7/12/2012 1 Disclaimer…………….

7/12/2012
Wound Care Dollar$ and Sense…….
A common sense approach to creating Policies
and Formularies to make the most of your
Wound Care Budget AND provide great clinical
outcomes!
Presented By Vivienne Campbell, LVN, DSD, WCC
Regional Clinical Solutions Specialist, Joerns Healthcare LLC
To The CAHF Summer Institute
July 24, 2012
La Costa Resort and Spa
At the Conclusion of this Presentation you will be able
to…..
•Discuss the high cost of caring for wounds and understand that an ounce
of prevention is worth a TON of cure!
•Understand the basic principles of Moist Wound Healing
•Identify and correctly stage pressure ulcers, and differentiate between
pressure and non-pressure related skin conditions
•Select an appropriate treatment for any wound based on type, anatomical
location and amount of drainage
•Determine when NPWT can actually save you money by speeding up the
healing process
•Create a comprehensive and cost effective formulary of products for your
facilities wound care program
Disclaimer…………….
The images of various wound care products shown in
this presentation do not represent any endorsement or
recommendation by Joerns Healthcare, LLC or the
presenter and are included only as examples of the
many types of products available.
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The High Cost of Healing…………..
•A 1999 study showed the cost to the US Healthcare system for
treating pressure ulcers was approximately $6 Billion
•The cost to treat ONE pressure ulcer was between $2,000 and $40,000
depending on severity
•A more current study published in the Permanente Journal (Summer
2010) cited annual costs at over $11 Billion with costs to treat one full
thickness ulcer(stage III or IV) reaching as high as $129,248.00!
•These figures do not take into account the delays in rehabilitation,
extra hospital time and other associated expenses of treating these
conditions
The High Cost of Healing……………
•Lawsuits- Since many
jurisdictions see Pressure Ulcers
as evidence of abuse/neglect,
these cases are not subject to
caps associated with other
malpractice suits. Awards of
over $10 Million are not
uncommon.
•Even if you are able to defend
against a suit, the costs of
defense, time away from the
facility and poor publicity for
your facility carry a high cost as
well.
The high cost of healing……the human side
•. Pressure Ulcers, and their complications, kill more than 60,000
individuals every year in the United States alone!
•Delay in completing rehabilitation costs Millions in extra hospital days.
•Residents with pressure ulcers often must spend much of their time in
bed. This can lead to social isolation and depression.
•Pain, alteration of body image and possibility of infection and just a few
of the personal costs to the patient suffering form pressure ulcers
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With statistics like that, it is easy to see the
most important part of any Skin Care Policy
is……………….
****************************
************
PREVENTION
****************************
************
Essentials of Pressure Ulcer Prevention………….
•Individualized Assessment of Risk
•Admission and ongoing skin Assessment
•Pressure Redistribution/Reduction
•Nutritional Assessment and Intervention
•Individualized Interventions
Individualized Risk Assessment should address……..
•Immobility/Decreased Mobility
•Poor Nutrition/Hydration
•Unplanned Weight Loss/Weight significantly above or below IBW
•Low Lab Values- Hgb/Hct/Albumen/Prealbumen
•Moisture-due to incontinence, diaphoresis or heavy wound drainage
•Advanced Age-Causes an decrease in Sebum production, thinning of the
subcutaneous cells and breakdown of the collagen matrix
•Sensory Deficits-Due to neuropathy, parasthesias, SCI, Alzheimer's
•Fever/Change of Condition
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More Risk Factors to Consider
•Non-compliance with personal care, hygiene and/or medical
treatment
•Contractures
•Medications- Anticoagulants, Narcotic analgesia,
Corticosteroids, some psychotropics
•Previous history of pressure ulcers
•Underlying disease process- Diabetes, CVA, Cardiac Disease,
Respiratory disease, Renal disease, Cancer, neuro muscular
disorders, Adult Failure to Thrive
•End of Life (Hospice) Patients
•Use of splints, orthotic devices or restraints
Interventions for Prevention……Immobility
•Turn at least q2 Hrs and more often as individual needs may dictate.
•Reposition chair bound residents even more frequently…..every 60-90
minutes. If capable, instruct resident in pressure relieving exercises.
