1. Wound Management in the Elderly
Stephanie Yates, MSN, ANP, ANP-BC, CWOCN
Nurse Practitioner/CNS
Duke University Medical Center
Durham, NC

2. Skin Condition Key quality indicator To the family To the regulators
To other healthcare providers

3. Cost of Skin Breakdown To the facility To the healthcare system
To the patient

4. Documentation Absolutely important Assessment Reassessment
Follow-up care
Aspects of care that can’t be changed
Supportive measures – nutrition, consults, rehab
Physician communication

5. Alterations in Skin Integrity among Geriatric Population
Pressure Injuries
Skin Tears
Lower Extremity Ulcers
Venous
Arterial
Neuropathic
Incontinence-related Skin Breakdown

6. New terminology for Pressure Injury
A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Stage 3 Pressure Injury: Full-thickness skin loss
Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration

7. Assessing Risk for Skin Breakdown
Risk Assessment Tools
Braden Scale Score
Norton Score
Policy to define when risk assessment is repeated
Interventions/Protocol to address risk elements

8. Support Surfaces Old Terms – Pressure Reduction and Pressure Relief
New term – Pressure Redistribution
The ability of a support surface to distribute load over the contact areas of the human body

9. Support Surfaces
Components – air, foam, fluid, gel, etc.
Features – alternating pressure, air fluidized, low air loss, multi-zoned
Categories – active or reactive, powered or not, overlay or mattress
Regardless of support surface, patients will always need to be turned.

10. Types of support surfaces

11. What about bacteria in wounds?

12. Bacterial Levels in the Wound
Contamination
bacteria present on surface
Colonization
bacteria attach to tissue and multiply
Infection
bacteria invade healthy tissue and overwhelm immune defenses
There are three microbiological states that are possible in a wound - contamination, colonization, and infection. Contamination is characterized as the simple presence of micro-organisms in the wound but without proliferation. It is generally accepted that all wounds, regardless of etiology are contaminated. Humans have at least 1014 micro-organisms living in or on our bodies making a sterile wound impossible.
Colonization is characterized as the presence and proliferation of micro-organisms in the wound but without a host reaction. Colonization is a common condition in chronic wounds such as venous ulcers and pressure ulcers and does not necessarily delay the healing process.
When bacteria invade healthy tissues and continue to proliferate to the extent that their presence and by-products elicit or overwhelm the host immune response, this microbial state is known as infection. The classic signs and symptoms of infection include local redness, pain and swelling, fever, and changes in the amount and character of wound exudate.

13. Assessing for Infection
Inflammation vs Infection
Watch for changing in drainage, fever, local pain, signs of sepsis (hypotension, ^ pulse rate, ^ respirations)
Localized pain may be only sign of infection with immunocompromised patient
Look for infection when blood glucose elevated with no explanation

14. Criteria for identifying infection in chronic wounds
Increased exudate
Cellulitis and inflammation
Surface discoloration (yellow/green)
Friable granulation tissue (bleeds easily)
Wound Infection
Increased odor
Abscess formation
Increased pain/tenderness
Non-healing wound
Superficial pocketing of wound base
Wound deterioration or dehiscence
(Falanga, 1997)

15. Infection Colony counts > 105 per gram of tissue
Prolongs the inflammatory phase
Destroys surrounding tissue
Retards epithelialization and collagen deposition
Interrupts the wound healing cascade

16. Infection IFFE - Induration, Fever, Erythema, Edema
When and how to culture
Cleanse wound with saline, press with swab in
1 cm square area to express fresh exudate
Follow-up on cultures
Antibiotics - topical vs. systemic

17. Swab culture techniques
Levine technique
Clean wound prior to culture
Moisten swab with saline
Rotate swab over a 1 cm square area with sufficient pressure to express fluid from wound tissue
Has been correlated to tissue biopsy results
(Best Practice)
1 cm square
(Levine, 1976)

18. Does ALL Wound Care Need to be Done with Sterile Technique?

19. Wound Care Issues
Present literature suggests that pressure ulcer dressing protocols may use clean technique rather than sterile, but that appropriate sterile technique may be needed for those wounds that recently have been surgically debrided or repaired.
©National Pressure Ulcer Advisory Panel March 2014

20. Sterile technique
Sterile is generally defined as meaning free from microorganisms. 
Involves strategies used in patient care to reduce exposure to microorganisms and maintain objects and areas as free from microorganisms as possible.
Sterile technique involves meticulous hand washing, use of a sterile field, use of sterile gloves for application of a sterile dressing, and use of sterile instruments.
Sterile technique is considered most appropriate in acute care hospital settings, for patients at high risk for infection, and for certain procedures such as sharp instrumental wound debridement.

