1. Wound Care Best Practice Guidelines
VITAS Healthcare Corporation
Wound Care Best Practice Guidelines
Length: 60 minutes
50 minute presentation
10 minute question & answer
Target Audience:
Clinical healthcare workers and others who care for terminally ill patients and their families.
Instructions:
Distribute copies of the Guidelines to each participant. Present the presentation referring to the guidelines.
Facilitator:
Welcome to VITAS’ presentation on Wound Care Best Practice Guidelines.

2. Goal
To educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients.
Goal:
Many of the standard wound care protocols that normally work well with your typical patient, are not feasible with the hospice patient.
Therefore, our goal today is to educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients .

3. Objectives Identify preventative measures
Describe risk factors contributing to skin impairment
Describe the parameters of wound assessment including staging of wounds
Describe wound types and tissues
Describe care planning considerations and the selection of appropriate interventions
We will accomplish these goals by meeting the following objectives:
Objectives:
First, we will identify preventative wound care measures. Next, we will describe some risk factors that contribute to skin impairment. We will also describe the parameters of wound assessment with a focus on the staging of wounds. Next, we will describe wound types and end the session with a description of care planning considerations and how to select appropriate interventions for proper wound care.

4. Prevention Inspect skin Moisture control
Proper positioning and transfer techniques
Nutrition
Avoid pressure on heels and bony prominences
Use of positioning devices
Monitor and document
Preventing wounds from occurring is the best practice that we can offer our patients when it comes to wound care. Prevention measures include, but are not limited to, inspecting the skin and monitoring for proper moisture control. Of course, proper positioning, transfer techniques, and nutrition are essential for the comfort of the patient. Do your best to avoid pressure on the heels and bony prominences of the body, and use positioning devises whenever feasible. As always, remember to document the wound status as you monitor your patient.

5. Risk Assessment Alterations in mobility Level of incontinence
Nutritional status
Alteration in sensation or response to discomfort
Co-morbid conditions
Medications that delay healing
Decreased blood flow to lower extremities when ulceration is present
The assessment should include the patient’s skin condition, as well as those conditions which increase the risk for skin breakdown and influence the potential for wound healing. They are:
Alterations in the patient’s mobility
The patient’s level of incontinence and nutritional status
If there is any alteration in sensation or response to discomfort
Co-morbid conditions or medications that delay the patient’s ability to
heal; and
Decreased blood flow to the lower extremities when ulceration is present
These conditions will influence the patient’s propensity for skin breakdown and also the potential for healing.

6. Contributing Factors1 Friction Immobility Shear Pressure Ulcers
Let’s look at some of the common factors in a little more depth.
Nutrition is often a problem with hospice residents. To support wound healing, calories/kg are needed daily. Protein needs must be grams / kg each day. Most hospice residents are not able to take in or absorb the nutrition necessary for wound healing. Often Vitamin C and Zinc have been used to support wound healing, but these are not likely to be of benefit to hospice residents for the same reasons.
When the resident is exposed to Pressure over a given area which is greater than the capillary profusion pressure, the vessels are compressed and this leads to tissue ischemia. If pressure is applied to an area for a long enough period, the capillary vessels will collapse and thrombose.The oxygenation and nutrition of the tissue of the area involved is interrupted. Toxic metabolic byproducts accumulate in the tissue and lead to cell death.
Shearing can occur when adjacent surfaces slide across one another such as when the HOB is elevated. The skin and superficial tissue remain fixed against the bed linens while the deep tissue and skeleton slide down toward the foot of the bed. This also occurs when the resident is up in a wheelchair. It is defined as mechanical force which is parallel rather than perpendicular. The blood vessels become twisted and distorted resulting in a change in blood flow.
Friction is another factor which causes mechanical destruction of tissue. It is created by the force of two surfaces moving across each other creating a wound resembling an abrasion. Think of the resident who is pulled up in bed. This is like the abrasion with a rug burn.
Incontinence leads to maceration of the skin. Excessive moisture softens the connective tissue. Once macerated, the skin is more easily eroded. Moist skin is 5 Xs more likely to become ulcerated as dry skin. Also, there is the added risk of infection with fecal or urinary incontinence.
Immobility influences the resident’s ability to reposition themself when they have been in one position too long or to shift their weight. This predisposes them to both shear, friction and pressure problems.
The other factors which must be considered in wound development and healing include:
Circulation is necessary for wound prevention and healing and this is often compromised in elderly or hospice residents.
Immune function can also contribute to skin deterioration and poor wound healing.
Pressure
Incontinence
Malnutrition

