcer» The resident completely compresses a static

device » The pressure ulcer is not healing as expected,

and it is determined that pressure may be contributing to the delay in healing

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Prevention InterventionsPrevention Interventions

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Support SurfacesSupport Surfaces Use of recliners, guidance states

“The care plan for a resident who is reclining and is dependent on staff for repositioning should address position changes to maintain the resident’s skin integrity.”…..”Elevating the head of the bed or the back of a reclining chair to or above a 30 degree angle creates pressure comparable to that exerted while sitting, and requires the same considerations regarding repositioning as those for a dependent resident who is seated.”

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Support SurfacesSupport Surfaces Recliners continued

– Remember off-loading is one full minute of pressure relief

– Is the turning schedule in the best interest for the resident or per their wishes or is it in the best interest for staff

Foam vs. Gel vs. Air wheelchair cushions– Overall ensure it is the best for the individual resident

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Prevention InterventionsPrevention Interventions Develop an INDIVIDUALIZED turning & repositioning

schedule Tissue tolerance is the ability of the skin and it’s

supporting structures to endure the effects of pressure with out adverse effects

There is no standard/mandated “Tissue Tolerance Test”

“A skin inspection should be done, which should include an evaluation of the skin integrity and tissue tolerance, after pressure to that area, has been reduced or redistributed”

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Prevention InterventionsPrevention Interventions

After skin integrity and tissue tolerance has been assessed the resident then should be put on an appropriate INDIVIDUALZED turning and repositioning program

Ongoing monitoring of tissue tolerance and skin integrity should be done

Recommend assessing skin integrity and tissue tolerance upon admission and with a significant change of condition

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Lower Extremity WoundsLower Extremity Wounds

• Arterial Insufficiency

• Venous Insufficiency

• Peripheral Neuropathy/Diabetic

Referred to F309 Tag

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Arterial InsufficiencyArterial Insufficiency

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Arterial Insufficiency UlcersArterial Insufficiency Ulcers

Location– Toe tips and/or web spaces

– Phalangeal heads around lateral malleolus

– Areas exposed to pressure or repetitive trauma (shoe, cast, brace, etc.)

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Arterial InsufficiencyArterial Insufficiency

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Arterial Insufficiency Arterial Insufficiency InterventionsInterventions

Measures to Improve Tissue Perfusion– Revascularization if possible

– Lifestyle changes (no tobacco, no caffeine, no constrictive garments, avoidance of cold)

– Hydration

– Measures to prevent trauma to tissues (appropriate footwear at ALL times)

– Aspirin in doses of 75-325 mg oral/day

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NutritionConsider niacin; niacin has been shown to HDL-C & Triglycerides in oral dosages of 3,000mg/d

L-Arginine (vasodilator properties) oral intake of 6.6 g/day for 2 weeks improved symptoms of intermittent claudication

Provide nutritional support with 2,000 or more calories preoperatively and postoperatively, if possible; this has been benefited patients undergoing amputations

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Pain ManagementRecommend walking to near maximal pain three times per week.

Administer Cilostazol, 100mg BID, orally

Topical TherapyDry uninfected necrotic wound: KEEP DRY

Dry INFECTED wound: Immediate referral for surgical debridement/aggressive antibiotic therapy (Topical antibiotics are typically in-effective for arterial wounds)

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Topical Therapy (continued)Open Wounds

Moist wound healing

Non-occlusive dressings (e.g. solid hydrogel)

Aggressive treatment of any infection

Adjunctive TherapiesHyperbaric oxygen therapy

Intermittent pneumatic compression

Topical autologous activated mononuclear cells, twice per week (Autologel)

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Adjunctive Therapies (continued)High-voltage pulsed current (HVPC) electrotherapy

Patient Education

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Venous InsufficiencyVenous Insufficiency

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Venous Insufficiency UlcersVenous Insufficiency Ulcers

Location– Medial aspect of the lower leg and ankle

– Superior to medial malleolus

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Venous Insufficiency TreatmentVenous Insufficiency Treatment

Surgical obliteration of damaged veins

Elevation of legs

*Compression therapy to provide at least 30mm Hg compression at the ankle– Short stretch bandages (e.g. Setopress, Surepress)– Therapeutic support stockings– Unna’s boot– Profore layer wrap– Compression pumps

*ensure compression therapy in not contraindicated

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Venous Insufficiency TreatmentVenous Insufficiency Treatment

Topical TherapyAbsorb exudate (e.g. alginate, foam)

Maintain moist wound surface (e.g. hydrocolloid)

Chronic or non-responding wounds:Small Intestinal SubmucosaTechnology (Oasis Wound Matrix; Healthpoint)

Bi-layered cell therapy (Apligraf; Organogenesis, Inc.)

