Transcript WOUNDS

PRESSURE ULCERS AND
WOUNDS
By Monica Warhaftig, D.O.
Assistant Professor of Geriatrics
N.S.U.
Chronic Wounds
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Greater than 12 hours
Debridement
Cleansing
Dressing
Pressure redistribution
Multidisciplinary care
GOALS
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Types of wounds
Risk factors and Risk Scales
Local/Systemic Factors
Wound Care Healing
Wound care products
Types of Wounds
Location, Location, Location
• Pressure: sacrum, heels, trochanter
• Venous: Inside the leg -Medial
• Arterial- Lateral
• Diabetic: neuropathic areas
• Traumatic: anywhere
RISK ASSESSMENT:
Low score=high risk (16 or 12)
•The Norton Scale
*The Braden Scale
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*Extrinsic Factors
• Pressure Relief : proper patient positioning;
pressure devices: pressure greater that 32 mm
hg (ischial tubes 300) (sacrum up to 300)
• Special Beds: static and dynamic
• Friction : rubbing of a body part against
another or a surface..damage to stratum
corneum..ex patient pulled across a bed
• Shear Stress: head of bed elevated greater that
30 degrees..patient slides down(opp directions)
• Moisture: weakens the skin
*Stages of Wound Healing
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Inflammation- (approx. 2-3 days)
consists of a vascular and a cellular response
acute and chronic inflammation (neutrophils, cytokines, oxygen,
platelets rush to the site)
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Proliferation – (approx. 2-3 weeks)
Begins at the time of injury
Rebuilding begins with scaffolding of the skin
Revascularization of the wound begins
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Maturation Stage- (Approx 2-3 years)
Depositing of scar tissue
The body attempts to contract or close the wound
(Wounds are only ever 80% healed)
Systemic Factors that affect
Wound Healing
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Nutritional Status
Vascular Status
Metabolic Factors
Immunological Factors
Age
Medications (Steroids, etc)
Genetic
The Local Factors
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Necrotic tissue and foreign bodies
Drying of a wound
Microorganisms
Trauma (pressure, shearing, friction)
Fibrin
Oxygen
Edema
Intrinsic (Patient Status)
• Diabetes
• Anemia: decreases O2 to the wound
• Nutritional State (Serum chemistries, Albumin,
Prealbumin)
• Weight Loss (oxandrelone)
• Coagulopathic state
• Multiple comorbidities
• Incontinence;foley
• Immobility:turning q2 hours
What is a Pressure Ulcer ?
• Any lesion caused by unrelieved pressure
usually over a bony prominence that results
in damage to underlying tissue
Pressure ulcer stages
• Stage 1: epidermis; nonblanching
erythema
• Stage 2: epidermis/dermis; shallow
opening;blisters
• Stage 3: Subcutaneous tissue/fascia
• Stage 4: fascia + bone, tendon, muscle,
cartilage
Stage 1
• Intact Skin with nonblanchable erythema
(extravasation of blood from ischemic leaky
blood vessels) (up to 30 minutes)
Blanchable – means congested vessels…vanishes
shortly after pressure relief
Cone Shaped…apex to the skin (no indic of below)
Muscle & Ischemia– high metabolic rate less blood
supply ..More susceptible
Pressure Ulcer Staging
Stage I
Pressure Ulcer Staging
Stage I
Dark Skin
Pressure Ulcer Staging
Stage II
• Stage 2: Partial thickness skin loss
involving epidermis, dermis, or both. The
ulcer is superficial and presents clinically
as an abrasion, blister, or shallow crater.
Pressure Ulcer Staging
Stage II
Pressure Ulcer Staging
Stage II
Pressure Ulcer Staging
Stage II
Pressure Ulcer Staging
Stage II
Pressure Ulcer Staging
Stage III
Full thickness skin loss
involving damage to, or
necrosis of, subcutaneous
tissue that may extend down
to, but not through,
underlying fascia. The ulcer
presents clinically as a deep
crater with or without
undermining of adjacent
tissue.
Pressure Ulcer Staging
Stage III
Pressure Ulcer Staging
Stage III
Pressure Ulcer Staging
Full thickness skin loss
with extensive
destruction, tissue
necrosis, or damage to
muscle, bone, or
supporting structures
(e.g., tendon, joint,
capsule). Undermining
and sinus tracts also may
be associated with Stage
IV pressure ulcers
Stage IV
Stage IV
Stage IV
Pressure Ulcer Staging
Stage IV
Pressure Ulcer Staging
Stage IV
Venous Ulcers
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Due to venous insufficiency
Medial Aspect of the leg
Beefy Red
Jagged
Painless
Treat with compression
Venous Ulcer
Diabetic Ulcer
Venous Ulcers
Arterial Wounds
Complete or partial arterial
blockage may lead to tissue necrosis
and / or ulceration.
