1. Lotions, Potions and Dressings – What do I DO? Anna Braden, BSN, RN, CWOCN

2. Objectives Have a basic understanding of skin and wound assessment Have an understanding of basic dressing selection guidelines based on assessment Have a basic understanding of product categories

3. Anatomy Epidermis Dermis Subcutaneous tissue Fascia, Muscle, Bone

4. Injury Hemostasis: Coagulation Platelet aggregation Platelets Inflammation: Macrophages Neutrophils Granulocytes Debridement Resistance to infection Neovascular growth Granulation Collagen lysisCollagen synthesis Maturation: remodeling Healed wound Proliferation EpithelializationProteoglycan synthesis Contraction Wound Healing Wound Care: An Incredible Visual! Pocket guide, 2009

5. Wound healing Wikipedia, the free encyclopedia

6. Wound Healing Partial Thickness ◦ Epidermis, dermis Full Thickness ◦ Can be shallow or deep ◦ Subcutaneous tissue ◦ Fascia, Muscle

7. Factors affecting wound healing Perfusion/oxygenation Nutritional status!!!! Infection Corticosteroids/medications Aging Nicotine!!! Smoking Denervation Obesity Diabetes!!!! Most of all – patient’s cooperation

8. Skin Assessment Color Texture Temperature Turgor Odor Sensations

9. Wound Assessment 1. Location – anatomic landmarks 2. Size including a.Undermining b.Tunneling/sinus track 3. Wound bed appearance 4. Exudate a.Amount & characteristics 5. Odor 6. Pain 7. Peri wound skin

10. Infection? – Yes or No? Contamination Colonization Critical Colonization Infection ◦ Local vs systemic ◦ Elevated Glucose in diabetics ◦ Pain in neuropathic extremity Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 270-273

11. Skin Products Antimicrobial Emollient Humectant Preservative Skin protectant Surfactant Dimethicone Petrolatum Zinc Oxide ◦ <25% = creamy ◦ >25% = pasty

12. Dressing Selection – 1 st Basic Rule Dry shallow/superficial wound = Need to ADD moisture Dry deep/cavity wound = Need to ADD moisture = Need a Filler in order to pack undermining/tunneling areas = Need a Cover dressing Wet shallow/superficial wound = Need to wick/absorb moisture ***Peri wound skin: Protective barrier film*** Wet deep/cavity wound = Need to wick/absorb moisture = Need a Filler to pack undermining/tunneling areas = Need a Cover dressing ***Peri wound skin: Protective barrier film***

13. Then Dressing Selection Goes on based on: ◦ Does the wound need to be debrided?  Mechanical, enzymatic, autolytic ◦ Is there an infection present? ◦ Does the wound bed remain moist or is it drying up? ◦ Do the wound edges need to be opened? ◦ Is the wound bed being protected from injury, trauma etc.? ◦ Is the wound being insulated? “A dry cell is a dead cell”

14. Products Terms: ◦ Primary dressing ◦ Secondary dressing ◦ Filler ◦ MVTR – Moisture-Vapor Transmission Rate ◦ Epidermal stripping

15. Products - Antimicrobial Antiseptics, iodine, honey, hydrofera blue, mupirocin ointment, silver Indications: ◦ Partial or full thickness wounds ◦ Critical colonization, infection ◦ Odorous wound Primary or secondary dressing Advantages: ◦ Provides broad range of antimicrobial or antibacterial activity ◦ Reduces infection ◦ Prevents infection Disadvantages: ◦ Silver - May cause staining ◦ May cause stinging or sensitization ◦ Nanocrystalline Silver – inactivated by saline Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292

16. Products – Calcium alginate Called usually ‘alginate’ Polysaccharide derived from brown seaweed Partial or full thickness wounds Primary dressing/filler ◦ Usually needs a secondary/cover dressing Highly absorbent – moderate to heavily draining wounds Converts to a viscous/hydrophilic gel Hemostatic properties Change as needed – usually every 24-48 hours Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292

17. Products - Charcoal Activated carbon ◦ Absorbs toxins and wound degradation products Indications: ◦ Malodorous wounds ◦ Fecal fistulas Apply as a ‘filter’ for odor control If absorbing drainage, need to change when saturated Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292

18. Products – Collagen Enhances deposition of collagen fibers Chemoattractant to granulocytes & fibroblasts Bioresorbable Hemostatic properties Processed from bovine or porcine sources Indications: ◦ Full-thickness wounds with or without depths ◦ Noninfected wounds ◦ Minimal to moderate amount of drainage Apply to wound base ◦ Requires a secondary/cover dressing Packaged as gels, alginates, sheets, powders Contraindicated in bovine sensitivites Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292

