Lotions, Potions and Dressings – What do I do?
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Lotions, Potions and Dressings – What do I DO? Anna Braden, BSN, RN, CWOCN Objectives Have a basic understanding of skin and wound assessment Have an understanding of basic dressing selection guidelines based on assessment Have a basic understanding of product categories Anatomy Epidermis Dermis Subcutaneous tissue Fascia, Muscle, Bone Wound Healing Injury Hemostasis: • Coagulation • Platelet aggregation Platelets Inflammation: •Macrophages •Neutrophils •Granulocytes •Debridement •Resistance to infection •Neovascular growth •Granulation Collagen lysis Collagen synthesis Proliferation Epithelialization Proteoglycan synthesis Maturation: remodeling Healed wound Contraction Wound Care: An Incredible Visual! Pocket guide, 2009 Wound healing Wikipedia, the free encyclopedia Wound Healing Partial Thickness ◦ Epidermis, dermis Full Thickness ◦ Can be shallow or deep ◦ Subcutaneous tissue ◦ Fascia, Muscle Factors affecting wound healing Perfusion/oxygenation Nutritional status!!!! Infection Corticosteroids/medications Aging Nicotine!!! Smoking Denervation Obesity Diabetes!!!! Most of all – patient’s cooperation Skin Assessment Color Texture Temperature Turgor Odor Sensations Wound Assessment Location – anatomic landmarks 2. Size including 1. a. Undermining b. Tunneling/sinus track Wound bed appearance 4. Exudate 3. a. Amount & characteristics Odor 6. Pain 7. Peri wound skin 5. Infection? – Yes or No? Contamination Colonization Critical Colonization Infection ◦ Local vs systemic ◦ Elevated Glucose in diabetics ◦ Pain in neuropathic extremity Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 270-273 Skin Products Antimicrobial Emollient Humectant Preservative Skin protectant Surfactant Dimethicone Petrolatum Zinc Oxide ◦ <25% = creamy ◦ >25% = pasty Dressing Selection – 1st Basic Rule Dry shallow/superficial wound = Need to ADD moisture Wet shallow/superficial wound = Need to wick/absorb moisture ***Peri wound skin: Protective barrier film*** Dry deep/cavity wound = Need to ADD moisture = Need a Filler in order to pack undermining/tunneling areas = Need a Cover dressing Wet deep/cavity wound = Need to wick/absorb moisture = Need a Filler to pack undermining/tunneling areas = Need a Cover dressing ***Peri wound skin: Protective barrier film*** Then Dressing Selection Goes on based on: ◦ Does the wound need to be debrided? ◦ ◦ ◦ ◦ ◦ Mechanical, enzymatic, autolytic Is there an infection present? Does the wound bed remain moist or is it drying up? Do the wound edges need to be opened? Is the wound bed being protected from injury, trauma etc.? Is the wound being insulated? “A dry cell is a dead cell” Products Terms: ◦ ◦ ◦ ◦ ◦ Primary dressing Secondary dressing Filler MVTR – Moisture-Vapor Transmission Rate Epidermal stripping Products - Antimicrobial Antiseptics, iodine, honey, hydrofera blue, mupirocin ointment, silver Indications: ◦ Partial or full thickness wounds ◦ Critical colonization, infection ◦ Odorous wound Primary or secondary dressing Advantages: ◦ Provides broad range of antimicrobial or antibacterial activity ◦ Reduces infection ◦ Prevents infection Disadvantages: ◦ Silver - May cause staining ◦ May cause stinging or sensitization ◦ Nanocrystalline Silver – inactivated by saline Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292 Products – Calcium alginate Called usually ‘alginate’ Polysaccharide derived from brown seaweed Partial or full thickness wounds Primary dressing/filler ◦ Usually needs a secondary/cover dressing Highly absorbent – moderate to heavily draining wounds Converts to a viscous/hydrophilic gel Hemostatic properties Change as needed – usually every 24-48 hours Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292 Products - Charcoal Activated carbon ◦ Absorbs toxins and wound degradation products Indications: ◦ Malodorous wounds ◦ Fecal fistulas Apply as a ‘filter’ for odor control If absorbing drainage, need to change when saturated Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292 Products – Collagen Enhances deposition of collagen fibers Chemoattractant to granulocytes & fibroblasts Bioresorbable Hemostatic properties Processed from bovine or porcine sources Indications: ◦ Full-thickness wounds with or without depths ◦ Noninfected wounds ◦ Minimal to moderate amount of drainage Apply to wound base ◦ Requires a secondary/cover dressing Packaged as gels, alginates, sheets, powders Contraindicated in bovine sensitivites Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 292 Products - Composite Combine distinct dressing components