By Mark Vance, RN WCC

 Non-healing wounds  Eschar  Odor  Caregiver support  Environment  Nutrition and hydration  Supply management and understanding of products  Comorbidities

Assessment of Wound 1. Location, type, and cause of wound 2. Drainage 3. Wound base 4. Staging of wound, or determining partial thickness vs. full thickness 5. Surrounding skin 6. Odor 7. Pain

Assessment of Client and Caregiver Wishes 1. What does client want? Aggressive care vs. conservative care 2. What are caregivers able to do in helping hospice nurses and patient? 3. What are caregivers willing to do? 4. What type of environment are you dealing with? 5. What resources do you have?

Assessment of Wound Potential for Healing 1. What time frame does client have? Days, weeks, or months? 2. Severity of wound, to include size of wound, type of wound, slough and eschar in wound. 3. Patient wants vs. needs 4. Available supplies

Patient Centered Goals 1. Build trust and rapport with patient 2. Understand impact of wound to patient and caregivers 3. Education on wound healing or decline and outcome of wound 4. Negotiate treatment plan, what works for patient vs. best practice

Types of Wounds and How They Develop  Pressure ulcers caused by improper turning, poor nutrition, less than ideal support surface  Surgical wounds typically caused by infection, poor nutrition, fragile skin  Tumors caused by cancer  Skin tears typically caused by falls or bumping into furniture.  Stasis ulcers caused by venous or arterial insufficiency  Radiation burns caused by radiation therapy

1. Hemostasis: coagulation, clot formation, release growth factors 2. Inflammatory phase: leakage of plasma, neutrophils and macrophages 3. Proliferative phase: reformation of tissue 4. Maturation phase: can take up to 1 year to complete.

Acute wounds are defined as disruptions in the integrity of the skin and underlying tissues that progress through the healing process in a timely and uneventful manner. The acute surgical wound is an example of a healthy wound in which healing can be maximized. A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing.

 Type of wound and location  Measurements to include length, width, depth and tunneling or undermining  Wound base; type of tissue, include percentages  Wound drainage and odor  Periwound  Age of wound  Ability of wound to heal  Nutrition

 Build goals for care  Find appropriate care for wounds  Meet client and caregiver needs and wants  Provide comfort and support  Focus on managing vs. healing wound

 Transparent Film  Hydrocolloid  Hydrogel  Calcium Alginate  Hydrofiber; Aquacel  Collagen  Foam  Antimicrobial dressings  Gauze

Description: Polyurethane with porous adhesive layer Indications: Primary & Secondary dressing Stage 1 & II ulcers Non-draining Advantages: Ready wound inspection Water tight Prevents or reduces friction Change every 5-7 days Disadvantages: Non-absorptive May adhere to wound Non-absorptive

Description: Hydrophilic colloid particles bound to polyurethane foam Indications: Stage I to IV ulcers Partial & full thickness Necrotic wounds Preventive for high-risk friction areas Secondary dressing or under taping procedures Advantages: Facilitate autolytic debridement Impermeable Conformable Absorptive, minimal to moderate drainage Disadvantages: May be hard to remove Shears off easily Not recommended for heavy drainage

Description: Water or glycerin based sheet or gel. Available with silver (SilvaSorb Gel) Indications: Stage II to IV ulcers Partial & full thickness Painful wounds Radiation-damaged tissue Dermabrasion Advantages: Non-adherent Rehydrates wound bed Reduces wound pain Can use with topical meds Disadvantages: May require secondary dressing Surrounding skin maceration Not for heavy drainage

Description: Nonwoven composite of fibers from calcium-sodium alginate (seaweed) Indications: Partial & full thickness Moderate to heavy drainage Stage III or IV ulcers Dehisced wounds Sinus tracts, tunnels, or cavities Infected wounds Advantages: Absorbent & nonocclusive Trauma-free removal Use with infected wounds Reduces change frequency Sheets & ropes available Disadvantages: Not with dry eschar, burns, heavy bleeding Need secondary dressing May produce odor Possible bed damage

Description: Sodium carboxymethylcellulose that interacts with wound exudate. Also in silver Indications: Partial to full-thickness Moderate to heavy drainage Donor sites Dehisced wounds Stage III to IV ulcers Sinus tracts, tunnels, or cavities Advantages: Highly absorptive Trauma-free removal Disadvantages: Not with dry eschar, non- exudating wounds, 3 rd degree burns, or heavy bleeding Requires secondary dressing to secure

Description: Combination of 2 distinct products made as a single dressing; may include absorptive layer, foam, hydrocolloid. Indications: Partial to full thickness Stage I to IV ulcers Minimal to heavy drainage Surgical incisions Advantages: Facilitates autolytic debridement Conformable Multiples shapes and sizes Easy to apply and remove Most have adhesive border Disadvantages: Adhesive border may limit use on fragile skin Wound damage if not properly used & monitored

Description: Major body protein; stimulates cellular migration & contributes to new tissue development & wound debridement Indications: Partial and full thickness Stage III & some IV ulcers Dermal ulcers Donor sites Surgical wounds Advantages: Absorbent, nonadherent Forms biodegradable gel Conforms well Use with topical agents Change every 1-3 days Use for minor slough Disadvantages: Not for 3 rd degree burns Not for necrotic wounds Needs secondary dressing

Description: A hydrophilic, polyurethane film coated foam, non occlusive nonadherent absorptive Indications: Partial to full thickness Minimal to heavy drainage Stage II to IV ulcers Surgical wounds Ulcers Infected & non infected wounds Advantages: Nonadherent Trauma-free removal Absorbs min to heavy Easy to apply and remove Change every 3-5 days Disadvantages: Not for non-draining or dry eschar Second dressing to secure May macerate surrounding skin if not changed

Description: Immediate and sustained release of ionic silver; effective barrier to bacterial penetration Indications: All wounds except: Stage I ulcer, 3 rd degree burns, and non-draining Infected wounds Highly colonized wounds Over grafts or skin substitutes Under compression Advantages Inhibits growth of bacteria, especially antibiotic-resistant strains Effective up to 7 days Disadvantages Secondary dressing required Incompatible with oil- based products Possible sensitivity to silver

 Hydrofera Blue  Iodoflex and iodosorb  Charcoal dressings  Wound fillers  Various tapes and ways to secure dressings

 If wound is too moist, then soak up drainage.  If wound is too dry, then moisturize it.  Use the right product for the right wound.  Meet patient’s needs, not your own.

Bryant, Ruth A., and Denise P. Nix. Acute & Chronic Wounds: Current Management Concepts. St. Louis, MO: Elsevier/Mosby, Print. Collier, Kyna Setsor, Bridget McCrate Protus, Connie L. Bohn, and Jason M. Kimbrel. Wound Care at End of Life: A Guide for Hospice Professionals. Montgomery: HospiScript Sevices, Print. Morgan, Nancy, and Donna Sardina. Skin and Wound Mangement Course: Seminar Workbook. Stevensville: Wound Care Education Institute, Print.