WOUND CARE

SKIN LAYERS Epidermis Dermis Subcutaneous

PARTIAL THICKNESS

WOUND: Injury not through dermis

FULL THICKNESS WOUND: Injury through all layers of skin

How thick is 2.075 mm?

A plastic ruler A house key A U.S. Nickel

On average*, a pressure ulcer 2.075 mm or deeper is classified at least as a Stage III.

How thick is 2.075 mm? A plastic ruler A house key A U.S. Nickel

Localized area of

tissue breakdown

resulting from

compression of soft

tissue between a

bony prominence

and an external

surface

Compression of soft tissue leads to:- Tissue anoxia - (hypoxia especially of such severity as

to result in permanent damage)- Cell death

Deep tissue trauma can occur with relatively little superficial damage - Difficult to discern the

extent of tissue damage

“Pressure Ulcers can develop within 24 hours of the insult or take as long as 5 days to present themselves” – Ratliff and Rodeheaver, 1999

• Pressure is highest between

the soft tissue and the bony

prominence

• Tissue injury starts at the

bone/ tissue interface and

extends outwards

Accounts for the undermining commonly seen in pressure ulcers!

Sacrum – 36.0 Scapula – 2.4 Heel – 30.3 Occiput – 1.3 Ischium – 8.0 Elbow – 6.9 Malleolus – 6.1 Trochanter – 5.1 Knee – 3.0

StagingFor pressure ulcers ONLYDescribes only the level of tissue damage

or lossDoes not describe levels of progression

or healing

Non-blancahble erythema of intact skin

May include:-discoloration-warmth/coolness-edema-change in tissue consistency

Partial thickness loss of dermis presents as ashallow open ulcer

with red pink wound bed, without slough or bruising. open or intact

blister shiny or dry shallow

ulcerMay be painful

Full-thickness skin lossSubcutaneous fat may be visible May extend down to but not through underlying fasciaMay be shallow or deep, with/without undermining or tunneling Eschar and/or slough may be present but does not hide depth of tissue loss

Full-thickness skin loss Extensive destruction of tissue, with visible or palpable muscle,

bone, tendon May include undermining / sinus tracts May be shallow or deep Slough or eschar may be present

Full thickness tissue loss in which the base of the ulcer is covered with eschar or slough so that full extent of injury cannot be assessed. The stage cannot be determined

Purple or maroon area of intact skin, or blood-filled blister due to damage of underlying tissue from pressure or shear. May evolve into ulcer

Cannot reverse stage – a healing Stage 3 does not become a Stage 2.

Maintain Healthy SKIN

Surface Keep Moving Incontinence Management

Nutrition

If patient can be turned and has at least two intact turning surfaces, use a mattress overlay such as an air cushion or alternating pressure pad

If patient has breakdown on more than one surface, use a pressure reduction (low air loss) mattress

Patient must still be repositioned to promote pulmonary, renal, and vascular function along with protecting skin integrity

Head of bed no higher than 30 degrees, unless pt is eating, to prevent shearing. If possible get pt up to cushioned sit for meals

No more than 2 items between patient and surface - any more will alter pressure-reducing ability of surface

MUST FLOAT HEELS!!!!!!

Avoid HOB elevation above 30 degrees

Use lifting device for transfer/transport.

Consider trapeze to help patients with self-transfer

Chair Bound PatientsLimit chair sitting to an hour or reposition every hour.Encourage patients to shift weight every 20 minutes if able.Sit in upright position

Use pillow behind back if needed

Pressure reduction/relief devices do not replace repositioning

Correct Cause of Incontinence if possible• Offer frequent or timed toileting • Keep toilet aids within easy reach• Rule out possible UTI• Check for fecal impaction

- Frequent cause of fecal/urinary incontinence- Correct diet - Initiate measures to normalize stool frequency/

consistency

Contain or Absorb Incontinence Use absorptive under pads to wick moisture away

from the skin. Limit use of adult incontinence garments (AKA

diapers) to:Specific patient request Incontinent patients while ambulating

Check absorptive pads and diapers frequently for soiling.

Use breathable under pads if on specialty bed.

URINEWater saturates skin, increases risk of friction and erosion

Ammonia raises pH, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes

STOOL

Fecal enzymes damage skin, promote erosion, worse in high volume diarrheaGI Bacteria may be pathogenicWater overhydrates the skin

CLEANSE – routine daily cleansing for everyone

MOISTURIZE – cleanse and moisturize after each major incontinent episode

PROTECT – apply moisture barrier for significant urine/stool/double incontinence

Protein and Calories Multivitamin Vitamin C Zinc Hydration Dietician consult of course!

