Ms Leak - Fixing the Puzzle Dressing on Wounds
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Transcript of Ms Leak - Fixing the Puzzle Dressing on Wounds
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What do you see
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Wound Management
Kathy leak
Sister Wound Care B.a (Hon’s)
Doncaster & Bassetlaw Hospitals NHS Foundation Trust
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Best Practice guideline
• The practitioner can:
– Describe wound location
– Measure size of wound
– Describe wound bed
– Exudate
– Wound odour
– Pain
– Condition of surrounding skin
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Best practice Guideline
• Documentation
– Detail any shared care
– Reflect assessment findings
– Timescale
– Information given
– Wound management
– SINGLE MULTIDISCIPLINARY
DOCUMENT
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Best Practice Guideline
• Ongoing Review
– Regular assessments
– Timely and comprehensive
– Pt compliance
– Objectives met
– If not why not
– Reassess/ discharge
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Current issues in wound
management
• Changing patient profiles
• Complex wounds
• Wound assessment/decision making tools
• Identifying wound infection
• Innovation in wound care
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The 21st Century Patient: Older, sicker
and more complex
The wound site
Psychological
issues
Physical
problems:
concurrent illness
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Multiple pathologies
• Patients will often present with complicated clinical pictures
• Diabetes, anaemia, cardiovascular disease and respiratory conditions may co-exist in a number of patients.
• This clinical picture will have a direct effect on the wound healing potential of the patient.
• In elderly patients with chronic wounds, cells are found to be immature and unable to function normally (Henderson 2006)
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What makes a complex wound
complex?
Excess
bacteria
Alkalinic pH
Devitalised
tissue
Excessive proteases
Cell senescence
Poor local
vascular supply
Excess exudate
production
Prolonged
inflammation
Psychosocial
issues
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How do we deal with wounds such
as this?
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The key to dealing with complexity in
wound care lies in thorough and
accurate assessment
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HEIDI
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Assessment
History
• Presenting wound
• Medical background
• Drug history
• Social background
• Nutritional status
• Psychological status
• Patients’ perspective
Examination
• Basic skin assessment
• Type of wound
• Anatomical description of wound
• Size
• Wound bed appearance
• Exudate
• Odour
• Pain
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Investigations
• Bloods
• X-ray
• Doppler
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Wound bed preparation
• The key aim of treatment is to progress the
wound to healing or the best outcomes
possible
• The primary concerns are the removal of
necrotic/sloughy tissue and the prevention
of infection
• Wound debridement is a dynamic process
which continues until all necrotic tissue is
removed
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Black
• Treatment objectives
– Debride
– Maintain bacterial
balance
– Maintain moisture
balance
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Wound Management
Choosing the Right Dressing
• Hydrogels– Two basic forms – sheets
and gels
– Sheets for shallow wounds
– Gels for cavities and
desloughing and debriding
– Secondary dressings
required to keep insitu
– Maceration can occur
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Wound Management
Choosing the Right Dressing• Hydrocolloids
– Mixture of pectins, gelatins, sodium carboxymethylcellulose and elastomers
– Create an environment that encourages autolysis in sloughy necrotic wounds
– Reduce pain in wounds
– Provide an hypoxic environment which encourages angiogenesis
– Has a characteristic odour
– Require wound overlap of at least 2cm
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Black/yellow wound
Treatment Objectives
1. Debride
2. Maintain Bacterial
Balance
3. Maintain Moisture
Balance
4. What dressing?
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Yellow
• Treatment objectives
– Debride
– Maintain bacterial
balance
– Maintain moisture
balance
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Wound Management
Choosing the Right Dressing
• Alginates
– First used in 1940’s
– Made of seaweed
– Composed of galuronic and mannuronic acid – the quantities of these determines the gel forming properties
– Galuronic forms a firmer gel
– Mannuronic forms a softer gel
– For moderate to high exudate wounds
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Sometimes the yellow is green
Why?
What dressing ?
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Dehiscence: yellow red wound
• Treatment objectives
– Maintain bacterial
balance
– Maintain moisture
balance
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Wound Management
Choosing the Right Dressing
• Foam dressings
– Made using advanced polymer technology
– They are non-adherent, absorb large amounts of exudate, can be used as a secondary dressing
– Hydropolymer swells into wound bed as exudate is absorbed
– Can absorb several times their own weight in exudate
– For moderate to heavy exudating wounds
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Anyone like to guess what is
wrong here!
