A WOC Nurse’sA WOC Nurse sApproach to Dressings

Faculty

Catherine T. Milne, APRN, MSN, BC-ANP/CS, CWOCNAdvanced Practice Nurse

Wound Ostomy ContinenceConnecticut Clinical Nursing Associates

Bristol, Connecticut

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Learning Objectives

• Compare and contrast the various categories of advanced wound care dressings

• Identify wound dressing materials with nonadherentproperties

• Evaluate the effect of collagen/oxidized regenerated cellulose on wound healing vs plain collagen-containing dressings

• Identify wound types for which a contact layer dressing would be appropriate

• Establish an appropriate dressing plan for a patient with a wound

Which Dressing to Use?

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Clinical Decision Making

PatientAssessment

WoundAssessment

CareSetting

Clinical Decision Making

Care Setting

Outpatient

AcuteHospitalSelf Care

LTAC

SNF

HomeCare

LTAC = long-term acute care; SNF = skilled nursing facility.

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Clinical Decision Making

Patient Assessment

• General information• General information

• Social/family support

• Age

• Employment

C biditi• Comorbidities

Clinical Decision Making

Patient Assessment

“You have to know the past to understand the present ”You have to know the past to understand the present.

– Dr. Carl Sagan, Astronomer

• Diabetes

• Complex regional pain syndrome

• Crohn’s disease

• Rheumatoid arthritis

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Patient Physical Exam

Head-to-toe assessment will aid in clinical decision making for dressing selection

Clinical Decision Making

Wound Assessment

Acute wound—a wound that is followingAcute wound—a wound that is followinga predicted pattern that should result in complete healing

Expected healing rates

Pressure ulcers7 weeks at Stage II

10 weeks at Stage III

19 weeks at Stage IV

Neuropathic—12 weeksDiabetic foot ulcers

Neuropathic 12 weeks

Ischemic—16 weeks

Venous ulcers 8 weeks

Split thickness donor sites6.8-12.9 days

2-3 weeks, if large and painful

Association for Advancement in Wound Care. http://aawconline.org. Accessed: January 10, 2012. Valdes AM, et al. Ostomy Wound Manage. 1999;45(6):30-36. Bolton L. Wounds. 2012;24(1):8-9.

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Clinical Decision Making

Wound Assessment

Healing can be predictiveHealing can be predictive

• Reduction in wound area per week– 40% reduction by week 3 in venous ulcers has 70%

healing rate

• Using benchmarks – 66% at outpatient wound centers

– Percentage healed at 12-week endpoint using RCTs

RCTs = randomized control trials.Phillips TJ, et al. J Am Acad Dermatol. 2000;43(4):627-630. Fife CE, et al. Wounds. 2012;24(1):10-17. Bolton L. Wounds. 2012; 24(1):18-24.

Clinical Decision Making

Wound Assessment

Chronic WoundChronic Wound• A wound that experiences a physiological delay through any of the normal,

orderly, sequential phases of healing– The wound may be categorized as a delayed-healing or nonhealing

chronic wound

• A delayed-healing chronic wound does not progress through a predefined healing pattern due to neglect, misdiagnosis, inappropriate treatment, or the inability to obtain or appropriately use necessarytreatment, or the inability to obtain or appropriately use necessaryresources in caring for the wound

– A delayed-healing chronic wound may deteriorate to a nonhealing wound

• A nonhealing chronic wound is a wound that does not progress through a predefined healing pattern due to underlying concurrent disease states and comorbidities that cannot be corrected or ameliorated

Association for Advancement in Wound Care. http://aawconline.org. Accessed January 10, 2012.

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Delayed-Healing Chronic Wound

Macroscopic Wound Environment

• Remove nonviable tissue• Remove nonviable tissue

• Identify and treat infection

• Address metabolic concerns

• Offload/pressure redistribution

I f i• Improve perfusion

• Remove mechanical forces impacting wound surface

Mechanical ForcesContribute to Pain

Substance P—mediator of neurogenic inflammationReleased with noxious stimuli from skinReleased with noxious stimuli from skin

Vasodilatation and plasma protein leaks

Infiltration of additional inflammatory mediators

PAIN

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Delayed-Healing Chronic Wound

Microscopic Wound Environment

• Identify and treat bioburden• Identify and treat bioburden

• Remove cellular debris

• Improve microcirculation

• Address protease imbalances

Delayed Healing Chronic Wound

F b MFebruary May

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Matrix Metalloproteases

Matrix Metalloproteases

• Intracellular production with extracellular release

• Cell to cell communication tool• Cell-to-cell communication tool

• Cell-to-matrix communication tool

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Matrix Metalloproteases

• Over 23 identified types

• Need calcium for structure C4 20

• Need calcium for structure

• Need zinc for activity

• Function in a neutral pH

CaCalcium

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Matrix Metalloproteases

• Expressed by cells when other biochemical signals are sensed

– Inflammatory cytokines• TNF-�, IL-�

• Cells expressing MMPs– Macrophages, fibroblasts, neutrophils, endothelial cells,

epithelial cells

TNF-� = tumor necrosis factor-alpha; IL-� = interleukin-beta; MMPs = matrix metalloproteases.

