Transcript Lotions, Potions and Dressings – What do I do?

Lotions, Potions and Dressings –
What do I DO?
Anna Braden, BSN, RN, CWOCN
Objectives
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Have a basic understanding of skin and
wound assessment
Have an understanding of basic dressing
selection guidelines based on
assessment
Have a basic understanding of product
categories
Anatomy
Epidermis
 Dermis
 Subcutaneous tissue
 Fascia, Muscle, Bone
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Wound Healing
Injury
Hemostasis:
• Coagulation
• Platelet aggregation
Platelets
Inflammation:
•Macrophages
•Neutrophils
•Granulocytes
•Debridement
•Resistance to
infection
•Neovascular growth
•Granulation
Collagen lysis
Collagen synthesis
Proliferation
Epithelialization
Proteoglycan
synthesis
Maturation: remodeling
Healed wound
Contraction
Wound Care: An Incredible Visual! Pocket guide, 2009
Wound healing
Wikipedia, the free encyclopedia
Wound Healing
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Partial Thickness
◦ Epidermis, dermis
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Full Thickness
◦ Can be shallow or deep
◦ Subcutaneous tissue
◦ Fascia, Muscle
Factors affecting wound healing
Perfusion/oxygenation
 Nutritional status!!!!
 Infection
 Corticosteroids/medications
 Aging
 Nicotine!!! Smoking
 Denervation
 Obesity
 Diabetes!!!!
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Most of all – patient’s cooperation
Skin Assessment
Color
 Texture
 Temperature
 Turgor
 Odor
 Sensations
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Wound Assessment
Location – anatomic landmarks
2. Size including
1.
a. Undermining
b. Tunneling/sinus track
Wound bed appearance
4. Exudate
3.
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Amount & characteristics
Odor
6. Pain
7. Peri wound skin
5.
Infection? – Yes or No?
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Contamination
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Colonization
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Critical Colonization
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Infection
◦ Local vs systemic
◦ Elevated Glucose in diabetics
◦ Pain in neuropathic extremity
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 270-273
Skin Products
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Antimicrobial
Emollient
Humectant
Preservative
Skin protectant
Surfactant
Dimethicone
 Petrolatum
 Zinc Oxide
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◦ <25% = creamy
◦ >25% = pasty
Dressing Selection – 1st Basic Rule
Dry shallow/superficial
wound
= Need to ADD moisture
Wet shallow/superficial
wound
= Need to wick/absorb moisture
***Peri wound skin: Protective
barrier film***
Dry deep/cavity wound
= Need to ADD moisture
= Need a Filler in order to pack
undermining/tunneling areas
= Need a Cover dressing
Wet deep/cavity wound
= Need to wick/absorb moisture
= Need a Filler to pack
undermining/tunneling areas
= Need a Cover dressing
***Peri wound skin: Protective
barrier film***
Then Dressing Selection
Goes on based on:
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Does the wound need to be debrided?
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Mechanical, enzymatic, autolytic
Is there an infection present?
Does the wound bed remain moist or is it
drying up?
Do the wound edges need to be opened?
Is the wound bed being protected from injury,
trauma etc.?
Is the wound being insulated?
“A dry cell is a dead cell”
Products
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Terms:
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Primary dressing
Secondary dressing
Filler
MVTR – Moisture-Vapor Transmission Rate
Epidermal stripping
Products - Antimicrobial
Antiseptics, iodine, honey, hydrofera blue, mupirocin ointment,
silver
 Indications:
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◦ Partial or full thickness wounds
◦ Critical colonization, infection
◦ Odorous wound
Primary or secondary dressing
 Advantages:
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◦ Provides broad range of antimicrobial or antibacterial activity
◦ Reduces infection
◦ Prevents infection
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Disadvantages:
◦ Silver - May cause staining
◦ May cause stinging or sensitization
◦ Nanocrystalline Silver – inactivated by saline
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292
Products – Calcium alginate
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Called usually ‘alginate’
Polysaccharide derived from brown seaweed
Partial or full thickness wounds
Primary dressing/filler
◦ Usually needs a secondary/cover dressing
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Highly absorbent – moderate to heavily
draining wounds
Converts to a viscous/hydrophilic gel
Hemostatic properties
Change as needed – usually every 24-48 hours
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292
Products - Charcoal
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Activated carbon
◦ Absorbs toxins and wound degradation products
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Indications:
◦ Malodorous wounds
◦ Fecal fistulas
Apply as a ‘filter’ for odor control
 If absorbing drainage, need to change when
saturated
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Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292
Products – Collagen
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Enhances deposition of collagen fibers
Chemoattractant to granulocytes & fibroblasts
Bioresorbable
Hemostatic properties
Processed from bovine or porcine sources
Indications:
◦ Full-thickness wounds with or without depths
◦ Noninfected wounds
◦ Minimal to moderate amount of drainage
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Apply to wound base
◦ Requires a secondary/cover dressing
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Packaged as gels, alginates, sheets, powders
Contraindicated in bovine sensitivites
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292