•Use pillows, foam cushions, wedges to support extremities and to aid in
positioning and padding against skin to skin contact.
•Active and Passive ROM to keep joints moving and circulation flowing
•Offload pressure from heels by “free floating”
And……Let’s not forget……
SUPPORT SURFACES!!!!!!
Pressure Redistributing Support Surfaces
There are many types of therapeutic support surfaces available to the
health care provider today. A pressure reducing mattress can make a
big difference in a residents skin integrity as well as comfort.
These mattress replacements basically work in one of three ways:
•Pressure redistribution through
increased surface contact points
•Immersion-sinking into the
surface of the mattress
•Envelopment-the surface
literally wraps around the
resident
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Friction and Shearing, Forces to be reckoned with!
Since pressure ulcers can be caused by Pressure (force
against the tissue perpendicular to the surface), Shearing
(Force parallel to the tissue) or Friction (resistance to
motion in a parallel direction) a good support surface should
provide mitigation for all these issues
Whenever handling residents, staff should be careful not to
drag across surfaces. Use the buddy system to lift, move
and place the resident in a new position
Use pillow, foam wedges, pommel cushions, etc, to decrease
the risk of shearing injury
Interventions for Malnutrition and Dehydration
•Since poor appetite is often due to oral hygiene
and dental issues make sure that residents
receive good oral care in the morning and after
meals.
•If dentures poorly fitted or dental caries is
present, get a dental referral
•Make sure the right consistency of food is
being served to accommodate the residents
dentation and swallowing issues
•Consider cultural and ethnic
preferences and enlist help of
family and friends in providing
favorite foods
• Persons with Alzheimer’s and
other dementias sometimes
forget to drink. Offer fluids
frequently throughout the
day.
Incontinence Management
•Keep resident clean and dry. Check for incontinence
frequently, and WASH AND DRY the area thoroughly with each
incontinence episode.
•Use moisture barrier ointments EVERY TIME
•Bowel and Bladder training as appropriate
•Frequent toileting
•Encourage adequate fluid intake
•Encourage a diet rich in nutrients and fiber to maintain bowel
regularity
•Foley Catheters/Rectal tubes as a last resort for severe cases
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Over Weight, Under Weight and Unplanned
Weight Changes
•Consult with the facility Registered Dietician for
guidance on Protein Supplements, Vitamin and Minerals.
•Consider the elevated hygiene needs of the morbidly
obese resident and make sure to bathe well with special
attention to washing and drying the skin folds thoroughly.
•Over weight individuals may require wider beds than
the traditional hospital bed in order to have room to
maintain good bed mobility. Even if not a “bariatric”
resident, consider a wider bed to promote mobility and
better skin integrity
•Pad areas where bony prominences are evident and pad
where skin to skin contact is a risk
Issues of resident Non- Compliance
•Residents have the right to refuse treatment, but only if they are
informed of the risks vs. benefits of their choices
•Provide the appropriate education needed and document. This needs
to be an ongoing process
•Offer residents choices that will result in desired behavior. For
instance, instead of saying “would you like to go take a shower?” ask “
would you prefer your shower now, or after lunch?” This allows the
resident a feeling of control over his care while still accomplishing the
necessary task.
•If the resident is alert enough to understand, try making a contract
for care and get them to sign.
•DOCUMENT, DOCUMENT, DOCUMENT!!!!!
Formulary Ideas For Preventing Pressure Ulcers
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Every Formulary For Prevention Should Include…
•A good quality Barrier cream/ointment- Examples include(but not
limited to) Calmoseptine, Lantiseptic, Baza, Critic-Aid Clear, Aloe Vesta.
Brand and price not nearly as important as consistent use!
•A gentle, effective skin cleanser- Mild soap and water are fine, but
require using linens and may not always be the most cost effective.
Consider packaged wipes and sprays that are easy to use, gentle and
effective for cleansing without irritating the skin. Aloe Vesta, Cavilon,
Carra Foam are just a few examples.
•An Arsenal of effective cushions and devices to prevent frictions and
shear, offload pressure, cushion against skin to skin contact and assist
with proper body alignment. Wheel Chair cushions, Geri Sleeves, Foam
Bolsters, Pommel Cushions and devices for off loading heel pressure.
