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Pharmacists & wounds

Carmen GeorgeClinical Nursing Specialist Services

Role of the pharmacist

Dispenser(Shop keeper)AssessorAdvisor?ClinicianReferrer?????????

Overview of how wounds heal

2 stages of wound healing

HaemostasisVasoconstriction responseresponsePlatelet responseBiochemical response

Tissue repairInflammationReconstructionmaturation

Wound healing physiology

Inflammation 0- 3 daysCapillaries contract & thrombose to facilitate haemostasisIschaemia in wound causes release of histamine causing vasodilation of surrounding tissuesMore blood to surrounding tissue causing swelling heatMore blood to surrounding tissue causing swelling, heat, erythema and discomfortPolymorphs & macrophages arrive to wound to provide a defence response

Reconstruction 2- 24 daysMaturation 24- 365 days

Wound healing physiology

Inflammation 0- 3 daysReconstruction 2- 24 days

Polymorphs kill pathogens and macrophages digest bacteria and debris. cleaning up the woundMacrophages also stimulate fibroblasts to produce collagenNew vascular network is built by the process ofNew vascular network is built by the process of angiogenesis-new capillary development can be seen in granulation tissueEpithelial cell migration occurs from wound edges and from hair follicles etc. Mitosis thickens epitheliumWound contraction occurs simultaneously within this period

Maturation 24- 365 days

Wound healing physiology

Inflammation 0- 3 daysReconstruction 2- 24 daysMaturation 24- 365 days

Remodelling phaseRemodelling phaseTensile strength of wound is increasedDecreased vascularityScar size decreases

This model is acute wound healing as opposed to chronic wound healing

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No person no wound

A holistic assessment of the client should be undertaken in conjunction with a wound assessment, to not only determine why the wound is present but to also uncover anywound is present but to also uncover any factors that will retard healing

K.Carville

What characteristics of the patient and their wound should be included in a comprehensive woundcomprehensive wound assessment?

Wound Assessment

Type of woundType of healingTissue lossClinical appearance

Measurement DimensionsExudateSurrounding skinpp

Location PainWound Infection

Type of Healing

Primary intentionSecondary IntentionDelayed Primary Intention

Type of Wound

Surgical incisionTraumatic-abrasion, laceration, penetrating, contusion, skin tearsBurns-minor, majorLower limb ulcers-vasculitic ulcer, diabetic ulcer, venous, arterial neuropathic etcPressure ulcer

Tissue loss

Superficial-epidermisPartial-epidermis and dermisFull-Epidermis, dermis and subcutaneous tissue

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Clinical Appearance

EpithelialisingGranulatingContractingSloughgEscharAngiogenesis

Location

Documented as a point of referenceIdentifies problems associated with accessEase of dressing procedureg pHighly movable partProne to friction and shear

Measurement Dimensions

Point of referenceCan be repeatedObjectiveLengthDepthDepthVolume replacementUnderminingTracts

Exudate

AmountColourViscosityColourOdourType

Surrounding Skin

Does it need protecting?MacerationOedemaErythemaDenudedLesionsReactions to tapes or dressings

Pain

May need addressing prior to procedureMay indicate infectionMay be related to wound practices or products

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Wound Infection

Growth of an organism in a wound with associated tissue reactionInfection delays wound healingIdentify patients at risk ie those with predisposing conditions

Extra information required usually for

Skin tearsLower limb ulcersPressure ulcers

Skin Tears Lower Leg Assessments

Presence or absence of dorsalis pedis and posterior tibial pulses Ankle and calf measurementsNeurological sensitivity to touch and painABPI

Pressure Ulcer AssessmentStage 1

Observable pressure-related alterations of intact skin whose indicators as compared to the adjacent or opposite area in the body mayarea in the body may include changes in one or more of the following: Skin temperature,tissue consistency and/or sensation

Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers AWMA 2001

Stage 2

Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as anpresents clinically as an abrasion, blister, or shallow crater

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Stage 3

Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer y gpresents clinically as a deep crater with or without undermining of adjacent tissue

Stage 4

Full thickness skin loss involving with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures eg tendon or joint capsule. j pUndermining and sinus tracts may also be associated with Stage 4 pressure ulcers.