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Matrix Metalloproteases

• Each specific MMP has its own job – CollagenasesCollagenases

– Elastases

– Gelatinases

– Stromelysins

• Each identified by a number—MMP-1, MMP-2, etc.

Matrix Metalloproteases

• Will degrade ECM– Implicated in inflammatory diseaseImplicated in inflammatory disease

states, including the delayed-healingchronic wound

ECM = extracellular matrix.Ulrich D, et al. J Wound Ostomy Continence Nurs. 2011;38(5):522-528. International consensus. Acellular matrices for the treatment of wounds. An expert working group review. London: Wounds International, 2010.

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Matrix Metalloproteases

YiYing

Yang

MMPs—The Ying

• Necessary for normal wound repair– Degrade ECM at time of injury to allow cellular movementDegrade ECM at time of injury to allow cellular movement

to site of injury

– Activate growth factors stored in ECM

– Reorganize ECM to improve tensile strength at end of wound repair

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MMPs—The Yang

• Overproduction due to excessive cytokine production caused by

– Necrotic tissue

– Bioburden

– Repeated trauma

– Local tissue injury

MMP Overproduction

• Degradation of ECM

• Reduction in growth factors• Reduction in growth factors

• Cell receptor sites destroyed

• Cell migration inhibited

Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Philadelphia, PA: Lippincott, Wilkins and Williams; 2011. International consensus. Acellularmatrices for the treatment of wounds. An expert working group review. London: Wounds International, 2010.

MMP-1, MMP-2, MMP-8, MMP-9 well known “evil-doers”

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Clinical Decision Making

PatientAssessment

WoundAssessment

CareSetting

Clinical Decision Making

PatientAssessment

TopicalWound

Dressing

WoundAssessment

CareSetting

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Dressing Categories

Topical Dressings

Identify the Goal of Therapy

• Debride?• Debride?

• Control bioburden?

• Reduce and control pain?

• Diminish the persistent inflammatory response?

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Function

• Absorb exudate

Topical Dressings

Form

• Powder • Absorb exudate

• Decrease trauma at wound bed during dressing changes

• Reduce bioburden

• Powder

• Liquid

• Cream

• Ointment

G l • Provide components of an ECM

• Bind proteases

• Gel

• Sheet

• Rope

Topical Dressings

Active

• Aid in changing

Passive

• Cover wound• Aid in changingbiological or chemicalenvironment in wound

• May also havecharacteristics of passive dressings

• Cover wound

• Maintain moisturebalance

• May protect from outside environmentalinsults via physicalinsults via physicalbarrier

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Alginates PASSIVE

Antimicrobials PASSIVE/ACTIVE

Topical Dressing Categories

Collagen PASSIVE/ACTIVE

Composites PASSIVE

Contact layers PASSIVE/ACTIVE

Foams PASSIVE

Hydrocolloids PASSIVE/ACTIVE

Hydrofibers PASSIVE

Hydrogels PASSIVE

ORC/collagen ACTIVE

Transparent films PASSIVE

ORC = oxidized regenerated cellulose.

Antimicrobials

PASSIVE or ACTIVE?

• Brand dependent• Brand dependent– Absorb and kill

– Absorb and cidal

– Release and kill

– Release and cidal

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Hydrocolloids

Passive

• Facilitate moist wound environment• Facilitate moist wound environment

• Manage exudate

• Provide autolytic debridement

• Offer barrier to microorganisms

A ti ?Active?

• Oxygen-depleted environment thought to protect nerve endings and thus reduce pain

Queen D. Technology Update: Understanding hydrocolloids. Wounds International. www.woundsinternational.com/product-reviews/technology-update-understanding-hydrocolloids. Accessed January 12, 2012.

Collagens

• Use an exogenous form of collagen to provide a structural matrix

• Provide chemoattractants to stimulate macrophages and fibroblasts and their subsequent biochemical processes to stimulate normal healing cascade

Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Philadelphia, PA: Lippincott, Wilkins and Williams; 2011. Fleck C, et al. Adv Skin Wound Care. 2007;20(5):256-259.

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Collagens

• Can be degraded by sustained high levels of MMPs

ORC/Collagen

• 45% ORC

• 55% collagen bovine• 55% collagen—bovine

• Bioresorbable

• Open-pored matrix

Hall J. Podiatry Today. 2002;15(8):26-30.

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Benefits ofORC/Collagen Combination

• Binds more MMPs than ORC or collagen alone

Cullen B. Ostomy Wound Manage. 2002;42(Suppl 6):8-13.

ORC/Collagen

• Acts by binding and inactivating MMPs

• ORC stimulates cell proliferation• ORC stimulates cell proliferation

• Protects growth factors

• With or without silver

Cullen B, et al. Int J Biochem Cell Biol. 2002;34(12):1544-1556. Cullen B, et al. Wound Repair Regen. 2002;10(1):16-25.