So, you did all you could to
PREVENT a problem but your
resident still has an issue!
NOW WHAT?????????????
DON’T PANIC! Identify, Assess, and Treat!
Identify- Is it a pressure ulcer or a non-pressure related skin
condition? If a pressure ulcer, what stage?
Assess- Is there non-viable(necrotic) tissue in the wound bed?
Is the skin broken or intact? Is there exudate(drainage)or is
the wound bed dry? Where on the residents body is the wound
located? Once you have addressed these questions, you can
more easily determine how to
Treat- Choose the appropriate treatment based on the area
of the body the wound is located, the amount of drainage
present, the presence of necrotic tissue and any resident
specific issues. The goal of treatment for almost all wounds is
to provide an environment for
Moist Wound Healing
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What is Moist Wound Healing??????
Recent research has shown that wounds re-epithelialize twice as
fast in a moist environment than a dry one. Epithelium more readily
migrates over a moist wound surface than a dry one, and scarring is
less pronounced. Dry, scabbed wounds actually decrease the supply
of blood and nutrients to the wound bed further slowing healing. Pain
is also decreased in a moist environment.
Moist wound healing can be achieved with the use of Advanced
wound dressings, occlusive or semi occlusive dressings(such as
hydrocolloids or transparent film dressings) or by adding moisture to
dry wounds
The goal is to keep the wound bed moist while preventing maceration
of the peri wound tissues from too much moisture.
There are some wounds that are not appropriate for Moist
Wound Healing. These include areas of stable, dry, intact
eschar on the extremities
Wound Identification 101………………..
What is a Pressure Ulcer????
Pressure ulcers result when pressure is applied with great force over
a short period of time or less force over a longer period of time,
depriving tissues of oxygen and nutrients
Most pressure ulcers form over bony prominences, where combined
pressure, friction and shearing forces result in skin breakdown
Unlike other types of ulcerations, which have a disease process
associated with their development, pressure ulcers have heightened
requirements around Risk Assessment, proactive and appropriate
care giver interventions, assessment and response to interventions
and medical record management
Most, but not all pressure ulcers are avoidable with proper nursing
care and appropriate interventions. Pressure ulcers are the only
wounds that are staged, and staging is dictated by the type of tissue
damage within the wound bed.
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Stage I Pressure Ulcer………
A partial thickness insult to skin
integrity, a Stage I is the heralding
lesion of a pressure ulcer. Defined as
a persistent area of non-blanchable
redness or discoloration where the
skin remains intact, a stage one may
be difficult to visually assess in
darker pigmented individuals.
In dark skinned patients, may present
as an area of dusky or ashen
discoloration. More often identified
by tactile exam, feeling for
differences in the temperature,
texture and turgor of the skin as
compared to surrounding tissues
Stage II Pressure Ulcer……………..
A stage II Pressure Ulcer is a partial
thickness wound that generally presents as a
shallow crater, abrasion or serum filled
blister. The damage extends through the
epidermis and dermis but does not extend
into the underlying subcutaneous tissue
In the past, any fluid filled blister was
considered to be a stage II if located over a
bony prominence. New guidelines from the
National Pressure Ulcer Advisory panel now
state that a blood filled blister is to be
classed as a sDTI and staged as UTD, since
one cannot visually inspect the base of the
wound due to the presence of blood in the
blister
Stage III Pressure Ulcer…………..
A Stage III Pressure ulcer is a
full-thickness (beyond the
dermal layer) wound that goes
beyond the dermis through
subcutaneous tissues as far as,
but not through muscle fascia.
Undermining and tunneling may
be present, but no muscle
tissue, bone or other underlying
structures are exposed.
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Stage IV Pressure Ulcer……………
Stage IV Pressure ulcer is a
full thickness wound that
extends through the fascia into
muscle tissue, bone, joint,
capsules, tendon, even internal
organs. Frequently, tunneling
and undermining are present.
Unable to Determine Stage (UTD)
Since pressure ulcer staging is strictly
predicated by the type of tissue
damage within the wound bed, if there
is non- viable tissue within the wound
that occludes the visualization of the
extent of tissue damage, we are unable
to correctly stage the ulcer. In these
cases the stage is indicated as UTD.
