McDermott Wound Care[1]
Transcript of McDermott Wound Care[1]
Wound CareBest Practice Guidelines
VITAS Healthcare Corporation
Goal
To educate healthcare professionals on effective wound care protocols, in order
to ensure optimal care for our terminally ill patients.
Objectives
• Identify preventative measures
• Describe risk factors contributing to skin impairment
• Describe the parameters of wound assessment including staging of wounds
• Describe wound types and tissues
• Describe care planning considerations and the selection of appropriate interventions
Prevention
• Inspect skin• Moisture control• Proper positioning and transfer techniques• Nutrition• Avoid pressure on heels and bony prominences• Use of positioning devices• Monitor and document
Risk Assessment
• Alterations in mobility• Level of incontinence• Nutritional status• Alteration in sensation or response to discomfort• Co-morbid conditions• Medications that delay healing• Decreased blood flow to lower extremities when
ulceration is present
Contributing Factors1
FrictionFriction
MalnutritionMalnutrition
IncontinenceIncontinence
ShearShear ImmobilityImmobility
PressurePressure
Pressure Pressure UlcersUlcers
Assessment and Documentation
• Location
• Stage and Size
• Periwound
• Undermining
• Tunneling
• Exudate
• Color of wound bed
• Necrotic Tissue
• Granulation Tissue
• Effectiveness of Treatment
Assessment and Documentation
• Wound and Risk Assessment every visit
• Documentation on Wound Assessment Form every 7 days when 1 or more pressure ulcer exists
• Physician assessment and documentation on Physician Wounds Care Assessment tool
Pressure Ulcer Staging2
Stage Stage II Stage Stage IIII StageStage III III Stage Stage IVIV
Care Planning.
Overall strategy and scope of the treatment plan depends on patient’s
condition, prognosis, and reversibility of the wound.
Appropriate Goals
• Prevent complications or the deterioration of an existing wound
• Prevent additional skin breakdown• Minimize harmful effects of the wound
on the patient’s overall condition• Promote wound healing
Interventions
Dressing considerations should include:
• Patient’s condition and prognosis• Caregiver ability• Ease and continuity of use• Ability to maintain moisture balance• Frequency of change
Pain Management
1) Medicate the resident prior to dressing changes
2) Some treatment regimes may be uncomfortable for the resident
3) Provide maintenance doses of medication for those patients who have pain.
4) Adjuvant therapy may be appropriate5) Consider non-medicinal approaches
Types of Wounds3
• Pressure Ulcers
• Arterial Insufficiency
• Diabetic Ulcers
• Venous Insufficiency
• Surgical Wounds
• Tumors
Palliative Wound Care for the Imminent Patient
Think:• Comfort• Quality of Life
Treatment Choices:• Keep Current Treatment• Irrigation, Cover with DuoDERM Thin or
Bioclusive Dressing• Irrigation, Silvadene, Cover with Gauze
(if infection is suspected)
Basic Elements of Wound Care
• Cleanse Debris from the Wound
• Possible Debridement• Absorb Excess Exudate• Promote Granulation and
Epithelialization When Appropriate
• Possibly Treat Infections• Minimize Discomfort
Wet to Dry Dressings
Indicated for Mechanical Debridement ONLY
• Causes Injury to New Tissue Growth• Is Painful• Predisposes Wound to Infection• Becomes a Foreign Body• Delays Healing Time
Frequency
• Goal is to minimize the frequency of dressing change
• Daily dressing changes increase chances of infection and disrupts the healing of tissue
• Optimal wear time is 3-7 days
Decrease Frequency
of Dressing Changes
Interventions:Patients At-Risk or Stage I
• Assess “Risk for Breakdown”• Utilize skin creams and lotions
for dry skin• Utilize barrier products as
needed to minimize irritation from incontinence
• Reposition frequently• Encourage fluids as tolerated
and appropriate• Use pillows in bed for
positioning
Cleansing Wounds..
