Wound Care for Physicians Assessment, Documentation and Treatment

T.S.MUTHUKUMAR

Objectives


By the end of the presentation the participant will be able to

accurately assess and document patient wounds list basic wound care principles identify wound care products available at UHCMS

Assessment Wound Measurement

Length: head to foot Width: perpendicular to length Depth Undermining:Clock face Tunnel: tract in the wound

Assessment Wound measurement



Wound drawing

Photography

Wound Assessment
 

Wound bed:
Color: red, black (eschar), yellow (slough)

Exudate:
Color Odor Quantity

Periwound skin
Erythma, Maceration, denuded Palpate for induration, warmth, fluctuation

Wound Types


Pressure Ulcers
Tissue damage due to pressure Staged 1 to 4 based on depth of tissue involved


Only staged if wound bed visible otherwise unstageable or deep tissue injury Occiput Elbow Scapula Sacrum Ischium Malleolus Hip Braces, casts or tubing

Usually over pressure points

       

Pressure Ulcer Definition

A pressure ulcer is a localized injury to skin and/or underlying tissue usually over a bony prominence a result of pressure, or pressure in combination with shear and/or friction.


Pressure Ulcer Staging

The National Pressure Ulcer Advisory Panel has divided pressure ulcers into 4 stages based on anatomical tissue loss and has included two additional categories of suspected deep tissue injury and unstageable pressure ulcers.

UHCMC Focus

University Hospital Case Medical Center is committed to the prevention of all nosocomial pressure ulcers. The goal is zero incidence of pressure ulcers acquired during hospitalization.

Physician Role


CMS is asking that a pressure ulcer be properly documented by the physician upon admission. A pressure ulcer documented by the physician after the admission will be counted as a nosocomial pressure ulcer. This is even if there is admission documentation in the chart by other services such as nursing or dietary that the ulcer existed.

Physician Role


For the admission assessment the physician must view the patient from head to toe. Dressings must be removed, if possible, and the patient turned to view pressure points such as the heels, sacrum, occiput , elbows and scapula Pressure ulcers present on admission need to be documented as such and properly staged in the record.

Current Hospital Initiatives



Recent replacement of all patient beds with pressure reduction surfaces on Medical surgical floors. Evaluation of replacement beds for intensive care units and operating suites. Extensive nursing in-service on inassessment, prevention and treatment of pressure related skin problems.

Stage I


Intact skin with nonnonblanchable redness of a localized area usually over a bony prominence. Pigmented skin may not have visable blanching. Its color may be different from the surrounding area. The area may be painful, firm, soft, warmer or cooler than adjacent tissue.

Stage I

Stage I

Stage II


Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed. May also present as an intact or open/ruptured serum-filled blister. serumA shiny or dry shallow ulcer without slough or bruising (indicative of suspected deep tissue injury). Does not include: skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage II Pressure Ulcers

Stage II Pressure Ulcers

Stage II Pressure Ulcers

Stage III


Full thickness tissue loss. Subcutaneous fat may be visible but not bone, tendon or muscle are not exposed. The depth of a stage III pressure varies by anatomical location. The bridge of the nose, occiput and malleolus do not have subcutaneous tissue and stage III ulcer can be shallow.

Stage III Pressure Ulcer

Stage IV


Full thickness tissue loss with exposed bone, tendon and/or muscle. Slough or eschar may be present in some parts of the wound. Often includes undermining or tunneling.

Stage IV Pressure Ulcer

Unstageable Pressure Ulcer



Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore stage can not be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the bodys natural cover and should not be removed.

Unstageable Pressure Ulcer

Unstageable Pressure Ulcer

Unstageable Pressure Ulcer

Suspected Deep Tissue Injury



Purple or maroon localized area discolored intact skin or blood-filled bloodblister due to damage of underlying soft tissue from pressure and/or shear The area may be preceded by tissue that is firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The area may evolve rapidly to expose additional layers of tissue injury.

Suspected Deep Tissue Injury

Pressure vs. Vascular



It is important to distinguish between pressure and possible vascular causes of tissue injury. Pressure related injuries occur over bony prominences or areas of shearing. Pressure injury can also be related to equipment such as braces, casts and tubing.

