Wound CareBest Practice Guidelines

VITAS Healthcare Corporation

Goal

To educate healthcare professionals on effective wound care protocols, in order

to ensure optimal care for our terminally ill patients.

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

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

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

Contributing Factors1

FrictionFriction

MalnutritionMalnutrition

IncontinenceIncontinence

ShearShear ImmobilityImmobility

PressurePressure

Pressure Pressure UlcersUlcers

Assessment and Documentation

• Location

• Stage and Size

• Periwound

• Undermining

• Tunneling

• Exudate

• Color of wound bed

• Necrotic Tissue

• Granulation Tissue

• Effectiveness of Treatment

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

Pressure Ulcer Staging2

Stage Stage II Stage Stage IIII StageStage III III Stage Stage IVIV

Care Planning.

Overall strategy and scope of the treatment plan depends on patient’s

condition, prognosis, and reversibility of the wound.

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

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

Pain Management

1) Medicate the resident prior to dressing changes

2) Some treatment regimes may be uncomfortable for the resident

3) Provide maintenance doses of medication for those patients who have pain.

4) Adjuvant therapy may be appropriate5) Consider non-medicinal approaches

Types of Wounds3

• Pressure Ulcers

• Arterial Insufficiency

• Diabetic Ulcers

• Venous Insufficiency

• Surgical Wounds

• Tumors

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)

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

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

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

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

Cleansing Wounds..

• Remove Wound Debris• Sustain Moist Environment• Soften Necrotic Tissue• Debride the Wound• Reduce the Risk of

Bacterial Contamination and Infection

• Reduce Odor

Goals & Treatment Guidelines

• Dry to Minimal Exudate

• Moderate Exudate

• Copious Exudate

Interventions Stage I

GOALS:• Maintain skin integrity• Skin to remain clean and

odor free• Protect and moisturize skin

TREATMENTS:

Preferred agents (dry skin)• Aloe Vesta skin creamPreferred agents (at risk for

breakdown due to incontinence/pressure)

• Aloe Vesta protective ointment

• Dermarite Perigaurd barrier ointment

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

InterventionsStage 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

InterventionsStage 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

Interventions

• Necrotic Tissue in Ulcer Bed• Fungating Lesions• Infected Wounds• Skin Tears• Gangrenous Wounds• Diabetic Ulcers

InterventionsNecrotic Tissue in Ulcer Bed

• Mechanical Debridement• Autolytic Debridement• Sharp or Surgical Debridement*• Enzymatic or Biochemical Debridement*• Biological Debridement*

*Requires Approval

InterventionsNecrotic 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.

InterventionsFungating 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

InterventionsInfected 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

InterventionsSkin Tears

Goals:

• Prevent infection• Healing• Prevent further injury• Minimize dressing change

frequency

Treatments:

Preferred Agents:• Non-Sterile Gauze • Transparent Film

(Opsite)

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

Support Surfaces

Comfort and Shear Reduction Products:

• Pillows• Heel/Elbow Protectors• Foot Cradles• Sheepskin Pads

DO NOT USE DONUT TYPE DEVICES IN

WHEELCHAIRS

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)

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

Thank you

Together, we can make a difference!