The 411 on Wound CareMay 12 2010

Amy Clegg RN, MSN, NP-C, CWOCN

Dawn Engels RN, CWOCN

InfoQuestions

Objectives

• Identify Partial and Full Thickness Wounds• List 2 Barriers to Wound Healing• Identify Pressure Ulcer Stages• Identify Measures to Reduce Pressure Ulcers• Verbalize mechanism of VAC• Identify indications/contraindications for

VAC• Demonstrate VAC application

Would Healing

• Hemostasis – within 60 minutes• Inflammation- 20 minutes –4 days• Proliferation- 3-21 days • Remodeling- 21 days –2 years

Barriers to Wound Healing

Patient

Age

Nutrition

Necrotic Tissue Perfusion

HealthStatus

PressureLifestyle

Infection

Partial Versus Full Thickness

• Partial thickness wound

• Wound does not extend through the dermis

• Heals by regeneration

• Re-epithelization

Partial Versus Full Thickness

• Full thickness wound

• Wound extends through the dermis may extend to an organ, tendon, muscle bone

• Heals by contracting and scar tissue

Partial Thickness

•

                                     

Full Thickness

What is a Pressure Ulcer?

•Localized injury to skin and or underlying tissue usually over a bony prominence due to unrelieved pressure

•Can occur under a splint or cast

•3 most common locations sacrum, heels, and trochanter

To Stage or Not to Stage a Wound?

• Pressure ulcer staging is only to describe wounds that develop from pressure

• Pressure ulcer staging is not used to describe wounds from other causes such as skin tears, tape burns, diabetic foot, venous ulcer, or incontinence

What are the pressure ulcer stages?

• Suspected Deep Tissue Injury• Stage 1• Stage 2• Stage 3• Stage 4• Unstageable

Suspected Deep Tissue Injury

• Purple or maroon area of discolored skin or blood filled blister

• Maybe painful, firm, mushy, boggy, warmer or cooler as compared to adjacent side

• The wound may further evolve into full thickness tissue loss

Stage 1

• Intact skin with nonblanching redness

• Maybe difficult to detect in patients with darker pigment

• Maybe painful, firm, soft, warmer or cooler as compared to adjacent tissue

Stage 2

• Partial thickness skin loss of dermis

• Presents as a

shallow open wound with pink or red tissue

• Can also be a serum filled blister

Stage 3• Full thickness

skin loss. Subcutaneous fat may be visible

• Slough may be present but does obscure base of wound

• Depth varies by anatomical location

Stage 4

• Full thickness tissue loss with exposed bone, muscle or tendon

• Depth varies depending on anatomical location

Unstageable

• Full thickness tissue loss in which the base of the wound is covered by slough or eschar.

• Until enough slough or eschar is removed true depth cannot be determined

Measures to Reduce Pressure Ulcers

• Nutrition• Moisture Management• Specialty beds• Chair cushions• Repositioning• Determine risk- Braden Scale

VAC Mechanism of Action

• Maintains moist environment

• Removes exudate

• Promote granulation

• Promote perfusion

• Reduce edema

Indication/Contraindications VAC

• Indications• Dehisced wound• Pressure Ulcers• Open Abdominal

wounds• Traumatic wounds• Diabetic wounds• Skin grafts

•Contraindications

•Malignancy in wound

•Untreated Osteomyelitis

•Necrotic tissue

•Directly over vessels

•Active Bleeding

VAC Stations

• Apply• Cannister• Y Connect• Bridge• Foams

Thank you!

Questions?

References

• Google ImagesAyello, E. & Lyder, C. (2008). The new era of pressure

ulcer accountability. Advances in Skin & Wound Care, 21(3), 134-139.

National Pressure Ulcer Advisory Committee . Pressure ulcer stages revised by NPUAP. Retrieved on 6/5/08 at www.npuap.org.

Centers for Medicare and Medicaid Services, Hospital Acquired Conditions (Present on Admission Indicator): www.cms.hhs.gov/HospAcqCond/01_Overview.asp Retrieved on July 2008