WOUND CARE MANAGEMENT

“A Crash Course”

Alvyn “Joy” C. Halili, PT, CWS, FACCWSAcute Therapies Manager

Certified Wound Care SpecialistWinter Haven Hospital

OBJECTIVES

• Determine Basics in Wound Healing• Determine/Identify Current Methods in

Clinical Assessment• Identify Interventions Appropriate for Wounds

Encountered• Aid in Clinical Decision in Discharge Planning

or Continued Interventions

Contents

• Review of Skin Anatomy• Review of Phases in Healing• Review of the Clinical Team Approach in

Wound Healing• Review SOAP for Commonly Encountered

Cases

REVIEW OF SKIN ANATOMY

• Epidermis • BMZ• Dermis• Sub-dermis

Stratum Corneum

Stratum Lucidum

Stratum Granulosum

Stratum Spinosum

Stratum Basale/Germinativum

Basement Membrane Zone

DERMIS

DERMIS

REVIEW OF PHASES IN WOUND HEALING

• HEMOSTASIS• INFLAMMATORY• PROLIFERATIVE• REEPITHELIZATION• MATURATION/REMODELLING

ACUTE vs CHRONIC

• Acute• Sequence of Healing is within the expected time

frame of physiologic healing

• Chronic• Failed to proceed through an orderly and timely

process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result

THE CLINICAL TEAM

• Direct• Physician, ARNP, PA• Surgeon, Podiatrist, Dermatologist, Pathologist• Infectious Disease (ID)• Pharmacist• Nurses (Enterostomal Nurse, WC Nurse)• Ancillary (PT, OT, Dietary, Orthotist, Prosthetist)• Wound Care Specialist

CASE SUMMARY1. Arterial Insufficiency/Ulcers2. Venous Insufficiency/Ulcers3. Lymphedema4. Diabetic Ulcers5. Infected/Critically Colonized Surgical Wounds 6. Pressure Ulcers7. Traumatic Wounds8. Burns9. Atypical Wounds

S – SubjectiveO – ObjectiveA – AssessmentP - Plan

Arterial InsufficiencyS – Subjective: Complains of significant levels of pain O – Objective: ABI, Cardiac HistoryA – Assessment: distally located wounds, dry wounds, well shaped wounds, no pulse, no hair, poor capillary refillP – Plan- Keep it dry- Vascular Studies- Offloading – consider weight bearing restrictions- No compression if studies significant for PAD- Refer Vascular consult

Venous InsufficiencyS – Subjective: Complains of swelling, weeping, reoccurring problemO – Objective: ABI, Venous Doppler, CultureA – Assessment: Irregularly Shaped Wounds, Ulcers on Gaiter Area, Heavy Drainage,P – Plan:- Keep it dry- Elevation- Compression (35-45 mm Hg), Not Ted Hoses- Consider UNNA Boot/Multilayer Compression

dressing- Offloading – consider weight bearing restrictions- No compression if studies significant for PAD- Refer Vascular consult- Dietary Consult

Lymphatic SystemLike VenousS – Subjective:O – Objective: ABI, Venous Doppler, CultureA – Assessment: Ulcers can be on Gaiter Area, Heavy DrainageP – Plan:- Keep it dry- Elevation- Offloading – consider weight bearing restrictions- No compression if studies significant for PAD- Dietary Consult- Lymphedema Specialist (MLD,Compression,

exercises)

DiabeticS – Subjective: Complains of pain or no pain at all due to neuropathyO – Objective: ABI, Hgb A1c, PrealbuminA – Assessment: distally located wounds, Located on distally weight bearing areas, Charcot Foot DseP – Plan- Keep it dry- Vascular Studies- Offloading – consider weight bearing restrictions- No compression if studies significant for PAD- Refer to Podiatrist > Refer to Orthotist- Refer Vascular consult/Surgical Consult- Refer to Infectious Disease

Surgical WoundsS – Subjective: Variable, Pain, Fever, DehiscenceO – Objective: Prealbumin, Tissue biopsy, Culture and SensitivityA – Assessment: Determine presence of devitalized tissueP – Plan- Optimal moisture- Surgical Consult – Surgeon’s protocol/preference- Refer to Infectious Disease- Dietary Consult

NECROTIZING FASCIITIS

PRESSURE ULCER (PU)

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. A number of

contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be

elucidated.

Intact Skin

STAGES OF PRESSURE ULCERS

• STAGE I• STAGE II• STAGE III• STAGE IV• DEEP TISSUE INJURY(DTI)• UNSTAGEABLE

• Evolving Ulcer, Possible Stage III or IV

STAGE I

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.

Further description: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 skin tones. May indicate "at risk" persons (a heralding sign of risk)

STAGE I

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.

Further description: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 skin tones. May indicate "at risk" persons (a heralding sign of risk)

STAGE II

Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Further description:Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury

STAGE IIIStage 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 tissue loss. May include undermining and tunneling.

Further description: 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 pressure ulcers. Bone/tendon is not visible or directly palpable.

STAGE IV

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.

Further description: The depth of a stage IV pressure ulcer varies by anatomical location. 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.

Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of 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 compared to adjacent tissue.

Further description:Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

DEEP TISSUE INJURY

UNSTAGEABLE

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.

Further description: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.

WOUND MANAGEMENTDoes the patient have what it takes to heal?Is there infection?Is there mechanical stress?Is there necrotic tissue?Is there swelling, edema?Is the patient diabetic?Does the patient have peripheral arterial disease?Does the patient need financial support?Does the patient need nutritional support?Is the drainage controlled?Who is going to follow through?What available resource do I have in this facility that I can use?

ADVANCES IN WOUND CARE

• Debridement• Wet to Dry versus Active Dressings• NPWT (Negative Wound Pressure Therapy)• PLWS (Pulsatile Lavage with Suction)• Ultrasonic Debridement

References• Clinical Guide: Skin and Wound Care (Clinical Guide: Skin & Wound Care) Cathy

Thomas Hess RN BSN CWOCN (Author)• www.npuap.org• Wound Care Essentials: Practice Principles Sharon Baranoski (Author), Elizabeth A. Ayello

(Author)• Acute and Chronic Wounds: Current Management Concepts, 4e Ruth Bryant (Author),

Denise Nix (Author)• www.about.com Heather Brannon, MD• Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses Carrie

Sussman (Editor), Barbara Bates-Jensen (Editor)