Purpose – Immediately and accurately identify patients at risk for developing pressure ulcers

Early intervention for pressure ulcer prevention

Target resources appropriately

1. Sensory Perception• The ability of the patient to sense pressure on the

surface of the body2. Moisture

• Increases friability of skin• Increases the risk of skin breakdown by 5 times

3. Physical Activity• Frequency and duration that an individual ambulates• Not the type/amount of assistance the individual

requires to ambulate. 4. Mobility

• Ability to change & control body position in bed

5. Nutritional Intake 6. Friction & Shear

• Friction- Force that resists motion between two surfaces - Damages protective outer layer of skin

promoting skin ulceration- Occurs when a patient is dragged across bed

sheets• Shear

- Mechanical force parallel to an area

- Results from sliding and relative displacement of two opposing forces

- Major contributors to the stage, size, and shape of pressure ulcers

•Skin sticks to surface

•Deeper tissues move

in opposite direction

•Capillaries kink

•Local ischemia

Assessment is useless without interventions to decrease the risks

Braden score 18 or less Current or history of pressure ulcer Life expectancy of 6 months or less Incontinence with transfer or ambulation

difficulty regardless of Braden score

Choose intervention(s) from all 4 categories of the SKIN pneumonic

Instruct CaregiverKeep linens/pads smooth to prevent

bunching of fabric under Avoid more than 2 layers of linen between

patient and specialty mattress (including pads and diapers)

Float heelsKeep surface inflated according to

manufacture’s instructions

Instruct Patient and CaregiverReposition q 2 hours in bed, every hour in chair.

WC bound: shift weight every 20 minutes.

Avoid prolonged pressure to bony prominences

HOB no more than 30 degrees

Instruct Caregiver:Keep pt clean and dryCheck diapers at least every 2 hours

Use moisture barrier to peri-area with every diaper change

Incontinent product use(skin barriers, pads, undergarments, catheters)

Instruct Patient and CaregiverMonitor intakeBalanced dietMonitor weight weeklyEat 5 fruits or vegetables dailyIncorporate foods rich in Vitamin C

Scenario: Mrs. C. is 80 years old. She was recently hospitalized for pneumonia. She lives with her daughter who is her primary caregiver. She has a history of a sacral pressure ulcer which is healed. She is incontinent of urine and wears diapers. She walks with a walker but requires assistance also.

Verbalizes symptoms of exacerbation/complications, when to report and actions to take through education r/t

Avoid bunching of linens. Float heels in bed. Change position q 2 hrs in bed and q 1 hr in chair. Wash peri-area with soap & water and apply moisture barrier with each diaper change. Increase calories, protein and vitamins in diet.

All Braden scores are not created equal

Care Plan to deficits in each area

Skin Disorders Herpes Yeast Scabies Corns Calluses (hyperkeratotic

area) Papillomas (skin tags) Keratinous cysts Warts Keloids Seborrheic keratoses Actinic keratoses Common acquired nevus

(moles) Fungal infections

Fungal or yeast rash:

Solid rash with multiple satellite lesions

Grows on warm, moist skin

Decrease moisture by using dry cloth or gauze in folds (InterDry Ag)

Treat rash

Friction: Sanding away of the surface layer of the skin. More common when skin is fragile or macerated

Maceration: Tissue is water logged

Skin tears.

Drag/pull across the bed sheets, etc. especially if patient is being moved incorrectly

Contact dermatitis Enzymes, etc.

Denuded: Skin has been stripped by enzymes from incontinence or wound drainageVery painful and very wet

Excoriated: Scratch marks

VASCULARWOUNDS

Etiology related to poor arterial and/or venous blood flow

Usually appear in lower extremities

DIABETIC WOUNDS Neuropathic ulcer

usually on soles of the feet

Typically heavy callus rim due to repetitive trauma

Lack of sensation due to neuropathy

Impaired blood flow causing tissue ischemia

Most commonly due to smoking and atherosclerosis

Ulcers result from trauma

Pain with leg elevation, decreased pain when leg dependent

Feet pale when elevated, very red when dependent

Cool to touch and decrease/absent pedal pulses

Little or no leg/toe hair present

Wounds have punched out appearance Wound bed pale, mostly dry Tend to occur in distal part of leg in

areas exposed to repetitive trauma or pressure

Usually small and deep, necrosis common

Edema NOT common; if present, pt has both venous and arterial disease

Classic arterial wound

Note dependent rubor

Ischemic changes 65 yr old female, non-bypassable, refuses to quit smoking

One week later. Amputation 3 weeks later

Arterial wounds due to trauma and neuropathy due to alcohol abuse

Arterial ulcer at the metatarsal head

First priority is to improve tissue perfusion-Revascularization surgery is key to successful management-No tobacco

