WOUND CARE:IT’S ALL
GREEK TO ME
BY
CHERYL MARZOLI RN BHScN IIWCC
OBJECTIVES
• Provide a better understanding of wound
care
• How to: assess, provide interventions and
document about wounds.
• Understanding moist wound healing
• Discuss categories of dressing products, the
use of the products, NPT (negative pressure
therapy) and treatment of wounds.
WOUND
• DEFINITION: A wound is a bodily injury
caused by physical means, with disruption
of the normal continuity of structures. This
can be identified as an acute or a chronic
wound.
• ACUTE: Heals in approximately 2 weeks to
6 months
• CHRONIC: Takes 6 months or more.
ACUTE WOUND
CHRONIC WOUND
PHASES OF WOUND HEALING
• Stages of wound healing:
Hemostasis: immediate response
Inflammation: 0-4 days
Proliferation: 4-21 days
Granulation (Epithelialization) :4-21 days
Remodeling: up to 2 years
* this is for acute wounds, chronic wounds fail to progress
naturally
PHASE
GOAL
PRINCIPLE WOUND CELL
HOUSE BUILDING
CONTRACTOR
1
HEMOSTASIS
PLATELETS
CAPPING OFF
OFFENDING CONDUITS
2
INFLAMMATION
NEUTROPHILS
UNSKILLED LABORERS
CLEAR THE SITE
3
PROLIFERATION
MACROPHAGES
SUPERVISOR CELL
GRANULATION
LYMPHOCYTES
SPECIFIC PREPARERS
OF SITE
PLUMBER,
ELECTRICIAN
FRAMERS
ROOFERS/SIDERS
CONTRACTURE
4
REMODELING
ANGIOCYTES,
NEUROCYTES
FIBROBLASTS,
KERATINOCYTES
FIBROCYTES
REMODELERS
*Krasner, et al
STAGES OF PRESSURE ULCERS
Stage
Stage
Stage
Stage
1:
2:
3:
4:
reddened skin
blister (painful), shallow, pink ulcer
through the dermis
through to underlying structures
(bone, tendons, etc.)
Unable to stage: unable to visualize wound
bed due to eschar/slough
Suspected Deep Tissue Injury (SDTI):
purple localized area of discolored intact
skin, boggy, warmer or cooler compared
to adjacent tissues.
NOTE: NO reverse staging i.e. once a stage 3
always a stage 3, never changes to
stage 2
STAGE ONE
•Epidermis intact
•Area reddened
•Does not disappear
when pressure
relieved
•No drainage
•Reversible
STAGE TWO
STAGE THREE
STAGE FOUR
UNABLE TO STAGE
WHAT STAGE?
WHAT STAGE?
STAGING ALL OTHER WOUNDS
NOT PRESSURE ULCERS
Classification is based on the 3 layers of skin
Classify as superficial, partial or full thickness
i.e. a burn can be partial thickness (second
layer).
PARTIAL THICKNESS BURN
ASSESS THE PATIENT
1.Look at the whole patient not just the hole.
2. What are the patient’s concerns?
3. Is the wound new or old and how old?
4. Is this wound healable?
5. What are the patient’s co-morbidities?
6. How is the patients nutritional status
7. What medications if any could interfere
with
wound healing?
Probe the wound!!!!
Try and correct the causes that
may delay wound healing
•
•
•
•
•
•
Edema
Nutrition/Dietary consult
Alter medications
Glycemic control
Treat infection
OT/Physio consult
Documentation
•
•
•
•
•
•
•
•
Slough
Eschar
Granulation
Undermining
Erythema
Maceration
Exudate
Odor
* Location
* Size LxWxD
Moist Wound Healing
Motto…
If
If
If
If
If
its
its
its
its
its
wet……..DRY it!
dry………MOISTEN it!
irritated…SOOTHE it!
chronic…IRRITATE it!
palliative..COMFORT it!
Contamination, Colonization or
Infection
Contamination:
Bacteria-not attached to wound bed
-are not replicating
Colonization:
- Bacteria are attached to the wound
surface but are not replicating
Infected: -Bacteria are invasive, replication
and interfering with wound healing process
-may lead to a “HOST RESPONSE” leading to
systemic infection
SWABS
• Always take a swab from a newly cleaned
wound.
• Cleanse with normal saline or sterile water
• Take a swab by moving in a “Z” pattern
over the wound and turning the swab at
the same time
• Punch biopsy (Physician only)
• Do Not swab necrotic or slough tissue
Wound Cleansing
- Normal Saline or Sterile Water
– Irrigate with 20-30 ml syringe
– Use 18 angiocath
– 4-6 inches above the wound
– 5-15 PSI
• **MMP’S( matrix metalloproteases)
ANTISEPTIC SOLUTIONS
•
•
•
•
•
•
Acetic acid: pseudomonas
Proviodine: broad spectrum effectiveness
Hygeol: staph. and strep.
mechanical debridement
control odour
*acetic acid and hygeol are available
through the pharmacy
Wound Care Products
–
–
–
–
–
–
–
–
–
–
Liquid barrier
Transparent films
Hydrocolloids
Gauze dressings
Hydrogels
Foam dressings
Absorptive dressings
Calcium alginate
Charcoal dressings
Silver coated dressings
-non adherent dressings
-debriding agents
-antiseptic
LIQUID BARRIER
TRANSPARENT FILM
HYDROCOLLOID
•
GAUZE DRESSINGS
HYDROGEL
FOAM DRESSING
ABSORBENT DRESSINGS
CALCIUM ALGINATE
ODOUR CONTROL
CHARCOAL DRESSINGS
ANTIMICROBIAL DRESSING
OTHER DRESSINGS
• Non adherent dressings•
i.e.- mepital
• Debriding agents-mesalt, iodosorb
• Antiseptic- bactigras with a chlorhexidine
base
BIOLOGIC DRESSINGS
BIOLOGIC DRESSINGS
NEGATIVE PRESSURE THERAPY
• WATCH FOR PRECAUTIONS AND
CONTRAINDICATIONS WHEN ORDERING
• MAKE SURE WOUND IS MEASURED ON
INITIAL APPLICATION
• IF NO CHANGE WITHIN 2-2I/2 WEEKS
THEN DISCONTINUE
• E-Z CARE IS A NEW NEGATIVE PRESSURE
THERAPY
GOOD CANDIDATE FOR NEGATIVE
PRESSURE
QUESTIONS
THANKYOU