Wound Care Best Practice Guidelines

1. VITAS Healthcare Corporation Wound CareBest Practice Guidelines

2. Goal To educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients.

3. Objectives • Identify preventative measures • Describe risk factors contributing to skin impairment • Describe the parameters of wound assessment including staging of wounds • Describe wound types and tissues • Describe care planning considerations and the selection of appropriate interventions

4. Prevention • Inspect skin • Moisture control • Proper positioning and transfer techniques • Nutrition • Avoid pressure on heels and bony prominences • Use of positioning devices • Monitor and document

5. Risk Assessment • Alterations in mobility • Level of incontinence • Nutritional status • Alteration in sensation or response to discomfort • Co-morbid conditions • Medications that delay healing • Decreased blood flow to lower extremities when ulceration is present

6. Contributing Factors1 Friction Immobility Shear Pressure Ulcers Pressure Incontinence Malnutrition

7. Location Stage and Size Periwound Undermining Tunneling Exudate Color of wound bed Necrotic Tissue Granulation Tissue Effectiveness of Treatment Assessment and Documentation

8. Assessment and Documentation • Wound and Risk Assessment every visit • Documentation on Wound Assessment Form every 7 days when 1 or more pressure ulcer exists • Physician assessment and documentation on Physician Wounds Care Assessment tool

9. Stage I Stage II Stage III Stage IV Pressure Ulcer Staging2

10. Care Planning. Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound.

11. Appropriate Goals • Prevent complications or the deterioration of an existing wound • Prevent additional skin breakdown • Minimize harmful effects of the wound on the patient’s overall condition • Promote wound healing

12. Interventions Dressing considerations should include: • Patient’s condition and prognosis • Caregiver ability • Ease and continuity of use • Ability to maintain moisture balance • Frequency of change

13. Pain Management 1) Medicate the resident prior to dressing changes 2) Some treatment regimes may be uncomfortable for the resident • Provide maintenance doses of medication for those patients who have pain. • Adjuvant therapy may be appropriate • Consider non-medicinal approaches

14. Types of Wounds3 • Pressure Ulcers • Arterial Insufficiency • Diabetic Ulcers • Venous Insufficiency • Surgical Wounds • Tumors

15. Palliative Wound Care for the Imminent Patient Think: • Comfort • Quality of Life Treatment Choices: • Keep Current Treatment • Irrigation, Cover with DuoDERM Thin or Bioclusive Dressing • Irrigation, Silvadene, Cover with Gauze (if infection is suspected)

16. Basic Elements of Wound Care • Cleanse Debris from the Wound • Possible Debridement • Absorb Excess Exudate • Promote Granulation and Epithelialization When Appropriate • Possibly Treat Infections • Minimize Discomfort

17. Wet to Dry Dressings Indicated for Mechanical Debridement ONLY • Causes Injury to New Tissue Growth • Is Painful • Predisposes Wound to Infection • Becomes a Foreign Body • Delays Healing Time

18. Goal is to minimize the frequency of dressing change Daily dressing changes increase chances of infection and disrupts the healing of tissue Optimal wear time is 3-7 days Decrease Frequency of Dressing Changes Frequency

19. Interventions:Patients At-Risk or Stage I • Assess “Risk for Breakdown” • Utilize skin creams and lotions for dry skin • Utilize barrier products as needed to minimize irritation from incontinence • Reposition frequently • Encourage fluids as tolerated and appropriate • Use pillows in bed for positioning

20. Cleansing Wounds.. • Remove Wound Debris • Sustain Moist Environment • Soften Necrotic Tissue • Debride the Wound • Reduce the Risk of Bacterial Contamination and Infection • Reduce Odor

21. Goals & Treatment Guidelines • Dry to Minimal Exudate • Moderate Exudate • Copious Exudate

22. GOALS: Maintain skin integrity Skin to remain clean and odor free Protect and moisturize skin TREATMENTS: Preferred agents (dry skin) Aloe Vesta skin cream Preferred agents (at risk for breakdown due to incontinence/pressure) Aloe Vesta protective ointment Dermarite Perigaurd barrier ointment Interventions Stage I

