1. By Mark Vance RN WCC Multicare Home Health, Hospice And Palliative Care.

2. Types of Drains Active Drains Use negative pressure to remove fluids from wound. Passive Drains Use pressure from within wound and gravity to remove fluids from wound.

3. Types of Active Drains Use close sealed system under negative pressure to remove fluids  Most common is pleurx chest tube.  There is also Jackson Pratt and Hemovac. These systems use negative pressure to draw out fluid from wound. Dressing changes need to be sterile.

4. Closed Drains Pleurx and Jackson Pratt

5. Dressing Changes for Drains Closed active drains; Dressing change should be sterile and per MD orders. Typically 3 to 4 times a week or as needed for excessive drainage. Open passive drains; Dressing change is aseptic and need to be completed as needed for soilage of dressing. Need to pay attention to periwound tissue.

6. Open Passive Drains Penrose Drain and Tube Drains.

7. Ostomy Care Ostomy care in hospice patients can be easy to manage or difficult to manage. Majority of hospice patients have long term ostomy appliance and manage ostomy change well. There are times that due to illness they are no longer able to manage own appliance and need help from nurses.

8. Changes With Ostomy Patients 1. Change in abdomen due to either ascities or severe weight loss. 2. Changes in nutrition and stool consistency. 3. Inability to manage own appliance and inability of family to manage appliance. 4. Increase in peristomal skin issues.

9. Different Options to Help with Ostomy Care. 1. Consider changing appliance type. If using 2 piece consider switching to 1 piece. 2. Reinforce teaching with client’s and caregivers on proper skin care. a. Crusting technique. b. Use of skin prep and adhesive remover. c. Use of warm water to clean skin.

10. Crusting Technique  Clean skin with warm water and dry well.  Sprinkle irritated peristomal skin with stoma powder or miconazole antifungal powder.  Dab or spray powdered skin with skin prep consider use of no-sting skin prep.  Repeat 2-3 times.  Let skin prep dry well before applying appliance.

11. High Draining Wounds and Fistulas Some wounds and fistulas are high flow and it is difficult to manage drainage. 1. There are several different pouches available from Eakin, Hollister, and Coloplast have pouches available. 2. Also available are high absorbancy wound care products that absorb drainage. Examples are: ABD pads, Exudry, Xstrasorb, use of kerlix fluff gauze.

12. Wound Pouches

13. Seek Help Ostomy Companies Hollister Secure Start Program: 1-847-918-5257 1-888-808-7456 ext 1735 www.hollister.com

14. Ostomy Companies Continued Coloplast Ostomy Care Program Call 1-877-858-2656 to enroll, fax the patient enrollment form to 1-800-501-8533, or email your request to samples@coloplast.compatient enrollment formsamples@coloplast.com

15. Ostomy Companies Continued Convatec 1-800-422-8811 www.convatec.com Nu Hope 1-800-899-5017 USA/Canada 1-818-899-7711 Fax: 818-899-2079 http://nu-hope.com

16. Wound Care Products And How to Use Them Keep wound care simple. If wound moist, dry it up. If wound dry, moisturize it.

17. Dressing Categories Transparent Film Hydrocolloid Hydrogel Calcium Alginate Hydrofiber Aquacel Composite Collagen Foam Silver Other specialty dressings.

18. Transparent Film (Tegaderm) Description: Polyurethane with porous adhesive layer Indications: Primary & Secondary dressing Stage 1 & II ulcers Non-draining Advantages: Ready wound inspection Water tight Prevents or reduces friction Change every 5-7 days Disadvantages: May adhere to wound Non-absorptive May adhere to wound

19. Hydrocolloid (Duoderm CGF) Description: Hydrophilic colloid particles bound to polyurethane foam Indications: Stage I to IV ulcers Partial & full thickness Necrotic wounds Preventive for high-risk friction areas Secondary dressing or under taping procedures Advantages: Facilitate autolytic debridement Impermeable Conformable Absorptive, minimal to moderate drainage Disadvantages: May be hard to remove Shears off easily Not recommended for heavy drainage

20. Hydrogel (Curasol/wound gel) Description: Water or glycerin based sheet or gel. Available with silver (SilvaSorb Gel) Indications: Stage II to IV ulcers Partial & full thickness Painful wounds Radiation-damaged tissue Dermabrasion Advantages: Nonadherent Rehydrates wound bed Reduces wound pain Can use with topical meds Disadvantages: May require secondary dressing Surrounding skin maceration Not for heavy drainage