19. Products - Composite Combine distinct dressing components into a single dressing ◦ Absorptive part is different than alginate, foam, hydrocolloid, hydrogel Bacterial barrier Partial or full thickness wounds without depth Dry to heavy drainage – depending on dressing components Primary or secondary dressing Can be used with topical medications Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293

20. Products – Contact layer Protects the wound from direct contact with other agents/dressings Conforms to wound shape Porous Indications: ◦ Partial or full thickness wounds with or without depth ◦ Infected wounds ◦ Donor sites ◦ Split-thickness skin grafts Not intended to be changed with every dressing change Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293

21. Products – Fiber gelling Hydrofiber Moderate to heavy drainage Converts to gel - “snot”-like appearance Partial or full thickness wounds Usually needs a secondary dressing Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293

22. Products - Foam Absorptive and non-adherent Indications: ◦ Partial or full thickness wounds with or without depth ◦ Moderate to heavily drainage Contraindicated with dry eschar Frequently used as a secondary dressing after medication and/or primary dressing If used as primary dressing, apply appropriate secondary dressing Change every 24 hours or as needed Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293

23. Products - Hydrocolloid Contains gel-forming agents ◦ Forms a gelatinous mass Impermeable to contaminants = reducing risk of infection Promotes autolysis Indications: ◦ Partial or full thickness wound with or without depth ◦ Minimal to moderate drainage Avoid acutely infected wounds and dry eschar Use cautiously in diabetics Low MVTR Change every 3-5 days as needed Select dressing 1-2” larger than the wound Use light pressure of hands to allow body heat promote adhesion Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 294

24. Products - Hydrogel Adds moisture to dry wound bed Non-adherent Little or no absorption Cool & soothing Various formulations: ◦ Gel, sheets, impregnated gauze, with silver Apply according to instructions Use appropriate secondary dressing Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293

25. Products – Transparent film Indications: ◦ Shallow partial thickness ◦ Dry to minimal drainage = nonabsorbent  Low MVTR Can promote autolysis Creates “second” skin Apply without tension/stretching Allow for 1-2” border around wound Use skin sealant around wound edges Not for infected wounds Change every 4-7 days or as needed Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293

26. Products – Medications Collagenase/=Santyl ◦ Enzymatic debrider  Collagenase derived by fermentation of Clostridium histolyticum ◦ Need physician order ◦ Need some ‘contact’ with moist wound bed  Around edges or cross-hatching by physician ‘Xenaderm’ = BCT ◦ Balsam Peru ◦ Castor oil  Improve epithelialization  Protective covering  Aids in reduction of pain ◦ Trypsin – mild debrider Dakin’s solution ◦ 1/16 strength – odor control ◦ 1/25 strength – pseudomonas infection Metronidazole/Flagyl ◦ Crushed - odor control Thomas Hess, C. Clinical Guide to Skin and Wound care. 2013, 7 th Edition, p 557-559

27. Peri wound protection Prevent epidermal stripping ◦ Avoid tapes if possible ◦ Roll gauze, tubular stockinette, Montgomery straps ◦ Skin sealants Maceration ◦ Skin sealants ◦ Zinc oxide ◦ Re-evaluate current dressing and/or frequency Infection ◦ Candidiasis  Crusting technique with antifungal powder Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 300-301

28. Special Consideration: Palliative Wound Care S = Stabilize the wound P = Prevent new wounds E = Eliminate odor C = Control pain I = Infection prophylaxis A = Advanced absorbent wound dressings L = Lessen dressing changes Haas. M.L., Moore-Higgs, G.J. Principles of Skin Care and the Oncology Patient.2010. p 105.

29. Documentation Today – EMR/Electronic Medical Record ◦ Order ◦ Assessment ◦ Actual dressing change ◦ Teaching Must meet certain criteria for reimbursement Accurate and consistent ◦ Monitoring ◦ Legal Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 300-301

33. Presentwoc.com

34. Worldwidewounds.com

40. References Bryant, R., Nix, D. Acute and Chronic Wounds. Current Management Concepts. 4 th Edition. 2012. Hass, M.L., Moore-Higgs, G.J. 2010. Principles of Skin Care and the Oncology Patient, p 105, Milne, C.T., Corbett, L.Q., Dubuc, D.L., Wound, Ostomy, and Continence Nursing Secrets, Questions and Answers Reveal the Secrets to Successful WOC Care. 2003 Thomas Hess, C. Clinical Guide to Skin and Wound care. 7 th Edition. 2013. Wound Care: An Incredibly Visual! Pocket Guide. 2009. Wound healing, p 21.

41. Questions?