Patient Education

Appropriate antibiotics to treat infection

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Peripheral Neuropathy/Diabetic Peripheral Neuropathy/Diabetic Signs & SymptomsSigns & Symptoms

Relief of pain with ambulation Parasthesia of extremities Altered gait Orthopedic deformities Reflexes diminished Altered sensation (numbness, prickling,

tingling)

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Peripheral Neuropathy/Diabetic Peripheral Neuropathy/Diabetic Signs & SymptomsSigns & Symptoms

Intolerance to touch (e.g., bed sheets touching legs)

Presence of calluses

Fissures/cracks, especially the heels

Arterial insufficiency commonly co-exists with peripheral neuropathy!

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Peripheral NeuropathyPeripheral NeuropathyDiabetic LocationDiabetic Location

Plantar aspect of the foot Metatarsal heads Heels Altered pressure points Sites of painless trauma and/or repetitive

stress

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Peripheral NeuropathyPeripheral NeuropathyDiabetic TreatmentDiabetic Treatment

Pressure relief for heal ulcers

“Offloading” for plantar ulcers (bedrest, contact casting, or orthopedic shoes)

Appropriate footwear

Tight glucose control

Aggressive infection controlorthopedic consult for exposed bone and antibiotic therapy

Zyvox – approved for MRSA

Treatment for co-existing arterial insufficiency

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Topical Treatment– Cautious use of occlusive dressings– Dressings to absorb exudate– Dressings to keep dry wound moist

Chronic or non-responding wounds:– Recombinant human platelet-derived growth

factors (Regranex Gel; Johnson & Johnson)– Human fibroblast-derived dermal substitute

(Dermagraft; Smith & Nephew)– Bi-layered cell therapy (Apligraf; Organogenesis,

Inc.)

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Adjunctive TherapyHyperbaric Oxygen

MIRE - nitric oxide and monochromatic infrared photo energy (Anodyne Therapy LLC, Tampa, FL)

The V.A.C (KCI)

Patient Education

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Mixed EtiologyMixed Etiology

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Mixed EtiologyMixed Etiology

Use reduced compression bandages of 23-30 mm Hg at the ankle. Compression therapy should not be used in patients with ABI < 0.5

Keep extremities in neutral position

Protect from trauma

Pressure UlcersPressure Ulcers

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Pressure UlcersPressure Ulcers

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Contributing factors: Contributing factors: FrictionFriction

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Contributing factors: Contributing factors: FrictionFriction

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Contributing factors: ShearContributing factors: Shear

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Contributing factors: ShearContributing factors: Shear

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Contributing factors: Contributing factors: MoistureMoisture

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Contributing factors: Contributing factors: MoistureMoisture

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Topical TreatmentTopical Treatment

Wound Debridement Removal of devitalized tissue is considered

necessary for wound healing

Exception: Stable heel ulcers with a protective

eschar covering with no signs or symptoms of

edema,erythema, fluctuance, or drainage, do NOT

need debridement

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Wound DebridementWound Debridement

Mechanical: Use of wet-to-dry, hydrotherapy and wound irrigation to remove devitalized tissue

Disadvantage: non-selective, painful and can lead to excessive bleeding

NOTE: A wet-to-dry dressing should be used for debridement purposes ONLY

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Wound DebridementWound Debridement

Pulsatile Lavage– It is a form of mechanical

debridement to facilitate removal of larger amounts of debris

– Irrigation pressure should not exceed 15psi

– It is best discontinued once the wound is clean

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Pulsatile LavagePulsatile Lavage– It can cause dissemination of wound bacteria

over a wide area, exposing the resident and

care provider to potential contamination (JAMA Vol. 292 No. 24, December 22/29, 2004 & Nursing 2005, January 2005 Issue)

– Study at John Hopkins University School of Medicine, traced 11 patients infected with acinetobacter baumannii, back to the use of pulsatile lavage equipment. 3 of the patients required ICU care for sepsis and respiratory distress

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Pulsatile LavagePulsatile Lavage– Precautions must be used

» Use continuous suction» Keep splash shield in contact with the

wound/periwound» Empty suction waste container after each

use» Dispose of all single-use pulsatile lavage

components, then sterilize or disinfect all reusable items

» Always perform pulsatile lavage in a private room enclosed with walls and doors

» Thoroughly clean and disinfect environmental surfaces

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Pulsatile LavagePulsatile LavagePrecautions continued»Wear fluid proof gown,

mask/goggles or face shield and hair cover

»Resident should consider the use of a droplet barrier, such as a surgical mask

»Use a drape or towel to cover all resident lines, ports and wounds that aren’t being treated

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THANK YOU!!!THANK YOU!!!Jeri Lundgren, RN, CWS,

CWCN

Wound Care Consultant

Pathway Health Services

612-805-9703

[email protected]

1 F314 Follow-up Clinical Training January 23, 2006 Presented by Jeri Lundgren, RN, CWS, CWCN Wound...

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