Http://UDL.concord.org Carolyn Staudt [email protected] Project Manager.
Wound Care Overview Carolyn Watts MSN,RN, CWON February 16, 2007.
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Transcript of Wound Care Overview Carolyn Watts MSN,RN, CWON February 16, 2007.
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Wound Care Overview
Carolyn Watts MSN,RN, CWON
February 16, 2007
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Definition
A wound is a break in the integrity of the skin.
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Phases of Wound Healing
Inflammatory (immediate) Fibroblastic (day 4-20) Maturation (6-12 months)
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Factors Which Impact Wound Healing
Tissue perfusion and oxygenation Nutritional status Presence or absence of infection Diabetes Mellitus Corticosteroid administration Immunosuppression Age Stress Other systemic factors Topical therapy
Waldrop & Doughty, Acute and Chronic Wounds, 2000
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Patient Assessment
Medical/Surgical History Medications (include OTC) Nutritional Assessment Pain Psychosocial Assessment Cultural/ethical considerations
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Wound Assessment Location Stage/Classification Size (LxWxD in cms) Sinus Tract(s) Undermining Exudate Necrotic Tissue Granulation Tissue Signs/Symptoms of Infection Periwound Skin
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Acute Wounds
ClassificationPartial Thickness (involve epidermis/dermis
only)Full Thickness (involve subcutaneous tissue
and possibly underlying structures) Usually heal following normal wound
healing pathways
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Chronic Wounds
Pressure Ulcers Venous Stasis Ulcers Arterial Ulcers Neuropathic Ulcers Usually have impaired healing
mechanisms
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Pressure Ulcers
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Venous Stasis Ulcer
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Arterial Ulcer
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Neuropathic Ulcer
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Topical Therapy: Principles
Remove necrotic tissue and foreign bodies or particles
Identify and eliminate infection Obliterate dead space Absorb excess exudate Maintain a moist wound surface Provide thermal insulation Protect the healing wound from trauma and bacterial
invasion Doughty, Acute and Chronic Wounds, 1992
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Types of Topical Wound Dressings
Hydrocolloid dressings Hydrogel dressings Alginate dressings Transparent film dressings Foam dressings Absorption dressings Gauze dressings Composite dressings Biologic dressings Other
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SHALLOW DRY WOUNDS
Need hydrating dressing + cover dressing Options:
Amorphous hydrogels (Carrasyn V gel) Sheet hydrogels (ClearSite) Tegaderm Clear Acrylic Absorbent Dressing Transparent
dressings
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DEEP DRY WOUNDS
Need hydrating filler dressing + cover dressing
Filler dressing options: Amorphous gel (Carrasyn V gel) to wound bed, lightly
pack with damp saline gauze Gel soaked gauze packed lightly into wound bed
Cover dressing options: Gauze and/or ABD with hypoallergenic tape (paper or
stretchable cloth)
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SHALLOW DRAINING WOUNDS
Need absorbent dressing + cover dressing Options:
Foam dressings with adhesive border (Allevyn Island) *minimal drainage
Sheet alginate w/ silver, adhesive foam (Allevyn Island) or wrap gauze (Kerlix roll) *moderate drainage
Hydrofiber (Aquacel) w/ adhesive foam (Allevyn Island)or wrap gauze (Kerlix roll) *heavy drainage
Nonadherent contact layer (Adaptic, Mepitel, or Mepilex
Transfer) w/ gauze cover dressing and tape.
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DEEP DRAINING WOUNDS
Need absorbent filler dressing + cover dressing
Filler dressing options: Calcium alginate with silver (Acticoat Absorbent rope
or sheet), if antimicrobial needed Hydrofiber (Aquacel) Damp cotton gauze (Kerlix 4x4), pack loosely
Cover dressing options: Gauze, ABD/tape (if wound exposed to contaminants use
transparent dressing – Tegaderm) Waterproof foam dressing (Allevyn Island)
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Specialty Dressings
Ionic silver dressings Synthetic skin substitutes
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Specialty Products
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Wound Care Product Selection
Wounds are dynamic and will require different approaches during healing process
Continually reassess patient and wound Topical therapy is one part of your role - must
eliminate cause and support host Continually educate yourself on products to make
informed choices Work with specialty nurses (WOCN or Plastics) to
develop plan of care