SHAWNEEN SCHMITT, RN MSN MS CWOCN CFCN WOCN ADVISOR FOR THE WISCONSIN PRESSURE UCLER COALITION...
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Transcript of SHAWNEEN SCHMITT, RN MSN MS CWOCN CFCN WOCN ADVISOR FOR THE WISCONSIN PRESSURE UCLER COALITION...
SHAWNEEN SCHMITTSHAWNEEN SCHMITT, , RN MSN MS CWOCN CFCNRN MSN MS CWOCN CFCNWOCN ADVISOR FOR THE WISCONSIN PRESSURE UCLER WOCN ADVISOR FOR THE WISCONSIN PRESSURE UCLER
COALITIONCOALITION
October 21, 2010October 21, 2010
ObjectivesObjectives
Describe the phases of wound healingDefine “DIME”State a reason when advance wound care
treatments should to be considered List at least three types of advance modalities to
aid in wound healingDescribe three products that can used to enhance
wound healing for a pressure ulcerIdentify two resources for wound care product
information
Wound Healing PhasesWound Healing PhasesHemostasis: An injury to the skin/tissue takes place releasing
platelets to the open area to create a fibrin clot to protect the immune system and thermal regulation
Inflammatory Phase: The clotting factors stimulate the release of histamines causing vasodilatation and thinning of the cell wall releasing Neutrophils to start phagocytosis of bacteria and foreign debris. Keratinocytes found in the epidermis release cytokines and growth factors as well as the enzyme collagenase. This phase last 3-5 days
Proliferative Phase: This is found when wounds become full thickness and the soft tissue defect begins to replaced with new blood vessels and granulating tissue composed of hyaluronic acid and collagen produced by fibroblast cells. When this new tissue reaches the epithelial level then wound contraction can begin at the wound edge
Remodeling Phase: This occurs when epithelialization occurs, the wound in closed and the tissue tensile strength develops
Wound Bed PreparationWound Bed PreparationNormal wound healing follows an orderly process of the
three phases When a wound is stalled between the inflammatory and
proliferative phase, the wound may not heal. It becomes chronic requiring wound bed preparation to remove senescent (old/dead) cells that impair new cell migration and growth
D= debridementI = inflammation or infection assessmentM= moisture balanceE= Edge effect – this is referred to the wound edge and
failing to show signs of epithelialization that is the epithelial cells fail to migrate across from one wound edge to the other side. This is a chronic non-healing wound
If the wound has not reduced in size by 30% in 3-4 weeks then advance wound care should be considered
Medicare ViewpointMedicare ViewpointMedicare refers to the medical care needed to
treat chronic wounds as "wound therapy." A chronic wound is a sore, blister, or skin injury
that has not healed after 30 days of treatment by a doctor.
Chronic wounds are serious and need medical attention. They can take months or years to heal; and some never do heal. They can be very painful and cause a lot of discomfort for the person who has one.
http://www.medicare.com/services-and-procedures/wound-care-and-wound-therapy.html
Advanced Products to be ReviewedAdvanced Products to be ReviewedAntimicrobial dressings (Silver, Iodine, Honey)Antimicrobial dressings (Silver, Iodine, Honey)Antifungal products (Nystatin)Antifungal products (Nystatin)Specialty dressings (Hyluronic Acid, Interdry, Specialty dressings (Hyluronic Acid, Interdry,
Silicone)Silicone)Collagen (Prisma, Promogram, Fibracol)Collagen (Prisma, Promogram, Fibracol)Chemical Debrider (Santyl)Chemical Debrider (Santyl)Engineered Tissue (Apligraf, Dermgraft)Engineered Tissue (Apligraf, Dermgraft)Extracellular Matrix (Oasis, Integra)Extracellular Matrix (Oasis, Integra)Growth Factors (Regranex)Growth Factors (Regranex)Complimentary TherapyComplimentary TherapyNegative Pressure Wound Therapy (NPWT)Negative Pressure Wound Therapy (NPWT)
Antimicrobial DressingsAntimicrobial DressingsThese are topical products that incorporate agents
such as silver, cadexemer iodine or medical honeyWhen agents come in contact with wound exudate
they release their antimicrobial properties to reduce the bacterial load.
These dressings can come in a variety of delivery forms, shapes and sizesGels, Hydrocolloids, Foams, Alginates, Powders,
Fabric/clothIntended to be used in draining and non-healing
wounds Can be used in all types of woundsAdvantage: Reduce or prevent infectionDisadvantage: Staining of the skin, agent resistance
Antimicrobial Dressings Antimicrobial Dressings (cont)(cont)
Silver comes in various delivery systems and quantities that can create an immediate release or sustain release of the ionic Nanocrystal silver.