New with MDS 3.0, staging of UTD is
also used for sDTI and wounds that
cannot be visually assessed due to the
presence of non-removable dressings,
casts, splints or other devices
Suspected Deep Tissue Injury (sDTI)
A dark red, purple or maroon area
of discoloration of intact skin, or
a blood blister. There may also
be a mushy, boggy or indurated
quality to the tissue, and the
resident may complain of pain at
the site
sDTI should be well documented
with an accompanying anecdotal
note describing in detail what the
nurse is observing to substantiate
the designation of sDTI
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Non-Pressure Skin Conditions………………
Arterial Ulcers-Caused by inadequate circulation,
these conditions can be resolved only when the
underlying cause is corrected.
Diabetic Neuropathic Ulcers- Must have dx of
Diabetes and Peripheral neuropathy. Caused by
unstable blood glucose levels, foot deformities
and insensate foot
Severe Incontinent Dermatitis- Prolonged
exposure to urine and/or feces, resulting in
chemical burn and denuding of skin
More Non-Pressure…………
Kennedy Terminal Ulcer-As a patient nears the end
of life, organ systems begin to fail. As the largest
organ of the human body, the skin will often start to
deteriorate even with the best of care. This
phenomenon has also been noted to occur on the
posterior calves, Achilles area and heels
Venous Stasis Ulcers-Non-functioning, incompetent
valves in the lower extremities result in severe
edema. Ulcers develop due to fluid trying to escape.
Treatment requires controlling the underlying cause
(edema)
Dehisced Surgical Wound- The normal postoperative healing is interrupted by a separation of
the wound edges, often due to swelling or
underlying infection, as well as issues with the
patients underlying condition.
Pressure or non-pressure, Most wounds can
be treated using the same guidelines for
treatment…..
Rule #1- If it’s “dirty”, clean it up!- A wound will not heal if it
is full of non-viable tissue. Debridement of the necrotic matter
must be removed before healing can commence.
Exception to this-Dry, Stable, Intact Eschar on the extremities
should NOT be debrided except if there is evidence of infection
or the wound is otherwise impeding the patients recovery
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Rule #2-If it’s too wet, absorb the drainage to
create a MOIST wound healing environment
A wound that is too wet will develop Peri-wound maceration and will
not heal properly. Choose a dressing or a system that will help
absorb the excess while maintaining a moist wound bed
Rule #3-If it’s too dry, add some moisture!
A dry wound is more painful, slower to heal and can
develop necrotic tissue more easily than a moist wound.
Use a product that will add moisture to the wound.
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Rule #4-If the wound bed is moist, maintain
the moisture!
A moist wound is a happy wound, so seal in moisture to
promote the best healing!
Rule # 5………Control the bacteria load
All wounds carry some degree of bacteria. The mere presence of
surface bacteria is NOT necessarily indicative of infection.
One symptom is not enough to presume infection is present. Before
getting a wound culture, the wound should show at least three
signs/symptoms of infection
When infection is suspected, definitive diagnosis is reached by a
tissue biopsy, not a swab culture. If swab is the only option, use the
Levine Technique, swabbing 1cubic cm CLEAN wound bed with enough
pressure to obtain wound fluid
When diagnosis of infection is confirmed, avoid using antiseptics with
cytotoxic qualities(Dakins, Povidone Iodine,H202, acetic acid)
Cadexomer Iodine(Iodasorb) or any of the many silver products on the
market are very effective against a broad range of microorganisms
without the cytotoxic effects.
Other Factors to consider when selecting a
wound treatment………..
Primary Goal of Treatment- Based on the assessment of the wound and
the goal for treatment. Drainage control/containment, odor mitigation, pain
control, prevent/treat infection, covering a wound for cosmetic reasons or
infection control, debridement are but some of the issues to be considered
Wound Related issues-Location of wound on the body, type of wound, bio
burden, depth of wound will influence dressing choices
Patient Related factors-Activity level, continence, mentation, allergies to
medications/materials, compliance with care and treatment
Cost- Consider reimbursement issues, cost per day for treatment. Keep in
mind that nursing time is money! Less frequent dressing changes actually
speed healing and use less valuable staff time. A very low cost product
that does not stay in place suddenly becomes very expensive!
