171213 Wound Care in General Practice · that the underlying pathophysiology be addressed where...
Transcript of 171213 Wound Care in General Practice · that the underlying pathophysiology be addressed where...
Wound Management in General Practice
December 2017
Jan Rice Director, Jan Rice WoundCareServices Pty Ltd
At the end of this webinar it is anticipated that the attendee will be able to:
• Name 4 of the most common types of wound classification
• Name the 3 most common wound classification seen in aged care
• Name the tissue types described in wound management
• Discuss to management aims for the various tissue types
• Name the most common generic listings of dressings
• Name 4 topical antimicrobials
• Discuss the best practice management of venous leg ulcers
• Discuss the management principles of arterial leg ulcers
• List the 6 stages of pressure injury
• List 4 factors influencing healing
Topics to be discussed
• Common wound types
• Common dressings available
• Typical presentations of the most common of these wounds
• Cleaning wounds/wound management
• Signs for review and perhaps referral on
Categorising of wounds
• Acute
• Chronic
• Surgical
• Non surgical
• Skin tears
• Pressure injuries
• Venous leg ulcers
• Arterial leg ulcers
• Inflammatory ulcers
Acute wounds
• Generally surgical or non surgical and healing in a normal time frame
• Generally less than 4-6 weeks old
Chronic wounds
• Again can be surgical or non surgical but have not progressed along the normal healing trajectory and so are older than 6 weeks and no end is in sight-possibly even getting worse
Pressure injuries
• Stage i
• Stage ii
• Stage iii
• Stage iv
• Unstageable
• Suspected deep tissue injury
www.woundsaustralia.com.au
Venous leg ulceration
• Classifies according to the CEAP system although only generally amongst medical staff
CEAP classification of chronic venous disease
Clinical classification
C0No visible or palpable signs of venous disease
C1 Telangiectasies or reticular veins
C2 Varicose veinsC3 Edema
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or athrophie blanche
C5 Healed venous ulcerC6 Active venous ulcer
Arterial leg ulcers
• Arterial disease can be seen in those who have diabetes, past history of smoking, hyperlipidaemia, hypercholesterolaemia and hypertension
Once you have a name for the wound types you can almost “Google” it and you will find a management pathway
Certainly looking there are text books on all of these wounds and injuries
Principle of management of acute wounds
• Stop the bleeding
• Apply a protective dressing
• Ensure there is no oedema
• Inspect in 2-3 days, watch for S & S of infection
• Ensure good nutrition and hydration
Principles of chronic wound management
• Ensure underlying pathology is being addressed
• Generally antimicrobials and good wound cleansing are required
• Reduce oedema
• Ensure excellent skin care
• Provide good nutrition and hydration
• Seek help if wound is stagnant
Skin tears
• If you classify the skin tear according to the STAR tool then there is no need to keep inspecting the wound and protocols of care can be set reducing confusion in care management and promoting best practice
• Standardisation of common wound types care also means better utilisation of wound care dressings etc
Pressure injuries
• Again if classified we know what to expect and can minimise confusion as to what products to use and how to manage and what to expect
Leg ulceration
• Venous leg ulcers require –elevation and compression
• Arterial leg ulcers require restoration of the arterial flow , prevention of infection and management of pain-may be considered palliative if none of the above can be achieved
• www.woundsaustralia.com.au
• Impregnated mesh dressings
• Low adherent lightly absorbent pads
• Super absorber pads
• Protective film wipes
• Film sheets
• Foam and foam like absorbent dressings
• Hydrocolloid wafers and paste
• Hydrogel sheets and amorphous with or without additives
Generic names for dressings
• Calcium alginates • HydroFibre • Hypertonic salt dressings • Cadexomer iodine • Silver • Tea Tree Oil dressings • Antimicrobial Binding dressings • Medicated honey • Zinc paste bandages • Biofilm inhibitors and surfactants
Generic names for dressings
Decision making process of dressing selection
• What is your aim?
