AWOCNurseA WOC Nurse s’s Approach to Dressings · AWOCNurseA WOC Nurse s’s Approach to...
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A WOC Nurse’sA WOC Nurse sApproach to Dressings
Faculty
Catherine T. Milne, APRN, MSN, BC-ANP/CS, CWOCNAdvanced Practice Nurse
Wound Ostomy ContinenceConnecticut Clinical Nursing Associates
Bristol, Connecticut
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Learning Objectives
• Compare and contrast the various categories of advanced wound care dressings
• Identify wound dressing materials with nonadherentproperties
• Evaluate the effect of collagen/oxidized regenerated cellulose on wound healing vs plain collagen-containing dressings
• Identify wound types for which a contact layer dressing would be appropriate
• Establish an appropriate dressing plan for a patient with a wound
Which Dressing to Use?
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Clinical Decision Making
PatientAssessment
WoundAssessment
CareSetting
Clinical Decision Making
Care Setting
Outpatient
AcuteHospitalSelf Care
LTAC
SNF
HomeCare
LTAC = long-term acute care; SNF = skilled nursing facility.
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Clinical Decision Making
Patient Assessment
• General information• General information
• Social/family support
• Age
• Employment
C biditi• Comorbidities
Clinical Decision Making
Patient Assessment
“You have to know the past to understand the present ”You have to know the past to understand the present.
– Dr. Carl Sagan, Astronomer
• Diabetes
• Complex regional pain syndrome
• Crohn’s disease
• Rheumatoid arthritis
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Patient Physical Exam
Head-to-toe assessment will aid in clinical decision making for dressing selection
Clinical Decision Making
Wound Assessment
Acute wound—a wound that is followingAcute wound—a wound that is followinga predicted pattern that should result in complete healing
Expected healing rates
Pressure ulcers7 weeks at Stage II
10 weeks at Stage III
19 weeks at Stage IV
Neuropathic—12 weeksDiabetic foot ulcers
Neuropathic 12 weeks
Ischemic—16 weeks
Venous ulcers 8 weeks
Split thickness donor sites6.8-12.9 days
2-3 weeks, if large and painful
Association for Advancement in Wound Care. http://aawconline.org. Accessed: January 10, 2012. Valdes AM, et al. Ostomy Wound Manage. 1999;45(6):30-36. Bolton L. Wounds. 2012;24(1):8-9.
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Clinical Decision Making
Wound Assessment
Healing can be predictiveHealing can be predictive
• Reduction in wound area per week– 40% reduction by week 3 in venous ulcers has 70%
healing rate
• Using benchmarks – 66% at outpatient wound centers
– Percentage healed at 12-week endpoint using RCTs
RCTs = randomized control trials.Phillips TJ, et al. J Am Acad Dermatol. 2000;43(4):627-630. Fife CE, et al. Wounds. 2012;24(1):10-17. Bolton L. Wounds. 2012; 24(1):18-24.
Clinical Decision Making
Wound Assessment
Chronic WoundChronic Wound• A wound that experiences a physiological delay through any of the normal,
orderly, sequential phases of healing– The wound may be categorized as a delayed-healing or nonhealing
chronic wound
• A delayed-healing chronic wound does not progress through a predefined healing pattern due to neglect, misdiagnosis, inappropriate treatment, or the inability to obtain or appropriately use necessarytreatment, or the inability to obtain or appropriately use necessaryresources in caring for the wound
– A delayed-healing chronic wound may deteriorate to a nonhealing wound
• A nonhealing chronic wound is a wound that does not progress through a predefined healing pattern due to underlying concurrent disease states and comorbidities that cannot be corrected or ameliorated
Association for Advancement in Wound Care. http://aawconline.org. Accessed January 10, 2012.
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Delayed-Healing Chronic Wound
Macroscopic Wound Environment
• Remove nonviable tissue• Remove nonviable tissue
• Identify and treat infection
• Address metabolic concerns
• Offload/pressure redistribution
I f i• Improve perfusion
• Remove mechanical forces impacting wound surface
Mechanical ForcesContribute to Pain
Substance P—mediator of neurogenic inflammationReleased with noxious stimuli from skinReleased with noxious stimuli from skin
Vasodilatation and plasma protein leaks
Infiltration of additional inflammatory mediators
PAIN
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Delayed-Healing Chronic Wound
Microscopic Wound Environment
• Identify and treat bioburden• Identify and treat bioburden
• Remove cellular debris
• Improve microcirculation
• Address protease imbalances
Delayed Healing Chronic Wound
F b MFebruary May
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Matrix Metalloproteases
Matrix Metalloproteases
• Intracellular production with extracellular release
• Cell to cell communication tool• Cell-to-cell communication tool
• Cell-to-matrix communication tool
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Matrix Metalloproteases
• Over 23 identified types
• Need calcium for structure C4 20
• Need calcium for structure
• Need zinc for activity
• Function in a neutral pH
CaCalcium
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Matrix Metalloproteases
• Expressed by cells when other biochemical signals are sensed
– Inflammatory cytokines• TNF-�, IL-�
• Cells expressing MMPs– Macrophages, fibroblasts, neutrophils, endothelial cells,
epithelial cells
TNF-� = tumor necrosis factor-alpha; IL-� = interleukin-beta; MMPs = matrix metalloproteases.