21. Clean Technique Clean means free of dirt, marks, or stains.
Clean technique involves strategies used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another.
Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies.
No “sterile to sterile” rules apply.
This technique may also be referred to as non-sterile.
Clean technique is considered most appropriate for long- term care, home care, and some clinic settings; for patients who are not at high risk for infection; and for patients receiving routine dressings for chronic wounds such as venous ulcers, or wounds healing by secondary intention with granulation tissue.

22. General Rules for Changing Dressings
Disinfect area around bedside where supplies are going to be placed (over bed table etc.,)
Place trash bag near by
Perform hand hygiene
Gather all necessary supplies, equipment
Don clean disposable gloves
Remove tape and outer dressings and dispose of in trash container
Assess the wound for color, edema, exudate, odor etc.,
Remove soiled gloves, dispose of and perform hand hygiene
Put on clean gloves
Apply dressing and secure
Dispose of all supplies
Remove gloves and perform hand hygiene

23. Clean exam gloves and PPE as appropriate
Procedure
Intervention
HH Indicated
PPE to be Used
Supplies Indicated
Instrumentation
Wound Cleaning
Yes
Clean exam gloves and PPE as appropriate
Normal saline or prepared sterile wound cleanser. Sterile supplies such as 4x4 or cotton applicators
Irrigation performed with sterile device while maintaining clean technique
Routine dressing changes; NO debridement
Sterile supplies using clean technique
Dressing change with mechanical, chemical or enzymatic debridement
Dressing change with sharp, conservative bedside debridement
Sterile gloves and PPE as appropriate
Sterile supplies and sterile technique due to the potential for entering new, unaffected tissues
Sterile supplies and sterile technique
APIC Text of Infection Control and Epidemiology; 4th edition 2014

24. Points to Remember
Contamination of the wound is minimized by not touching it. Blotting excess fluid that pools in the wound and cleaning the periwound skin with moist gauze is acceptable.
Contamination of the wound from supplies is avoided by opening and preparing all that is needed before removing the dressing and putting on fresh clean gloves.
Contamination of the local environment and supplies is avoided by organizing the procedure to ensure that anything coming into contact with the wound does not contact jars, bottles, tubes, bedside table or supplies to be kept for use at a later date.

25. What about wound cleansing?

26. Which wounds need cleansing?
“Dirty” wounds – wounds caused by bites, trauma with foreign objects or debris
Infected wounds
Debate over clean granulating wounds – post surgical wounds, leg ulcers, other chronic wounds

27. Avoid Antiseptics
Povidone Iodine – (Betadine) – Use solution only – 1% or 10% is acceptable
Hydrogen peroxide – damages healing wounds, do NOT use in deep wounds – no safe dilution
Sodium hypochlorite – Dakin’s solution – safe dilution is .025% (not .25% usually ordered)
Acetic Acid – no safe dilution

28. Characteristics of “safe” wound cleansers
pH balanced
Non-cytotoxic
Long shelf life

29. Examples of safe wound cleansers
Normal Saline
Commercially available “wound cleansers” – not the same as “skin cleansers”
Smith & Nephew – Dermal Wound Cleanser
Bard – Biolex Wound Cleanser
ConvaTec – Saf-clens
Medline – Skintegrity
Etc…..

30. Necrotic Wounds Consider whirlpool or pulse lavage for cleaning
May use “harsh” agents if healing is not the objective – may help with odor control
Dakin’s solution

31. Debridement Options Sharp debridement – scalpel or scissors
Mechanical debridement – wet-to-dry dressings and whirlpool/pulse lavage
Chemical debridement – enzymatic agents
Autolytic debridement – occlusive dressing allows body to debride itself

32. Principles of Topical Therapy
Debride non-viable tissue
Treat infection
Gently pack open space
Manage drainage
Maintain moist wound surface
Protect from trauma
Insulate – maintain body temperature

33. Factors to consider Filler needed or just a cover dressing?
Amount of drainage expected?
Occlusion needed?
Adhesive safe or not?
Cost/frequency of change/availability?
Goal desired?

34. Gauze Dressings Cheap Require frequent dressing changes to keep moist
Use moist-to-moist instead of wet-to-dry for healing

35. Hydrocolloid Dressings
Made of carboxymethyl- cellulose
Surface is adhesive
Forms a gel when drainage is absorbed
Promotes autolytic debridement
Use with caution in infected wounds

36. Hydrofibers Non-woven dressing used for absorption
Wicks drainage vertically
Used as a filler for draining wounds
Requires a secondary dressing
Absorbs more than an alginate

37. Calcium alginate dressings
Derived from seaweed
Used as a filler for moderately draining wounds
Turns to a gel when in contact with wound fluid
Requires a secondary dressing

38. Hydrogel Dressings Available in gel or sheet form
Used to hydrate a dry wound
Sheet can be used as primary dressing
Gel can be used with gauze
Promotes autolytic debridement
Reduces frequency of dressing changes
Watch for maceration

39. Foam Dressings Available as a filler or a cover dressing
Available with or without adhesive
Absorbs drainage but doesn’t let the wound bed dry out
Cushions and insulates
May stick if too little drainage

