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1 F314 Follow-up Clinical Training January 23, 2006 Presented by Jeri Lundgren, RN, CWS, CWCN Wound Care Consultant Pathway Health Services.

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Presentation on theme: "1 F314 Follow-up Clinical Training January 23, 2006 Presented by Jeri Lundgren, RN, CWS, CWCN Wound Care Consultant Pathway Health Services."— Presentation transcript:

1 1 F314 Follow-up Clinical Training January 23, 2006 Presented by Jeri Lundgren, RN, CWS, CWCN Wound Care Consultant Pathway Health Services

2 2 Training Objectives Know what a comprehensive risk assessment should include Discuss individualized turning and repositioning Understand the treatment for lower extremity wounds Describe the causes of pressure ulcers Differentiate between pressure reduction verses pressure relief Discuss the application of pulsatile lavage in wound management

3 3 Risk Assessment Guidance states Although the requirements do not mandate any specific assessment tool, other than the RAI, validated instruments are available to assess risk for developing pressure ulcers

4 4 Risk Assessment Tools BRADEN SCALE Mobility Activity Sensory Perception Moisture Friction & Shear Nutrition *Please note: Using the Braden scale requires obtaining permission at or (402)

5 5 Regardless of any residents total risk score, the clinicians responsibility for the residents care should review each risk factor and potential cause(s) individually an overall risk score indicating the resident is not at high risk of developing pressure ulcers does not mean that existing risk factors or causes should be considered less important or addressed less vigorously than those factors or causes in the resident whose overall score indicates he or she is at a higher risk of developing a pressure ulcer. Risk Assessment Tools

6 6 A COMPREHENSIVE risk assessment should be done: –Upon admission –*Weekly for the first four weeks after admission* –With a change of condition –Quarterly

7 7 Comprehensive Risk Assessment Overall skin condition - including tissue tolerance Medical diagnosis and co-morbidities Medications or Treatments Degree of Mobility Incontinence of Bowel and/or Bladder Scarring over bony prominences Contractures Bedfast or Chair-bound

8 8 Comprehensive Risk Assessment Cognitively impaired Resident choice Restraints Unrelieved pain Slouching in a chair Repeated hospitalizations or ER visits with-in 6 months Nutrition and hydration

9 9 Comprehensive Risk Assessment The overall goal of the risk assessment is to ensure that individualized interventions are attempted to stabilize, reduce or remove the underlying risk factors

10 10 Prevention Interventions: Provide appropriate pressure reduction or relief

11 11 Prevention Interventions Choose appropriate pressure reducing surfaces while in bed and sitting Pressure Reduction: Is the reduction of interface pressure, not necessarily below capillary closure pressure Pressure Relief: Is the reduction of interface pressure below capillary closure pressure Capillary closing pressure is also individual to the resident

12 12 Support Surfaces There is no standardize testing or requirements for support surfaces There is no set mandate or recommendation as to when a specific type of support surface should be used. Guidance states: Appropriate support surfaces or devices should be chosen by matching a devices potential therapeutic benefit with the residents specific situation: for example, multiple ulcers, limited turning surfaces and ability to maintain position.

13 13 Support Surfaces Surveyors should consider the following pressure redistribution issues: –Static devices (e.g., solid foam or gel mattresses) may be indicated when a resident is at risk or delayed healing. A specialized reduction cushion or surface might be used to extend the time a resident is sitting in a chair; however, the cushion does not eliminate the necessity for periodic repositioning

14 14 Support Surfaces pressure redistribution issues continued: –Dynamic pressure reduction surfaces may be helpful when: »The resident cant assume a variety of positions without bearing weight on a pressure ulcer »The resident completely compresses a static device »The pressure ulcer is not healing as expected, and it is determined that pressure may be contributing to the delay in healing

15 15 Prevention Interventions

16 16 Support Surfaces Use of recliners, guidance states The care plan for a resident who is reclining and is dependent on staff for repositioning should address position changes to maintain the residents skin integrity.…..Elevating the head of the bed or the back of a reclining chair to or above a 30 degree angle creates pressure comparable to that exerted while sitting, and requires the same considerations regarding repositioning as those for a dependent resident who is seated.