• Where is the wound located?
• What type of tissue do you have ?
• How much exudate and what type of exudate?
• How much pain and what type of pain?
• What products do you have available or access to?
Wound tissue descriptor and possible aim
• Necrotic tissue—eschar or slough---maintain or remove??
• Granulation tissue--protect
• Hypergranulation tissue--reduce
• Epithelium--protect
• Macerated tissue—manage exudate
• Infected tissue-use antimicrobials
• Foul smelling tissue-antimicrobials/debride
Matching tissue type & colour & product
• Black necrotic---****if aiming to heal--cleansing dressing, but if dry and ischaemic keep dry
• Green Infected----antimicrobial dressing
• Wet yellow necrotic ---antimicrobial dressing
• Dry yellow necrotic ---rehydrating dressing
• Red granulation---protect
• Hypergranulation---antimicrobial dressing
• Pink epithelium---protect
This is not a prescription but a guide to where to start—it is imperative that the underlying pathophysiology be addressed where possible
WorldofWounds 23
Dry hard black-almost no erythema, nil odour, ‘quiet’ DO NOT HYDRATE!!! Keep dry
Soft, boggy, offensive black often with peri wound maceration—have someone debride but usually after a few days of antibiotics-if you debride without antibiotic coverage there is often uncontrolled bleeding
Infected wounds
These wounds have thick purulent exudate often brown/red in colour or green
• requires systemic antibiotic therapy, exudate control and safe topical therapy
Yellow (sloughy) wounds
The drier yellow/brown tissue if not able to be debrided requires rehydration to assist autolytic debridement
The moist creamy yellow wet tissue requires an antimicrobial that will help to manage exudate
Clinicians must however be able to identify other yellow tissue…..
• Tendon
• Bone-creamy / white
• Fat / Subcutaneous tissue
Healthy red (granulating)
This tissue should be almost level with the perimeter of the wound and not bleed easily when cleansed
This tissue requires some moisture but not too much and it requires a dressing that will protect
Poor quality granulation tissue
• Can present as pale tissue with irregular tissue and copious exudate and non healing edges
• This tissue often requires an antimicrobial, very good cleansing and exudate management and peri wound protection
Hypergranulation tissue
• Bleeds easily and raised above side edges of wound
• May also present as loose ‘bubbles’ of tissue within deeper wounds
• Sometimes described as ‘Jelly like’ tissue
• Flattens when pressed for short length of time • The aim here is to control
exudate, apply direct pressure and consider antimicrobials
Pink (epithelialising) tissue
• This represents the wound in the final stages of healing, it may be transparent and pearly pink
• Young epithelium wrinkles when pressed and has a matt finish appearance with minimal exudate
-requires some hydration and protection, particularly against friction and shear
In planning the treatment the clinician must also consider the depth of wound
• For pressure injuries use the pressure injury classification tools, other will be described according to the burn classifications of superficial, partial, thickness, deep partial and full thickness
• Determining depth will influence product choice
Wound exudate assessment is perhaps the final side of the triangle in product selection
Exudate is often described as , nil, minimal, moderate and heavy, but in reality these are very subjective and determined by product selection.
Naturally the type of exudate needs also to be considered • www.woundsinternational.com for an excellent document on
wound exudate
Assessing if progress is being made is often done by......
• Calculating size change
• Tissue type progresses from necrotic to healthy granulation or epithelium
• Exudate volume decreases
• Pain settles/ subsides
• Peri-wound condition appears normal
• Malodour disappears 45%granulation tissue
25%epithelium
15%fibrinoustissue/slough15%nectrotictissue
Principles
• Treat the underlying cause if possible
• Control all known factors that may influence healing
• Select product or device to manage wound based on tissue assessment, volume and type of exudate, depth or wound, condition of peri wound and ability to purchase
• Plan to review regularly, adjust as tissue changes and maintain integrity once healed
Consider…
• Where the wound is located?
