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Wound Assessment and Dressing Selection

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Presentation on theme: "Wound Assessment and Dressing Selection"— Presentation transcript:

1 Wound Assessment and Dressing Selection
Noreen Campbell RN BScN MA IIWCC Lt CSW TCS Systems North Saanich, BC, Canada

2 Maturation/Remodeling
Wound Healing Process Maturation/Remodeling Day years Epithelialisation Proliferation Day 4-21 Inflammation Day 1-4 Kane Hemostasis immediate

3 Homeostasis – first 24 hours
‘Meat’ Illustration of wound healing - as building after a disaster and collapse of a house. This is the sequence in simple terms -- subsequent slides is illustrate more completely the activities associated with subsequent steps.

4 ‘Mess’ Inflammation 1-4 days Hemostasis Platelets
The initial reaction to injury is hemostasis -- the stopping of damage and return to normal. There is no healing at this point.

5 ‘Full’ Proliferation day 4 - 21 Inflammation
Leakage of plasma and WBCs Debridement Macrophages Phagocytosis Neutrophils Inflammation - is the dilatation of the blood vessels and the rush of the white cells and serum products that will begin 'cleaning' the wounds. -- removal of dead tissue and bacteria. This sets the stage for rebuilding ‘Full’

6 Fibrin, Collagen Bridge to Skin
Yellow, caramel like surface, pain Granulation peeking, epithelial starting 6

7 ‘Baby skin’ Epithelialization Proliferation
Release of growth factors from macrophages Granulation Lymphocytes Neurocytes Angiocytes Contractile proteins Fibroblasts At this point - growth factors are released and not only the removal of dead tissue takes place but the building blocks of new tissue is laid down. This is a primitive stage and the new tissue will transform to the anatomical structures they will replace as healing progresses. A number of requirements exist at this stage - a moist environment, good nutrition, proper temperature and all of the 'healing' elements. This is the ideal point of using growth hormones or wound stimulants. The wound is clean and ready to close.

8 Maturation/Remodeling up to 2 years
Normal Hypertrophic With incision Keloid Extends to normal tissue Epithelialization Resurfacing migration of skin cells Epithelial tissue development Keratinocytes Epithialization is the point that the granulation tissue develops a matt finish appearance and is the precursor of skin - as it develops the skin will thicken and become more secure. New epithial tissue is moist but as it develops there will be less drainage until skin is complete. ] Growth hormone products are beneficial until the skin is developed. These products may cause callus formation to be rapid and callus care must be monitored to ensure the wound does not prematurely close with bacteria trapped. If this happens - the wound will breakdown, osteomyelitis or if the patient can resist the bacteria the wound will close. ‘stronger’ Well healed scar – always a scar…weaker tensile strength

9 Individual assessment
Potential for Healing Individual assessment Wound Care Regulation of Wound Healing Cascade of overlapping events Growth factors Cytokines Matrix metalloproteinases (MMPs) Tissue inhibitors of MMPs Hormones Although the wound healing cycles is the same for all patients to some degree. The efficiency of healing is influenced by many factors. Diabetics have delayed wound healing due to missing or reduced healing factors. Fortunately, specific elements which are reduced - may be replaced with another factor in the healing cycle. This is why growth hormones or wound stimulants are used and their exact mechanism is not know.

10 Tissue depth? Probe… 10

11 Culture Infection Heat Redness Swollen Pain Not with neuropathy
Blood Sugars elevated Culture 11

12 Infection: Assess Clean Wound
Wound Cleansing Potable tap water Saline Boiled cooled water Mild soap Dove no dye or perfume Cochrane Review 2011 water for cleansing