• Remove Wound Debris• Sustain Moist Environment• Soften Necrotic Tissue• Debride the Wound• Reduce the Risk of
Bacterial Contamination and Infection
• Reduce Odor
Goals & Treatment Guidelines
• Dry to Minimal Exudate
• Moderate Exudate
• Copious Exudate
Interventions Stage I
GOALS:• Maintain skin integrity• Skin to remain clean and
odor free• Protect and moisturize skin
TREATMENTS:
Preferred agents (dry skin)• Aloe Vesta skin creamPreferred agents (at risk for
breakdown due to incontinence/pressure)
• Aloe Vesta protective ointment
• Dermarite Perigaurd barrier ointment
Interventions Stage II, III, IV
Dry to Minimal Exudate
GOALS:• Minimize dressing changes• Maintain moist environment• Prevent infection• Prevent additional skin
breakdown
TREATMENTS:
Preferred agents:• Hydrofiber (Aquacel)• Viscopaste• Hydrocolloid (DuoDERM
Extra Thin)
Follow product guidelines for frequency of dressing change
InterventionsStage II, III, IV
Moderate Exudate
GOALS:• Minimize dressing changes• Maintain moist environment• Prevent infection• Prevent additional skin
breakdown
TREATMENTS:
Preferred Agents:• Hydrofiber (Aquacel)• Hydrocolloid (DuoDERM
Signal)
Follow product guidelines for frequency of dressing change
InterventionsStage II, III, IV
Copious Exudate
GOALS:• Minimize dressing changes• Manage Exudate• Prevent infection• Prevent additional skin
breakdown
TREATMENTS:
Preferred Agents:• Hydrofiber (Aquacel)• Hydrocolloid (DuoDERM
Signal)
Follow product guidelines for frequency of dressing change
Interventions
• Necrotic Tissue in Ulcer Bed• Fungating Lesions• Infected Wounds• Skin Tears• Gangrenous Wounds• Diabetic Ulcers
InterventionsNecrotic Tissue in Ulcer Bed
• Mechanical Debridement• Autolytic Debridement• Sharp or Surgical Debridement*• Enzymatic or Biochemical Debridement*• Biological Debridement*
*Requires Approval
InterventionsNecrotic Tissue in Ulcer Bed
• Prior to debridement interventions, assess whether it will enhance wound healing or promote infection or cause undue pain.
• Do NOT institute aggressive debridement if the patient is within days/week of death, or if the eschar is stable, dry, non-draining, and wound is not infected.
• For Intact black heel – relieve pressure – no dressing or debridement – if opens then refer to necrotic treatments.
InterventionsFungating Lesion
Goals:• Removal of exudate• Odor control• Pain control
Non-Pharmacological measures to control odor include:
• Oil of Wintergreen• Charcoal briquettes or Coffee
grounds• Dryer Sheets
Treatments:
Preferred Agents• Non-Adherent Gauze Dressing
(Telfa)• Zinc Oxide Paste (Viscopaste)• Activated Charcoal Dressing
(Carboflex)
Atropine solution may be used to control bleeding
Metrogel cream can be used to control odor
InterventionsInfected Wounds…
Diagnosis of wound infection:• Swab Cultures not
recommended• Based on clinical signs (fever,
increased pain, friable granulation tissue, foul odor)
Tissue culture or biopsy is not optimal for the hospice patient.
Treatments:
Preferred agents:• Hydrofiber (Aquacel Ag)• Silvadene ointment and
non-sterile gauze
DO NOT USE:• Providine Iodine• Iodophor• Dakin’s solution• Hydrogen peroxide• Acetic Acid
InterventionsSkin Tears
Goals:
• Prevent infection• Healing• Prevent further injury• Minimize dressing change
frequency
Treatments:
Preferred Agents:• Non-Sterile Gauze • Transparent Film
(Opsite)
Interventions
Ischemic (Gangrenous) Wounds
• Draining wounds– Cover with Telfa or
gauze and wrap with Kerlix
• No drainage– Cover with gauze and
Kerlix • Change QD and PRN
Venous Stasis or Diabetic Ulcers
• Draining wounds– Cover with Telfa or
Adaptic with a Kerlix wrap changed QD
– Cleanse with normal saline using bulb syringe
• Non-draining wounds– Cover with gauze and
wrap with Kerlix – Apply tape to the Kerlix
to prevent further injury to surrounding skin
– Change QD
Support Surfaces
Comfort and Shear Reduction Products:
• Pillows• Heel/Elbow Protectors• Foot Cradles• Sheepskin Pads
DO NOT USE DONUT TYPE DEVICES IN
WHEELCHAIRS
Support Surfaces
Multiple Pressure Points (greater than 2 turning surfaces)• Standard Mattress• 3-4” Eggcrate Overlay on Standard Bed• Gel Mattress Overlay• Wheelchair Foam Pad• Wheelchair Gel Pad
Multiple Pressure Points (fewer than 2 turning surfaces)• Static Air Mattress• Alternating Pressure Pad and Pump• Low Air Loss Mattress (requires approval)
In Summary….
• Determine the plan of care based on the patient’s characteristics
• Evaluate the wound status every visit and at a minimum of weekly
• Evaluate the effectiveness of the treatment regime
• Try to provide consistent wound care among all caregivers
• Completely document status of wound
Thank you
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