7. Assessment and Documentation
Location
Stage and Size
Periwound
Undermining
Tunneling
Exudate
Color of wound bed
Necrotic Tissue
Granulation Tissue
Effectiveness of Treatment
This is a list of your basic criteria for assessment and documentation.
Review Slide
It is important to note the effectiveness of the treatment. If the current treatment is not effective, then it needs to be revised.

8. Assessment and Documentation
Wound and Risk Assessment every visit
Documentation on Wound Assessment Form every 7 days when 1 or more pressure ulcer exists
Physician assessment and documentation on
Physician Wounds Care Assessment tool
Hospice RN will visually assess risk and any existing pressure ulcer each visit.
Hospice RN will visit each patient with a staged wound, at least every 7 days.
When one or more pressure ulcer exists, the Hospice RN will document on the Wound Assessment Form at least, every 7 days.
A physician assessment of the wound will assist the team in identifying appropriate interventions and realistic goals. Physician assessments should be documented on the Physician Wound Care Assessment tool.
Both of the assessment tools are available to you on the Inet.

9. Pressure Ulcer Staging2
Stage I
Stage II
Stage III
Stage IV
Please Refer to page 6 in the Guidelines document
The National Pressure Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001.
Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
Pressure Ulcer Stages
Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compares to adjacent tissue.
Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark pigmented skin tones. May indicated “at risk” persons (a heralding sign of risk).
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III ulcers. Bone/tendon is not visible of directly palpable.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage IV ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

10. Care Planning.
Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound.
Before selecting any treatment plan, identify the likelihood of the wound healing and the benefits of pursuing a specific treatment plan.
Document all factors that may affect healing. Keep in mind that under ideal circumstances a wound needs at least 2 to 4 weeks to show evidence of healing. Many hospice patients will not have 2 to 4 weeks. In many terminally ill patients we do not expect a wound to heal, so aggressive intervention may not be appropriate.
Review advance directives or other care instructions that may impact the scope or selection of treatment options.
Comfort should always guide the selection of the treatment approach.

11. Appropriate Goals
Prevent complications or the deterioration of an existing wound
Prevent additional skin breakdown
Minimize harmful effects of the wound on the patient’s overall condition
Promote wound healing
Appropriate care planning goals for hospice patients may include:
Preventing complications of the wound, such as infection or odor
Of course, you will work to prevent additional breakdown of the skin
We want to do our best to minimize harmful effects of the wound on the
patient’s overall condition. This would be things like depression, social
isolation or general discomfort.
In many of our hospice patients, we know that promoting wound healing
may be unrealistic. Therefore, let’s take a look at some specific
interventions for wound care that might be more feasible.

12. Interventions Dressing considerations should include:
Patient’s condition and prognosis
Caregiver ability
Ease and continuity of use
Ability to maintain moisture balance
Frequency of change
When choosing wound care interventions, some of the things to consider are:
Condition and Prognosis – If patient has poor potential for healing or has a prognosis of less than 1 week, then aggressive measures may not be appropriate.
Caregiver ability – Treatment needs to be provided consistently by all caregivers. So you want to choose one that will offer continuity and ease of use.
Goal is to keep a moist wound environment which promotes re-epitheliazation and healing. Too much moisture can delay healing and cause further tissue damage (maceration).
Research has shown that the prolonged period that the modern dressings remain in place, speeds up the healing time and decreases the chance of infection.