It is an effective barrier to bacterial penetration in wound tissue
Requires wounds to have moderate to large drainage to be effective
Patients can develop an allergic reaction to silver and some forms of silver can be cytoxic
Not to be used on patient’s receiving an MRI or have EKG or EEG electrodes on
Do not use any oil-based products on skin near silver dressing
Requires often a secondary dressingSome silver dressings can manage odor when combined
with charcoal, several can causing staining of surrounding skin
Antimicrobial Dressings Antimicrobial Dressings (cont)(cont)
Cadexemer iodine is a type of sustained release iodine that does not affect the fibroblast formation in tissue and collagen growth. It helps to absorb slough, tissue debris and exudates. It lasts up to 72 hours.
It comes in the form of a gel/paste or a mesh padIt is affective in wet wounds with moderate to large
exudatesIt should not be used in people with sensitivity to iodineIt is contraindicated in patients with thyroiditis,
Graves disease, nontoxic goiter and pregnant or nursing mothers.
The product may need to be changed before 3 days if it turns from an orange-rust color to a yellow-brown color
Requires a secondary dressing
Antimicrobial DressingsAntimicrobial Dressings (cont)(cont)
Medical Honey is Active Leptospermum Honey from New Zealand, possess unique qualities that make it ideal for the management of chronic and acute wounds and burns.
It is effective against a broad spectrum of bacteria, including antibiotic-resistant strains such as MRSA and VRE
Can be used for autolytic debridement of sloughIt has been used successfully along with other advanced
wound care modalities, including being used before, during, and after negative pressure applications
It is appropriate for all types of wounds and comes in a gel, hydrocolloid or as an alginate
Can be left in place from 1 -3 days depending on the amount of exudates and does require a secondary dressing.
Antifungal ProductsAntifungal ProductsThese products are designed to inhibit the growth of
organisms (fungi/yeast) that can cause superficial skin infections
The pH of the skin is in an acidic range varying to different parts of the body. This is important to maintain because it regulates the permeability and integrity of the skin cells. Once the defense is altered fungi and bacteria can enter and penetrate the skin usually in moist dark areas such as skin folds
These products come in the form of powders (for folds) or creams/ointments (for open areas)
Two primary ingredients are either Miconozole 2% or Fluconazole (Nystatin)
Should be discontinued when yeasty (red satellite rash) subsides
Chemical DebriderChemical DebriderCollagenase is a type of chemical enzymatic debriding agent
derived from the fermentation of the bacterium – Clostridium histolyticum which aids in the digestion of necrotic collagen tissue
Collagen comprises 75% of the body’s skin tissue. Thus this enzyme can contribute to the formation of granulating tissue.
Product is contraindicated with patient’s having a sensitivity
A secondary dressing is requiredThe half-life of this product is 26 hours requiring daily
dressing changesRequires a prescriptionProducts no longer available are ointments with papain-
urea
Specialty DressingsSpecialty DressingsThese are dressings have unique properties that
can manage bacteria , aid in autolytic debridement, pain management and/or protects newly formed granulating tissue. Can be used in all types of woundshyaluronic acid (an avian protein) comes in the form
of a cellulose or liquid that forms a gel with the wound exudates
Interdry is a product that is a polyurethane coated silk-like fabric impregnated with silver used between skin folds to reduce skin to skin friction and can be a barrier for MRSA, MSRE, VRE, Pseudomonas
Silicone dressings are thin and flexible gel-like that aid in pain management as well as aid in reducing hypertrophic and keloid scar formation
Collagen DressingsCollagen DressingsCollagen is the most abundant protein in the body
which is produced by fibroblasts which is found in the connective tissues such as skin, bone and ligaments
In wound healing, collagen stimulates granulating and epithelialization
It can also create an environment for wound debridement by binding with enzymes (proteases) while protecting growth factors needed for granulation
Can be used on all types of wounds including skin grafts and donor sites. Cannot be used over eschar
This type of dressing is a bovine collagen produced in sheets, pads or gels that is absorbed into the new tissue as well as helps maintain a moist wound environment
Requires a secondary dressing
Extracellular MatrixExtracellular MatrixMatrix dressings are made from the small intestine
lining of a pig that consists of collagen and growth factors that support cell growth
It provides a natural extracellular matrix (grid or scaffold) that has a three dimensional structure to aid in tissue remodeling/building
This is a very thin dressing that isn’t removed but reapplied over it on a weekly basis till wound is epithealized
Not to be used on people sensitive to porkRequire dressing to be rehydrated with sterile
saline after application and covered with a secondary dressing
Growth FactorsGrowth FactorsThere is only one FDA-approved platelet-derived growth
factor comprised of cytokines that activates cells to form new granulating tissue and blood vessels
It has been approved only for use on diabetic ulcers and requires adequate blood flow that is not ischemic
Chronic wounds have been found deficient in growth factors
Doing serial sharp debridement enhances the growth factor effectiveness
Contains a preservative that may cause sensitivity reaction
Requires a prescription and is expensive ($700.00 /tube)Is applied daily in a carefully measured dose and can
only be left in place for 12 hours. Needs a secondary dressing of moist saline gauze
Engineered TissueEngineered TissueThis type of tissue is a biologic substitute or synthetic
skin that can emulate normal skin functions (such as allowing vapor transmission, resists shear and friction and act a bacterial barrier) to aid in accelerating wound healing
This tissue contain one or both epidermal and dermal cells that have the cytokines, growth factors, structural support to help restore wound healing but does not contain hair follicles, blood vessels or nerve endings
Can only be applied by a physician or a trained person under the direction of a doctor and requires a prescription.