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Creating a Comprehensive Wound Formulary
A well stocked treatment cart should include……
•Hydrogel
•Calcium Alginate
•Foam Dressing
•Hydrocolloid
•Composite Cover Dressing
•Steri Strips
•Latex Free Gloves
•Transparent Film Dressing
•Non-Sterile Gauze
•Wound Cleanser or Normal
Saline
•Medical Tape
•Skin Prep
•Barrier Cream/Ointment
Having these items available will make it simple to treat the greater
majority of the wounds you encounter. Additional pharmaceuticals
and more advanced dressings can be added on a case by case basis.
Wound Gel……………….
Wound gels are generally 90%water in an amorphous gel
base. They are effective for adding moisture to a dry
wound bed, and can be used to help soften necrotic tissue
so it can be more easily removed from the wound bed.
Examples of wound gel include Suresite, Curasol,
Woun’dress, Intrasite gel. Other types of wound
gel….Silversorb Gel(contains silver), Medihoney(Medical
grade Honey)
Calcium Alginate and Hydrofiber Dressings
Calcium Alginate dressings are made of calcium
and sodium derived from seaweed. Very
absorbent, it wicks exudate from the wound
bed while maintaining a moist healing
environment. They come in sheet and ribbon
form. Examples :Sorbsan, Kaltostat, Curasorb,
Algicell
Hydrofiber Dressings are similar
to alginates in their absorptive
qualities, but are made of
Hydrocolloid Fibers. Aquacel and
Aquacel Ag are Hydrofiber
dressings
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Foam Dressings………….
Made from various types of polyurethane foam,
these dressings are both absorbent and provide a
bit of soft padding over the wound. Available in a
variety of shapes and sizes, with or without selfadhesive backings.
The polyurethane foam absorbs moderate to large
amounts of exudate while holding moisture on the
wound bed
Hydrocolloids…………..
These wafer-type dressings are self adhesive, flexible and water
resistant. Containing gel forming agents such as
Carboxymethylcellulose and Gelatin, they absorb small to moderate
amounts of drainage and provide for a moist wound bed. Generally
considered to be occlusive, they become semi-permeable to water
vapor as drainage is absorbed.
Available in many
sizes and shapes, as
well as in paste form,
hydrocolloids can be
used to assist in
autolytic debridment
as well as on
modrately draining
wounds
Composite Cover Dressings………
Many different types of composite
dressings available, a good cover dressing
will be waterproof, flexible, absorbent
and self adhering.
Coversite,
stratsorb and even
Band Aids are
examples of
composite dressings
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Transparent Film Dressings……………
These clear dressings are used as a primary
dressing for superficial, lightly draining
wounds, as well as a securement method over a
cover dressing. They are also useful for
protecting intact skin from forces of friction.
Transparent dressings provide a moist healing
environment and are gas permeable, allowing
the escape of water vapor.
Consider the delivery system when choosing
this type of dressing for ease of application.
If using on intact skin to protect from friction,
be sure the order indicates to change only when it
becomes displaced to avoid pulling off fragile skin
with dressing. Opsite, Tegaderm are examples of
Transparent film dressings.
Wound Cleansers or Normal Saline…..
It is a matter of choice. Normal
saline provides a great cleansing
agent at a very cost effective price.
Commercially prepared wound
cleansing products have a surfactant
to help loosen soil and can provide
antibacterial and odor controlling
properties as well. Some is packaged
so that the spray provides the
correct PSI to help break up slough
so it is easily washed from the wound.
Be careful that there are no
cytotoxic ingredients if you choose a
commercially prepared cleanser.
Anti-microbials…………………
Avoid use of cytotoxic agents, especially for use in packing wounds.
If necessary to decrease surface bio burden, use of Dakins or
Acetic Acid to irrigate is acceptable if rinsed with NS after
irrigation.
Silver dressings are broad spectrum anti-microbials with low
incidence of sensitivity in most patients. Do not use with Santyl
(Collangenese enzymatic debrider), silver renders the collangenese
ineffective.
Cadexomer Iodine is safe to use in most wounds and has low side
effects. Check for patient history of Idodine sensitivity before use
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Other Treatment Cart Essentials……….
Non-Sterile Gauze-Sponges for cleaning as for use
as secondary dressing, rolled gauze for wrapping
extremity wounds.