13. Pain Management
1) Medicate the resident prior to dressing changes
2) Some treatment regimes may be uncomfortable for the resident
Provide maintenance doses of medication for those patients who have pain.
Adjuvant therapy may be appropriate
Consider non-medicinal approaches
Pain management is an important aspect of any plan of care.
Medication schedules should coincide with dressing changes.
Enzymatic debriders and some gels are known to be uncomfortable. Surgical debridement would also cause discomfort if administered without local anesthesia.
Keep in mind that some wounds are more painful than others –ulcers due to arterial insufficiency.
Muscle relaxants or anti-inflammatories may be indicated with large, invasive wounds where underlying structures are involved.
Music or diversional therapy may be helpful at the time of dressing changes.

14. Types of Wounds3 Pressure Ulcers Arterial Insufficiency
Diabetic Ulcers
Venous Insufficiency
Surgical Wounds
Tumors
Let’s review the types of wound problems common in hospice residents.
Pressure ulcers result from the unrelieved pressure, shearing, and skin irritation and result in damage to underlying tissue --they usually occur over bony prominences.
Arterial Insufficiency often appears as those ulcers with black eschar on the lower leg and foot --the skin surrounding the wound appears to be very thin, shiny and usually hairless --the foot may feel cold and appear dusky red or pale in color--typically they occur on the lateral aspect more frequently than medial. They are the result of arterial disease. They are often painful which is often worse at night. The pain is often relieved when the legs are lowered. Contributing factors include smoking, high fat/cholesterol diet, obesity, diabetes. About 10% of the leg ulcers are of this type.
Diabetic ulcers are typically on the plantar surface of the foot and the 2nd metatarsal head is very common. Neuropathy associated with diabetes results in a decreased sensation which increases susceptibiltiy.They are usually painless. They are the type of leg ulcer about 5% of the time. Since diabetics typically have atherosclerosis, they are associated with Diabetes and that is where their name comes from. They are more common in diabetics with poor dietary control, who smoke or where improperly fitting shoes or have poor care of their feet.
Venous Ulcers are the most common type of leg ulcer. About 70% of people with ulcers of the legs have this type. They result from venous disease. They occur in the so-called gaiter area--halfway up the calf and down to just below the ankle. The skin will likely feel itchy and appear mottled brown or have black staining and may appear crusty in the gaiter area. The legs may become painful with sitting. Venous ulcers develop in this type of leg. Other conditions can contribute to the development such as elev.BP, obesity, varicose veins, etc.
Surgical wounds Not going to spend much time talking about these types of wounds today. They present a challenge when infected or with dehiscence.
Tumors or Fungating of cancer onto the skin surface occurs most often in CA of the breast, but may occur with other types of cancers including head and neck CA, malignant melanomas, and sarcomas. The lesion may be a small crusted area or a large ulcerated area with profuse exudate and capillary bleeding. They are often disfiguring, distressing and isolating. Odor and exudate management may be a particular problem in this type of wound.

15. Palliative Wound Care for the Imminent Patient
Think:
Comfort
Quality of Life
Treatment Choices:
Keep Current Treatment
Irrigation, Cover with DuoDERM Thin or Bioclusive Dressing
Irrigation, Silvadene, Cover with Gauze
(if infection is suspected)
Every effort should be made to keep the patient comfortable and enhance the quality of life. This is especially true if the patient is near death or uncomfortable.
If a patient appears to be imminent (less than one week), and has a current wound treatment in place, it is appropriate to continue the treatment in place.
Consistent with wound care guidelines, the appropriate care may be simply to irrigate the wound with normal saline using a 35ml syringe and 19g needle to clear debris from the wound. To minimize dressing changes, apply a non-sting skin prep around the wound edge and cover with Duoderm Thin or a Bioclusive dressing. Change this dressing Q 3 to 5 days.
If you suspect the wound is infected, irrigate the wound with saline with the 35ml syringe and 19g needle and apply Silvadene and cover the wound with gauze. Change QD. When using gauze in the wound – take great care not to allow the gauze to come in contact with the wound bed or new tissue.