Requires a secondary dressing changed weekly until the wound is healed
Complimentary TherapyComplimentary TherapyThese therapeutic modalities are designed to enhance
wound healing along with conventional/primary wound careElectrotherapy (E-Stim) is the application of an
electrical current to transfer energy through the wound/skin attracting cells for new blood vessel growth (angiogenesis) there by accelerating wound healing. It is contraindicated for people with cancer, osteomyelitis, implanted electrical devices
Ultrasound delivers sound waves in the form of mechanical vibration on the cellular level thereby encouraging growth factor and collagen production, increase nitric oxide and angiogenesis
Ultraviolet Light is used to increase epithelial cell growth, destroy bacteria and stimulate granulating tissue. This is still investigational due to the increase potential for skin cancer.
Complimentary Therapy Complimentary Therapy (cont)(cont)Hyperbaric Oxygen Therapy (HBOT) is the administration
of 100% oxygen to patients within an airtight tube or chamber at pressure greater than 1 atmosphere
Note: adequate oxygenation of the tissue in primary in wound healing and is needed for collagen transport, fibroblast formation and angiogenesis. A lack of oxygen is called hypoxia
HBOT is usually done once or twice daily approximately 45- 120 minutes in length for up to 4-6 weeks.
This treatment is primarily for diabetic wounds with impaired circulation for limb salvage. Studies indicate that it has no impact of pressure ulcer healing
Oxygen at high doses can be toxic and effect brain, lungs and ears
Often requires travel to HBOT site and in expensive
Negative Pressure Wound Therapy (NPWT)Negative Pressure Wound Therapy (NPWT) NPWT is a controlled application of continuous or intermittent
subatmospheric negative pressure applied to a wound bed by means of a specialized reticulated foam or gauze dressing, tubing attached to a pump and an occlusive adhesive cover dressing so it is air-tight
The purpose of this therapy is to create a balanced moist wound environment by removing excess exudates, bacteria and debris and create tissue growth by means of angiogenesis formation thereby improving blood and oxygen perfusion to the new tissue
NPWT is in place continuously and is changed usually 3 x per week up to an average of 4 months duration. Evidence of wound healing must be shown for this treatment to continue
Pumps are rented and dressings can be expensive if not covered by insurance
Pain management is very important in the beginning of treatmentIt is contraindicated for wounds with exposed blood vessels,
organs or nerves, malignancy in the wound, untreated osteomyelitis, nonenteric fistulas and wounds with eschar or non-debrided slough
ResourcesResourcesBryant, R. & Nix, D. (2007). Acute and Chronic Wounds.
Current Management Concepts (3rd Ed). Mosby. St. LouisHess, C. T. (2008). Skin & Wound Care (6th Ed.) Wolters
Kluwer, Philadelphia, PA.http://advancingthepractice.aawconline.org/index.php?option%
0B=com_content&task=section&id=9&Itemid=31http://mhcwoundcare.com/downloads/Woundcare_Module6_Gl
ossary.pdfhttp://www.nursing.uiowa.edu/sites/chronicwound/Krasner, D., Rodeheaver, G. & Sibbald, R. G. (2007) Chronic
Wound Care: A Clinical Source Book for Healthcare Professional (4th Ed). HMP Communications, Malvern, PA
Kuehn, B. (2007). Chronic Wound Care Guidelines Issued. JAMA. 279 (9).
Warriner, R. (2005). Infection and the Chronic Wound: A Focus on Silver. Advances in Skin & Wound Care. 18(1), 2-12.
Woo, K., Ayello, E., & Sibbald, R. G. (2007). The Edge Effect: Current Therapeutic Options to Advance the Wound Edge. Advances in Skin & Wound Care. 20(2), 99-117.