• What is the condition of the periwound?
• How great a risk is there of further contamination by other body fluids?
• How deep is the wound?
• Is there tunnelling and tracking?
Factor Effectonhealing Levelofevidence
Inadequatepefusion Increasedriskofinfection LevelI
Presenceofnonviabletissue
Increasedriskofinfection LevelI
Presenceofhaematomasorseromas
Causeswoundischaemia,increasesdeadspace,suppliesnutrientsforbacteria,increasesriskofinfection
LevelI
WoundInfection Prolongsinflammatoryphase LevelIExcessproteases Degradesextracellularmatrix LevelISystemicimmunedeficiency
Inhibitionofcellularproliferationandfunction,nutritionaldeficiency
LevelII
Systemicconditions,e.g.diabetes
Hyperglycaemia,increasedriskofinfection,woundischaemia
LevelII
Increasedage Impairedimmuneresponse LevelII
Obesity Increasedriskofinfection,wounddehiscenceandpressureinjury
LevelII
Malnutrition Proteinloss,increasedriskofpressureinjury
LevelII
Cigarettesmoking Higherincidenceofcomplications LevelII
Corticosteroids Detrimentaleffectongrowthfactorsandcollagendeposition
LevelII
Other important factors to be considered
• Nutritional factors
• Mechanical factors
• Wound temperature
• Desiccation and maceration
• Chemical stressors
• Patient factors
Normal RDI’s
Energy Protein VitaminC Zinc Iron
8-10Cal/kg
25-30cal/kg
50g/kg
1.2-2g/kg
40mg
100-200mg
12-15mg
15-25mg
12-16mg
10-30mg
Nutrition
• Mini-nutritional assessment scale-available from www.mna-elderly.com
For your free copy contact 1800 671 628 and also ask for the recipes using Arginaid extra and ask for the new patient guide- Support wound healing from the inside out.
Temperature
• Extremes of body temperature will cause tissue damage
• Optimum temperature of wound is 370C
• Sub-optimal temperatures occur if dressings are changed frequently
• Wherever possible warm wound cleaning solutions
Wound debris
• Necrotic tissue, dry scabs and excess slough will impair epithelial migration and impair the supply of nutrients to the wound.
• Wound debris prevents the formation of granulation tissue and prolongs the inflammatory phase of healing.
• Foreign material in the wound will do the same, e.g. cotton wool fibres, dog & cat hair.
Maceration
• ‘Softening and breakdown of skin resulting from longed exposure to moisture’(Anderson 1998)
• Difference between acute & chronic wound exudate, the chronic can be quite harmful to surrounding tissue
• Excessive moisture may predispose the wound to infection, skin sensitivities and irritations
• Apart from wound exudate other sources of excess moisture are urinary and faecal incontinence, and wet dressings from the shower!
Topical antiseptics-yes, no, sometimes?
• Bacteria cause local inflammation and are leucocytotoxic. They also damage epithelium, retard wound contraction, reduce wound tensile strength and trigger microthrombi. Therefore, the cytotoxicity of bacteria must be weighed against any possible antiseptic cytotoxicity
• More and more new research is demonstrating that there is a place for skin cleansing with antiseptics and in some cases cleansing wounds with antiseptics and then rinsing off with sterile saline
Further reading... www.ewma.org
• Wound complexity and healingP Vowden, J Apelqvist, C Moffatt
• Psychosocial factors and delayed healingC Moffatt, K Vowden, P Price, P Vowden
• Economic burden of hard-to-heal woundsM Romanelli, JC Vuerstaek, LC Rogers, DG Armstrong, J Apelqvist
• www.awma.com.au
• www.woundpedia.com
• www.worldwidewounds.com
• www.globalwoundacademy.com
• www.ewma.org
• www.woundinfection-institute.com
• www.woundsinternational.com
• Facebook- Regional Wounds Group
Resources