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NavigatingtheTreacherousWatersofWoundCare

Overcomingfearandemotion

• Peoplefeargoingintodeeperoceanwaterforfearofsharkbites• Realityis,mostsharkbitesoccurinwadingwaterdepth• Thelikelihoodofasharkbitepalesincomparisontodeathincarcrashesorevenlighteningstrikes• Ifwelookatthedatawegetabetterperspective

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SurfingInjuryRisk

• 2009AmericanJournalofSportsMedicine• Surfingissaferthansoccer

OvercomeEmotionandTradition

• WoundtreatmentsshouldbebasedonEvidenceandData• It’sdifficulttoovercome• “We’vealwaysdoneitthatway”• “Myaunthadawoundlikethatanditworkedforthem”• ”That’swhatthedoctorintheHospitalperscribed”

Pillarsofasuccessfulwoundcareprogram

• Properequipmentandsupplies• Currentwoundpracticesbasedonuptodateclinicalevidence• Welldefinedandorgainzed woundcareteam

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Getridofthecause90%

• Comparetoswimmerjuststarting…....doesnotneedtofocusonspecialtysuits.

• Drivenbyconditionofwoundbedandsurroundingtissue.• Treatmentsmayoptimizedtocreateanoptimalhealingenvironment,inaneconomicalway.• Agivenwoundmayhaveseveralappropriatetreatmentoptions• Treatmentshouldbechangedinnon-healingwoundafter2-4weeksifnoknowncauseforhealingdelay

WoundTreatmentOptions

MoisturedonatingMoistureabsorbingEnzymaticHemostaticAntimicrobial

CavityfillingStimulatorySubstrateprovidingArtificialmembranes

BasicTreatmentCatagories

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• Ifyouhavenecrotictissue—Debrideit• Ifitistoowet—Absorbit• Ifitistoodry—Moistenit• Ifthereisacavity—Fillit• Ifthereisinfection—Killit• Ifthereisbleeding—Stopit• Ifthereisodor—Eliminateit

TreatmentDecisions

• Necrotictissueremoval:collagenase• Absorptive:alginates,foams,andhydrofibers• Moisturedonating:hydrogels• Cavityfilling:packings(iodaform),gauze,alginates,andsilicones• Antimicrobials:Silvers(alginatesandgels),Antibiotics,PHMB,• Coagulants:Hemabate,QuickClot,andclottingpowders• Odorreducing:Carbonbased,charcol,andDakins

ExamplesofVariousCatagories

• Whenpossibleasingletreatmentisbest• Multipleproductsincreasescost.• Manytreatmentscanbechangedeveryotherdayorless (everythreedays,threetimesperweek,orevenweekly)• Nursingtimeispartoftreatmentcost

FrequencyofTreatment

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Autolytic:Slowest,usesbodiesownenzymestoslowlyeatawaynecrotictissue• Mechanical:Physicalremovalofnecrotictissue,ie wet-to-dry,pulselevage,whirlpool,ect…• Enzymatic:Chemicalenzymesthatdebrideawaynecrotictissueoveraperiodofdaystoweeks.• Surgical/Sharpdebridement

DebridementOptions

• Removalofnecrotictissuewithacuretteorblade.• Welldocumentedeffectivenessinhealingandpreventionofinfection.• Removalofsenescentcellsinthepresenceoflittlevisibleslough• Repeatedproceedures necessarytoachieveoptimaleffect.• Preformedbyatrainedclinician(PhysicianortrainedNursePractitioner).• Reducestheneedforexpensiveenzymatics

SurgicalSharpDebridement

• Collegenase (Santyl)• Obtainedfrombacteria• Selectivedebridementoftissuetypes• Viewedasworkingfromwoundbaseup

• Avoidusewithheavymetals• Whenpossible,quickerremovalofnecrosiscanbeachievedviasurgicaldebridement

CurrentEnzymaticDebridingAgents

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InhibitionofSantyl

• Antibiotics:Over-usemayleadtoresistantbugs• Silver:Bacteriostatic,noknownresistance,notanantibiotic,thereforenoresistancedevelops,butpatientsensitivitycan• Avoidtreatingculturesofbiofilm

Antimicrobials

• Pressurewillstopmostbleeding,don’trub• SilverNitratecautery• Monsel’sSoln.• QuickClot

BleedingWounds

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• Avoidculturesinwellhealingwoundswithoutsignsofinfection• Goldstandardistissuebiopsyafterremovalofnecrotictissueandslough• Lavinetechniquewhenbiopsynotpossible• Biopsyshouldbeperformedbytrainedclinician.

