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Priority # 1: Correct Priority # 1: Correct Causative FactorsCausative Factors
Pressure/Shear: Support surface + repositioning guidelines
Friction/Shear: Gentle skin care; minimal tape use; measures to prevent “scrubbing”
Venous: Leg elevation + compressionArterial: Revascularization? Measures to
optimize perfusion/protect limbsNeuropathy: offloading
Priority # 2: Systemic SupportPriority # 2: Systemic Support
Measures to optimize perfusion– Pain control; warmth; edema control; oxygen if
needed
Must have sufficient blood flow to heal—if wound poorly perfused & revascularization not an option, consider HBOT
Systemic SupportSystemic Support
Nutritional Support– 30 – 35 cal/Kg/day– 1.2 – 1.5 gm protein/Kg/day (glutamine & l-
arginine)– MVI– Zinc only if needed and only short-term– Consider oxandrolone for pt with significant wt
loss who does not respond to standard therapy
Systemic SupportSystemic Support
Tight Glucose Control– Goal: Normoglycemia– Impact of glucose >180– Implications: check glucose records each visit;
constantly reinforce link between glucose levels and ability to heal
Systemic SupportSystemic Support
Measures to minimize effects of high-dose steroids: topical Vit A to wound bed (25,000 – 100,000 IU daily, depending on size of wound)
Note limited research on this topic
Priority # 3: Principle-based Priority # 3: Principle-based Topical TherapyTopical Therapy
Goal: Promote wound healing by creating local environment that favors repair
Inflammatory phase: wound cleanup (debridement and bacterial control)
Proliferative phase: rebuilding (formation of granulation tissue to fill defect + new epithelium to resurface)
History of Wound CareHistory of Wound Care
Dominant Principles and Concepts– Limited knowledge re: wound healing– Primary focus: infection control
Common Approaches– Gauze dressings with antiseptic solutions– Aggressive cleansing– Mgmt refractory wounds: “more of the same”
vs. experimental agents
Shift to Moist Wd HealingShift to Moist Wd Healing
Winter’s Research: 40% reduction in time to epithelialization with moist surface
Subsequent studies: improved rates of healing full-thickness wounds; no increase in infection rates
Gradual shift in focus: from preventing infection to creating favorable environment for repair
Principle-Based Topical Principle-Based Topical TherapyTherapy
Eliminate impediments: necrotic tissue, excess bioburden, wound exudate, closed wound edges
Keep wound moist, insulated, and protected
Topical Therapy AcronymTopical Therapy Acronym
D = Debride necrotic tissue I = Identify and treat infection P = Pack dead space, lightly A = Absorb excess exudate M = Maintain moist wound surface O = Open wound edges P = Protect healing wound I = Insulate healing wound
Topical Therapy: Decision-Topical Therapy: Decision-Making GuidelinesMaking Guidelines
Wound Assessment:– Location– Dimensions and depth– Undermined/tunneled areas– Status of wound base: granulating? clean but
not granulating? necrotic?– Exudate– Status of wound edges/surrounding tissue
Necrotic WoundsNecrotic Wounds
When to debride:
--Anytime the goal is repair
--Anytime the wound is infected
OASIS Assessment OASIS Assessment ChallengesChallenges
Open Wounds:– Granulating vs. clean but not granulating– Closed versus open wound edges
Closed Incisions– Presence/absence of healing ridge– Epithelialization
Necrotic WoundsNecrotic Wounds
Debridement Options:– Surgical– Conservative sharp wound debridement– Enzymatic– Chemical– Autolytic
Infected WoundsInfected Wounds
Guiding Principle: must intervene when – there is invasive infection of soft tissue or bone
or– the bacterial loads on the surface of the wound
are sufficient to interfere with repair
Infected WoundsInfected Wounds
Wounds involving infection of soft tissue: – Clinical S/S: redness, heat, edema, pain,
exudate– Treatment: systemic antibiotics (culture based
if possible)
Wounds involving osteomyelitis:– Clinical S/S: exposed bone; nonhealing tunnel– Treatment: systemic antibiotics
Infected Wounds:Infected Wounds:
Culture guidelines:– Purpose: to determine infecting organism and
antibiotics to which it is sensitive– Procedure:
Wound biopsy (punch culture) OR
Modified swab: flush with N/S
swab 1 sq cm of viable tissue
till exudate produced
Infected WoundsInfected Wounds
Wounds with sufficient bacterial load at wound surface to interfere with repair:– Clinical S/S: deterioration in quantity or
quality of granulation tissue; persistent high volumes of exudate; pain
– Treatment: topical agents to reduce bacterial loads (cleansers, sustained release iodine or silver dressings)
Infected WoundsInfected Wounds
Topical Agents for Bacterial Control– Necrotic wounds: consider Dakin’s – Technicare cleanser for wd with daily dsg
changes (kills 99% of bacteria within 2 min): Caretech Labs
– Sustained release iodine (Healthpoint)– Sustained release silver agents (Acticoat,
Silvasorb, Aquacell Ag, Contreet, Actisorb)
Create/maintain open wound Create/maintain open wound edgesedges
Cauterize with silver nitrate
Refer for excision of wound edges
Dressing SelectionDressing Selection
Goals:– Wick and absorb exudate– Maintain moist wound surface– Provide bacterial barrier/protection against
trauma– Insulate
Dressing SelectionDressing Selection
Assessment parameters:– Wound depth > 0.5 cm?– Tunnels or undermined areas present?– Volume of exudate?
Dressing SelectionDressing Selection
Classify wound:– Deep and wet: > 0.5 cm deep (or tunnels or
undermining) + mod – lg amt exudate– Deep and dry: > 0.5 cm deep (or tunnels or
undermining) + minimal or no exudate– Shallow and wet: < 0.5 cm deep (no tunnels or
undermined areas) + mod – lg amt exudate– Shallow and dry: < 0.5 cm deep (no tunnels or
undermined areas) + minimal or no exudate
Dressing OptionsDressing Options
Deep and wet:– Filler dressing: alginate rope or hydrofiber
rope or damp gauze (least effective option); note Nugauze or Mesalt rope best for narrow tunnels
– Cover dressing: adhesive foam; gauze + tape or transparent adhesive dressing (consider need for bacterial barrier—e.g., pt who is incontinent and has trunk wound)
Dressing OptionsDressing Options
Deep and dry:– Filler dressing: layer of wound gel + damp
fluffed gauze; gel-soaked gauze– Cover dressing: gauze + transparent adhesive
dressing (maintains hydration and provides bacterial barrier)
Dressing OptionsDressing Options
Shallow and wet– Alginate + foam or gauze– Hydrofiber + foam or gauze– Nonadherent contact layer + gauze – Adhesive foam alone
Dressing OptionsDressing Options
Shallow and dry– Solid gel (glycerine-based gels better for
wounds with exudate)– Hydrocolloid– Nonadherent + wrap gauze (for wound on
extremity)– Transparent adhesive dressing (if no exudate)
Refractory WoundsRefractory Wounds
Definition: Wound that fails to show measurable progress for 2 consecutive weeks despite appropriate management
Management:– Assure correction etiologic factors– Assure adequate systemic support– Assure clean protected wound bed– Consider use of active wound therapy
Active Wound TherapyActive Wound Therapy
Definition: Agent that actively stimulates the repair process
Options:– Electrical Stimulation– Negative Pressure Wound Therapy– Growth Factors– Human Skin Equivalents
SummarySummary
Key goals:– Correct causative
factors– Provide systemic
support– Establish clean moist
wound bed– Monitor for progress– Intervene for failure to
progress!