Wound Assessment & Treatment - sagelink.ca · 2014-06-12 · Wound Assessment Form Date Jan 13 Feb...
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Wound Assessment & Treatment Cathy Lyle Advanced Practice Nurse Providence Care, SMOL site LTC Physicians CME June 2011
Transcript of Wound Assessment & Treatment - sagelink.ca · 2014-06-12 · Wound Assessment Form Date Jan 13 Feb...
Wound Assessment & Treatment
Cathy Lyle Advanced Practice Nurse Providence Care, SMOL site
LTC Physicians CME June 2011
Outline
l Is it healing? l Will it heal? l What colour is it? l How wet is it? l Is it infected?
Canadian Association of Wound Care (CAWC)
Wound Measure
l Size (cm) – L x W x D – Length – greatest distance across in any direction – Width – greatest width at 90 degrees to length
Wound Measure
l Size (cm) – L x W x D
– Depth – measure from deepest part of wound to top of wound margin
Wound Assessment Form
Date Jan 13 Feb 10 Apr 4 Apr 18 May 2
Size (cm) 9 x 6 5 x 4.5 3 x 1.75 1 x 1.5 Closed
Wound Base
80% black
20% black 100% granulation
100% granulation
Periwound White Intact Intact intact
Exudate Amt
Large Mod – large
Small - moderate
Small
Exudate Type
Purulent Serous Serous Serous
Odour 1 (faint) No No No
Stage X X 2 2
Pain No No No No
Measure Undermining
l Undermining (cm) – extent of wound unseen below the wound edges – Probe distance from the edge of the wound with
sterile Q tip – Place thumb at Q-tip where it appears at edge of
wound – Record distance in cm. – Use face of clock to record location with 12 o’clock
towards patient’s head
What colour is it?
l Black – eschar l Yellow – slough l Red – granulation tissue l Pink – epithelial tissue
Wound Assessment Form
Date Jan 13 Feb 10 Apr 4 Apr 18 May 2
Size (cm) 9 x 6 5 x 4.5 3 x 1.75 1 x 1.5 Closed
Wound Base
80% black
20% black 100% granulation
100% granulation
Periwound White Intact Intact intact
Exudate Amt
Large Mod – large
Small - moderate
Small
Exudate Type
Purulent Serous Serous Serous
Odour 1 (faint) No No No
Stage X X 2 2
Pain No No No No
Black – Eschar
l Black or brown l Soft or firm l Leather-like cap
Stage X
Hydrogel
l Description: amorphous gel which hydrates granulation tissue and rehydrates dry eschar and slough liquefying the necrotic tissue for easy removal.
l Indications: used on pressure ulcers (stage 2,3,4), partial- and full-thickness wounds, tunneling wounds, wound with minimal drainage, wounds with purulent drainage, and red, yellow, or black wounds.
Debridement
l Removes dead tissue which is medium for bacteria growth
l Reduces wound drainage and odour l Reveals true extent of wound – can’t determine
true size until healthy wound bed is uncovered l Only for healable wounds
Types of Debridement
l Autolytic – body’s own enzymes break down necrotic tissue – moist wound environment helps – pain free but slow – contraindicated for infected wounds
Types of Debridement
l Mechanical – Gentle irrigation (syringe, 250 mL Normal Saline) – Wet-to-dry dressings – Be a “Picker” – cut off dead tissue that you can lift
from wound bed – Painful – Nonselective – damages healthy tissue
Types of Debridement
l Sharp – Conservative – at bedside by physician with
scissors and scalpel – need skill and a way to stop bleeding that may occur if wound debrided to healthy, bleeding base – painful if debrided to bleeding base – faster
– Surgical – under anesthetic by surgeon – fastest and most effective method
When to debride?
l Debride only healable wounds – There is a potential to heal – There is adequate arterial perfusion – The overall goal is healing
When to debride?
l Do not debride when: – Unknown wound origin – Dry gangrene or ischemic wound – Affected limb has no pulse or decreased perfusion – Wound due to inflammatory or vasculitic process – No necrotic tissue – Treatment goal is wound maintenance
Hydrogel
l hydrates granulation tissue and rehydrates dry eschar and slough, liquefying the necrotic tissue for easy removal
l used on wounds with minimal drainage, wounds with purulent drainage, and red, yellow, or black wounds
Yellow - Slough
l Creamy yellow or grey l Firmly attached to wound bed or l Loosely-attached strings of tissue
Red – Granulation
l Bright red, moist, shiny l Granular, bumpy l If bleeds easily (friable) – may indicate
infection l If darker red – may indicate poor perfusion
Pink – Epithelial
l Whitish pink or pinky-purple l At first, seen as islands of white in midst of
wound bed – epithelial buds l Seen as ring of pink around rim of wound bed
Will it heal?
l Treatment decisions based on heal-ability of wound
l Not all chronic wounds heal l Healing potential influenced by cause of
wound, underlying co-morbidities, patient’s level of commitment to treatment plan
Wound Assessment
Assess the whole patient…
not just the hole in the patient
What affects healing?
l Low oxygen perfusion – Smoking – Chronic obstructive pulmonary disease, anemia – Peripheral vascular disease, coronary artery
disease, hypertension, diabetes, congestive heart disease
What affects healing?