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Matrix Metalloproteases
• Each specific MMP has its own job – CollagenasesCollagenases
– Elastases
– Gelatinases
– Stromelysins
• Each identified by a number—MMP-1, MMP-2, etc.
Matrix Metalloproteases
• Will degrade ECM– Implicated in inflammatory diseaseImplicated in inflammatory disease
states, including the delayed-healingchronic wound
ECM = extracellular matrix.Ulrich D, et al. J Wound Ostomy Continence Nurs. 2011;38(5):522-528. International consensus. Acellular matrices for the treatment of wounds. An expert working group review. London: Wounds International, 2010.
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Matrix Metalloproteases
YiYing
Yang
MMPs—The Ying
• Necessary for normal wound repair– Degrade ECM at time of injury to allow cellular movementDegrade ECM at time of injury to allow cellular movement
to site of injury
– Activate growth factors stored in ECM
– Reorganize ECM to improve tensile strength at end of wound repair
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MMPs—The Yang
• Overproduction due to excessive cytokine production caused by
– Necrotic tissue
– Bioburden
– Repeated trauma
– Local tissue injury
MMP Overproduction
• Degradation of ECM
• Reduction in growth factors• Reduction in growth factors
• Cell receptor sites destroyed
• Cell migration inhibited
Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Philadelphia, PA: Lippincott, Wilkins and Williams; 2011. International consensus. Acellularmatrices for the treatment of wounds. An expert working group review. London: Wounds International, 2010.
MMP-1, MMP-2, MMP-8, MMP-9 well known “evil-doers”
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Clinical Decision Making
PatientAssessment
WoundAssessment
CareSetting
Clinical Decision Making
PatientAssessment
TopicalWound
Dressing
WoundAssessment
CareSetting
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Dressing Categories
Topical Dressings
Identify the Goal of Therapy
• Debride?• Debride?
• Control bioburden?
• Reduce and control pain?
• Diminish the persistent inflammatory response?
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Function
• Absorb exudate
Topical Dressings
Form
• Powder • Absorb exudate
• Decrease trauma at wound bed during dressing changes
• Reduce bioburden
• Powder
• Liquid
• Cream
• Ointment
G l • Provide components of an ECM
• Bind proteases
• Gel
• Sheet
• Rope
Topical Dressings
Active
• Aid in changing
Passive
• Cover wound• Aid in changingbiological or chemicalenvironment in wound
• May also havecharacteristics of passive dressings
• Cover wound
• Maintain moisturebalance
• May protect from outside environmentalinsults via physicalinsults via physicalbarrier
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Alginates PASSIVE
Antimicrobials PASSIVE/ACTIVE
Topical Dressing Categories
Collagen PASSIVE/ACTIVE
Composites PASSIVE
Contact layers PASSIVE/ACTIVE
Foams PASSIVE
Hydrocolloids PASSIVE/ACTIVE
Hydrofibers PASSIVE
Hydrogels PASSIVE
ORC/collagen ACTIVE
Transparent films PASSIVE
ORC = oxidized regenerated cellulose.
Antimicrobials
PASSIVE or ACTIVE?
• Brand dependent• Brand dependent– Absorb and kill
– Absorb and cidal
– Release and kill
– Release and cidal
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Hydrocolloids
Passive
• Facilitate moist wound environment• Facilitate moist wound environment
• Manage exudate
• Provide autolytic debridement
• Offer barrier to microorganisms
A ti ?Active?
• Oxygen-depleted environment thought to protect nerve endings and thus reduce pain
Queen D. Technology Update: Understanding hydrocolloids. Wounds International. www.woundsinternational.com/product-reviews/technology-update-understanding-hydrocolloids. Accessed January 12, 2012.
Collagens
• Use an exogenous form of collagen to provide a structural matrix
• Provide chemoattractants to stimulate macrophages and fibroblasts and their subsequent biochemical processes to stimulate normal healing cascade
Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Philadelphia, PA: Lippincott, Wilkins and Williams; 2011. Fleck C, et al. Adv Skin Wound Care. 2007;20(5):256-259.
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Collagens
• Can be degraded by sustained high levels of MMPs
ORC/Collagen
• 45% ORC
• 55% collagen bovine• 55% collagen—bovine
• Bioresorbable
• Open-pored matrix
Hall J. Podiatry Today. 2002;15(8):26-30.
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Benefits ofORC/Collagen Combination
• Binds more MMPs than ORC or collagen alone
Cullen B. Ostomy Wound Manage. 2002;42(Suppl 6):8-13.
ORC/Collagen
• Acts by binding and inactivating MMPs
• ORC stimulates cell proliferation• ORC stimulates cell proliferation
• Protects growth factors
• With or without silver
Cullen B, et al. Int J Biochem Cell Biol. 2002;34(12):1544-1556. Cullen B, et al. Wound Repair Regen. 2002;10(1):16-25.