Products - Composite
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Combine distinct dressing components into a
single dressing
◦ Absorptive part is different than alginate, foam,
hydrocolloid, hydrogel
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Bacterial barrier
Partial or full thickness wounds without depth
Dry to heavy drainage – depending on
dressing components
Primary or secondary dressing
Can be used with topical medications
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products – Contact layer
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Protects the wound from direct contact with
other agents/dressings
Conforms to wound shape
Porous
Indications:
◦ Partial or full thickness wounds with or without
depth
◦ Infected wounds
◦ Donor sites
◦ Split-thickness skin grafts
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Not intended to be changed with every
dressing change
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293
Products – Fiber gelling
Hydrofiber
 Moderate to heavy drainage
 Converts to gel - “snot”-like appearance
 Partial or full thickness wounds
 Usually needs a secondary dressing
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Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293
Products - Foam
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Absorptive and non-adherent
Indications:
◦ Partial or full thickness wounds with or without
depth
◦ Moderate to heavily drainage
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Contraindicated with dry eschar
Frequently used as a secondary dressing after
medication and/or primary dressing
If used as primary dressing, apply appropriate
secondary dressing
Change every 24 hours or as needed
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293
Products - Hydrocolloid
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Contains gel-forming agents
◦ Forms a gelatinous mass
Impermeable to contaminants = reducing risk of infection
 Promotes autolysis
 Indications:
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◦ Partial or full thickness wound with or without depth
◦ Minimal to moderate drainage
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Avoid acutely infected wounds and dry eschar
Use cautiously in diabetics
Low MVTR
Change every 3-5 days as needed
Select dressing 1-2” larger than the wound
Use light pressure of hands to allow body heat promote adhesion
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 294
Products - Hydrogel
Adds moisture to dry wound bed
 Non-adherent
 Little or no absorption
 Cool & soothing
 Various formulations:
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◦ Gel, sheets, impregnated gauze, with silver
Apply according to instructions
 Use appropriate secondary dressing
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Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293
Products – Transparent film
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Indications:
◦ Shallow partial thickness
◦ Dry to minimal drainage = nonabsorbent
 Low MVTR
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Can promote autolysis
Creates “second” skin
Apply without tension/stretching
Allow for 1-2” border around wound
Use skin sealant around wound edges
Not for infected wounds
Change every 4-7 days or as needed
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products – Medications
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Collagenase/=Santyl
◦ Enzymatic debrider
 Collagenase derived by fermentation of Clostridium histolyticum
◦ Need physician order
◦ Need some ‘contact’ with moist wound bed
 Around edges or cross-hatching by physician
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‘Xenaderm’ = BCT
◦ Balsam Peru
◦ Castor oil
 Improve epithelialization
 Protective covering
 Aids in reduction of pain
◦ Trypsin – mild debrider
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Dakin’s solution
◦ 1/16 strength – odor control
◦ 1/25 strength – pseudomonas infection
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Metronidazole/Flagyl
◦ Crushed - odor control
Thomas Hess, C. Clinical Guide to Skin and Wound care. 2013, 7th Edition, p 557-559
Peri wound protection
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Prevent epidermal stripping
◦ Avoid tapes if possible
◦ Roll gauze, tubular stockinette, Montgomery straps
◦ Skin sealants
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Maceration
◦ Skin sealants
◦ Zinc oxide
◦ Re-evaluate current dressing and/or frequency
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Infection
◦ Candidiasis
 Crusting technique with antifungal powder
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301
Special Consideration:
Palliative Wound Care
S = Stabilize the wound
 P = Prevent new wounds
 E = Eliminate odor
 C = Control pain
 I = Infection prophylaxis
 A = Advanced absorbent wound
dressings
 L = Lessen dressing changes
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Haas. M.L., Moore-Higgs, G.J. Principles of Skin Care and the Oncology Patient.2010. p 105.
Documentation
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Today – EMR/Electronic Medical Record
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Order
Assessment
Actual dressing change
Teaching
Must meet certain criteria for reimbursement
Accurate and consistent
◦ Monitoring
◦ Legal
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301
Presentwoc.com
Worldwidewounds.com
References
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Bryant, R., Nix, D. Acute and Chronic Wounds.
Current Management Concepts. 4th Edition. 2012.
Hass, M.L., Moore-Higgs, G.J. 2010. Principles of Skin
Care and the Oncology Patient, p 105,
Milne, C.T., Corbett, L.Q., Dubuc, D.L., Wound,
Ostomy, and Continence Nursing Secrets,
Questions and Answers Reveal the Secrets to
Successful WOC Care. 2003
Thomas Hess, C. Clinical Guide to Skin and Wound
care. 7th Edition. 2013.
Wound Care: An Incredibly Visual! Pocket Guide.
2009. Wound healing, p 21.
Questions?