Unable to stage pressure ulcers

Factors affecting wound healingDiabetes Anaemia SmokingVascularityAutoimmune diseases eg IBD,RA,ImmobilityInfectionMedicationsNutritional StatusMalignancy

External factors affecting wound healing

Availability of ProductsMedical Officers OrdersNursing Knowledge and skill? Pharmacists' knowledge of product performance

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Types of products

No such thing as the ‘ideal dressing’ ie one dressing wont do for all types of wounds.What are you trying to achieve?Short term objectivesShort term objectivesLonger term objectives

Refer to appropriate clinicianNursing, medical, hospital, clinic

Principles of wound management

Define/identify the aetiologyIdentify and if possible control or eliminate factors that can impair or effect wound healingSet long term and short term objectivesImplement a management plan/regimeReview and evaluate management regime regularlyPlan for wound healing maintenance

Why dress a wound??

To create an environment conducive to healingTo promote comfortTo protect the wound and surrounding tissueTo reduce pain by excluding

To control and prevent odourTo contain drainageTo immobilise an injured body partTo apply compression for p y g

air from nerve endingsTo maintain temperature in the woundTo control and prevent haemorrhage

pp y phaemorrhage or venous stasisTo prevent and manage clinical infection in woundsTo decrease distress for client and carers by covering the wound.

K Carville 2005

Ideal Dressing

Removes excess exudateMaintains a moist wound healing environmentAllows gaseous exchange if appropriateProvides thermal insulation

Does not cause sensitivity or allergic reactionProtects against mechanical traumaAllows removal without traumatising the new tissue

of woundProvides barrier to pathogensDoes not promote infectionDoes not shed fibres or leak out toxic substances

Is easy to applyIs comfortable to wearIs adaptable to body partsDoes not interfere with body functionIs cost effective

K Carville 2005

Types of dressings

Natural fibre dry dressings-gauze, combine, lint, linenNon adherent dry or film coated dressings island dressings eg Telfa, Melolin, MeloliteTulle Gras eg Jelonet, Adaptic,CuticerinTulle Gras with antiseptics eg bactigras, InadineSemi permeable Film dressings eg Opsite, Tegaderm

Types of dressings

Foam dressings eg Biatain, Hydrasorb, Polymem, Allevyn, Lyofoam. Sheets or cavityCalcium Alginate dressings eg Kaltostat, Sorbsan, Algoderm, Algisite M. Sheets or ropeHydrocolloids eg Duoderm Comfeel, Cutinova Hydro (sheets, powder & pastes)Hydrogels eg Intrasite, Comfeel Purilon Duoderm. Tube,sheets, impregnated dressings

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Types of Dressings

Hydrofibres- Aquacel. Sheets and fillerMultilayer Absorbent dressings eg Alione, CombidermCharcoal dressings eg Carbonet, Carboflex, Actisorb PlusHypertonic Saline Inpregnated dressings eg Curasalt, Meslat, HypergelC d I di d iCadexomer Iodine dressingsInteractive wet dressings eg TenderwetSilicone dressings eg Mepitel, MepilexSilver dressings eg Acticoat, aquacel Ag, Polymem Silver etcCeramic wound treatment devices egCerdakCapillary wicking dressings eg VacutexHoney eg medihoney, B Naturals, L Mesitran

Modern Wound DressingsAbsorbent exudate managers

Leg Ulcer managementCompression bandaging

Absorbent Wound Fillers

Autolytic Debriders Antibacterial

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Anti infective silver dressings Sophisticated products available in Australia

Silver at the chemists? New Ideas ?

Wound Bed PreparationWhat does this mean?Basically preparing the

wound for healing

Includes debridement, exudate managementinfection control, and

Usually referring to chronic wounds that have stalled in the healing process

,conversion of static wounds to active wounds

Readings and Resources

AWMA 2000 Standards for Wound ManagementAWMA 2001 Clinical Practice Guidelines for the prediction and Prevention of Pressure UlcersCarville K. 2005 Wound Care Manual(5th edition). Silver Chain WASilver Chain. WAwww.worldwidewounds.orgSAWMA www.sawma.org.auAWMA www.awma.org.au