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Adam's Weak Spots > Wound Care and Lymphedema > Flashcards

Wound Care and Lymphedema Flashcards

1
Q

Prevalence of wounds in PC

A
  • 60% have 1+ wound at presentation
  • Average 1.8 wounds/pt at presentation
  • Average 1.5 new wounds before death
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2
Q

Prognostic significance of malignant wounds

A

1966: 3 months’ avg. survival
1993: 11 months’ avg. survival
Today: no impact on survival
:. Treat wounds!
:. Don’t write off wound patients

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3
Q

Prognostic significance of
pressure ulcers

A

Correlated w. poor prognosis rather than causative

Nonmalignant patients: death HR 2.42
Malignant patients: death HR 1.48
Worse for women

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4
Q

5 primary goals of wound mx

A
  1. Wound healing
  2. Wound maintenance (i.e. stop growth)
  3. Wound palliation
  4. Wound prevention
  5. Achieving patient GOC

In PC setting, 5 > 4 > 3 > 2 > 1

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5
Q

What is a pressure wound?

A

Ischemic necrosis d/t to arterial, venous, lymphatic stasis.

The stasis is caused by prolonged pressure over hard surface +/- friction/shearing.

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6
Q

Patient risk factors for pressure wounds

A
  • Advanced age
  • Multimorbidity
  • Cachexia
  • Neuropathy
  • Peripheral vascular disease
  • Paralysis
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7
Q

What is the primary pressure ulcer risk assessment scale?

A

Braden Risk Assessment

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8
Q

Describe the Braden Risk Assessment

A

24-point scale, lower = higher risk
<17 is considered at-risk

6 items, rated 1-4 each
1. Sensory function
2. Moisture
3. Activity (out of bed)
4. Mobility (in bed)
5. Nutrition
6. Friction/shear

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9
Q

What score does the Braden score correlate with in palliative pts?

A

Palliative Performance Scale

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10
Q

NPUAP Stages 0-I of Pressure Injury

A
  1. Healthy skin
  2. Nonblanchable erythema + intact skin
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11
Q

NPUAP Stage II of Pressure Injury

A

Exposed dermis or intact blistering
- Visible tissue is healthy/viable
- No visible fat/deeper tissue
- No granulation tissue or slough

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12
Q

NPUAP Stage III of Pressure Injury

A

Full thickness skin loss to subq tissue
- Fat + granulation tissue present
- Depth depends on anatomical loc’n
- No muscle/fascia/bone visible
- +/- slough that may make it unstageable

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13
Q

NPUAP Stage IV Pressure Injury

A

Full-thickness skin + tissue loss
- Exposed connective tissue, incl. Bone
- +/- slough that may make it unstageable

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14
Q

NPUAP Stage X Pressure Injury

A

Wound is too obscured to stage
- Slough and/or eschar
- Debridement will reveal stage III-IV
- Stage I-II don’t make slough
- Don’t debride dry stable eschar

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15
Q

What mnemonic reflects a sample approach to wound healing?

A

“DIME”

(D)ebridement/(D)ownloading
(I)infection/(I)nflammation management
(M)oisture balance
(E)dge management

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16
Q

Describe debridement approaches

A

Sharp debridement of dead tissue
- Reduces infx risk
- Promotes healing
- At bedside or in OR

Debriding wound products
- Hydrocolloids, hydrogels, alginates

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17
Q

Describe wound downloading

A

AKA offloading, pressure redist’n
- Goal is maximum surface area exposed
- Repositioning
- Soft surfaces and/or moving surfaces
- Lifting affected areas (esp. heels)

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18
Q

Describe bacterial flora of
Acute vs. chronic wounds

A

Acute: gram+ aerobes

Chronic: gram- and anaerobes

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19
Q

4 “stages” of wound infection

A
  1. Colonised without infection
  2. Superficial tissue infection
  3. Deep tissue infection
  4. Sepsis
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20
Q

What are some complications
of wound infections?

A
  • fistulae/sinuses
  • Abscess formation
  • Osteomyelitis
  • Compartment syndrome
  • Sepsis
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21
Q

What is the first sign/symptom
of wound infection?

A

Escalating pain–always look for infx

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22
Q

Approaches to superficial vs. deep wound tissue infections

A

Superficial: topical treatments
e.g. topical antibiotics
e.g. silver- or iodine-infused dressings

Deep: systemic antibiotics

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23
Q

Primary inflammatory mediator
in chronic wounds

A

Matrix metalloproteinases (MMPs)
* Released by neutrophils/macrophages
* Released by cancer cells
* Released 2* interleukins + TNF-a

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24
Q

How do MMPs impair healing?