No debridement in dry, uninfected necrotic wounds until ischemia resolved

Also called venous stasis ulcers

About 70% of all chronic leg ulcers

60% will recur

Inadequate calf muscle pump which causes

Distension of the veins which pulls valves apart resulting in elevated

Pressure causing capillaries to leak Resulting in edema Changes in the tissues make them

more susceptible to trauma and ulceration

Risk factors include-DVT-Obesity-Pregnancy-Prolonged standing-Aging-Previous surgery or trauma to leg

Clinical Findings:-30-40% are superior to the medial malleolus and remainder primarily on lower 1/3 of calf-Wound bed is flat, irregularly shaped-Moderate to heavy exudate depending on amount of edema

Clinical Findings-Surrounding skin with edema, hyperpigmentation-Pain most often when leg is dependent, pain decreases with leg elevation

Edema - leg looks like up-side down bottle.

Red in color.

Painful.

Irregular shape.

Clear or serosanguineous fluid.

Brown-black hue to periwound skin from RBC breakdown.

Shallow. Gaiter area of

leg.

Venous stasis ulcer with dermatitis

4+ edema

Ischemic

Improve venous return-ligation of veins-elevation of legs

COMPRESSION THERAPY-eliminates capillary leakage-reduces/eliminates edema-Wounds will not heal without compression

Contraindications to compression:-uncompensated CHF-active thrombus-ischemic disease of lower extremity

Generally not used in presence of active cellulitis until patient on antibiotics for 72 hours

Therapeutic Support Stockings-wonderful if pt will wear them-wait until ulcer is healed-TEDs are NOT therapeutic for venous insufficiency

Compression Wraps-Unna’s boot-Profore- Coban 2-layer compression system

-Tubigrip-CircAid /

Farrow wrap-Pneumatic pumps-NO ACE BANDAGES

Proper compression Improper compression

More improperly wrapped compression

Slow healing venous ulcer

Ulcer after 1 week of compression and wound care

Severe lymphedema with ulcerations

After compression

Diabetic neuropathy leads to -diminished sensation causing undetected trauma-decreased perspiration causing dry cracked skin-muscle/ligament/bone atrophy resulting in structural changes in foot causing increased and repetitive pressure

Breakdown occurs in areas exposed to painless, repetitive trauma from friction or pressure

Most common on plantar aspect of foot

Sometimes at heel, tops of toes, between toes

Reduce or eliminate pressure and traumaby offloading foot-pressure relief for heel ulcers-modify footwear to avoid pressure

Control diabetes

Infected diabetic ulcers with communicating sinus tracts

Idiopathic neuropathy, ulceration post plantar wart removal

Same ulcer, failed graft from patient walking on wound

Toe amputation, partial take of skin graft

Healing with local care

Re-ulceration in two months from non-compliance with shoewear

Location Measurements in centimeters width x length x depth Any tunneling/undermining Color of wound bed Condition of surrounding tissue/skin Drainage, odor, pain

MEASURING WOUNDS

Use a single-use measuring guide.

Across longest and widest areas.

Which is length?

12:00

6:00

3:009:00

Which is width?

Use a cotton tip applicator Place tip in deepest part of

wound Mark skin level with

finger Measure length from

applicator tip to level marked with finger

Definition Tissue destruction to underlying intact skin

along wound edges. Measuring

Use cotton tip applicator. Mark distance between tip and wound edge. Indicate extent of undermining and location by

using clock face.

Definition A measurable tract extending from the wound bed.

Measuring Use cotton tip applicator. Mark length between tip and wound edge. Indicate location by using clock face.

Serous is a clear, water plasma.Sanguineous indicates fresh bleeding.Serosanguineous is a pale, more watery

drainage than sanguineous drainage.Purulent is a thick, yellow, green, or

brown drainage.

Foul smelling – expected in the presence of eschar or slough, and/or infected wounds.

Mild – may be associated with wound care products.