Signs on the extremity:
• Pulselessness of the extremity
• Painful ulceration
• Small, punctate ulcers that are usually well
circumscribed
• Cool or Cold skin
• Delayed capillary return time (briefly push on the end of
the toe and release, normal color should return to the toe
in 3 seconds or less)
Arterial Disease
• Atrophic appearing skin (shiny, thin, dry)
• Loss of digital and pedal hair
• Can occur anywhere, but is frequently seen on
the dorsum (top) of the foot.
• Utilize noninvasive vascular tests:
• Doppler, waveform, Ankle Brachial Indices
(ABI) and Transcutaneous Oxygen Pressure
measurements (TCPO2) to aid in your
diagnosis. Duplex scanning and arteriograms
may also be performed if indicated.
Arterial Disease
Ankle brachial index (ABI) : arterial blood
flow in the lower extremities determines
level of ischemia:
Normal >1.0; LEAD = 0.9;
Borderline is <0.60-0.8;
Severe is <0.5. (The ABI can be falsely
elevated in people with diabetes.(calcified
noncompressible vessels)
• Recheck the ABI periodically
• Toe pressure (TP) in patients with diabetes
in whom LEAD is suspected. Toe pressure
<30 indicates LEAD.
Arterial Ulcers
Slowing factors
• Temperature ; cold or open
• Necrotic tissue
• Exudate (too much vs dry wound)
Infection
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Contamination
Colonization
Critical Colonization
Infection
*Signs of Infection
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Delayed Healing
Change in Exudate
Change in Pain
Change in Granulation Tissue
Change in Smell
Change in Size
Fever
Leukocytosis
Types of debridement
• Autolytic – (Occlusive Dressings) the body
heals itself
• Mechanical – using gauzes
• Enzymatic – chemical enzymes
(Collagenase, Papain, )
• Sharps – scalpel, laser, surgery
• Biosurgical – maggots, leeches
Topical Dressings
• Occlusive Dressings
• Divided into polymer films, polymer foams,
hydrogels, hydrocolloids, alginates, and
biomembranes.
• Dressings left in place until fluid leaks from
the sides (3 days to 3 weeks)
Products
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Primary/secondary type of dressing
Hydrophyllic
Hydrogel
Alginate
Foam
Accuzyme
panafil
Transparent Film
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Autolytic debridement
Primary or secondary dressing
Partial thickness wounds
*Stage I or II pressure ulcers
Superficial burns
Hydrocolloids (Autolytic)
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Primary or secondary dressing
*Partial and full thickness wounds
Pressure ulcers
*Necrotic wounds
Granular wounds preventative dressing
Used as a secondary dressing or under
compression
Hydrogels
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Stage 2 to stage 4 pressure ulcers
Partial and full thickness
*Painful wounds
Skin tears
Minor burns
*Necrotic wounds
Collagens
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*Infected Wounds
Tunneling Wounds
Surgical Wounds
Can be used with other topical agents
*Not for necrotic wounds
Negative Pressure Therapy
• VAC Device
• For Nonhealing wounds and fecal
incontinence
• Removes Interstitial Fluid from the
wound
Antimicrobial Dressings
• Infected Wounds
• Controls bacteria bioburden
• Effective against a broadspectrum of
microorganisms
• IODOSORB
• AQUACEL
• IODOFLEX
Saline –soaked Gauze Dressings
• Saline soaked and not allowed to dry
• Similar to occlusive dressings
• However, Time intensive for nursing
• *Used for Partial and full thickness wounds
• Draining wounds
• Wounds requiring debridement packing,
Or management of tunnels, tracts or dead space
• Surgical incisions/Burns/pressure ulcers
Calcium Alginate
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Highly absorptive- brown seaweed
*exudative wounds.
Alginates do not adhere to a wound
Can damage epithelial tissue if the wound
dries
FOAM
• Nonocclusive absorptive wound dressing
• Partial and full thickness
wounds…minimal to heavy drainage
• Stage II to IV press. Ulcers
• *Infected and non-infected
*Compression Therapy
• Venous Ulcers
• Used to manage edema and promote the
return of venous blood to the heart
• Use cautiously with arterial ulcers
Advanced Wound Care Products
• Platelet Derived Growth Factors
• OTHERS
*Healing Factors – The Push Scale
• Wounds heal by contraction and scar
formation (Can’t reverse stage)
• Push Scale
• Measures:
Size: greatest length (head to toe) and the
greatest width (side to side) using a centimeter
Exudate: none, light, moderate, heavy
Tissue Type: 4-any necrotic tissue; 3-any amount
of slough…no necrotic tissue; 2-clean wound
with granulation tissue; 1-wound closed
Tissue Types
• Slough-yellow or white..strings or thick clumps
• Granulation tissue-pink or beefy red tissue ,shiny, moist,
granular appearance
• Epithelial tissue: new pink or shiny tissue
grows in from the edges
• Necrotic Tissue (eschar) : Black, brown, or tan firmly
adheres to the wound bed
• Closed/resurfaced-wound completely covered
What stage is it?
What Stage ?
What type of wound ?
What type of wound ?
Review
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Picture
Stage of pressure ulcer/type of wound
Intrinsic/Extrinsic factors
Scoring for assessment
Factors in healing scales
Factors in Infection
SKIN TEARS