21. Calcium Alginate (Curasorb/Sorbsan) Description: Nonwoven composite of fibers from calcium-sodium alginate (seaweed) Indications: Partial & full thickness Moderate to heavy drainage Stage III or IV ulcers Dehisced wounds Sinus tracts, tunnels or cavities Infected wounds Advantages: Absorbent & nonocclusive Trauma-free removal Use with infected wounds Reduces change frequency Sheets & ropes available Disadvantages: Not with dry eschar, burns, heavy bleeding Need secondary dressing May produce odor Possible bed damage

22. Hydrofiber (Aquacel) Description: Sodium carboxymethylcellulose that interacts with wound exudate. Also in silver Indications: Partial to full-thickness Moderate to heavy drainage Donor sites Dehisced wounds Stage III to IV ulcers Sinus tracts, tunnels or cavities Advantages: Highly absorptive Trauma-free removal Disadvantages: Not with dry eschar, non- exudating wounds, 3 rd degree burns or heavy bleeding Requires secondary dressing to secure

23. Composites (All dress, viasorb, stratasorb) Description: Combination of 2 distinct products made as a single dressing; may include absorptive layer, foam, hydrocolloid. Indications: Partial to full thickness Stage I to IV ulcers Minimal to heavy drainage Surgical incisions Advantages: Facilitates autolytic debridement Conformable Multiples shapes and sizes Easy to apply and remove Most have adhesive border Disadvantages: Adhesive border may limit use on fragile skin Wound damage if not properly used & monitored

24. Collagen (Fibercol, Promogran matrix, Silver Prisma matrix) Description: Major body protein; stimulates cellular migration and contributes to new tissue development and wound debridement Indications: Partial and full thickness Stage III and some IV ulcers Dermal ulcers Donor sites Surgical wounds Advantages: Absorbent, nonadherent Forms biodegradable gel Conforms well Use with topical agents Change every 1-3 days Use for minor slough Disadvantages: Not for 3 rd degree burns Not for necrotic wounds Needs secondary dressing

25. Foam (Allevyn) Description: A hydrophilic, polyurethane film coated foam, non-occlusive nonadherent absorptive Indications: Partial to full thickness Minimal to heavy drainage Stage II to IV ulcers Surgical wounds Ulcers Infected & non-infected wounds Advantages: Nonadherent Trauma-free removal Absorbs min to heavy Easy to apply and remove Change every 3-5 days Disadvantages: Not for non draining or dry eschar Second dressing to secure May macerate surrounding skin if not changed

26. Silver Dressings Description: Immediate and sustained release of ionic silver; effective barrier to bacterial penetration. Indications: All wounds except: Stage I ulcer, 3 rd degree burns and non-draining Infected wounds Highly colonized wounds Over grafts or skin substitutes Under compression Advantages Inhibits growth of bacteria, especially antibiotic- resistant strains Effective up to 7 days Disadvantages Secondary dressing required Incompatible with oil- based products Possible sensitivity to silver

27. Specialty Dressings Medihoney Description: Made from Manuka Honey. Comes in several products. Product balances the PH in wound bed to lower PH level and moisturize the wound. Also helps with debriding wounds. Wound types: Partial to full thickness wounds. Stage 2, 3 and 4 pressure ulcers. Product types: Medihoney Gel, Medihoney Paste, Medihoney alginate, Medihoney HCS.

28. Hydrofera Blue Description: A foam dressing containing two organic pigments, methylene blue and gentian violet, in open- celled polyurethane foam. Uses: Pressure ulcers, venous stasis ulcers, diabetic foot wounds, abrasions, lacerations, surgical wounds. Advantages: Up to 7 day wear time, antimicrobial, non- cytotoxic, cheaper than other antimicrobial dressings. Available in variety of sizes. Disadvantages: Needs secondary dressing to hold in place. Wear time varies. Can stick to wounds.

29. Remember … Use the right product for the right wound. If not sure, ask your Wound Certified nurses or read the product insert. Be conscious of wound care costs. Have fun with wound care … it can be challenging but rewarding when products are effective and wounds heal quickly.

30. Now Lets Look At Some Pictures.

31. Stage 2 Pressure Ulcer

33. Stage 3 Pressure Ulcer

35. Stage 4 Pressure Ulcer

37. Unstageable Pressure Ulcer

39. References Bryant, Ruth A., and Denise Nix P. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier/Mosby, 2012. Print. Carmel, Jane, Janice Colwell, and Margaret Goldberg T. Wound, Ostomy and Continence Nurses Society Core Curriculum. N.p.: n.p., n.d. Print. Doughty, Dorothy Beckley, and Laurie McNichol L. Wound, Ostomy, and Continence Nurses Society Core Curriculum. N.p.: n.p., n.d. Print. Vuolo, Junlie, BA, RN. "Current Options for Managing the Problem of Excess Wound Exudate." Nursing Times. EMAP Publishing Limited Company, 1 June 2004. Web. 11 Sept. 2016.