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Wound Pain and Dressing Changes
• Wound pain is a common phenomena
• Dressing changes produce the most pain• Dressing changes produce the most pain
• Gauze is associated with most pain
• Hydrofibers, alginates, hydrogels, hydrocolloids, soft silicone, and combination materials produce the least pain
Moffatt CJ, et al. Understanding Wound Pain and Trauma: An International Perspective. Position Document: Pain at Dressing Changes. http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2002/Spring_2002__English_.pdf. Accessed February 5, 2012.
Contact Layer Dressings
• Antimicrobial with nonadherent contact layer
• Silver nonadherent dressing shown to reduce biofilm• Silver nonadherent dressing shown to reduce biofilmin vitro within 24 hours
• MRSA: complete kill
• Enterococcus fecalis (VRE): complete kill
• Pseudomonas: >3 log reductiong
MRSA = methicillin-resistant staphylococcus aureus; VRE = vancomycin-resistant enterococci.McInoy L, et al. Are silver containing dressings effective against bacteria in biofilms? Poster presented at: Wounds UK 2009. Clark R, et al. The evaluation of absorbent silver containing dressing in vitro; Systagenix wound management. Poster presented at: 15th Annual CAWC Conference; October 29-November 1, 2009; Quebec City, Quebec. Clark R, et al. Simulated in use tests to evaluate a non-adherent antimicrobial silver alginate dressing. Poster presented at: 15th Annual CAWC Conference; October 29-November 1, 2009; Quebec City, Quebec.
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Contact Layers
PASSIVE or ACTIVE?
• Silver nonadherent dressing• Silver nonadherent dressing– In vitro—low force in removal of fibrin clot
– In vitro—low adherence to wound tissue at day 7
Clark R, et al. The evaluation of absorbent silver containing dressings in vitro; Systagenix wound management. Poster Presented at: 15th Annual CAWC Conference; October 29-November 1, 2009; Quebec City, Quebec. Clark R, et al. From lab to leg: The importance of correlating in-vitro and in-vivo test systems to clinical experience. Poster presented at: SAWC Spring meeting; April 17-20, 2010; Orlando, Florida.
Contact Layers
• In vivo—10 patients with silver nonadherent with additional 10 as control with generic calcium alginate
• Assessment– Adherence
– Pain (Wong-Baker)
– Visible fibers left in wound bed
N d f li k t d i h– Need for saline soak at dressing change
Clark R, et al. From lab to leg: The importance of correlating in-vitro and in-vivo test systems to clinical experience. Poster presented at: SAWC Spring Meeting; April 17-20, 2010; Orlando, Florida.
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Contact Layers
Indications• Fragile periwound skinFragile periwound skin• Pressure ulcers • Venous ulcers • Diabetic ulcers • Donor sites, trauma/injuries, and surgical wounds,
including cavitiesincluding cavities• Moderate to highly exudating wounds• Prophylactically in clinical situations placing patient at
risk for infection
Clark R, et al. Wounds International. 2010;1(5):1-6.
Contact Layers
What effect may these dressings haveon the wound microenvironment?
• Substance P
• MMP levels
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Clinical Decision Making
PatientAssessment
TopicalWound
Dressing
WoundAssessment
CareSetting
Case Studies
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Case 1
• 76-year-old female
• Medical history• Medical history– COPD, GERD, venous insufficiency, osteoarthritis
• Sustained a syncopal event– During this incident she fell against her dishwasher, sustaining
a partial degloving of her right lower extremity
COPD = chronic obstructive pulmonary disease; GERD = gastroesophageal reflux disease.
Case 1
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Case 1
PatientAssessment
WoundAssessment
CareSetting
TopicalWound
Dressing
Case 2
• 47-year-old male
• Presented at outpatient wound center with a 3 month• Presented at outpatient wound center with a 3-monthhistory of a plantar foot ulcer
• Medical history– Morbid obesity, HTN, nicotine abuse
• Recently diagnosed with type 2 diabetes
• Works as a teacher in a local high school
HTN = hypertension.
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Case 2
Case 2
PatientAssessment
WoundAssessment
CareSetting
TopicalWound
Dressing
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Case 3
• 78-year-old female developed coccyx pressureulcer while hospitalizedulcer while hospitalized
• Underwent debridement and was transferred to a long-term care facility
• Became combative with dressing changes
f• Area was also frequentlysoiled with fecal and urinary effluent
• Wound measured 6.2 cm long x 4.8 cm wide x 1.2 cm deep
Case 3
Week 12
• Wound measurement• Wound measurement– 1.8 cm long x 1.5 cm
wide with no depth
PatientAssessment
WoundAssessment
CareSetting
TopicalWound
Dressing
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Case 3
Week 16—healed
PatientAssessment
WoundAssessment
CareSetting
TopicalWound
Dressing
Summary
• To choose appropriate topical dressing– Head-to-toe patient assessmentHead to toe patient assessment
– Comorbidities• Producing large amounts of inflammatory mediators?
• Uncontrolled MMPs?
– Care setting• Frequency of dressing changes
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