Think of color Red – usually indicates

granulation tissue. Yellow – slough – soft necrotic

tissue Black – Eschar – firm/hard

necrotic tissue

Unable to stage pressure ulcer with eschar

May or may not debride wound eschar depending on location

Describe the appearance of skin immediately surrounding the wound.

Measure and document the size of each characteristic

Redness of the skin due to capillary congestion.

Common cause – unrelieved pressure

Abnormal firmness of tissue with a definite margin. Marked by loss of elasticity and pliability. Cause is usually infection.

Softening of tissues by soaking in fluids. Dissolving connective tissue components causing degenerative changes.

Causes: wound drainage, contact with stool and/or urine.

Loss of superficial epidermis.

Common causes: unrecognized or treated maceration, tape on fragile skin

Discoloration: An increase or decrease in pigmentation not consistent with surrounding skin; may be purple, brown, etc. Commonly seen with venous ulcers.

Edema: Presence of abnormally large amounts of fluid in the interstitial space. Seen with venous ulcers.

Firm, thickened area of tissue usually seen on the diabetic foot from repeated pressure or shear.

Wound Healing and Barriers Principles of wound

management Dressing Selection guidelines

Only two ways to heal –

Regeneration – partial thickness wound or

Granulation – full thickness wound

(Proliferation, remodeling)

Injury not through dermis

Inflammatory phase Epithelialization Re-establishment of normal skin

Injury through all layers of skin

Inflammatory phase Proliferation phase Contraction Epithelialization Maturation

Inflammatory phase Starts with surgery or injury – lasts 3-4 days fragile bond The four cardinal signs of inflammation, as

described by the Roman physician and science writer Celsius, are:

Rubor - redness Tumor - swelling Calor - heat Dolor - pain

To heal wounds, our bodies use a large collection of cell types, proteins, and molecules.

Photo: Dennis Kunkel Microscopy, Inc.

PROLIFERATION/RECONSTRUCTION/

CONTRACTIONAs per Merriam-

Webster: proliferation is to grow by rapid production of new parts, cells, buds, or offspring

lasts 4-21 days – pink granulation tissue, collagen

REMODELING Can last up to 2

years

80%

60%

40%

20%

PRIORITIES-Correct Etiology-Provide Systemic Support-Use appropriate therapy

• GOAL-Healing-Maintenance

MONITOR RESPONSE

-Expect improvement in 2-4 weeks-Change regimen if maceration or increased depth due to increased exudate-Failure to improve most commonly due to systemic factors – reassess and correct

DIDN’T HEAL:= Diabetes

= Infection= Drugs

= Nutrition = Tissue necrosis

= Hypoxia = Excessive tension on wound edges

= Another wound

= Low temperature

Keep wound clean, warm, dark, moist, protected

Remove necrotic tissue (slough, eschar)

Treat infection Fill dead space Maintain moist wound environment Protect from infection/trauma/cold

Debridement essential for infected wounds

Critical first step when healing is goal

SurgicalFastest way to a clean wound

HERE SHOWING CALLUS REMOVAL

Eschar on heel After debridement

DO NOT debride dry stable eschar from heel wounds

Apply to wound daily per manufacturer’s instructions

Slow, but less painful, less expensive

AUTOLITICAUTOLITIC

with the use of Dakin’s

with the use of wet to dry gauze dressings. Wet gauze sticks to wound bed. When it dries, pull it off to remove dead tissue. Do not moisten dried gauze. VERY PAINFUL

Medical grade maggots

Application of maggots

BIOLOGICALBIOLOGICAL

Drainage from maggot therapy

Fat and happy maggots!

Historically Historically, maggots have been known for centuries to

help heal wounds. Many military surgeons noted that soldiers whose wounds became infested with maggots did better --- and had a much lower mortality rate --- than did soldiers with similar wounds not infested. William Baer, at Johns Hopkins University in Baltimore, Maryland, was the first physician (an orthopedic surgeon, actually) in the U.S. to actively promote maggot therapy; his results were published posthumously by his colleagues in 1931. MDT was successfully and routinely performed by thousands of physicians until the mid-1940's, when its use was supplanted by the new antibiotics and surgical techniques that came out of World War II. Maggot therapy was occasionally used during the 1970's and 1980's, when antibiotics, surgery, and other modalities of modern medicine failed. In 1989, physicians at the Veterans Affairs Medical Center in Long Beach, CA, and at the University of California, Irvine, reasoned that if maggot therapy was effective enough to treat patients who otherwise would have lost limbs, despite modern surgical and antibiotic treatment, then we should be using maggot therapy BEFORE the wounds progress that far, and not only as a last resort

Natural History of Blow Flies Maggots, by definition, are fly larvae, just as

caterpillars are butterfly or moth larvae. there are thousands of species of flies, each with its own habits and life cycle. We use Phaenicia sericata (green blow fly) larvae.

