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.

Thank You for Your Attention Thank You for Your Attention

Q&A?

sschmitt@communitymemorial.com