A

Hyperinflammatory state:
* Damage extracellular matrix
* Kill fibroblasts and epithelial cells
* Inactivate growth factors

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25
Q

Name 2 dressings designed
to inactivate MMPs

A

Promogran©
Prisma© (= Promogran© with Ag+)

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26
Q

How does excess moisture
impair wound healing?

A
  • Excessive tissue maceration
  • Reduces tissue tensile strength
  • Damage from toxic exudate products
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27
Q

What components of exudate
can impair wound healing?

A
  • Proinflammatory mediators
  • MMPs
  • bacteria/bacterial toxins
  • Necrotic products
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28
Q

What is the pathophysiology of
exudate formation?

A
  • High capillary permeability
  • Vascular perm. Factors from cancer
  • Increased venous/lymphatic pressure
  • Iatrogenic (creams, hydrogels)
29
Q

Dressing approach to
Highly exudative wounds

A
  1. High absorbency dressings (see below)
  2. Noncontact layer underneath
  3. Consider plastic on top to protect clothing/fabrics
  4. Consider abdo pads (not in contact) to save expensive absorbent dressings
  5. Don’t change contact layer too often
30
Q

What is an option for
extreme exudate accumulation?

A

Negative pressure wound therapy
(i.e. suction)

Ostomy bags

31
Q

What are “edge effects” in the
DIME approach to wounds?

A

Refers to failure in wound to “edge” inward (i.e. heal).

  • Can be managed with NPWT, hyperbaric O2, skin grafts
  • Remember that malignant wounds don’t heal
32
Q

What are 2 mnemonics for signs of
deep and superficial wounds infx?

A

Superficial: NERDS
Deep: STONES

33
Q

“NERDS” Mnemonic

A

⅗ predictive of superficial wound infx

NERDS:
* Nonhealing (or worsening)
* Exudate
* Red wound bed
* Debris
* Smell worsening

34
Q

“STONES” Mnemonic

A

4/6 predictive of deep wound infx

STONE(EE)S:
* Size increasing
* Temp increasing (use IR thermometer)
* Osteum exposed
* New breakdown
* Exudate/Erythema/Edema
* Smell worsening

35
Q

How common are malignant wounds?

A

15% of advanced cancer patients
* 60% are exophytic/fungating
* 40% are erosive

36
Q

What 4 cancers are most associated
with malignant wounds?

A
  • Breast
  • Lung
  • Head/Neck
  • Primary skin
37
Q

What are approaches to treating malignant wounds?

A

Malignant wounds are unlikely to heal,
And will not heal w/o cancer treatment

  • Systemic chemo/hormonal/immunotx
  • Local radiation
  • 6% miltefosine topically (single small study)
38
Q

List approaches to wound pain mx

A

regular/prn opioids, incl. Fentanyls
Topical opioids
EMLA
Nonadherent base dressings
Avoid gauze

39
Q

List options for
wound odour mx

A
  1. Systemic/topical metronidazole
  2. Charcoal-containing dressing
  3. Wound cleansing
  4. Topical antiseptics
  5. Debridement
  6. Environmental management
    - Aromatherapy
    - Ventilation
    - Pet litter/charcoal under bed
    - Baking soda
40
Q

What are 2 “natural” options for
debridement and wound odour mx?

A

Sugar pastes
Honey

Both create hyperosmotic env’t
Honey may have some added effects

40
Q

What is the risk of bleeding
from malignant wounds?

A

<10%

41
Q

List local options
for wound bleeding mx

A
  • Reduce freq. of dressing changes
  • Calcium alginate
  • ORC collagen
  • Silver nitrate cautery
  • Thromboplastin
  • Zinc chloride paste (Mohs’ paste)
  • topical/po TXA
42
Q

What is the main contraindication for compression tx in VENOUS leg ulcers?

A

Inadequate arterial supply (per ABI)

43
Q

List the main categories of wound care products

A

Absorbents
Hydrating agents
Protease inhibitors
Antimicrobials
Anti-odour
Nonadherent layers

44
Q

What are 5 considerations in choosing a wound care product

A
  • Wound shape/depth
  • Wound moisture
  • Patient preference
  • Availability
  • Cost
45
Q

What is lymphedema?