Medical Maggots are now produced by Monarch Labs and can be obtained by Licensed health care providers

Medicinal maggots have three actions: 1) they debride (clean) wounds by dissolving the dead (necrotic), infected tissue; 2) they disinfect the wound, by killing bacteria; and 3) they stimulate wound healing

      Eggs are off-white, and laid in clusters of 25-500.

One-day-old larvae are only about 2 mm in length, and almost transparent.

By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

DAY 1

DAY 3

DAY 7

All wounds are contaminated Culture if wound is infected. Routine

culture of all wounds not necessary Use Modified Swab technique

-cleanse with sterile saline-swab one square centimeter of viable tissue x 5 seconds with enough force to produce exudate

Systemic antibiotics if indicated Topical treatments

-Dakins Solution: 0.025% is wound strength and is bactericidal to most bacteria found in wounds and non-cytotoxic. ¼ strength solution most often used-Povidone-iodine: Use solution only, never scrub. Use 10% or less concentrated solution

-Acetic acid: Toxic to Pseudomonas in 5% solution; this is also toxic to all cells needed for repair. 0.25% commonly used

Stop use of these products when wound is clean!!!

Antibacterial Dressings

-Cadexomer iodine -Sustained release silver dressings-Polyhexamethylene Biguanide (AMD)-Hypertonic

Topical Antibiotics-Polysporin/Neosporin: Staph aureus, E.Coli, Pseudomonas-Silvadene: Pseudomonas, E.Coli, Staph aureus-Bactroban (Mupirocin): MRSA-Gentamicin: Pseudomonas, E.Coli, Staph aureus

LIGHTLY pack wounds to allow for drainage

Over packing creates a plug and puts pressure on tissue

NO STUFFING!

Choose a dressing based on volume of exudate

minimal exudate needs dressings that add or trap moisture

moderate exudate needs dressings that absorb without dehydrating

large amount exudate needs highly absorbent dressings

To add or maintain moisture:

Damp gauze Gels – Solosite, Curagel

+ Cover dressing to retain moisture

Transparent film – OpSite, Tegaderm Non-adherent gauze – Adaptic, Vaseline

gauze

Filler Dressings-Calcium Alginate -Hydrofiber -Gauze

Cover Dressings-Polyurethane Foam – Allevyn, Polymem-ABD and other gauze

To absorb exudate

Hydrocolloid – Duoderm, Tegasorb Able to absorb minimal to moderate

amount of exudate Provides insulation and protection from

bacterial invasion and trauma Yellowish exudate and odor normal with

removal Change dressing 1-2 x week

Based on amount of drainage and presence of infection

Infected wounds need to be monitored daily

Heavily draining wounds may need to be changed 2-3 times a day

As drainage decreases, increase time between dressing changes

Choose cover dressings that protect from the environment-Transparent films, foams, waterproof tapes-63 layers of gauze needed to protect from bacterial invasion

Protect wounds from re-injury Decrease dressing frequency to prevent

thermal shock

SHALLOW/SUPERFICIAL WOUNDS

MODERATE – HEAVY EXUDATE

Goals: Absorb exudates, maintain moist surface; support

autolysis if necrotic tissue; protect and insulate

Need: Absorptive cover dressing:

Alginates, foam, gauze, hydrocolloid (if not too wet)

SHALLOW/SUPERFICIAL WOUNDS

MINIMAL OR NO EXUDATE

Goal: Maintain or create moist surface; protect and insulate

Need: Hydrating or moisture retentive cover dressing:

Gels, hydrocolloids, transparent thin films, non-

adherent gauze

CAVITY WOUNDSMODERATE – HEAVY EXUDATE

Goals: Fill dead space; absorb excess exudates; maintain moist wound

surface; protectNeed: Filler and cover

dressingFillers: alginates, gauze

Cover: Gauze, ABD, transparent film, foam

CAVITY WOUNDSMINIMAL OR NO EXUDATEGoals: Fill dead space; maintain moist wound; protect and insulateNeed: Hydrating filler dressing;

cover dressingFiller: Gel, damp gauze

Cover: Gauze, ABD, transparent film, foam

Review of last session SKIN ACCRONYM

Surface Keep moving Incontinence management

Nutrition