Malnutrition
– More calories and protein needed when healing – Serum albumin (3.5-5 gm/dl) – Prealbumin (20-40 mg/dl) – Vitamin C, zinc, iron needed for collagen formation – Vitamin A needed for epithelialization
Dehydration
– Large amounts of wound drainage contribute
What affects healing?
l Age – Skin thins, higher risk for trauma – Slower inflammatory response – Healing takes longer
What affects healing?
l Other chronic diseases – Rheumatoid arthritis, renal failure, cancer – Immunocompromised patients (unable to mount
adequate inflammatory response) l Medication and treatments
– Radiation, chemotherapy – disrupts cell formation – Anti-inflammatory meds (NSAIDS) – suppresses
inflammatory response
What affects healing?
l Psycho-physiological stress – Includes pain and noise – Stimulates sympathetic nervous system –
vasoconstriction l Local factors
– Foreign bodies l packing left in or causing too much pressure l sutures
What affects healing?
l Patient’s expectations and level of commitment to treatment – What is important to patient? – What is patient’s goal? Healing or maintenance – How does patient want to spend time?
Is it healable?
l Yes, wound has good potential to heal, treatment goal is to close wound – proceed with best practices in wound care
l No, wound will probably not close – poor potential for healing, treatment goal is to maintain condition of wound – focus on promoting client function and comfort with wounds (living with wounds)
Periwound Assessment
l Intact – normal epithelial skin l Macerated/excoriated – wet, white opaque skin l Induration – feels firmer than surrounding
tissue l Erythema – bright red, blanches or doesn’t l Callus – thick, dry epidermis l Dehydrated – dry, flaky with fissure, cracks
Tissue Injury from Moisture
l Wet skin becomes soft and macerated – more prone to breaking down with pressure/friction – more prone to bacteria and yeast infection
l Incontinent patients 5X more likely to have skin breakdown
l Where damage occurs? – perineal area, skin folds, around wounds
Moisture Prevention & Treatment
l Protect periwound skin – No Sting barrier film – Zinc oxide, vaseline – Cover wound edges (picture frame) - hydrocolloid
(Tegasorb) – Use products that wick drainage away from
periwound (foams cut to fit wound bed size)
Product Categories
l Gauze l Films l Hydrocolloids l Calcium Alginates l Hydrofibres l Foams l Silver Impregnated l Cadexomer Iodine
Gauze
l Minimal absorbency – small to mod draining wounds
l Wear time: dependent on amount of exudate, usually daily
l Does not promote a moist wound environment
l Painful (#1 painful dressing)
Transparent Film
l Adhesive, semipermeable, waterproof and impermeable to bacteria and contaminants, permits water vapour to cross the barrier
l For wounds with little or no exudate, wounds with necrotic tissue or slough, can be used in high friction areas
l Wear time: 7 days
Hydrocolloid
l Impermeable to bacteria & other contaminants, moist wound healing environment, promoting granulation and/or autolytic debridement, self-adhesive and mold well.
l For wounds with light to moderate exudate l Wear time: up to 7 days (usually 3-5)
Acrylic
l Transparent, breathable membrane that allows vapour to transfer out
l Exudate solutes remain, colouring dressing
l Change in 21 days or when dressing leaks
l Derived from brown seaweed, interacts with wound exudate to form a soft gel that maintains a moist healing environment
l Used for wounds with moderate to heavy drainage, can absorb up to 20 times it’s weight
l Requires secondary dressing; can be used in combination with hydrocolloid or foam to increase wear time
Calcium Alginate
l Man-made fibrous dressing (100% pure carboxymethylcellulose), interacts with wound exudate to form soft gel that maintains a moist healing environment, can absorb up to 30 times its weight.
l For wounds with moderate – heavy drainage l Requires secondary dressing; can be used in
combination with hydrocolloid or foam to increase wear time
Hydrofibre
Foam
l non-linting absorbent dressings that vary in thickness
l have a non-adherent layer allowing for nontraumatic removal
l provide a moist environment and thermal insulation.
