1. EENY, MEENY, MINEY, MO CHOOSING the RIGHT DRESSING for the WOUND Denise McConnell, APRN, CNS, MS, CWOCN

2. OBJECTIVES  The attendee will be able to:  Identify 4 types of dressings based on wound description  Identify 3 goals of wound care  Identify 4 road blocks to healing and how to resolve them

3. DECISIONS TO BE MADE  HEAL THE WOUND(S)  MAINTAIN THE WOUND(S)  PALLIATIVE CARE OF PATIENT/ WOUND(S)

4. THE RIGHT DRESSING  The appropriate dressing will:  Protect the wound bed and surrounding tissue  Promote healing  Decrease infections  Control pain  Control costs

5. THE WRONG DRESSING  The inappropriate dressing will:  Inhibit healing  Leading to stalling or deterioration of wound  Lead to infection  Lead to injury of the periwound tissue  Cause pain

6. GOALS OF WOUND CARE  Managing the moisture of the wound bed  Prevention of infection and bioburden  Promoting an environment that is physiologically conducive to healing  Pain management  Protection from injury  Trauma  Cold  Improving quality of life

7. WHAT’S THE PROBLEM  Treatment should begin with identification of type of wound and identification of road blocks (real/potential) to healing. TYPE:  ARTERIAL VENOUS  SURGICAL AUTOIMMUNE  PRESSURE ULCERS  DIABETIC/NEUROPATHIC  TRAUMA/BURNS ROAD BLOCKS:  PAD VENOUS HTN  HYPERGLYCEMIA  SMOKING  OBESITY  PROTEIN-CALORIC MALNUTRITION  PYSCHOSOCIAL ISSUES

8. WHAT’S NEXT?  The next step is to remove/correct the road blocks.  Angiogram with intervention to improve arterial circulation  Diabetic education for better glycemic control  Compression of lower extremities  Smoking cessation  Weight loss  Adequate protein/calories to promote healing  Psychosocial support

9. ASSESSMENT  Is there:  Necrotic, slough, bioburden  Infection, inflammation  Tunneling, undermining  Drainage-wet, dry  Periwound intact, skin damage  Presence of pain

10. TREATMENT DECISIONS  Debridement  Antibiotics, antiseptics, bactericidal  Wound fillers  Moisture management  Stimulation  NPWT  Grafts/donors/flaps  Compression  Pressure relieving/reducing

11. DEBRIDEMENT  Debridement-the removal of devitalized tissue. Wound will not progress if necrotic tissue present.  Enzymatic –collagenase  Hyper-sodium chloride gel, ribbon or pads  Honey-medical grade  Hypochlorite solution (Dakin’s 0.25-0.5%)  Biologics-larvae  Surgical

12. DEBRIDEMENT

13. DEBRIDEMENT

14. ANTIINFECTIVES  Use of antimicrobials, bactericidal, bacteriostatic-used to manage infections or colonization of wounds.  Topical MupirocinCadexomer iodine gel/pad Silver sulfadiazine Silver dressings Hypochlorite solution (Dakin's 0.25-0.5%) Acetic acid 0.25% (Vinegar) Methylene blue/Crystal violet  Systemic-IV or P.O.

15. ANTIINFECTIVES

16. WOUND FILLERS  Packing-fills in dead space of tunnels or undermining.  Gauze moistened normal saline or medicated  Packing strips  Plain  Plain with the addition of topical medication  Medicated –iodoform, silver  Calcium alginates/hydrofibers  NPWT

17. WOUND FILLERS

18. MOISTURE MANAGEMENT- WET  Absorb exudate- excess drainage can lead to increase bioburden in wound, odor, maceration of periwound area, or hypergranulation of tissue Calcium alginatesHydrofibers FoamsComposites-ABD pads Gauze padsHydrocolloids Hydrogel sheetsPolymer-based dressing NPWTWound managers (ostomy pouches)

19. MOISTURE MANAGEMENT- WET

20. MOISTURE MANAGEMENT- DRY  Dry wound bed can lead to desiccation of the cells, platelets and growth factors.  The dressing should provide a moist wound environment that functions to maintain that moisture. Foam Transparent film HydrofiberHydrogel gel/sheets Impregnated gauzeHydrocolloids NPWT

21. MOISTURE MANAGEMENT - DRY

22. WOUND STIMULATION  Tissue engineered skin-matrix of collagen, fibroblasts, keratinocytes and growth factors. Comes in sheets. Human sources.  Collagen-stimulates healing. Comes in pouches, vials, gels, pads, powders freeze-dried sheets. Source can be bovine, porcine, sheep or avian.  Growth factors-cause cell proliferation.

