Date post: | 24-Jan-2016 |
Category: |
Documents |
Upload: | ellen-gallagher |
View: | 214 times |
Download: | 0 times |
Wound Care:Where do we go from here?
Jesse M. Cantu, RN, BSN, CWS, FACCWS
April 20, 2012
San Antonio, TX
Disease Management(Wound Care Management)
• Evidence Based
• Best Practices
• Standards of Care
• Positive Outcomes
• Cost Containment
• Evolution of Dressings
• Summary
Wounds
• Types– Acute – Chronic
• Closure
• Phases of Wound Healing
Wounds
• Acute wound
– Planned / unplanned event
– Healing proceeds in an orderly and timely fashion
– Examples:
• Surgical
• Abrasion / laceration
Acute Wound
• Surgical incision
Wounds
• Chronic wound
– Exists two weeks or longer
– Does not proceed through normal healing process
– Examples:
• Pressure ulcers
• Diabetic / neuropathic ulcers
Chronic Wound
• Pressure ulcer
Chronic Wound
• Venous ulcer
Chronic Wound
• Post-operative dehisced wound
Wound Closure
• Primary intention
• Delayed primary
• Secondary intention
What do you do if the burden is too big?
Evidence Based / Best Practice
• Randomized control trials
• Protocols (NPUAP, WOCN, Canadian guidelines, AHCPR)
• Moist Wound Healing (George Winters)
• Wound Bed Preparation (Vincent Falanga)
The Building Blocks of the Foundation for Wound Care
Debride Moisture TopicalsOff-Load
Debride Moisture TopicalsOff-Load
SUCCESSFUL WOUND CARE
HYPERBARICSGROWTH FACTORS
BIOENGINEERED TISSUES
BIOLOGICDRESSINGS
NEGATIVE PRESSURETHERAPY
SILVER DRESSINGS
Best Practices
• Evidence Based
• Wound Bed Preparation
Wound Bed PreparationWhat Does It Mean?
Originally
• Debridement
Fibrotic Tissue
Hyperkeratotic Rim
Wound Bed PreparationWhat Does It Mean?
Today
“…a very comprehensive approach aimed at reducing edema and exudate, eliminating or reducing the bacterial burden and, importantly, correcting the abnormalities … contributing to impaired healing.”
Vincent Falanga , MD
Professor, Boston University School of Medicine
Other Voices….
“Think of it as removing various ‘burdens’ from the wound and the patient.”
• Exudate• Bacteria
• Necrotic/cellular debris
Elizabeth A. Ayello, PhD, RN & Janet Cuddigan, PhD RN
Standards of Care
• NPUAP
• WOCN
• AHCPR
• Canadian Guidelines
Positive Outcomes
• Wound Assessment at each dressing change
Cost Containment
• Wet to Dry Dressings (Gauze and Saline)– Frequent dressing changes
• Moist Wound Healing (George Winters 1961)
• Active Wound Healing (NPWT, Hyperbarics)
Evolution of Dressings
• Debridement
• Maintain a moist wound environment
• Reduce bacteria load
• Prolong dressing interval changes
• Stem cell technology
Summary
• Wound management not wound care– Need to jump start nonhealing or slow wounds
• Adequate assessment, debridement, and wound irrigation based on Best Practices, Evidence based, Standards of Care, Positive Outcomes, and Cost containment
• Case studies
Wound Care as Wound Management
• Properly treated wounds create the ideal win-win situation by decreasing hospitalizations, promoting wound healing in the home, improving quality of life, and improving patients’ sense of independence and well being.
Other Voices….
Wound Bed Preparation is “the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures.”
Schultz G, Sibbald G, Falanga V, et al:Wound bed preparation: A systematic approach to wound management.Wound Rep Regen 2003
What’s Needed to Heal a Diabetic Neuropathic Ulceration?
Control of Diabetes and General Health
Adequate Diet
Blood Supply
Absence of Infection
Regular Debridement
Offloading of Pressure
Moist Healing Environment
Total Contact Casts Custom Splints
Therapeutic Shoes Removable Cast Walkers
Common Methods to Common Methods to “Off-Load” the Foot“Off-Load” the Foot
So what is this going to cost me?
A lot less than traditional care…
“Incidence, Outcomes, and Cost of Incidence, Outcomes, and Cost of Foot Ulcers in Patients with Foot Ulcers in Patients with
Diabetes”Diabetes”
• What is the cost of a new foot ulcer, not previously treated?
Ramsey, Reiber, et al. Diabetes Care, Mar 1999 – Univ of Washington
–$27,987 over a two year period!
1. Benefits of a Closed Environment
• Moisture Balance• Reduction of
Nosocomial Infections• Prevents patient
interaction with the wound
2. Promotes Perfusion
• Replacement of fibrinous tissue with granulation tissue
• Filling deficits in wounds
• Wound constriction
• Promotes granulation tissue formation
Dompmartin A, et al J Wound Care 2004 June
4. Benefits of Maintaining a Moist 4. Benefits of Maintaining a Moist Wound BedWound Bed
Why do we keep a wound moist?
Promotes rapid migration of epidermal cells across the wound bed
Promotes perfusion
Why do we keep a wound moist?
Promotes rapid migration of epidermal cells across the wound bed
Promotes perfusion
Barrier against environmental contamination
Benefits of Using Negative Pressure Therapy as an Adjunct
70 patients with chronic, non-healing wounds
treated with VAC following skin grafts
100 % of the grafts healed in an average
of 48 days
Carson SN, Overall K, Lee-Jahshan S, Travis E.Ostomy Wound Manage. 2004 March
Escalating Bacterial Loads
• Contamination – Presence of nonreplicating microorganisms in the wound
• Colonization – Presence of nonreplicating microorganisms adhering to the wound, NOT causing injury to the host
• Critically Colonized – Bacteria cause a delay in wound healing
• Infection Local to Systemic – Presence of replicating microorganisms in wound and presence of injury to the host
Ayello and Cuddigan, 2003
BACTERIAL
LOAD
Wound Bed Preparation:Wound Bed Preparation:Combining Topicals with NPWTCombining Topicals with NPWT
Control of:
• Contamination, colonization and critical colonization to optimize the wound bed
• Odor
Case Studies
The Challenge of a Large Deficit Wound and Poor Vascularity
Ready for grafting