WoundCultures

• CalciumAlginate(maxorb)• Hydrofibers(aquacel)• Iodaform• SilvasorbCavity• Hydrogelimpregnatedgauze

CavityFilling

• CollegenDressings(Fibercol,Puracol,Cellerate)• GrowthFactors(Regranex,Oasis)• Trypsincontainingagents(Xenoderm,Granulex)

StimulatoryAgents

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• Apligraf• SkinGrafts• SkinFlaps

Tissuedressings

• Onrareoccasionsthesetreatmentsmaystillbeappropriate.• Wet-to-dry• Dakin’sSolution• Betadine,Iodine,ect…

OlderTreatmentstoAvoid

• Woundbedconditiondrivestreatmentchoice.• Removalofnecrotictissuepreventsinfection,reducesbioburden,andstimulatesnewgrowth• Singleproductuse,withattentiontocostincrucialintodaysenvironment• Re-evaluatewoundsfrequentlyandconsiderchangesif2-4weekspasswithoutimprovement

DressingSelectionSummary

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TheWoundCareDreamTeam

Sailboatstory

• Intrototeammembers:eduardo,Megan….(woundcareteam)• Intortoboat:MakuMaki(rightequipment)• IntrotoCaptain:NedWebster(effectiveleadership)• Identificationofgoal:GettothefloridaKeys(clearlyidentifiedpurpose)• Problems:stormontheHorizon.(Unexpectedresults)• Innovation:formationofideasandsolutions• Solution:fixingthesails:(solutiontocorrectresuts)• Unpacking:(AfterActionReview)

• LargestOrganoftheBody• Subjecttoinjuryandfailure• LayersoftheSkin– Epidermis– Dermis– Subcutaneous–MuscleandFascia

AnatomyofSkin

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• PressureUlcers• ArterialUlcers• VenousUlcers• DiabeticNeuropathicUlcers• SurgicalWounds--Dehisance

TypesofWounds

• Stageone=Redness• Stagetwo=Damagetoepidermisandordermis,butnotsubcutaneous.• Stagethree=Damagedownintothesubcutaneoustissue,butnottomuscleandfascia• Stagefour=DamagethroughSubcutaneoustolevelofmuscleandfascia

PressureUlcers

• Rednessonly• Skinisintact• Underlyingdamagemaynotbeevident• Earlyrecognitioniskey

StageIPressureUlcer

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• BrokenSkin• Involvesepidermisand/ordermis

Nosloughornecrosispresent

StageIIPressureUlcer

• Moresignificantdamagetoskin• Involvesepidermis,dermis,andsubcu-tanious tissue

StageIIIPressureUlcer

• Mostseveredamagetoskin• Involvesalllayersofskindowntomuscleandfascia

StageIVPressureUlcer

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• Cannotvisulizewoundbed• Numbernotassigneduntilfulldamageisdetermined

UnstageablePressureUlcer

• Nonpressurerelated,interruptionorblockageofbloodflow• DistalportionofthelowerExtremity,ankle,topoffoot,toes• Woundbeddryandpale,minimalexudate• Intermittentcluadication,decreasedpulses,painonelevation,cooltotouch,decreasedcapillaryrefill

ArterialUlcers

}Openlayerofskinandorsubcutaneoustissue} Venoushypertensionfromcompromisedvalves,partialorcompletevenousobstruction,musclepumpfailure(paralysis)

} Pretibialarea}Woundbedmoistandgranulating,withminimaltocopiousexudate.} Painindependant position.Oftenrecurring.

VenousUlcers

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• PeripheralneuropathyfromDiabetes• Balloffootovermetatarsalheads,topoftoes• Resemblesarterial,frequentlyinfected• Dx ofDMrequired,withimpairedsensation,mayhaveCharcotdeformity.

NeuropathicUlcers

• TypicalPostsurgicalwoundsshouldbeclean,wellapproximated,andlittletonodrainage• Ifearlyonabreakdownoccurs,notifythesurgeonascontinuedcaremaystillbewithintheglobalperiod• Signsofconcern:non-healing,increasederythema,increasedorpusdrainage,woundseparation,increasedpain

SurgicalWounds