Venous Ulcers
    

Medial lower leg Champagne Glass leg Dependent edema Hemosiderin staining Weeping wound with irregular borders

Venous Ulcers

Arterial Ulcers
   

Cold, hairless leg Lack of pulse Pain on elevation Relief on dependent position Wound with punched out appearance and pale or necrotic wound bed

Arterial Ulcers

Neuropathic/Diabetic Ulcer

  

Plantar surface of the foot

Round wound surrounded by callas Lack of sensation Foot deformity: Charcot foot.

Surgical Wounds
    

Dehiscence Infection Fistula Necrosis Altered wound healing

Principles of Wound Healing

 Protect

wound and provide a moist wound environment

Cover wound Fill in wound cavity Moisten dry wounds Control excessive moisture

Protect and Manage Moisture



Wet to Moist NOT Wet to Dry

New post operative wounds to monitor bleeding Twice a day dressing changes that increase risk of contamination Can reduce frequency of dressing change by adding moisture (Duoderm Hydrogel) Painful

Protect and Manage Moisture



Mepilex Border Dressings

Silicone dressing of various sizes Non occlusive to allow for air flow Reduces pain and further trauma when removed Change every 3 to 5 days For stage I and II PU, skin tears or for cover dressings.

Protect and Manage Moisture



Xenaderm Ointment
Protective barrier to skin Perineal Dermatitis Skin Tears Radiation Dermatitis Requires MD order Apply once to twice a day and after incontinence

Protect and Manage Moisture



Hydrocolloid (Duoderm)
Wound cover and protection Occlusive for minimal exudate Change 2 to 3 times per week Used in home care to reduce visits Can cause trauma to area when removed

Protect and Manage Moisture



Mepilex Transfer Dressing

For heavily draining wounds such as weeping venous wound or bullous lesions Silicone foam dressing Easy to remove with little trauma to tissue Wicks drainage. Requires absorbent cover dressing Change when saturated

Principles of Wound Healing

 Fill


wound cavity

Hydrofiber (Aquacel)
For moist and draining wounds  Easy to apply. Comes in rope and sheets  Change based on amount of drainage. Daily to every 3 days.  Turns to gel. Easy and less painful to remove and apply.

Principles of Wound Healing

 

Negative Pressure Therapy KCI Wound VAC (Vacuum Assisted Closure)

Wound filled with sterile foam. Covered with occlusive drape and attached to negative pressure pump. Removes exudate from wound Promotes angiogenesis and wound contraction Changed 3 times per week Reduces exposure to contamination and pain Expensive. Can be used at home with insurance approval. Not covered at home by Medicaid

Principles of Wound Healing



Promote a clean wound base free from infection

Irrigate wound with each dressing change with normal saline or wound cleaner to reduce bioburden Antimicrobial dressings
  

Aquacel AG Mesalt (Hypertonic saline) Wound VAC Silver Dressing

Appropriate antibiotic therapy

Anti infective Agents



Antibacterial fluids can be added to wet gauze dressings:

Sulfamylon (mafenide) Dakins Solution (for short period for infected, odorous wounds) Same concerns as previously noted for wet to moist dressings

Principles of Wound Healing



Remove nonviable tissue from the wound to promote new growth and reduce medium for infection
Debridement


Surgical:Sharps: immediate
Excisional Debridement removal of tissue and not just loose tissue fragments.

Enzymatic: Collagenase/Santyl oint.

Apply once or twice a day. Cover with dry dressing Necrotic Tissue needs to be scored with scalpel Can be slow process

Principles of Wound Healing



Investigate and resolve underlying causes

Pressure Ulcers
  

Pressure relief Reduce risk of shear Incontinence care Compression if arterial involvement ruled out Revascularization Glucose Control Off loading footwear

Venous Insufficiency


Arterial Ischemia


Neuopathic/Diabetic Ulcers
 

Principles of Wound Healing



Collaboration
Physician: Plastics, Vascular, Dermatology, Infectious Disease Nursing, WOCN Dietitian Diabetic Educator Physical Therapy Social Service Home Care

Thank You