l moderate to large draining wounds
Preventing Tape/Adhesive Damage
l Protect periwound skin – No Sting barrier film – Picture frame wound – hydrocolloid (Tegasorb)
l Remove adhesive carefully – Alcohol dissolves adhesive bond – Clear film removal technique
Managing Bacterial Burden
l Proven effectiveness in wound healing l Inflammation is helpful in acute wound healing
– Induces vasodilatation and increases blood flow – Brings antibodies and phagocytic cells to remove
wound debris, microorganisms, foreign debris, – Usual signs are pain, redness, swelling, increased
temperature, purulent drainage
Managing Bacterial Burden
l In chronic wounds infected with persistent microbial burden, the inflammatory response is prolonged and actually releases enzymes and cell mediators that harm the tissue host
l Thrombosis and vasoconstriction lead to tissue hypoxia – promotes bacterial proliferation
Managing Bacterial Burden
l Chronic wounds may become “stuck” in the inflammatory phase – excessive drainage, increased slough on wound bed – usually due to presence of bacteria, fungi, viruses in wound bed
Bacterial Burden Continuum
Contamination Colonization Local
infection Systemic infection
Critical colonization
Managing Bacterial Burden
l Local infection – Pain – Redness in periwound
tissue – Swelling in periwound
tissue (induration) – Increased temperature – Purulent drainage – Foul odour
vs l Critical colonization – Delayed healing – Increased exudate – Discolored granulation
tissue – friable, exuberant – New areas of breakdown
or slough on wound – Foul odour – New pain
Superficial Increased
Reference: Sibbald, Woo, Ayello, Increased Bacterial Burden and Infection: The Story of NERDS and STONES, Advances in Skin & Wound Care, October 2006
Bacterial Burden
NERDS N – nonhealing wound E – exudative wound R – red and bleeding wound D – debris in the wound
S – smell from the wound
Deep Compartment Infection
Reference: Sibbald, Woo, Ayello, Increased Bacterial Burden and Infection: The Story of NERDS and STONES, Advances in Skin & Wound Care, October 2006
STONES
S – size is bigger
T – temperature increased O – os (probes to or exposed bone) N – new areas of breakdown E – exudate, erythema, edema S – smell
Managing Bacterial Burden
l Clean the wound – Cleansing and irrigation with normal saline or sterile
water to remove exudate and surface debris – Irrigate with syringe (20 – 30 cc) plus angiocath (18
- 20 gauge)
– Debride necrotic tissue
l Use topical antimicrobial agents
Managing Bacterial Burden
– Minimum inhibitory concentration (20 - 40 ug/mL)
l Nanocrystalline silver has antiinflammatory and antimicrobial effect – Effective against broad range gram positive and
negative bacteria, aerobes, anerobes, fungi, yeast, viruses
– Affects bacteria DNA, enzymes, cell membranes – Low possibility of developing resistance
Managing Bacterial Burden
l Nanocrystalline silver has antiinflammatory and antimicrobial effect – Actisorb Silver (Johnson & Johnson) – Silvercell (Johnson & Johnson) – Aquacell Silver (Convatec) – Acticoat Silver (Smith & Nephew) – Acticoat 7 Silver (Smith & Nephew)
Cadexomer Iodine
l combines iodine and a modified starch in the form of a gel or a pad in order to reduce bacterial load
l time-released antimicrobial l change when the colour changes from
brown to a yellow-grey
Other Antimicrobial Dressings
l Mesalt (hypertonic saline gauze) l Medihoney (hospital grade manuka honey) l 10% Povidone-Iodine (Betadine)
Staging Pressure Ulcers
l National Pressure Ulcer Advisory Panel (NPUAP)
l 4 stages of tissue injury l Stage X
Stage 1
l Persistent redness as a result of inflammation response
l Skin intact l Very painful l Blanch test – normally turns white with
pressure l Usually repairs itself when pressure removed
Stage 1
Stage 2
l Skin is open l Partial thickness injury (epidermis, dermis) l Very superficial (blister, abrasion, shallow crater) l Heals in a few days with moist wound healing products
if pressure relieved l Exception: if moisture is the cause of skin breakdown
Stage 2
l Skin is open l Partial thickness injury (epidermis, dermis) l Very superficial (blister, abrasion, shallow crater) l Heals in a few days with moist wound healing products
if pressure relieved l Exception: if moisture is the cause of skin breakdown
Stage 2
Stage 3
l Full skin thickness is damaged and into subcutaneous tissue
Stage 3
Stage 3
Stage 4
l Damage extends through subcutaneous tissue to the muscles, bones, tendons, joints
l Undermining may occur
Stage 4
Stage X
l Stage X – unable to stage, wound covered with slough or eschar
Stage X
Negative Pressure Wound Therapy: VAC
l Description: Noninvasive active therapy using localized negative pressure. It removes excess interstitial fluid, decreases edema and bacterial colonization, increases blood supply and granular tissue formation, and enhances epithelial and cell migration.
l Indications: Granular draining wounds; full- thickness wounds; venous, arterial, diabetic, and pressure ulcers; surgical wounds; flap and grafts; and acute traumatic wounds.
Negative Pressure Wound Therapy: VAC
l Contraindications: necrotic tissue, enteric fistulas, untreated infection or osteomyelitis, malignancy
l Change indicator: dressings are change M-W-F for most wounds, leave on for 5 days for graft.
l Wear Time: dependent on goal of therapy