16. Basic Elements of Wound Care
Cleanse Debris from the Wound
Possible Debridement
Absorb Excess Exudate
Promote Granulation and Epithelialization When Appropriate
Possibly Treat Infections
Minimize Discomfort
These are examples of wound care interventions which may be part of the plan of care.
Each resident’s plan of care will likely differ. There are many different methods of caring for a wound and all would be considered appropriate. Our goal is to define what makes sense in light of the resident’s status and desires.
Additionally, each intervention should be re-evaluated every 2 weeks to determine whether the plan is still appropriate. It does not mean that a change is indicated, even if the wound is not responding to the current regime, but that it is the best option for this patient at this time. Failure of a wound to heal does not mean that all possible approaches should be exhausted, nor does it imply an alternate plan of care was more appropriate.
A physician assessment can be helpful for a number of reasons.
1) They will be able to help us identify appropriate interventions and realistic goals for each wound.
2) They will also be able to document why the development of a wound or lack of healing was an unavoidable outcome.

17. Indicated for Mechanical Debridement ONLY
Wet to Dry Dressings
Indicated for Mechanical Debridement ONLY
Causes Injury to New Tissue Growth
Is Painful
Predisposes Wound to Infection
Becomes a Foreign Body
Delays Healing Time
Wet to Dry dressing with gauze is not recommended or indicated for treatment, except for a debridement technique.
Epithelial cells can grow into the gauze fibers and fibers can become embedded in the tissue, causing the gauze to become a foreign body in the wound. Upon removal it can cause injury and removal of new tissue growth, delaying healing time and can be painful.
Research has shown that gauze dressings can actually predispose the wound to infection, as gauze is permeable to bacteria.

18. Frequency Goal is to minimize the frequency of dressing change
Daily dressing changes increase chances of infection and disrupts the healing of tissue
Optimal wear time is 3-7 days
Decrease Frequency
of Dressing Changes
Research has shown that the prolonged period that the modern dressings remain in place, speeds up the healing time and decreases the chance of infection. Therefore, the goal is to minimize the frequency of dressing changes. Frequent dressing changes will increase the chances of infection, and disrupts the healing of tissue. 3 – 7 days is the recommended wear time for a dressing.

19. Interventions: Patients At-Risk or Stage I
Assess “Risk for Breakdown”
Utilize skin creams and lotions for dry skin
Utilize barrier products as needed to minimize irritation from incontinence
Reposition frequently
Encourage fluids as tolerated and appropriate
Use pillows in bed for positioning
Use standard approaches in all of our patients to minimize the potential for skin breakdown and prevent the incidence of further deterioration of existing wounds.
Standards include:
Frequent monitoring of the skin.
Relieving pressure every 2 hours or more often.
Lotions will help reduce friction and moisturize dry skin. Do not massage bony prominences.
Incontinence can be better managed by using a petroleum-based product which we usually
see called “ointments”. They work to seal out wetness and irritants.
You can float the heels when in bed with pillows and position the patient so bony
prominences are not in direct contact with each other (take care not to occlude blood flow)
It is helpful to convert tube feedings over to bolus feedings so the patient is not required to
sit upright in bed for long periods. It is better for the HOB to be raised only between 30-60
degrees to minimize shear.
Finally, lifting devices can help reduce friction.

20. Cleansing Wounds.. Remove Wound Debris Sustain Moist Environment
Soften Necrotic Tissue
Debride the Wound
Reduce the Risk of Bacterial Contamination and Infection
Reduce Odor
Cleansing wounds should be part of any wound care regime.
Irrigation will remove wound debris
It helps to sustain a moist environment, and soften any Necrotic Tissue
Debrides the wound and reduces the risk of bacterial contamination and infection
Finally, it helps to reduce the odor.
Normal saline is the cleansing agent of choice because it is not cytotoxic and has no side effects. Antiseptics are known to be cytotoxic and also have some untoward effects. These include Betadine, Dakins, Acetic Acid, and Hydrogen Peroxide.
Current research suggests that the use of a 35 ml syringe with a 19 gauge needle produces the correct pressure to achieve removal of surface contaminants and debris in the wound. This is a good method of debridement with hospice patients.