23. Dry to Minimal Exudate GOALS: Minimize dressing changes Maintain moist environment Prevent infection Prevent additional skin breakdown TREATMENTS: Preferred agents: Hydrofiber (Aquacel) Viscopaste Hydrocolloid (DuoDERM Extra Thin) Follow product guidelines for frequency of dressing change Interventions Stage II, III, IV

24. Moderate Exudate GOALS: Minimize dressing changes Maintain moist environment Prevent infection Prevent additional skin breakdown TREATMENTS: Preferred Agents: Hydrofiber (Aquacel) Hydrocolloid (DuoDERM Signal) Follow product guidelines for frequency of dressing change InterventionsStage II, III, IV

25. Copious Exudate GOALS: Minimize dressing changes Manage Exudate Prevent infection Prevent additional skin breakdown TREATMENTS: Preferred Agents: Hydrofiber (Aquacel) Hydrocolloid (DuoDERM Signal) Follow product guidelines for frequency of dressing change InterventionsStage II, III, IV

26. Interventions • Necrotic Tissue in Ulcer Bed • Fungating Lesions • Infected Wounds • Skin Tears • Gangrenous Wounds • Diabetic Ulcers

27. InterventionsNecrotic Tissue in Ulcer Bed • Mechanical Debridement • Autolytic Debridement • Sharp or Surgical Debridement* • Enzymatic or Biochemical Debridement* • Biological Debridement* *Requires Approval

28. InterventionsNecrotic Tissue in Ulcer Bed • Prior to debridement interventions, assess whether it will enhance wound healing or promote infection or cause undue pain. • Do NOT institute aggressive debridement if the patient is within days/week of death, or if the eschar is stable, dry, non-draining, and wound is not infected. • For Intact black heel – relieve pressure – no dressing or debridement – if opens then refer to necrotic treatments.

29. Goals: Removal of exudate Odor control Pain control Non-Pharmacological measures to control odor include: Oil of Wintergreen Charcoal briquettes or Coffee grounds Dryer Sheets Treatments: Preferred Agents Non-Adherent Gauze Dressing (Telfa) Zinc Oxide Paste (Viscopaste) Activated Charcoal Dressing (Carboflex) Atropine solution may be used to control bleeding Metrogel cream can be used to control odor InterventionsFungating Lesion

30. Diagnosis of wound infection: Swab Cultures not recommended Based on clinical signs (fever, increased pain, friable granulation tissue, foul odor) Tissue culture or biopsy is not optimal for the hospice patient. Treatments: Preferred agents: Hydrofiber (Aquacel Ag) Silvadene ointment and non-sterile gauze DO NOT USE: Providine Iodine Iodophor Dakin’s solution Hydrogen peroxide Acetic Acid InterventionsInfected Wounds…

31. Goals: Prevent infection Healing Prevent further injury Minimize dressing change frequency Treatments: Preferred Agents: Non-Sterile Gauze Transparent Film (Opsite) InterventionsSkin Tears

32. Ischemic (Gangrenous) Wounds Draining wounds Cover with Telfa or gauze and wrap with Kerlix No drainage Cover with gauze and Kerlix Change QD and PRN Venous Stasis or Diabetic Ulcers Draining wounds Cover with Telfa or Adaptic with a Kerlix wrap changed QD Cleanse with normal saline using bulb syringe Non-draining wounds Cover with gauze and wrap with Kerlix Apply tape to the Kerlix to prevent further injury to surrounding skin Change QD Interventions

33. Comfort and Shear Reduction Products: Pillows Heel/Elbow Protectors Foot Cradles Sheepskin Pads DO NOT USE DONUT TYPE DEVICES IN WHEELCHAIRS Support Surfaces

34. Support Surfaces Multiple Pressure Points (greater than 2 turning surfaces) • Standard Mattress • 3-4” Eggcrate Overlay on Standard Bed • Gel Mattress Overlay • Wheelchair Foam Pad • Wheelchair Gel Pad Multiple Pressure Points (fewer than 2 turning surfaces) • Static Air Mattress • Alternating Pressure Pad and Pump • Low Air Loss Mattress (requires approval)

35. In Summary…. • Determine the plan of care based on the patient’s characteristics • Evaluate the wound status every visit and at a minimum of weekly • Evaluate the effectiveness of the treatment regime • Try to provide consistent wound care among all caregivers • Completely document status of wound

36. Thank you Together, we can make a difference!