A

Protein-rich insterstitial fluid
(and sequelae)
ALMOST ALWAYS ASYMMETRICAL

45
Q

Specific causes of Lymphedema

A
  • Cancer treatment (sx, XRT)
  • Chronic venous insufficiency
  • Tropical illnesses
  • Primary lymphedema (congenital)
46
Q

General cause of lymphedema

A

Damage to lymph vessels/nodes
Congenital absence/abn of same

47
Q

Oncology-Associated lymphedema features

A
  • Associated w. Node dissection / XRT
  • 1-2 year latency from tx → onset
  • Can also mark cancer recurrence
48
Q

Which 4 cancers are most associated with lymphedema?

A
  • Breast ca (20-30%)
  • Gyne Cancer (5-50%)
  • Prostate ca (5-30%)
  • Melanoma + Sarcoma (5-30%)
49
Q

List 5 lymphedema sequelae

A
  • High protein → fibrosis
  • Abnormal fat distribution
  • Skin changes
  • Fibrosis can trap nerves/vessels → pain
  • Infection ←→ worse lymphedema
50
Q

List 4 chronic skin changes in lymphedema

A
  1. Hyperkeratosis
  2. Thickened skin folds
  3. Hyperpigmentation
  4. Inflammation
51
Q

List the 3 stages of lymphedema progression

A
  1. Spontaneously resolves w. Elevation
  2. No spontaneous resolution
    a. Will progress to fibrosis if untx
  3. Skin changes develop
52
Q

DDx of unilateral limb swelling consistent with lymphedema (i.e. alternative dx) (3)

A
  • Cancer recurrence
  • DVT
  • Cellulitis
53
Q

Skin care in lymphedema (4)

A
  1. Fastidious skin hygiene
  2. Low-pH moisturiser
  3. Avoid extremes of temperature
    a. Heat → hyperemia → swelling
    b. Cold → rebound vasodilation
  4. Avoid punctures if at all possible
54
Q

General patient advice for lymphedema patients.

A
  1. Skin care (see slide 55)
  2. Ongoing exercise
    a. Resistance exercise can improve LE
    b. Cardio can prevent obesity
    c. Obesity worsens LE
55
Q

What is the basis of lymphedema tx?

A

Combined Decongestive Therapy (CDT)

56
Q

Describe combined decongestive therapy (CDT)

A

Physical therapy for lymphedema
(a) increase current drainage routes
(b) develop collaterals

  • Intensive phase to reduce edema
  • Maintenance phase to preserve
  • Patient responsible for maintenance
57
Q

Describe CDT in lymphedema Stage I

A
  • Compression garments
  • Elevation as able
58
Q

CDT in Stage II lymphedema

A
  • Initial non-elastic bandaging
  • Skin care
  • Manual lymphatic drainage
  • Followed by chronic compression garment use
59
Q

Describe Manual Lymphatic Drainage (MLD)

A
  • Goal is to enhance lymphatic vessel contractility/volume
  • Proximal → distal massage
  • Requires trained professional
  • About 45 minutes
  • Followed by bandaging
  • “Simplified lymphatic drainage” can be done at home
60
Q

CDT in Stage III lymphedema

A
  1. 2-4 week intensive treatment
    a. education/psychological support
    b. Skin care / cellulitis precautions
    c. Multilayer bandaging
    d. exercise/weight management
  2. Full-time maintenance per patient
  3. Aim to repeat in 1 year
61
Q

What are the principles and advantages of bandaging in lymphedema?

A
  • Inelastic—not ACE/tensor type
  • Remain on 24h day; off only for tx
  • remain on at night indefinitely
  • Replaced by custom compr’n garment
  • Benefit 20-60% reduction in edema
62
Q

List 4 exercise goals/tips in lymphedema

A
  • Weight control
  • Abdominal breathing to enhance thoracic duct flow
  • Weight training safe/healthy
  • Over-vigorous exercise can be counterproductive
63
Q

Mechanisms of compression tx in lymphedema.

A
  • Reduce pressure gradient
  • Mimic flow created by muscle contraction
  • Ultimately improve volume/elasticity of lymph vessels
64
Q

Contraindications to limb compression

A
  1. Acute DVT
  2. Fragile CHF (can shift fluid to chest)
  3. Arterial insufficiency
  4. Wounds
  5. Pain
65
Q

Drug classes that may worsen lymph/edema (4)

A
  1. NSAIDs
  2. CCBs
  3. Alpha antagonists
  4. Diuretics (more complicated)
66
Q

How can diuretics interact with lymphedema?

A
  1. Likely to reduce edema
    a. Especially if comorbid venous edema
  2. Increase tissue [protein] and :. fibrosis
    a. This is a long-term issue
    b. Less of a concern <1 year use

Adam's Weak Spots (8 decks)

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