Medical Tape-Many types available, be
sure to select one that is latex free and
hypoallergenic
Steri Strips- Ideal for use on skin tears where
the skin edges can be approximated, as well as
used to provide skin closure for surgical wounds
Last but not least……………
Skin Prep-available in wipes and spray form, creates a
protective barrier on the skin to prevent irritation and
damage from tape and adhesive dressings. Also useful
on intact blisters and boggy heels to toughen and
protect the skin.
Barrier Cream-an important part of your prevention
arsenal, barrier cream can be used around the wound
margin to protect from maceration due to excessive
drainage
Non-Latex Gloves-With so many people suffering
from Latex allergies, it just makes sense, both for
patient safety and staff safety!
Negative Pressure Wound Therapy…................
A powerful and (believe it or not!) cost effective addition to your
wound care arsenal!
Negative Pressure wound therapy is the application of negative
atmospheric pressure to a wound bed. A filler, either sponge or gauze, is
placed in the wound bed, then sealed with a transparent film and pressure
is applied using drain attached to a special vaccum pump. It helps to
manage large amounts of drainage while promoting moist wound healing,
decreases bacterial load and edema, increases capillary blood flow to the
wound and provides mechanical pull on a cellular level to hasten granulation
and wound contraction.
Generally considered to be a more
expensive treatment modality, NPWT can
actually save money when one factors in
faster healing times and a decrease in the
staff time required to apply and monitor
the treatment.
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Advantages of NPWT
•Faster Healing time- In one study, a 22.2cm wound took 247 days to
heal using conventional treatment, while a wound of the same size
treated with NPWT achieved closure in 97 days. The cost to closure
with the conventional treatment was $23,465.00, factoring in staff
time as well as dressing costs. The NPWT cost to closure, however, was
$14,546.00.
(Philbeck et al 1999)
•In Long Term Care, facilities are constantly under scrutiny to assure
that wounds are healed in a timely fashion. It can cause real issues on
survey if treatment does not yield positive results. NPWT is often
useful in “kick starting” a recalcitrant or chronic wound and help to
avoid issues with the State around wound treatment.
When to consider NPWT……………….
•Heavily draining stage III or IV Pressure Ulcers- exudate that
cannot be managed with a maximum of daily dressing changes will be
more cost effectively handled with NPWT and qod or q3d dressing
changes
•“Stalled”, recalcitrant or chronic wounds-often a short course of
NPWT will start a wound on the road to healing
•Dehisced surgical wounds with moderate to heavy drainage
•Diabetic Neuropathic Ulcers-help to bring capillary circulation to the
wound bed
•Venous Stasis Ulcers-manages drainage as well as decreasing edema,
an underlying cause of Stasis Ulcers
NPWT Options…………….
In recent years, many companies have come out with Negative Pressure
Wound Therapy systems, at a variety of price points. What should you
look for in an NPWT system?
•Dressing options-find a system that will allow you to choose between a
foam based dressing or an antimicrobial gauze filler.
•Settings- Look for a unit that lets you fine tune the atmospheric
pressure to best meet the patients clinical condition and tolerance to
pain. Also, look for a system that gives the option for both continuous
and intermittent suction settings
•Ease of use- The system should be simple to set up, simple to monitor
with an easy to read screen and intuitive alarms.
•Education and clinical support- Choose a provider that offers Clinical
Education for your staff as well as clinicians who can assist in determining
appropriateness of therapy, dressing selection and technique for dressing
placement.
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Sample Treatment Protocols…………
Stage I Pressure area- Provide for pressure
reduction/redistribution. Use of APP overlays, floating heels,
increased turning schedule. Check labs, especially H&H and Albumen
or pre albumen levels. RD consult as indicated.
If located on an incontinent area, protect from moisture. Cleanse
with soap and H2O or cleanser, pat dry and apply Barrier Cream. Use
TID and PRN for incontinent episode
If not on an incontinent area, protect from potential friction and
injury with Transparent film dressing or skin prep. If using
Transparent film, make sure order states to change only when
displaced to avoid removal of epidermis during dressing removal.
Stage II Pressure ulcer- Interventions as per Stg I
PLUS…..