23. WOUND STIMULATION

24. NEGATIVE PRESSURE WOUND THERAPY  Contact layer-foam, gauze  Negative pressure  Purpose:  Maintain a moist environment  Stimulation of perfusion-formation of granulation tissue  Cell division by mechanical stretching  Management of bioburden

25. GRAFTS/DONOR/FLAPS  Prevent trauma-pressure reducing/redistribution cushions/beds  Graft/donor-protect-transparent films, fine mesh gauze-impregnated  Use turn sheets-prevent shear  If an extremity involved, keep elevated and compression (if indicated)

26. MISCELLANEOUS  Skin tears-approximate edges and use skin bonding product or steristrips. Cover with absorbent dressing.  Hypergranular tissue-reduce bioburden, topical antimicrobial agents, foam dressings  Periwound protection-use of absorbent dressings, skin protectants that will prevent hydration of skin.

27. MISCELLANEOUS

28. MISCELLANEOUS  Hypothermia-keep area warm, protective dressing, decrease length of time wound exposed.  Fistulas-use of wound managers, ostomy pouches  Trauma-use low air loss mattresses, w/c cushions, heel/feet boots/pads, sacral dressings

29. COMPRESSION  Standard for venous hypertension of lower extremities  Increases/augments rate of blood flow in the calves.  Discourages leakage of veins into interstitial tissues leading to edema  Methods: Compression wrapsStockings Orthosespneumatic pumps Short stretch wrap

30. PRESSURE RELIEVING/REDUCTION  Low air loss mattress  Wheel chair cushions  Shoes  Wheel chair  Total contact cast/modified cast

31. COST  Is patient able to purchase supplies, medications  Resources-insurance, family, Medicare, Medicaid  Who provides care-home health, clinic, family, doctor’s office  Where to obtain supplies-DME, stores, donations

32. BIBLIOGRAPHY  Broussard, C.L. (2007). Dressing decisions. In Drasner,D., Rodeheaver, G.T., Sibbald,R.G. (Eds.), Chronic wound care: a clinical source book for healthcare professionals (4 th Ed.) (pp. 249-262). Malvern, PA: HMP Communications  Bryant, R.A., Nix, D.P., Rolstad, B.S. (2012). In Bryant, R.A., Nix, D.P. (Eds), acute and chronic wounds: current management concepts (4 th Ed.) (pp 279-288). St. Louis, Missouri: Mosby Elsevier.  Cockbill, S.M.E., Turner, T.T. (2007). The development of wound-management products. In Drasner,D., Rodeheaver, G.T., Sibbald,R.G. (Eds.), Chronic wound care: a clinical source book for healthcare professionals (4 th Ed.) (pp. 233-248). Malvern, PA: HMP Communications  Krasner, D.L., Sibbald, R.G., Woo, K.Y. (2011). Wound dressing product selection: a holistic, interprofessional patient-centered approach: a kestrel woundsource white paper. Retrieved January, 2015, from http://www.woundsource.com  Ovington, L., Rolstad, B.S. (2007). Principles of wound management. In Bryant, R.A., and Nix, D.P. (Eds.), acute and chronic wounds: current management concepts (3 rd Ed.) (pp 391-460). St. Louis, Missouri: Mosby Elsevier.  Ramundo, J.M. (2012). Wound debridement. In Bryant, R.A., Nix, D.P. (Eds), acute and chronic wounds: current management concepts (4 th Ed.) (pp 279-288). St. Louis, Missouri: Mosby Elsevier.