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The 411 on wound care
- 1. The 411 on Wound Care May 12 2010 Amy Clegg RN, MSN, NP-C, CWOCN Dawn Engels RN, CWOCN Questions Info
- 3. Objectives • Identify Partial and Full Thickness Wounds • List 2 Barriers to Wound Healing • Identify Pressure Ulcer Stages • Identify Measures to Reduce Pressure Ulcers • Verbalize mechanism of VAC • Identify indications/contraindications for VAC • Demonstrate VAC application
- 4. Would Healing • Hemostasis – within 60 minutes • Inflammation- 20 minutes –4 days • Proliferation- 3-21 days • Remodeling- 21 days –2 years
- 5. Barriers to Wound Healing Lifestyle Pressure Age Health Patient Nutrition Status Necrotic Tissue Perfusion Infection
- 6. Partial Versus Full Thickness • Partial thickness wound • Wound does not extend through the dermis • Heals by regeneration • Re-epithelization
- 7. Partial Versus Full Thickness • Full thickness wound • Wound extends through the dermis may extend to an organ, tendon, muscle bone • Heals by contracting and scar tissue
- 11. What is a Pressure Ulcer? •Localized injury to skin and or underlying tissue usually over a bony prominence due to unrelieved pressure •Can occur under a splint or cast •3 most common locations sacrum, heels, and trochanter
- 13. To Stage or Not to Stage a Wound? • Pressure ulcer staging is only to describe wounds that develop from pressure • Pressure ulcer staging is not used to describe wounds from other causes such as skin tears, tape burns, diabetic foot, venous ulcer, or incontinence
- 14. What are the pressure ulcer stages? • Suspected Deep Tissue Injury • Stage 1 • Stage 2 • Stage 3 • Stage 4 • Unstageable
- 15. Suspected Deep Tissue Injury • Purple or maroon area of discolored skin or blood filled blister • Maybe painful, firm, mushy, boggy, warmer or cooler as compared to adjacent side • The wound may further evolve into full thickness tissue loss
- 16. Stage 1 • Intact skin with nonblanching redness • Maybe difficult to detect in patients with darker pigment • Maybe painful, firm, soft, warmer or cooler as compared to adjacent tissue
- 17. Stage 2 • Partial thickness skin loss of dermis • Presents as a shallow open wound with pink or red tissue • Can also be a serum filled blister
- 18. Stage 3 • Full thickness skin loss. Subcutaneous fat may be visible • Slough may be present but does obscure base of wound • Depth varies by anatomical location
- 19. Stage 4 • Full thickness tissue loss with exposed bone, muscle or tendon • Depth varies depending on anatomical location
- 20. Unstageable • Full thickness tissue loss in which the base of the wound is covered by slough or eschar. • Until enough slough or eschar is removed true depth cannot be determined
- 21. Measures to Reduce Pressure Ulcers • Nutrition • Moisture Management • Specialty beds • Chair cushions • Repositioning • Determine risk- Braden Scale
- 22. VAC Mechanism of Action • Maintains moist environment • Removes exudate • Promote granulation • Promote perfusion • Reduce edema
- 23. Indication/Contraindications VAC • Indications •Contraindications • Dehisced wound •Malignancy in wound • Pressure Ulcers •Untreated Osteomyelitis • Open Abdominal wounds •Necrotic tissue • Traumatic wounds •Directly over vessels • Diabetic wounds •Active Bleeding • Skin grafts
- 28. VAC Stations • Apply • Cannister • Y Connect • Bridge • Foams
- 30. References • Google Images Ayello, E. & Lyder, C. (2008). The new era of pressure ulcer accountability. Advances in Skin & Wound Care, 21(3), 134-139. National Pressure Ulcer Advisory Committee . Pressure ulcer stages revised by NPUAP. Retrieved on 6/5/08 at www.npuap.org. Centers for Medicare and Medicaid Services, Hospital Acquired Conditions (Present on Admission Indicator): www.cms.hhs.gov/ HospAcqCond/01_Overview.asp Retrieved on July 2008