into a single dressing ◦ Absorptive part is different than alginate, foam, hydrocolloid, hydrogel Bacterial barrier Partial or full thickness wounds without depth Dry to heavy drainage – depending on dressing components Primary or secondary dressing Can be used with topical medications Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293 Products – Contact layer Protects the wound from direct contact with other agents/dressings Conforms to wound shape Porous Indications: ◦ Partial or full thickness wounds with or without depth ◦ Infected wounds ◦ Donor sites ◦ Split-thickness skin grafts Not intended to be changed with every dressing change Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293 Products – Fiber gelling Hydrofiber Moderate to heavy drainage Converts to gel - “snot”-like appearance Partial or full thickness wounds Usually needs a secondary dressing Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293 Products - Foam Absorptive and non-adherent Indications: ◦ Partial or full thickness wounds with or without depth ◦ Moderate to heavily drainage Contraindicated with dry eschar Frequently used as a secondary dressing after medication and/or primary dressing If used as primary dressing, apply appropriate secondary dressing Change every 24 hours or as needed Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293 Products - Hydrocolloid Contains gel-forming agents ◦ Forms a gelatinous mass Impermeable to contaminants = reducing risk of infection Promotes autolysis Indications: ◦ Partial or full thickness wound with or without depth ◦ Minimal to moderate drainage Avoid acutely infected wounds and dry eschar Use cautiously in diabetics Low MVTR Change every 3-5 days as needed Select dressing 1-2” larger than the wound Use light pressure of hands to allow body heat promote adhesion Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 294 Products - Hydrogel Adds moisture to dry wound bed Non-adherent Little or no absorption Cool & soothing Various formulations: ◦ Gel, sheets, impregnated gauze, with silver Apply according to instructions Use appropriate secondary dressing Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4 th Edition, p 293 Products – Transparent film Indications: ◦ Shallow partial thickness ◦ Dry to minimal drainage = nonabsorbent Low MVTR Can promote autolysis Creates “second” skin Apply without tension/stretching Allow for 1-2” border around wound Use skin sealant around wound edges Not for infected wounds Change every 4-7 days or as needed Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293 Products – Medications Collagenase/=Santyl ◦ Enzymatic debrider Collagenase derived by fermentation of Clostridium histolyticum ◦ Need physician order ◦ Need some ‘contact’ with moist wound bed Around edges or cross-hatching by physician ‘Xenaderm’ = BCT ◦ Balsam Peru ◦ Castor oil Improve epithelialization Protective covering Aids in reduction of pain ◦ Trypsin – mild debrider Dakin’s solution ◦ 1/16 strength – odor control ◦ 1/25 strength – pseudomonas infection Metronidazole/Flagyl ◦ Crushed - odor control Thomas Hess, C. Clinical Guide to Skin and Wound care. 2013, 7th Edition, p 557-559 Peri wound protection Prevent epidermal stripping ◦ Avoid tapes if possible ◦ Roll gauze, tubular stockinette, Montgomery straps ◦ Skin sealants Maceration ◦ Skin sealants ◦ Zinc oxide ◦ Re-evaluate current dressing and/or frequency Infection ◦ Candidiasis Crusting technique with antifungal powder Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301 Special Consideration: Palliative Wound Care S = Stabilize the wound P = Prevent new wounds E = Eliminate odor C = Control pain I = Infection prophylaxis A = Advanced absorbent wound dressings L = Lessen dressing changes Haas. M.L., Moore-Higgs, G.J. Principles of Skin Care and the Oncology Patient.2010. p 105. Documentation Today – EMR/Electronic Medical Record ◦ ◦ ◦ ◦ Order Assessment Actual dressing change Teaching Must meet certain criteria for reimbursement Accurate and consistent ◦ Monitoring ◦ Legal Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301 Presentwoc.com Worldwidewounds.com References Bryant, R., Nix, D. Acute and Chronic Wounds. Current Management Concepts. 4th Edition. 2012. Hass, M.L., Moore-Higgs, G.J. 2010. Principles of Skin Care and the Oncology Patient, p 105, Milne, C.T., Corbett, L.Q., Dubuc, D.L., Wound, Ostomy, and Continence Nursing Secrets, Questions and Answers Reveal the Secrets to Successful WOC Care. 2003 Thomas Hess, C. Clinical Guide to Skin and Wound care. 7th Edition. 2013. Wound Care: An Incredibly Visual! Pocket Guide. 2009. Wound healing, p 21. Questions?
