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WOUND CARE:IT’S ALL GREEK TO ME

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

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WOUND CARE:IT’S ALL GREEK TO ME

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  1. WOUND CARE:IT’S ALL GREEK TO ME BY CHERYL MARZOLI RN BHScN IIWCC

  2. 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.

  3. 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.

  4. ACUTE WOUND

  5. CHRONIC WOUND

  6. 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

  7. House building theory

  8. STAGES OF PRESSURE ULCERS Stage 1: reddened skin Stage 2: blister (painful), shallow, pink ulcer Stage 3: through the dermis Stage 4: through to underlying structures (bone, tendons, etc.) Unable to stage: unable to visualize wound bed due to eschar/slough

  9. 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

  10. STAGE ONE • Epidermis intact • Area reddened • Does not disappear when pressure relieved • No drainage • Reversible

  11. STAGE TWO

  12. STAGE THREE

  13. STAGE FOUR

  14. UNABLE TO STAGE

  15. WHAT STAGE?

  16. WHAT STAGE?

  17. STAGING ALL OTHER WOUNDSNOT 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).

  18. PARTIAL THICKNESS BURN

  19. 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?

  20. Probe the wound!!!!

  21. Try and correct the causes that may delay wound healing • Edema • Nutrition/Dietary consult • Alter medications • Glycemic control • Treat infection • OT/Physio consult

  22. Documentation • Slough * Location • Eschar * Size LxWxD • Granulation • Undermining • Erythema • Maceration • Exudate • Odor

  23. Moist Wound HealingMotto… If its wet……..DRY it! If its dry………MOISTEN it! If its irritated…SOOTHE it! If its chronic…IRRITATE it! If its palliative..COMFORT it!

  24. 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

  25. 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

  26. 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)

  27. 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

  28. Wound Care Products • Liquid barrier • Transparent films -non adherent dressings • Hydrocolloids -debriding agents • Gauze dressings -antiseptic • Hydrogels • Foam dressings • Absorptive dressings • Calcium alginate • Charcoal dressings • Silver coated dressings

  29. LIQUID BARRIER

  30. TRANSPARENT FILM

  31. HYDROCOLLOID

  32. GAUZE DRESSINGS

  33. HYDROGEL

  34. FOAM DRESSING

  35. ABSORBENT DRESSINGS

  36. CALCIUM ALGINATE

  37. ODOUR CONTROLCHARCOAL DRESSINGS

  38. ANTIMICROBIAL DRESSING

  39. OTHER DRESSINGS • Non adherent dressings- • i.e.- mepital • Debriding agents-mesalt, iodosorb • Antiseptic- bactigras with a chlorhexidine base

  40. BIOLOGIC DRESSINGS

  41. BIOLOGIC DRESSINGS

  42. 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

  43. GOOD CANDIDATE FOR NEGATIVE PRESSURE

  44. QUESTIONS

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