17 17 Support Surfaces Recliners continued –Remember off-loading is one full minute of pressure relief –Is the turning schedule in the best interest for the resident or per their wishes or is it in the best interest for staff Foam vs. Gel vs. Air wheelchair cushions– Overall ensure it is the best for the individual resident

18 18 Prevention Interventions Develop an INDIVIDUALIZED turning & repositioning schedule Tissue tolerance is the ability of the skin and its supporting structures to endure the effects of pressure with out adverse effects There is no standard/mandated Tissue Tolerance Test A skin inspection should be done, which should include an evaluation of the skin integrity and tissue tolerance, after pressure to that area, has been reduced or redistributed

19 19 Prevention Interventions After skin integrity and tissue tolerance has been assessed the resident then should be put on an appropriate INDIVIDUALZED turning and repositioning program Ongoing monitoring of tissue tolerance and skin integrity should be done Recommend assessing skin integrity and tissue tolerance upon admission and with a significant change of condition

20 20 Lower Extremity Wounds Arterial Insufficiency Venous Insufficiency Peripheral Neuropathy/Diabetic Referred to F309 Tag

21 21 Arterial Insufficiency

22 22 Arterial Insufficiency Ulcers Location –Toe tips and/or web spaces –Phalangeal heads around lateral malleolus –Areas exposed to pressure or repetitive trauma (shoe, cast, brace, etc.)

23 23 Arterial Insufficiency

24 24 Arterial Insufficiency Interventions Measures to Improve Tissue Perfusion –Revascularization if possible –Lifestyle changes (no tobacco, no caffeine, no constrictive garments, avoidance of cold) –Hydration –Measures to prevent trauma to tissues (appropriate footwear at ALL times) –Aspirin in doses of mg oral/day

25 25 Arterial Insufficiency Interventions Nutrition Consider niacin; niacin has been shown to HDL-C & Triglycerides in oral dosages of 3,000mg/d L-Arginine (vasodilator properties) oral intake of 6.6 g/day for 2 weeks improved symptoms of intermittent claudication Provide nutritional support with 2,000 or more calories preoperatively and postoperatively, if possible; this has been benefited patients undergoing amputations

26 26 Arterial Insufficiency Interventions Pain Management Recommend walking to near maximal pain three times per week. Administer Cilostazol, 100mg BID, orally Topical Therapy Dry uninfected necrotic wound: KEEP DRY Dry INFECTED wound: Immediate referral for surgical debridement/aggressive antibiotic therapy (Topical antibiotics are typically in- effective for arterial wounds)

27 27 Arterial Insufficiency Interventions Topical Therapy (continued) Open Wounds Moist wound healing Non-occlusive dressings (e.g. solid hydrogel) Aggressive treatment of any infection Adjunctive Therapies Hyperbaric oxygen therapy Intermittent pneumatic compression Topical autologous activated mononuclear cells, twice per week (Autologel)

28 28 Arterial Insufficiency Interventions Adjunctive Therapies (continued) High-voltage pulsed current (HVPC) electrotherapy Patient Education

29 29 Venous Insufficiency

30 30 Venous Insufficiency Ulcers Location –Medial aspect of the lower leg and ankle –Superior to medial malleolus

31 31

32 32 Venous Insufficiency Treatment Surgical obliteration of damaged veins Elevation of legs *Compression therapy to provide at least 30mm Hg compression at the ankle –Short stretch bandages (e.g. Setopress, Surepress) –Therapeutic support stockings –Unnas boot –Profore layer wrap –Compression pumps * ensure compression therapy in not contraindicated

33 33 Venous Insufficiency Treatment Topical Therapy Absorb exudate (e.g. alginate, foam) Maintain moist wound surface (e.g. hydrocolloid) Chronic or non-responding wounds: Small Intestinal SubmucosaTechnology (Oasis Wound Matrix; Healthpoint) Bi-layered cell therapy (Apligraf; Organogenesis, Inc.) Patient Education Appropriate antibiotics to treat infection

34 34 Peripheral Neuropathy/Diabetic Signs & Symptoms Relief of pain with ambulation Parasthesia of extremities Altered gait Orthopedic deformities Reflexes diminished Altered sensation (numbness, prickling, tingling)

35 35 Peripheral Neuropathy/Diabetic Signs & Symptoms Intolerance to touch (e.g., bed sheets touching legs) Presence of calluses Fissures/cracks, especially the heels Arterial insufficiency commonly co-exists with peripheral neuropathy!

