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)
How would you treat bleeding malignant wounds?
- Minor:
- calcium alginates
- oxidized regenerated cellulose
- topical thromboplastin
- silver nitrate cautery
- Major
- ligation
- electrocautery
- cryotherapy
- TXA 500 mg po bid
- Moh’s paste (zinc oxide)
- radiation
Prognosis of malignant wounds
- malignant wound not necessarily associated with reduced survival
- should not be a reason for stopping cancer treatment in high PPS patients
Compression therapy in wounds
- Cochrane review - good for venous leg ulcers
- elastic better than inelastic
- not for malignant wounds
Venous leg ulcers
- DIME model
- pentoxifylline 400 mg po tid + compression (Cochrane metaanalysis)
Prevention of venous leg ulcers
- paraplegia, fracures, contractures high risk
- loss of muscle pump
- compression therapy for prevention
- stockings
Classification of pressure ulcers
- Stage 1
- erythem, no open wound
- blanchable
- Stage 2:
- broken skin
- shallow ulcer
- red-pink
- Stage 3:
- crater sore
- subcutaneous fat visible, no bone or muscle
- Stage 4:
- deep sore with damage to bone, muscle, tendon
- Unstageable ulcers
- depth of ulcer completely obscured by slough or escar
Examples of absorbant wound management products
- Foam
- topical analgesic
- Hydrofibre (Aquacel)
- topical anitmicrobial
- Alginate
- hemostatic
- alginate with ethylene-methyl-acrylate layer
- topical antimicrobial and non adherent
- cellulose pulp
- non adherent
- Silver complex
- skinfold management to prevent moisture lesions
Examples of hydrating agents for wound management
- Hydrocolloid
- Hydrogel
- Autolytic debridement
Examples of protease modulators of wound management
- Promogran
- Oxidized regenerated cellulose dressings
- topical hemostatic agent
- Prisma
Examples of topical antimicrobials for wound management
- nanocrystalline silver
- absorbent
- Ionic silver and hydrogel
- hydrating and absorbent and antimicrobial
Anti odour wound management products
- Metronidzaole
- Charcoal (Actisorb silver)
Components of good skin care
- Skin cleansing
- minimize change in pH
- Moisturizing and hydrating
- emollients trap moisture under barrier
- Protection
- barrier layer
Moisture protection
- disposable pads and close fitting underwear/ diapers
- fluid handling system to wick fluid away
- remember dignity of patient
- urinary catheter intermittent or indwelling
- Anal or stomal bags
- practicality depending on position
- leakage and skin damage
Methods of debridement
- Autolytic
- dressings
- Biological
- larva, maggots
- Mechanical
- ultrasound, water
- Surgical / sharp
- bedside or OR
- Chemical
- active dressings,
- medical grade honey
- Enzymatic
- collagenase agents
Necrotic tissue management in short prognosis/ EOL
- promote and maintain dry scab (vs normal debridement)
- anstringent antiseptics
How to protect granulation tissue
- Granulation tissue:
- semi occlusive, non gauze dressing
- foam dressing non adherent
Management of fistula
- Barrier products to prevent maceration
- Collect effluent in closed stoma bag/device
- Manage odour with closed bag
- nurtition and fluids
- supportive care to maintain dignity, autonomy
Melanosis
- generalized darkening of skin
- dark urine
- show of melanoma cell dissemination in metastatic melanoma
Hyperpigmentation
- adrenal insuff
- chemotherapy SE
Xerosis
- Skin dryness
- chemo, nutrition, low protein
Erythroderma
- General redness of skin
- End stage skin disease
- cutaneous lymphoma
- some solid tumours
- emollients and steroids
Paraneoplastic syndrome: dermatomyositis
- common in melanoma, lymphoma
- heliotrop rash
- papules Gottron’s over joints
- proximal muscle weakness
- poikiloderma (erythema over chest, photsensitive areas)
- steroids, immunosuppressive agents
Tinea corporis and cruris
- large psoriaform plaques over buttocks, back, inguinal region, medial thigh, pubic region, genital, perianal region
- dermatophytes
- Dx: KOH scraping
- Tx: topical agents (imidazole)
- fluconazole
Diaper dermatitis
- urinary incontinence
- maceration
- burning pain
- Tx:
- zinc oxide
- topical steroid + barrier
