Wound care Flashcards
What is the magnitude of wound issues in palliative care?
- 60% PC referral have wound
- most common area for advanced illness is sacrococcygeal
- cancer patients - abdomen, chest, breast
- non cancer- extremities
What is successful wound management?
- wound healing
- wound maintenance
- wound palliation (some wound cannot be healed, short prognosis, etc)
- fulfilment of patient concerns
- wound prevention
- wound complication prevention (fistula, sinuses, osteomyelitis)
Pathophysiology of pressure ulcers
- ischemic necrosis of skin and tissues
- results from arterial, venous, lymphatic stasis
- bony protuberances
- prolonged pressure, mechnical shearing forces
List risk factors for pressure ulcers
risk factors:
- age
- comorbidities
- cachexia
- neuropathy
- paralysis
- PVD
Braden Scale
- sensitive specific tool
- predicting pressure ulcer risk
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Describe a model for wound healing
D - Debridement and Downloading (Pressure redistribution)
- debride necrotic wound bed at bedside or in OR if large
- hydrocolloids, hydrogels, alginates autolytic debridement
- Pressure redistribution (increased contact area vs relief)
- respositioning, reaction support surfaces, lifting body part
I - Infection and Inflammation
- acute wound Gram postiive
- chronic wounds Gram negative and anaerobes
- tissue destruction by bacterial endo /exotoxins
- abscess, sinus, fistula, compartment sx, osteomyelitis
- PAIN ESCALATION predicts infection
- Superficial infection - topical antimicrobials
- Deep infection/ systemic - systemic antimicrobials
- Matrix metalloproteinases (MMPS) inflammation
- Cytokines, macrophages, neutrophils
M - Moisture Balance
- moist healing general principle
- extremes of moisture or dry are bad
- wound exudates are rich in MMPs, bacterial toxins, proinflammatory mediators, tissue necrosis
- absorption of exudate in dressing
- foam > hydrofibres > alginates > hydrocolloids
- NPWT (negative pressure wound therapy) for extreme exudate
- moist healing not appropriate for malignant wounds or gangrene
E - Edge Effects
- failure of dermis or epithelium to edge inwards
- NPWT
- HBOT
- growth factor therapy
- skin grafting
- NPWT and HBOT contraindicated for malignant wounds
Short version of wound healing model
D- Debridement and Downloading
I- Infection and Inflammation
M- Moisture balance
E- Edge effects
Describe clinical model for SUPERFICIAL wound infections
NERDS : >3 = superficial compartment infection
N - non healing
E- exudate
R - Redness
D - debris in wound
S - Smell (increased)
Describe clinical model for DEEP compartment wound infection
STONES - > 4 = highly sens and spec for deep infection
Pain escalation
S - size of wound (increased)
T - temperature (fever)
O - Os (palpable exposed bone)
N - New areas of breakdown
E- Exudate, erythema
S - Smell (increased)
Malignant wounds : classification
- breast, head and neck, primary skin, lung primary
- fungating
- heterogenous
- metastatic wounds from remote primary
Tools for malignant wound assessment
- Toronto Symptom Assessment System for Wounds (TSAS-W)
- Global Wound Distress Score (GWDS)
Treatment of Malignant Wounds
- Systemic chemo, hormonal tx, radiation, photodynamic tx
- need to be evaluated by med onc and rad onc
- surgical excision in select cases
- Cochrane sys review : topical 6% miltefosine (cytotoxic agent) to reduce progression of fungating wounds
Interprofessional team and malignant wound management
- social work
- spiritual care
- psychologists
- OT : self care needs, assitive devices,
- PT: prevention and tx of edema, reflex sympathetic dystrophy
- wound care
How would you treat Pain in wounds ?
- Pain
- r/o infection
- dressing changes (adherent dressings, wound cleansing, debridement)
- systemic opioids
- adjuvant analgesics
- topical opioids, EMLA, foam with ibuprofen
- non adherent dressing (mepetel, telfa, silvercel)
- gauze bad
- Fentanyl pre-dressing changes
How would you treat Exudate in wounds?
- caused by high capillary permeability in wound tissue
- increased vasc permeability by cancer cells
- hydrating products can increase
- Cochrane review : no one class of dressing better than another
- Absorbent, non adherent dressing based on cost, availability, convenience
- ET nurse for ++ effluent –> ostomy pouch and skin barrier
How would you treat odour in malignant wounds?
- decomposing necrotic tissue and gram negative infections
- volatile fatty acids (cadaverine and putrescine) released by anaerobic bacteria
- Systemic metronidazole 250-500 mg po bid
- nausea, metallic taste
- disulfarim reaction with ETOh
- Topical metronidazole (0.75% gel)
- Odour absorbing dressing
- wound cleansing, antiseptics, debridement of necrotic tissue
- Environmental control (pet litter, baking soda, aromatherapy, peppermint)