21. Goals & Treatment Guidelines
Dry to Minimal Exudate
Moderate Exudate
Copious Exudate
There are specific treatment modalities and preferred agents for each stage of wound care. In the next few slides we will review goals and treatment guidelines for the following wound types:
Dry to Minimal Exudate
Moderate Exudate
Copious Exudate

22. Interventions Stage I Aloe Vesta skin cream
GOALS:
Maintain skin integrity
Skin to remain clean and odor free
Protect and moisturize skin
TREATMENTS:
Preferred agents (dry skin)
Aloe Vesta skin cream
Preferred agents (at risk for breakdown due to incontinence/pressure)
Aloe Vesta protective ointment
Dermarite Perigaurd barrier ointment
Refer to page 10 and 11 in Guidelines
Read Goals and Treatments

23. Interventions Stage II, III, IV
Dry to Minimal Exudate
GOALS:
Minimize dressing changes
Maintain moist environment
Prevent infection
Prevent additional skin breakdown
TREATMENTS:
Preferred agents:
Hydrofiber (Aquacel)
Viscopaste
Hydrocolloid (DuoDERM Extra Thin)
Follow product guidelines for frequency of dressing change
Refer to page 12 of the guidelines
Review slide
Although the preferred agents are listed here, there are 2nd and 3rd line agents in the guidelines.
Take note that the recommended frequency of dressing change for Aquacel is 5-7 days & prn; Viscopaste is 3 days & prn; and Duoderm is 5-7 days & prn.
There is a decrease in the number of required dressing changes with the use of these preferred products. This increases the quality of life for our patients.

24. Interventions Stage II, III, IV
Moderate Exudate
GOALS:
Minimize dressing changes
Maintain moist environment
Prevent infection
Prevent additional skin breakdown
TREATMENTS:
Preferred Agents:
Hydrofiber (Aquacel)
Hydrocolloid (DuoDERM Signal)
Follow product guidelines for frequency of dressing change
Refer to page 13 of the guidelines
Review slide
Again the preferred agents are listed here, there are 2nd and 3rd line agents in the guidelines.
Take note that the recommended frequency of dressing change for Aquacel is 5-7 days & prn, Duoderm Signal is changed every 3-7 days.
Again it is important to follow the guidelines for the frequency of dressing changes for these products.

25. Interventions Stage II, III, IV
Copious Exudate
GOALS:
Minimize dressing changes
Manage Exudate
Prevent infection
Prevent additional skin breakdown
TREATMENTS:
Preferred Agents:
Hydrofiber (Aquacel)
Hydrocolloid (DuoDERM Signal)
Follow product guidelines for frequency of dressing change
Refer to page 14 in Guidelines
These preferred agents remain the same as with moderate exudate.
Pleas note that the frequency for dressing change on a copious wound will be more frequent, usually 3-7 days. Always remember to follow the product guidelines.

26. Interventions Necrotic Tissue in Ulcer Bed Fungating Lesions
Infected Wounds
Skin Tears
Gangrenous Wounds
Diabetic Ulcers
In the next few slides, we are going to review protocols for the management of the following types of wounds:
Necrotic Tissue in Ulcer Bed
Fungating Lesions
Infected Wounds
Skin Tears
Gangrenous Wounds
Diabetic Ulcers

27. Interventions Necrotic Tissue in Ulcer Bed
Mechanical Debridement
Autolytic Debridement
Sharp or Surgical Debridement*
Enzymatic or Biochemical Debridement*
Biological Debridement*
*Requires Approval
Mechanical Debridement - Irrigate with Normal Saline using the 35 ml syringe with a 19 gauge needle, or use of Saf-Clens. This is when a Wet-to Dry dressing can be indicated for a limited time.
Autolytic Debridement – Use Opsite or Duoderm and change every 5-7 days. This promotes self-digestion of necrotic tissue from enzymes in the wound fluid.
Surgical Debridement – This intervention dissects necrotic tissue from viable tissue with Scalpel or scissors. It must be performed by a Physician and can be done at the bedside. However, it does require approval.
Enzymatic or Biochemical Debridement – Is topically applying enzymes to dissolve necrotic tissue (Santyl Ointment Collegenase). This intervention also needs approval.
Biological Debridement – is Maggot Therapy. Patients must consent and be stable with good healing potential. This requires approval.