For a dry wound- cleanse with NS or cleanser. Apply wound gel
to wound and cover with a composite cover dressing. Check q
shift and change q day and prn soiled/displaced
For a wound that is moist-clean with NS or cleanser. Skin Prep
to intact peri wound skin. Apply Hydrocolloid or transparent film
dressing. Check q shift and change q3days and prn
soiled/displaced.
For a wound with heavier drainage-Cleanse as above. Apply skin
prep to peri wound. Cover with Foam dressing and secure with
tape. If exudate not managed with foam, consider calcium
alginate.
Stage III and IV Pressure Ulcers-Interventions as previously
stated PLUS consider stepping up the support surface to APM or LAL
mattress for increased pressure redistribution
Wound with Necrotic Tissue- Debride utilizing method of choice. If using
Santyl for enzymatic debridement, DO NOT USE SILVER DRESSINGS!!!
Silver will deactivate the action of Collangenese. Use absorptive dressing
to manage exudate and liquefying necrosis. If < 40% of wound bed has
necrotic matter and is heavily draining, consider NPWT.
Clean Wound, Moderate to large drainage- Cleanse, skin prep to peri
wound, fill in dead space with Calcium Alginate and cover with composite
dressing. Change q day and prn. Consider NPWT for heavily draining
wounds.
Clean wound, scant or no drainage- Cleanse and prep. Saturate gauze
with Hydrogel and loosely pack wound to fill in dead space. Cover with
composite dressing. Change q day and prn.
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Treating Non- Pressure wounds…………
Venous stasis ulcers- Treat according to amount of exudate. Foam
dressings work especially well for absorbing the usually large amounts
of drainage these wounds tend to have. Use rolled gauze to secure
and avoid tape directly on the fragile skin. NPWT often useful in
helping manage edema and excessive drainage
Arterial Ulcers-with dry stable eschar, DO NOT DEBRIDE! Use skin
prep to protect and prevent from opening. Off load pressure, treat
underlying cause.
Skin Tears- Clean gently. If skin edges can be approximated, use
steri strips and, if needed, cover with a non-adherent dressing.
Check placement daily, and monitor for s/s of infection. If unable to
approximate skin edges, dressing choice is based on amount of
drainage/bleeding.
Diabetic Neuropathic Ulcers-Dressings chosen based on amount of
drainage. Consult with orthotist for proper footwear. Control blood
glucose levels. Podiatry or WOCN to help with debridement of hyper
keratinized peri wound tissues. NPWT can also be useful in speeding
healing of these wounds.
Severe Incontinent Dermatitis-Keep skin clean and dry as possible.
Use extra heavy barrier ointment, preferably one that adheres to
denuded tissue. Instruct CNA’s to be cautious when cleaning so as not
to further damage the skin. If needed consider Foley catheter or rectal
tube to divert urine and feces to promote healing.
Kennedy Terminal Ulcer-Treat like a stage I, protect from further
injury with barrier ointment, increased turning schedule, TSS. Educate
family and staff.
Dehisced Surgical Wound- Choose dressing to manage drainage. NPWT
frequently used in treating these conditions.
Test Your Knowledge……a game
There are two boxes of a variety of wound care
products. Each contestant will be given a picture
and description of a wound. When I say”Go” , go to
your box and gather the materials you think you
would need to treat your wound. Whoever is first
to correctly gather all the necessary supplies and
explain your rationale for your choices, will get an
awesome prize…………Ready? Set?
GO!!!!!!!!
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7/12/2012
In Conclusion…………
Treating wounds costs literally Billions of healthcare dollars every
year, but it need not break the bank for your facility.
Creating a streamlined formulary of basic wound care products for
your treatment carts can provide for the majority of wounds you will
be called upon to deal with.
Understanding the basics of moist wound healing, and how to maintain
a moist wound bed is critical to appropriate wound dressing selection
Selective use of pharmaceuticals, specialty dressings and advanced
products such as NPWT on a case by case basis rounds out your
ability to make the most of your wound care dollars!
Thank You for your Participation……it
has been a pleasure!
If you would like more
information on this topic,
or on how Joerns Healthcare
can be YOUR facility’s Total
Clinical Solutions Partner, please
feel free to contact us!
1-800-966-6662
Salamat
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