36 36 Peripheral Neuropathy Diabetic Location Plantar aspect of the foot Metatarsal heads Heels Altered pressure points Sites of painless trauma and/or repetitive stress

37 37

38 38 Peripheral Neuropathy Diabetic Treatment Pressure relief for heal ulcers Offloading for plantar ulcers (bedrest, contact casting, or orthopedic shoes) Appropriate footwear Tight glucose control Aggressive infection control orthopedic consult for exposed bone and antibiotic therapy Zyvox – approved for MRSA Treatment for co-existing arterial insufficiency

39 39 Peripheral Neuropathy Diabetic Treatment Topical Treatment –Cautious use of occlusive dressings –Dressings to absorb exudate –Dressings to keep dry wound moist Chronic or non-responding wounds: –Recombinant human platelet-derived growth factors (Regranex Gel; Johnson & Johnson) –Human fibroblast-derived dermal substitute (Dermagraft; Smith & Nephew) –Bi-layered cell therapy (Apligraf; Organogenesis, Inc.)

40 40 Peripheral Neuropathy Diabetic Treatment Adjunctive Therapy Hyperbaric Oxygen MIRE - nitric oxide and monochromatic infrared photo energy (Anodyne Therapy LLC, Tampa, FL) The V.A.C (KCI) Patient Education

41 41 Mixed Etiology

42 42 Mixed Etiology Use reduced compression bandages of mm Hg at the ankle. Compression therapy should not be used in patients with ABI < 0.5 Keep extremities in neutral position Protect from trauma

43 Pressure Ulcers

44 44 Pressure Ulcers

45 45 Contributing factors: Friction

46 46 Contributing factors: Friction

47 47 Contributing factors: Shear

48 48 Contributing factors: Shear

49 49 Contributing factors: Moisture

50 50 Contributing factors: Moisture

51 51 Topical Treatment Topical Treatment Wound Debridement Removal of devitalized tissue is considered necessary for wound healing Exception: Stable heel ulcers with a protective eschar covering with no signs or symptoms of edema,erythema, fluctuance, or drainage, do NOT need debridement

52 52 Wound Debridement Wound Debridement Mechanical: Use of wet-to-dry, hydrotherapy and wound irrigation to remove devitalized tissue Disadvantage: non-selective, painful and can lead to excessive bleeding NOTE: A wet-to-dry dressing should be used for debridement purposes ONLY

53 53 Wound Debridement Pulsatile Lavage –It is a form of mechanical debridement to facilitate removal of larger amounts of debris –Irrigation pressure should not exceed 15psi –It is best discontinued once the wound is clean

54 54 Pulsatile Lavage –It can cause dissemination of wound bacteria over a wide area, exposing the resident and care provider to potential contamination (JAMA Vol. 292 No. 24, December 22/29, 2004 & Nursing 2005, January 2005 Issue) –Study at John Hopkins University School of Medicine, traced 11 patients infected with acinetobacter baumannii, back to the use of pulsatile lavage equipment. 3 of the patients required ICU care for sepsis and respiratory distress

55 55 Pulsatile Lavage –Precautions must be used »Use continuous suction »Keep splash shield in contact with the wound/periwound »Empty suction waste container after each use »Dispose of all single-use pulsatile lavage components, then sterilize or disinfect all reusable items »Always perform pulsatile lavage in a private room enclosed with walls and doors »Thoroughly clean and disinfect environmental surfaces

56 56 Pulsatile Lavage Precautions continued »Wear fluid proof gown, mask/goggles or face shield and hair cover »Resident should consider the use of a droplet barrier, such as a surgical mask »Use a drape or towel to cover all resident lines, ports and wounds that arent being treated

57 57 THANK YOU!!! Jeri Lundgren, RN, CWS, CWCN Wound Care Consultant Pathway Health Services

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