28. Interventions Necrotic Tissue in Ulcer Bed
Prior to debridement interventions, assess whether it will enhance wound healing or promote infection or cause undue pain.
Do NOT institute aggressive debridement if the patient is within days/week of death, or if the eschar is stable, dry, non-draining, and wound is not infected.
For Intact black heel – relieve pressure – no dressing or debridement – if opens then refer to necrotic treatments.
Prior to debridement interventions, assess whether it will enhance
wound healing or will create an environment that will promote infection
or cause undue pain.
Do NOT institute aggressive debridement if the patient is within
days/week of death, or if the eschar is stable, dry, non-draining, and
wound is not infected.
For Intact black heel – relieve pressure – no dressing or debridement –
if opens then refer to necrotic treatments.
This completes our review of interventions related to necrotic tissue in the ulcer bed. Now let’s take a look at interventions for fungating lesions.

29. Interventions Fungating Lesion
Goals:
Removal of exudate
Odor control
Pain control
Non-Pharmacological measures to control odor include:
Oil of Wintergreen
Charcoal briquettes or Coffee grounds
Dryer Sheets
Treatments:
Preferred Agents
Non-Adherent Gauze Dressing (Telfa)
Zinc Oxide Paste (Viscopaste)
Activated Charcoal Dressing (Carboflex)
Atropine solution may be used to control bleeding
Metrogel cream can be used to control odor
Because rapid healing of fungating lesions in hospice patients are unrealistic, our goals should be three-fold:
To remove the exudate
To control the odor; and most importantly…
To control the pain
The standard treatments and preferred agents are listed here.
Review Preferred agents
However, there are some non-pharmacological interventions that we can use to reduce odor, such as:
Oil of Wintergreen – Saturate a cotton ball and place in patient’s room
Charcoal briquettes or coffee grounds in a container placed under
patient’s bed
Dryer sheets placed over a vent in patient’s room

30. Interventions Infected Wounds…
Diagnosis of wound infection:
Swab Cultures not recommended
Based on clinical signs (fever, increased pain, friable granulation tissue, foul odor)
Tissue culture or biopsy is not optimal for the hospice patient.
Treatments:
Preferred agents:
Hydrofiber (Aquacel Ag)
Silvadene ointment and non-sterile gauze
DO NOT USE:
Providine Iodine
Iodophor
Dakin’s solution
Hydrogen peroxide
Acetic Acid
The current thinking suggests that wound infection should be diagnosed primarily on the basis of clinical signs (fever, increased pain, friable granulation tissue, foul odor).
Necrotic tissue is not necessarily a sign of infection; however necrotic tissue does support microorganism growth.
For hospice patients who have a good potential for wound healing, it may be appropriate to utilize a two-week trial of a topical antibiotic to a wound with clinical symptoms suspicious of a local infection. Tissue culture or biopsy would not be optimal for a hospice patient. The antibiotic selected should be effective against gram-negative, gram-positive, and anaerobic organisms.
Appropriate topical antibiotic choices include Triple Antibiotic or silver sulfadiazine. Oral antibiotics are not indicated unless the wound is clearly infected.
The preferred agents for an infected wound are: Review preferred agents
Avoid the use of antiseptics such as providone iodine, iodophor, Dakin’s solution, hydrogen peroxide, and acetic acid. These agents have been shown to be cytotoxic to granulation tissue and can actually delay the healing process. These solutions are also drying agents and a moist wound environment is necessary for healing. The constant application of an anti-microbial agent is not necessary to produce wound healing or avoid infection. These products should be used under careful direction of a wound care physician.
Remember that tissue culture or biopsy is not optimal for the hospice patient.

31. Interventions Skin Tears
Goals:
Prevent infection
Healing
Prevent further injury
Minimize dressing change frequency
Treatments:
Preferred Agents:
Non-Sterile Gauze
Transparent Film (Opsite)
The goals for our patients with skin tears are to prevent infection, promote healing, prevent further injury, and minimize dressing change frequency.
The preferred agents for treatment are non-sterile gauze, and transparent film.

