10.2 (8.4 Fistula bits) Palliative wound and ostomy care Flashcards
What are three types of skin failure?
Acute, chronic and end stage
Name 3 causes for:
(a) acute skin failure
(b) chronic skin failure
Acute skin failure:
- Peripheral arterial disease*
- Severe sepsis/septic shock*
- Respiratory failure*
- Mechanical ventilation
- Liver failure
Chronic skin failure:
- Peripheral arterial disease*
- Diabetes*
- Nephropathy*
- Neurodegen disorders
V - PAD
I - sepsis
N - cancer
D - liver or kidney failure
I - radiation, chemo
C
A - eczema
T - trauma
E - diabetes
What are 2 examples of end stage skin failures?
Are they avoidable or unavoidable injuries?
Kennedy terminal ulcers (KTUs)
Trombley-Brennan terminal tissue injury (TB-TTI)
Generally unavoidable injuries
2 ways to distinguish KTUs from TB-TTI
KTU:
- Over bony prominences
- Develop < 2 months prior to death
TB-TTI:
- Found in locations with little to no pressure (e.g thighs)
- Median time to death is 36 hours
Name 3 characteristics of KTUs (in terms of appearance)
Sacroccoygeal location*
Sudden onset*
Butterfly or pear shape*
Irregular borders
Purple, blue, black or red color
What are the 11 parts of systematic wound assessment?
How often should this be done?
- Location
- Etiology or type of skin damage
- Dimension
- Base description (e.g. granulation, nerotic, eschar, slough, epithelial, mixed)
- Undermining/tunneling (stage III or IV pressure injuries only)
- Stage
- Drainage
- Odor
- Periwound skin
- Pain
- Infection
Done weekly or with change in condition
LED
BUS
DOPPI
What are 5 common symptoms associate with wound?
Pain, odor, bleeding, exudates, pruritus
FS: DOPPI
Drain (bleeding, exudates)
Odor
Periwound skin - pruritus
Pain
Infection
What can exacerbate wound symptoms? List 2
Infection
Lymphedema
Name wound pain interventions:
- 4 meds
- 4 care methods
4 meds:
- Systemic antibiotics
- Systemic medications (opioids, adjuvants)
- Topical opioids
- Topical anesthetics (2% lidocaine jelly 3-5 min before wound care)
4 interventions:
- Anti-microbial dressings
- Non-adherent dressing (foams, silicone)*
- Soaking dressing before removal with NS or tap water*
- Gentle irrigation/patting/blotting wound bed*
- Decrease number of changes with moisture retentive dressings*
- Use of burn nets or garments to secure dressing and normalize body image
- If adhesives needed, use skin protectants and apply skin tape
Key components to wound bed preparation
Tissue that is nonviable must be debrided
Infection or inflammation must be managed
Moisture imabalance or exudate control must be addressed
Edge margins of wound must be examined for non-adherence
TIME
Common wound debridement methods
Autolytic debridement: hydrogel (Tegaderm) dressings
Biological debridement: larval therapy
Chemical debridement: iodine, medical grade honey
Surgical and sharp (doctor) debridement: scalpel, scissors, forceps by trained tissue viability nurse or surgeon
Enzymatic debridement: collagenase agents
Mechanical debridement: ultrasound and water irrigation devices
FS: ABCDE + M
Name 4 agents to help to control wound odour and drainage
- Flagyl (spray, powder, tablets, gel)*
- Honey*
- Charcoal*
- Silver*
- Foams
- Calcium alginate
- Dakin solution (diluted bleach)*
How to manage wound related bleeding issues as below:
- Prevention (3)
- Minor bleeding (3)
- Major bleeding (2)
- Hemorrhage as a terminal event (3)
Prevention:
- Non-adherent dressing
- Wet dressings before removal
- Gentle cleansing or irrigation
Minor bleeding:
- Pressure
- Silver nitrate sticks
- Epinephrine soaks
- Calcium alginate
Major bleeding:
- Vascular intervention
- Radiation
Terminal bleed:
- Dark towel
- Benzo PRN
- Cover with blankets as blood loss can cause hypothermia
What are 2 peri-wound skin barriers to reduce pruritus and moisture-associated skin damage?
- Liquid polymer acrylates
- Dimethicone
- Zinc-oxide skin barrier* (triad)
- Petroleum skin barrier* (Vaseline)
Name 2 pressure-injury risk assessment tools
Braden Scale
Norton Scale (Norton hears a who…)
Hospice Pressure Ulcer Risk Assessment Scale
Name 4 risk factors for pressure-injury
- Advanced age*
- Protein-calorie malnutrition*
- Immobility*
- Shear*
- Friction
- Moisture*
- Incontinence
- Altered sensory perception
Name 4 ways to reduce/manage pressure-injury
- Maximizing nutrition and hydration*
- Pressure redistribution*
- Skin care (TIME)*
- Managing incontinence*
- Controlling wound related symptoms
- Providing psychosocial support
FS: think of cause -> intervention
Age - psychosocial support
Malnutrition - hydration + nourish
Immobility - pressure redistribution
Shear/friction - skin care
H20/Moisture - manage incontinence
Name 3 ways to facilitate pressure redistribution? What about foam rings or cutouts?
- Regular repositioning*
- Heel suspension devices and protective dressing*
- Support surfaces on beds and chairs (e.g. roho cushion)*
- Minimize or reduce medical device
Don’t use foam rings or cutouts
Describe the 4 stages of NPUAP pressure injury staging system
Stage 1 pressure injury: non-blanchable erythema of intact skin
Stage 2: partial thickness skin loss with exposed dermis
Stage 3: full thickness skin loss (adipose tissue is visible)
Stage 4: full thickness skin and tissue loss (fascia, muscle, tendon, ligament, cartilage or bone visible)
FS:
Epidermis - Dermis - Hypodermis/SC tissue - Muscle
Skin = epidermis, dermis, hypodermis
What are 3 ways to prevent incontinence related dermatitis
- Non-invasive containment products (absorptive products, fecal pouch, condom catheter, etc.)*
- Invasive containment productrs (urine catheter, fecal management system)*
- Incontinence care (pH balanced, non-rinse cleanser; skin moisturizer; skin barrier)*
- Treatment of candidiases
2 types of skin tears
Partial thickness (separation of epidermis from dermis)
Full thickness (separation of both epidermis and dermis from underlying structures - fat)
Name 4 ways to prevent skin tears
- Asssess for risk upon admission and whenever condition change
- Implement systematic prevention protocol
- Have individuals at risk wear long sleeves, long pants, knee high socks*
- Shin guard*
- Safe patient handling techniques*
- Involve patients and families in preventative strategies
- Condult dietician to ensure adequate nutrition and hydration*
- Keep skin moisturized at least 2 times per day*
FS:
Nourish (dietician)
Moisturize (twice a day)
Cover skin (long sleeves, skin guard)
Careful patient handling
How to manage new skin tears (5 steps)
- Cleansing with non-toxic solution (NS)
- Control bleeding and remove clots
- Approximating skin flap when possible
- Apply skin protectant on peri wound area
- Apply hydrogel (tegaderm), alginate, foam or non adherent dressing
Chronic critical limb ischemia:
- What is the etiology?
- How does it manifest? (3)
- What is the possibility of healing?
Arterial occlusive disease
Manifest as rest pain, ulceration or gangrene
Healing is not realistic goal when invasive vascular interventions are not available