13 Wound Imperatives and Antimicrobials
Product Function Cost * CDA Promogran Prisma is above with silver MMP binding ON the wound “let it dance with the wound” Promogran 28 sq cm $ sq cm $55.95 Prisma 28 sq cm $26.95 Iodosorb cadexomer iodine Cochrane level support red. Infection, promote healing, but pain reports may limit use Ointment $ Gm Paste $58.95not recommended Inadine povidone iodine Non-adherent sheets 9.5x9.5cm $2.30 Silver dressings Support of efficacy lacking Expensive 4x4” $18.95 Honey dressings Expensive $ gm Canadian Diabestes Association Store –

14 Eschar: risk infection and delay healing
Stable Wet Black Dry Hard Drainage Marbling Breakdown Autoamputation? Debride Iodosorb + cast padding Inadine PHD

15 Debride Unstable Eschar
Drainage Fluctuance Iodine produce will become paler with release of iodine

16 Surgery, expensive, pain, non-selective Conservative Sharp
Debridement Advantage Disadvantage Surgical Fast Surgery, expensive, pain, non-selective Conservative Sharp Bedside, pain, Scope of practice Skill Maggot Selective, disinfect wound, stimulate healing Ordering process, $120 treatment, dressing change 48 hours Enzyme (Santyl) Selective $ tube, weeks Mechanical Wet to dry Saline Compresses Irrigation Shower Non-selective Pain (wet to dry) Labour - compresses Autolytic (natural) Moisture (gel) Natural, selective Slow 16

17 MDT 4 days 17

18 What type of debridement?
92yo anesthetic risk Trauma scooter accident Inner thigh 18

19 Differentiation: drainage or allergy?
Contact Dermatitis pattern Sensitivity Localized to wound and product Drainage Direction of pooling

20 Blister: drain if risk expansion

21 Edge: Undermined, rolled edge
Packing – think ‘wicking’.

22 Dressing: think ‘Band Aid’ ‘protect, absorb, hold layers’
Function Product Cost Protection Surface protection Silicon (7 days) severe pain or fragile Mepitel $ ”x7” Inadine (antimicrobial+) Inadine $2.30 4”x4” Jelonet (petrolatum mesh) 10cmx40cm $3.50 Tin 10 cm x 7M $36.00 Adaptic non-adherent $3.75 3”x8” 3pkg Absorb Alginates – lowest absorb., sticks if insufficient exudate Hydrocolloid Minimal exudate containment and hold Do not recommend There are no standards for stating performance of dressings (i.e. absorption). Standard for approval ONLY safety not efficacy.

23 Function Product Cost Foam Rated high exudate but generally <5ml 4”x4” protection layer built into dressing Fragile skin Adhesive border strength varies and can damage skin, change when drainage at border Mepilex 3”x3” $3.75 Allevyn Gentle 3x3 $3.95 Tegaderm 3.5”x3.5” $4.59 **do not recommend unless dressing one week Acrylic poor expensive Do not recommend Absorbent Dressing Classic Pads- incontinent pad 17x20cm can hold 750ml (stay dry) 10x20cm 3 $1.95 Ultra 17x40cm 2 $3.00 Classic super 50 $33.00 Gauze – chronic wound or > 48 hours Clean not Sterile poor absorption Adequate cover dry gangrene 2x2” 200 $1.95 4x4” 200 $6.50 Non-sterile clean package Cast padding Holds dressings padding Protouch 17 rolls $17.59 Single roll $1.50

24 Function Product Cost Tape – peal factor is tension to remove, adhesive is ability to hold Fragile skin may strip or tear. *consider skin strength **how many dressings ***how frequent Order of peal factor Transpore (3M) +++ Kind Removal (3M) ++ Mepitac silicon + Transpore $1.65 roll Kind Removal silicon roll $6.95 Mepitac silicon $11.50 Stockinet - TubiFast Roll or meter* Blue normal limb adult Yellow larger Blue 10M $16.95* Yellow 10M $10M $23.75 Tubigrip elastic Size determines pressure – straight may constrict limb Skin barriers If you need these the products are not appropriate Steroids Good for immediate skin reactions i.e venous excema

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