40. Transparent Dressings
Very thin polyurethane sheet with adhesive
Impermeable to water and bacteria
Allows slow evaporation
Use in superficial wounds with little exudate
Can be used over other dressings

41. Contact layer
Woven or perforated polymer net that prevents adherence to wound bed
Use in clean wounds
Requires a secondary dressing
Adaptic, Xeroform or Vaseline gauze
Also silicone sheets, Wound Veil

42. Collagen dressings Available as sheets, particles, pads and rope
Indicated for refractory wounds
Collagen incorporated into wound as structure for healing
Use in moist wounds
Requires a secondary dressing

43. Composite dressings
Combinations of two or more of the previously mentioned dressings
Consider make-up and desired goals

44. Antimicrobial Dressings
Used to treat wounds that have “stalled” when an increased bioburden may be the problem
Used to treat wounds clinically known to be infected (in conjunction with systemic antibiotic therapy)
Sometimes used for prevention in high risk patients

45. Topical antimicrobials
Silver compounds
Silver sulfadiazine
Silver impregnated dressings
Cadexomer iodine (Iodosorb & Iodoflex)
PHMB impregnated dressings (Kerlix AMD)
Sodium hypochlorite solution (Anasept)
Manuka honey (Medihoney)
Mupirocin (Bactroban)
Metronidazole gel (Metrogel)
Antibiotics

46. Silver Dressings
Believed by many to provide an environment conducive to the preparation of the wound bed for healing by controlling the bio environment (bacteria)
The evidence base is still in its infancy (really), but early reports point toward accelerated healing when other factors are corrected (i.e., malnutrition, necrotic tissue, etc.)

47. Silver Dressings Advantages: Disadvantages:
Physicians seem to like using silver in wound care
Product may be left in the wound for an extended period of time without losing efficacy (5-7 days)
Disadvantages:
Cost (Product can range from $10-20 per unit)
Discoloration from some products may alarm patients/ caregivers
Products are often used incorrectly (changed too often) and have specific nuances

49. Cadexomer Ointment or Pads with Iodine (Iodosorb/Iodoflex)
Iodine molecules encased in a protective matrix which breaks down as wound exudate is absorbed, allowing for a gradual release of iodine
Absorbs exudate, contributes to the elimination of slough
Very little in the literature to support this delivery system
Advantages:
~ prescribers are familiar with iodine
~Can be left in wounds for several days
Disadvantages:
~improperly used
~awareness of iodine toxicity and other contraindications are sometimes ignored

51. PHMB impregnated gauze
Polyhexamethylene Biguanide (a compound similar to chlorhexidine)
An antiseptic that has a broad range effectiveness against gram positive and gram negative microorganisms
Prevents infection, no claims for treatment of infection

52. Sodium Hypochlorite Solution (Anasept)
0.057% sodium hypochlorite in an isotonic saline solution
Clear amorphous isotonic hydrogel with % sodium hypochlorite
maintain microbiocidal activity for at least 24 hours

53. Manuka Honey (Medihoney)
Contains active Leptospermum honey from New Zealand
Effective on hard-to-heal wounds and burns
Helps to debride wounds and keep wound beds clean of necrotic tissue
Indicated for diabetic foot ulcers, venous leg ulcers, arterial leg ulcers, pressure ulcers (I-IV), 1st and 2nd degree burns, donor sites, traumatic and surgical wounds

54. Negative Pressure Wound Therapy
Once thought to be a “second line therapy”, is now considered by some to be a “first line” intervention.
Advantages: seen to rapidly decrease wound dimensions in some patients and reduce costs in all care settings by reducing the overall number of dressings
Anecdotal findings point to a reduction in wound infections
Disadvantages: requires intensive staff education

55. Reassessment Few dressings can take a wound from beginning to healed.
Reassess wound and adjust dressing regimen as needed.
Policy on wound reassessment.
Standardize wound measurement techniques or have same person measure weekly.

56. Guidelines for Care
AHRQ (formerly AHCPR) guidelines are outdated and archived
WOCN Society has guidelines for pressure ulcers and lower extremity ulcers
AMDA published in 2008 and reaffirmed in 2013
2014 NPUAP/EPUAP/PPPIA guideline

57. References
Baranoski, S. & Ayello, E.A. (eds.). (2011). Wound Care Essentials: Practice Principles (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
Bryant, R.A. (ed.). (2012). Acute and Chronic Wounds: Current Management Concepts (4th ed.). St. Louis: Mosby.
Hess, C.T. (2012). Clinical Guide to Skin & Wound Care (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

58. References
– National Pressure Ulcer Advisory Panel website
- Information about using the Braden Scale for risk assessment.
- Website for the WOCN Society; resource for guidelines
- Website for the American Medical Directors Association, resource for AMDA guidelines and online journal.