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Epithelial Regeneration:
Pink wound• Treatment objectives
– Maintain bacterial
balance
– Maintain moisture
balance
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Wound Management
Choosing the Right Dressing
• Film dressings
– Primary and secondary
dressing
– Clear polyurethane coated
with an adhesive
– Conformable
– Resistant to shear and
friction
– Prevent bacterial
colonisation
– Do not absorb EXUDATE
– Vapour permeable
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Wound Infection Continuum
Spreading Infection Local Infection Critically Colonised Colonised
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Dealing with increased bacterial load
• Recognise importance of bacterial load
– Contamination, colonisation, infection
• Monitor the impact of bacteria on healing
– Pain, exudate, bleeding, odour, systemic effects
• Treat the wound appropriately
– Wound debridement
– Antimicrobial dressings: containing povidone iodine/iodine (e.g. Inadine, Iodosorb/Iodoflex) or silver (e.g. Acticoat, Actisorb Silver, Flamazine)
– Increase frequency of dressing changes
– Systemic antibiotics
• Address host systemic factors
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How do we know when a wound
is infected ?• Presence of pus?
• Inflammation?
• Delayed healing
• Discolouration of the wound
• Friable Granulation Tissue
• Unexpected pain or tenderness
• Pocketting at the base of the wound
• Bridging
• Odour
• Cellulitis?
• Positive culture?
• Serous exudate
plus positive
culture?
• Localised pain?
• All of the
above? Cutting
and Harding
(1994)
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The effects of bacteria on wounds
• Compete with the bodies cells
for oxygen and nutrients
• Cell destruction can lead to
further necrosis
• Odour develops due to
anaerobic bacteria giving off
ammonia and other waste
products
• Cross contamination between
patients is common
• Systemic effects follow if left
untreated
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Biofilms
• Form when a collection of
bacteria attach to a surface and
subsequently encase
themselves in an exopolymeric
material
• As a “community” benefit
from metabolic efficiency
• Sometimes appear as a “glaze”
on surface of wounds
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Abscess formation
• Collection of pus and
necrotic material
• Pus contains bacteria and
white cells
• Contained within a wall of
fibrin and phagocytes
• May lead to lymphangitis
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Cellulitis: local infection
• Bacterial infection causing a spreading, non-suppurative inflammation of the skin.
• Most commonly haemolytic strep.
• Painful and often oedematous
• Ulceration and necrosis may ensue if severe.
• Lymphangitis also common.
• Can be confused with inflammation
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Spreading Infection
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Wound Management
Choosing the Right Dressing• Antiseptics and
disinfectants
– Silver – flamazine,
particularly effective in
treating pseudomonas
– Film dressings containing
silver reduce colonisation
– Silver and carbon dressings
reduce bacterial count and
odour
• Iodine
– No proven resistance to
iodine
– No adverse affects on
wound healing
– Rapidly deactivated in
presence of pus
– Cadexomer iodines absorb
exudate in exchange for
iodine
– Useful in treating colonised
wounds
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Exudate management
3
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Discharge
• Wound exudate is normal.
• Copious exudate and
continued inflammation
may indicate infection
• Seropurulent and
haemopurulent discharges
indicate liquefaction of
tissues as a result of the
micro-organisms in the
wound.
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Wound Exudate
• Assess exudate
– Colour; viscosity; volume; odour
• Assess wound
– Acute; chronic; infection; fistula; oedema; bleeding
• Document
– High; moderate; low
• Select dressing
– Conventional; NPWT; wound manager
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Summary
• Accurate assessment
• Appropriate dressing
leads to
• Happy patient
• Happy nurse
• Happy manager
HAPPY ENDING
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References and Further Reading
Cooper R (2004) A review of the evidence for the use of topical antimicrobial agents in wound care. http://www.worldwidewounds.com/2004/february/.../Topical -Antimicrobial-Agents.htm
Collier M (2004) Recognition and management of wound infections, http://www.worldwidewounds.com/2004/janu.../Management-of-Wound-infections.htm
Cutting K and Harding K (1994) Criteria for identifying wound infection, J. Wound Care 3 (4), pp 198-201
Kingsley A, White R and Gray D, (2004) The Wound Infection Continuum: a revised perspective, August, pp 22-25
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References and further reading
• Lansdown ABG, (2004) A review of the use of silver in wound care: facts and fallacies, Br. Journal Of Nursing, (TV Supplement), Vol 13, No. 6 pp s 6 – s 19.
• ReillY J McIntosh J And Currie K. (2002) Changing surgical practice through feedback of performance data. Journal Of Advanced Nursing, 38 (6) pp 607-614.
• Sunghal H and Zamit C, (2002) Wound Infection, http://www.emedicine.com/med/topic/2422.htm
• Tachi M, Hirabiayashi S, Yonehera Y, Suzuki Y and Bowler P. (2004) Comparison or bacteria-retaining ability of absorbent wound dressings, International Wound Journal, Vol 1 No. 3, pp 177- 181.