32. Interventions Ischemic (Gangrenous) Wounds
Draining wounds
Cover with Telfa or gauze and wrap with Kerlix
No drainage
Cover with gauze and Kerlix
Change QD and PRN
Venous Stasis or Diabetic Ulcers
Draining wounds
Cover with Telfa or Adaptic with a Kerlix wrap changed QD
Cleanse with normal saline using bulb syringe
Non-draining wounds
Cover with gauze and wrap with Kerlix
Apply tape to the Kerlix to prevent further injury to surrounding skin
Change QD
For gangrenous wounds that are draining cover with Telfa or gauze and wrap with Kerlix.
If there is no drainage, cover with gauze and Kerlix and change QD and PRN. Be sure to use saline to soak off dressing if it adheres. Debridement is not indicated with this type of lesion.
For diabetic ulcers, cleanse with normal saline using bulb syringe. Skin prep may be useful to surrounding tissues.
For draining wounds, the best choice is Telfa or Adaptic with a Kerlix wrap changed QD. These wounds need careful inspection by a wound care physician to assess treatment options.
For non-draining wounds, cover with gauze and wrap with Kerlix. Apply tape to the Kerlix to prevent further injury to surrounding skin. Change QD.

33. DO NOT USE DONUT TYPE DEVICES IN WHEELCHAIRS
Support Surfaces
Comfort and Shear Reduction Products:
Pillows
Heel/Elbow Protectors
Foot Cradles
Sheepskin Pads
DO NOT USE DONUT TYPE DEVICES IN WHEELCHAIRS
It is important to note that patients may still develop pressure ulcers while using support surfaces, regardless of the type of device used.
There is no compelling evidence that one support surface consistently performs better than all others, under all circumstances.
Float lower extremities on a pillow below the calves. Some facilities utilize sponge cradle boots (also called bunny boots) for patients at risk of breakdown on their heels.
In a wheelchair, a 4” eggcrate mattress will provide pressure relief.
Avoid donut type devices in wheelchairs.

34. Support Surfaces
Multiple Pressure Points (greater than 2 turning surfaces)
Standard Mattress
3-4” Eggcrate Overlay on Standard Bed
Gel Mattress Overlay
Wheelchair Foam Pad
Wheelchair Gel Pad
Multiple Pressure Points (fewer than 2 turning surfaces)
Static Air Mattress
Alternating Pressure Pad and Pump
Low Air Loss Mattress (requires approval)
For multiple pressure points with greater than 2 turning surfaces, use the following:
Standard Mattress
3-4” Eggcrate Overlay on Standard Bed
Gel Mattress Overlay
Wheelchair Foam Pad
Wheelchair Gel Pad
For multiple pressure points with fewer than 2 turning surfaces, we recommend the patient use:
Static Air Mattress
Alternating Pressure Pad and Pump
Low Air Loss Mattress – which requires approval

35. In Summary….
Determine the plan of care based on the patient’s characteristics
Evaluate the wound status every visit and at a minimum of weekly
Evaluate the effectiveness of the treatment regime
Try to provide consistent wound care among all caregivers
Completely document status of wound
Remember that a clean pressure ulcer with adequate blood supply and innervation is expected to require at least 2-4 weeks to show evidence of wound healing. Many of our patients may not even live that long.
Hospice nurses should evaluate the wound on each visit.
Each type of treatment plan should be given at least 2 weeks to see the outcome of that treatment before considering the modification of the plan of care. Start with the preferred agents and then move on from there if you evaluate that they are not effective.
It is important that all dressing changes are performed in a uniform manner. Each nurse and family member may have their own technique which may influence the effectiveness of the intervention. It is important to follow product guidelines.
Be sure to document the wound status thoroughly. Utilize dieticians and physicians to substantiate unavoidable decline and risk factors associated with wounds which fail to heal.

36. Together, we can make a difference!
Thank you
Together, we can make a difference!
Thank you for your time and – TOGETHER WE CAN MAKE A DIFFERENCE