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Wound Pain and Dressing Changes

• Wound pain is a common phenomena

• Dressing changes produce the most pain• Dressing changes produce the most pain

• Gauze is associated with most pain

• Hydrofibers, alginates, hydrogels, hydrocolloids, soft silicone, and combination materials produce the least pain

Moffatt CJ, et al. Understanding Wound Pain and Trauma: An International Perspective. Position Document: Pain at Dressing Changes. http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2002/Spring_2002__English_.pdf. Accessed February 5, 2012.

Contact Layer Dressings

• Antimicrobial with nonadherent contact layer

• Silver nonadherent dressing shown to reduce biofilm• Silver nonadherent dressing shown to reduce biofilmin vitro within 24 hours

• MRSA: complete kill

• Enterococcus fecalis (VRE): complete kill

• Pseudomonas: >3 log reductiong

MRSA = methicillin-resistant staphylococcus aureus; VRE = vancomycin-resistant enterococci.McInoy L, et al. Are silver containing dressings effective against bacteria in biofilms? Poster presented at: Wounds UK 2009. Clark R, et al. The evaluation of absorbent silver containing dressing in vitro; Systagenix wound management. Poster presented at: 15th Annual CAWC Conference; October 29-November 1, 2009; Quebec City, Quebec. Clark R, et al. Simulated in use tests to evaluate a non-adherent antimicrobial silver alginate dressing. Poster presented at: 15th Annual CAWC Conference; October 29-November 1, 2009; Quebec City, Quebec.

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Contact Layers

PASSIVE or ACTIVE?

• Silver nonadherent dressing• Silver nonadherent dressing– In vitro—low force in removal of fibrin clot

– In vitro—low adherence to wound tissue at day 7

Clark R, et al. The evaluation of absorbent silver containing dressings in vitro; Systagenix wound management. Poster Presented at: 15th Annual CAWC Conference; October 29-November 1, 2009; Quebec City, Quebec. Clark R, et al. From lab to leg: The importance of correlating in-vitro and in-vivo test systems to clinical experience. Poster presented at: SAWC Spring meeting; April 17-20, 2010; Orlando, Florida.

Contact Layers

• In vivo—10 patients with silver nonadherent with additional 10 as control with generic calcium alginate

• Assessment– Adherence

– Pain (Wong-Baker)

– Visible fibers left in wound bed

N d f li k t d i h– Need for saline soak at dressing change

Clark R, et al. From lab to leg: The importance of correlating in-vitro and in-vivo test systems to clinical experience. Poster presented at: SAWC Spring Meeting; April 17-20, 2010; Orlando, Florida.

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Contact Layers

Indications• Fragile periwound skinFragile periwound skin• Pressure ulcers • Venous ulcers • Diabetic ulcers • Donor sites, trauma/injuries, and surgical wounds,

including cavitiesincluding cavities• Moderate to highly exudating wounds• Prophylactically in clinical situations placing patient at

risk for infection

Clark R, et al. Wounds International. 2010;1(5):1-6.

Contact Layers

What effect may these dressings haveon the wound microenvironment?

• Substance P

• MMP levels

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Clinical Decision Making

PatientAssessment

TopicalWound

Dressing

WoundAssessment

CareSetting

Case Studies

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Case 1

• 76-year-old female

• Medical history• Medical history– COPD, GERD, venous insufficiency, osteoarthritis

• Sustained a syncopal event– During this incident she fell against her dishwasher, sustaining

a partial degloving of her right lower extremity

COPD = chronic obstructive pulmonary disease; GERD = gastroesophageal reflux disease.

Case 1

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Case 1

PatientAssessment

WoundAssessment

CareSetting

TopicalWound

Dressing

Case 2

• 47-year-old male

• Presented at outpatient wound center with a 3 month• Presented at outpatient wound center with a 3-monthhistory of a plantar foot ulcer

• Medical history– Morbid obesity, HTN, nicotine abuse

• Recently diagnosed with type 2 diabetes

• Works as a teacher in a local high school

HTN = hypertension.

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Case 2

Case 2

PatientAssessment

WoundAssessment

CareSetting

TopicalWound

Dressing

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Case 3

• 78-year-old female developed coccyx pressureulcer while hospitalizedulcer while hospitalized

• Underwent debridement and was transferred to a long-term care facility

• Became combative with dressing changes

f• Area was also frequentlysoiled with fecal and urinary effluent

• Wound measured 6.2 cm long x 4.8 cm wide x 1.2 cm deep

Case 3

Week 12

• Wound measurement• Wound measurement– 1.8 cm long x 1.5 cm

wide with no depth

PatientAssessment

WoundAssessment

CareSetting

TopicalWound

Dressing

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Case 3

Week 16—healed

PatientAssessment

WoundAssessment

CareSetting

TopicalWound

Dressing

Summary

• To choose appropriate topical dressing– Head-to-toe patient assessmentHead to toe patient assessment

– Comorbidities• Producing large amounts of inflammatory mediators?

• Uncontrolled MMPs?

– Care setting• Frequency of dressing changes

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