wound management_pcn krisna
DESCRIPTION
10th Malaysian Hospice Congress in Johor Bahru, MalaysiaTRANSCRIPT
Wound Care
By
Ms. Krisna Muthusamy SRN.SCM.NICU.FP.FTC. BSC. MA
Penang Hospice
FUNGATING AND SMELLY
TUMOURS
Unsightly and smelly lesion are a severe blow to self
image
Malodorous wounds lead to social isolation
Ulcerated cutaneous metastases often cause severe
pain
Wound with Maggot
Fungating Wounds
Aims of managing fungating wound
Control / pain / exudates / odour
Prevent infection
Fewer dressing changes
Trauma-free dressing removal
Cosmetic acceptability
Improved quality of life
Principles of Management Palliative oncologic treatment brings temporary
control of malignant ulceration
Chemotherapy bring about regression of lesion
Radiotherapy control bleeding and achieve
healing
Toilet mastectomy may be indicated for massive
breast lesions
Symptomatic treatment
Cleansing the wound
irrigation with normal saline
do not use antiseptic cleansing solution or
hypochlorites---toxic to granulating tissue
Debridement
encrusted purulent materials use wet-dry dressing
purulent slough--xerogel e.g Debrisan
black,necrotic tissue--streptokinase/elase to necrotic
area
Symptomatic treatment --continued
Control odor
regular cleansing with disinfectant solution e.g
povidone iodine ,sodium hypochlorite or
1% chlorhexidine
metronidazole gel +oral Flagyl 200-400mg tds
charcoal dressing
maalox
yogurt
honey
Symptomatic treatment ----continued
Control Bleeding:
pressure
soak gauze in 1;1000 epinephrine and apply
sucralfate paste (crush 1 gm sucralfate tablet in
2- 3ml water -soluable gel)
haemostatic dressing /sponge (Kaltostat /gelform
silver nitrate
radiotherapy
Symptomatic treatment ---continued
Wound dressing
layer next to wound --sterile and non adherent
permeable for exudate
second layer absorbent
outer layer--charcoal to absorb odour
change dressing as required
soak dressing before removal
clean wound with saline irrigation
Symptomatic treatment--continued
Control Pain
Maalox} relieve burning sensatins
yogurt }
consider NSAIDs
Pressure Sores
Damage to the skin
as a result of
extrinic pressure and
shearing force
Pressure Sore
Contributing Factors
Pressure: decrease blood flow-->tissue anoxia-->
^ capillary permeability-->edema-->cell death
Shearing force
Friction
Moisture
Other factors
Immobility/obesity/age/sensory and motor deficit
general malnutrition/hypoproteinemia
vitamin C /zinc deficiency
cachexia/anaemia /peripheral vascular disease
chronic steroid therapy
immunosuppression / maceration of skin
improperly applied cast, bandages
folds /bed crumbs,/hard mattresses
restraints bed rail, chipped bed pans
Sites
Posture Sites
supine rim of ears, inner knee ,heel
lateral trochanter, lateral condyle
of knee, malleolus
sitting sacrum
semi recumbent outer ankle
Prevention
Appropriate mattress
egg-crate /water bed/air bed/ foam /clinitron bed
turning --2 hourly/ use pillow or wedge cushions
wheelchair cushion--shift weight every 15 minutes
elbow/heel pads
bed cradles
AVOID AIR RINGS
Aims
Maintain quality of life
Promote potential healing
Prevent further damage
Relieve pain and discomfort
Prevent infection
Control odour and exduate
Minimize bleeding
SKIN CARE
Inspect skin
keep skin dry
skin moisturized
avoid trauma
do not elevate patient >30% avoid sliding/shear
lift patient /no restraint/no bed rals
avoid over heating/vigorous massage
avoid alcohol or astringents on area under pressure
Nutrition /General care
Keep plasma albumin above 3gm/dl
haemoglobin above 10 gm /dl
supplements/ high protein
vitamin C
zinc
General measures
get patent out of bed/ mobility
avoid sitting for long period
active /passage range of motion exercises
Treatment Keep plasma albumin above 3gm/dl
haemoglobin above 10 gm /dl
supplements/ high protein
vitamin C
zinc
General measures
get patent out of bed/ mobility
avoid sitting for long period
active /passage range of motion exercises
Treatment by stages
Stage Appearance Management
1 blanch/erythema relief pressure
non blanch/red tegaderm change prn
skin intact
2 superficial skin loss omiderm dressing
3 blister /eschar omiderm dressing
do not open blisters
progress >4/52 debride
Treatment by stages—continued Stages Appearance Treatment
4 clean ulcer with relief pressure
granulomatous base povidone iodine /duoderm
calcium alginate dressing
honey, sugar-povidone iodine
packing
5 Infected ulcer pressure relief
grey slough surgical/enzymatic debridement
charcoal for odour
sugar-povidone iodine pack
Wet to dry dressing
systemic antibiotics
Choice of dressing according to stage Stage Dressing
Blanching vapour permeable adhesive
skin intact replace every 5-7 days
Superficial clean hydrocolloid (5-7 days )
Ulceration little exudates--hydrocolloid
subcutaneous heavy exudates--- alginate
Ulceration pack with hydrocolloid paste
debride--hydrocolloid dressing
Infected debridement-pack with alginate ribbon
cover with film dressing
Stomas and Fistulas
Definitions
Stoma:
A surgically created opening to divert feces / urine out of the body
Fistula
an abnormal passage between two internal organs or frnm an internal organ to the surface
Bowel Stoma
Location depend on the level of obstruction
Determines the character and volume of the
effluent
Ascending colon ----high volume, liquid stool
Transverse colon----loose/softy formed stool
Descending colon----loose to formed stool
Sigmoid colon--------formed stool
Small bowel-----------frequent watery tool
Stoma Care
Respect the patient’s established regimen for stomas
Be sure the skin is clean / dry before applying new
stoma appliances
Use only mild soap to clean around the stoma
Rinse the skin thoroughly to remove the soap
Pat the skin dry gently
Use special powder or ointment
Replace stoma bag promptly
Make sure it stoma bad fits properly
Supra Pubic Catheter
Special Consideration
Allergic dermatitis change different appliance
Effluent dermatitis stoma paste/cream
steroid cream/antifungal antibacterial
Don’t allow appliance to overfill
Trauma change pouch 4-7 days
Gas /odour activated charcoal/ avoid gas forming food
Diarrhoea anti diarrhea pills / diet
Constipation diet, enema laxative
Bleeding stoma powder, pressure, rule out tumour
Ileal conduits
Barrier cream to protect skin
Pouch should be odor- proof and have a drainage
valve to drain the urine
Swab the skin around the pouch with acidic solution
(1part vinegar to 1 part water)
Pour 1-2 oz of same solution in pouch, patient to lie
supine for ½ hour-----aid flushing inside the stoma
Empty the pouch
Routine care similar to bowel stoma
Nephrostomy Change dressing every other day preferably after the
shower
Clean the skin with an bactericidal soap then paint
with povidone iodine
Apply slit gauze around the nephrostomy tube, loop
the tube to avoid traction -- >place a large gauge pad
over the looped tubing.
Connect tubing to standard urine bag
Possible problems
blockage, dislodgement and purulent discharge
Cutaneous Fistulas
When possible apply a stoma bag
Clean the skin around the fistula with water
(no soap, antiseptics )
Use filler to create flat surface
Choose right size stoma bag
Control odor
Multiple fistulas, use absorbent pad and normal
Dressing
Protect surrounding skin
Recto-perineal fistula
Cancerous wound can heal