Wound Care: Where do we go from here? Jesse M. Cantu, RN, BSN, CWS, FACCWS April 20, 2012 San...
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Transcript of Wound Care: Where do we go from here? Jesse M. Cantu, RN, BSN, CWS, FACCWS April 20, 2012 San...
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Wound Care:Where do we go from here?
Jesse M. Cantu, RN, BSN, CWS, FACCWS
April 20, 2012
San Antonio, TX
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Disease Management(Wound Care Management)
• Evidence Based
• Best Practices
• Standards of Care
• Positive Outcomes
• Cost Containment
• Evolution of Dressings
• Summary
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Wounds
• Types– Acute – Chronic
• Closure
• Phases of Wound Healing
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Wounds
• Acute wound
– Planned / unplanned event
– Healing proceeds in an orderly and timely fashion
– Examples:
• Surgical
• Abrasion / laceration
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Acute Wound
• Surgical incision
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Wounds
• Chronic wound
– Exists two weeks or longer
– Does not proceed through normal healing process
– Examples:
• Pressure ulcers
• Diabetic / neuropathic ulcers
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Chronic Wound
• Pressure ulcer
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Chronic Wound
• Venous ulcer
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Chronic Wound
• Post-operative dehisced wound
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Wound Closure
• Primary intention
• Delayed primary
• Secondary intention
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What do you do if the burden is too big?
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Evidence Based / Best Practice
• Randomized control trials
• Protocols (NPUAP, WOCN, Canadian guidelines, AHCPR)
• Moist Wound Healing (George Winters)
• Wound Bed Preparation (Vincent Falanga)
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The Building Blocks of the Foundation for Wound Care
Debride Moisture TopicalsOff-Load
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Debride Moisture TopicalsOff-Load
SUCCESSFUL WOUND CARE
HYPERBARICSGROWTH FACTORS
BIOENGINEERED TISSUES
BIOLOGICDRESSINGS
NEGATIVE PRESSURETHERAPY
SILVER DRESSINGS
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Best Practices
• Evidence Based
• Wound Bed Preparation
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Wound Bed PreparationWhat Does It Mean?
Originally
• Debridement
Fibrotic Tissue
Hyperkeratotic Rim
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Wound Bed PreparationWhat Does It Mean?
Today
“…a very comprehensive approach aimed at reducing edema and exudate, eliminating or reducing the bacterial burden and, importantly, correcting the abnormalities … contributing to impaired healing.”
Vincent Falanga , MD
Professor, Boston University School of Medicine
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Other Voices….
“Think of it as removing various ‘burdens’ from the wound and the patient.”
• Exudate• Bacteria
• Necrotic/cellular debris
Elizabeth A. Ayello, PhD, RN & Janet Cuddigan, PhD RN
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Standards of Care
• NPUAP
• WOCN
• AHCPR
• Canadian Guidelines
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Positive Outcomes
• Wound Assessment at each dressing change
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Cost Containment
• Wet to Dry Dressings (Gauze and Saline)– Frequent dressing changes
• Moist Wound Healing (George Winters 1961)
• Active Wound Healing (NPWT, Hyperbarics)
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Evolution of Dressings
• Debridement
• Maintain a moist wound environment
• Reduce bacteria load
• Prolong dressing interval changes
• Stem cell technology
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Summary
• Wound management not wound care– Need to jump start nonhealing or slow wounds
• Adequate assessment, debridement, and wound irrigation based on Best Practices, Evidence based, Standards of Care, Positive Outcomes, and Cost containment
• Case studies
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Wound Care as Wound Management
• Properly treated wounds create the ideal win-win situation by decreasing hospitalizations, promoting wound healing in the home, improving quality of life, and improving patients’ sense of independence and well being.
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Other Voices….
Wound Bed Preparation is “the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures.”
Schultz G, Sibbald G, Falanga V, et al:Wound bed preparation: A systematic approach to wound management.Wound Rep Regen 2003
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What’s Needed to Heal a Diabetic Neuropathic Ulceration?
Control of Diabetes and General Health
Adequate Diet
Blood Supply
Absence of Infection
Regular Debridement
Offloading of Pressure
Moist Healing Environment
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Total Contact Casts Custom Splints
Therapeutic Shoes Removable Cast Walkers
Common Methods to Common Methods to “Off-Load” the Foot“Off-Load” the Foot
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So what is this going to cost me?
A lot less than traditional care…
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“Incidence, Outcomes, and Cost of Incidence, Outcomes, and Cost of Foot Ulcers in Patients with Foot Ulcers in Patients with
Diabetes”Diabetes”
• What is the cost of a new foot ulcer, not previously treated?
Ramsey, Reiber, et al. Diabetes Care, Mar 1999 – Univ of Washington
–$27,987 over a two year period!
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1. Benefits of a Closed Environment
• Moisture Balance• Reduction of
Nosocomial Infections• Prevents patient
interaction with the wound
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2. Promotes Perfusion
• Replacement of fibrinous tissue with granulation tissue
• Filling deficits in wounds
• Wound constriction
• Promotes granulation tissue formation
Dompmartin A, et al J Wound Care 2004 June
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4. Benefits of Maintaining a Moist 4. Benefits of Maintaining a Moist Wound BedWound Bed
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Why do we keep a wound moist?
Promotes rapid migration of epidermal cells across the wound bed
Promotes perfusion
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Why do we keep a wound moist?
Promotes rapid migration of epidermal cells across the wound bed
Promotes perfusion
Barrier against environmental contamination
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Benefits of Using Negative Pressure Therapy as an Adjunct
70 patients with chronic, non-healing wounds
treated with VAC following skin grafts
100 % of the grafts healed in an average
of 48 days
Carson SN, Overall K, Lee-Jahshan S, Travis E.Ostomy Wound Manage. 2004 March
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Escalating Bacterial Loads
• Contamination – Presence of nonreplicating microorganisms in the wound
• Colonization – Presence of nonreplicating microorganisms adhering to the wound, NOT causing injury to the host
• Critically Colonized – Bacteria cause a delay in wound healing
• Infection Local to Systemic – Presence of replicating microorganisms in wound and presence of injury to the host
Ayello and Cuddigan, 2003
BACTERIAL
LOAD
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Wound Bed Preparation:Wound Bed Preparation:Combining Topicals with NPWTCombining Topicals with NPWT
Control of:
• Contamination, colonization and critical colonization to optimize the wound bed
• Odor
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Case Studies
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The Challenge of a Large Deficit Wound and Poor Vascularity
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Ready for grafting