Wound Care
Terminology:
Undermining: space under the skin.
Tunnel: Depth (hidden), use probe
Maceration: Softening from fluid excess
Desiccation: dry wound
Wound Prevention:
Risk for pressure ulcer:
Q 2 hr turn
30/30 rule:
Surface support:
foam, water, gel mattress
Low air loss mattress for stage 3-4
No donut
For heel, floatation, wt distribution in calf
4. Moisturizing soap. Not too hot or too long in bath or shower
5. Moisture control / prevention
Toileting program, scheduled
Foley
Moisture barrier
Topical antifungal for folds
Wick or diaper
Wound assessment:
MEASURE:
Measure
Exudate
Appearance
Suffering
Undermining
Re-evaluate
Edge
M: Measure – depth, length , width
E : Exudate : include Color and Consistency.
Quantity: Dry (no exudate), small, moderate,large (uncontrolled)
A : Appearance : Green – infection
Pale : epilthelialized
Yellow : slough
Red : granulation
Black : necrotic
S : Suffering
U : undermining
R : Re-evaluate
E : Edge – peri-wound assessment
Infection Clues : If not getting better. Better, then gets worse. Pain
Inability to heal : reinjury. Poor edema control. Exudate. Infection. Moisture balance
POPE:
Pain control:
Topical-
EMLA cream : lidocaine, prilocaine.
Morphine infused hydrogel (compounded)
8 mg MS in 8 mg hydrogel (or metronidazole gel can be used as carrier)
No wet to dry , no tapes
Pain Quantify: (PQRST)
P
– Palliative factors. Provoking factors
Q
– Quality
R
– Region
S- Severity
T – time, temporal
Odor
control ( bacterial load)
o
Topical metronidazole
o
Activated charcoal dressing , traps and prevents
odor locally
o
Silver impregnated dressing
o
Meta honey
o
Room deodorizers : kitty litter, coffee ground,
oils. Remove old dressing from room
Protect
wound bed
Non
adherent dressing
Manage
incontinence
Exudate
control – heal better in some but not too much moisture.
o
Transparent dressing. Provides moisture if wound
is not moist or dry. Waterproof. Maceration if left too long.
o
Hydrocolloid dressing. for light exudate.
Occlusive, waterproof. Not good for odor, not good for undermining, not good
for too much exudate.
o
Hydrogel. Limited absorption. For dry wound.
o
Allgenate. For moderate to heavy exudate. Forms
a gel. Could desiccate if not enough exudate.
o
Foam dressing. For multiple varieties of wounds.
May use for dry wounds.
Types of wound
Pressure ulcers:
stages:
I. Intact skin. epidermis only, non-blanchable.
II. Partial thickness skin loss. Through epidermis and into dermis, shallow open ulcer with red-pink base and no slough.
III. Full thickness skin loss. SubQ fat may be visible, slough may be present, may have tunneling.
IV. Full thickness skin loss with visible muscle, tendon or bone. Slough or eschar may be present in some parts of the wound bed and tunneling often exists.
Unstageable. Full thickness skin loss where base of the wound is covered by slough (yellow, tan, green, brown, gray) or eschar (tan, brown, black).
Evaluation:
Management:
Debridement:
autolytic dressing. gentle, debriding. May take longer
enzymes. Santyl (collagenase), or Papain (Accuzyme)
mechanical. hydrotherapy, pressure irrigation, magots, wet-to-dry (DON’T DO, painful)
surgical. Makes chronic wounds into acute wounds to start physiologic healing
Cleaning.
Antiseptics (Iodine base, peroxides, Dakin solution), may delay healing.
Water
NS
Dressing
Foams. Polyurethane pads, semi-occlusive, good for exudate, some pain relief.
Alginates. autolytic, both hemostatic and bacteriostatic ( good for exudates, bleeding wounds, infected wounds). Made out of seaweed.
Hydrogel. autolytic. either gel or solid, hydrates, good for dry wounds and cooling.
Hydrocolloid. Wafer or gelatin, decrease friction or shear. non-absorbant, not good for exudate.
Transparent films.
Gauze.
Silver. antimicrobial, can be placed on alginate.
Infected wounds
Topical anti-septic: Dakin solution
antimicrobials. anerobes (metronidazole powder, silver sulfadiazine). Areobes ( neomycin, polymixin, bacitracin)
Deep infection/sepsis. consider systemic antibiotics.
Malodorous wounds
Dressing. alginate. Activated charcoal dressing , traps and prevents odor locally. Silver impregnated dressing, Meta honey
ventilation
Absorbers. kitty litter, ground coffee, charcoal, candle flames. oils. Remove old dressing from room
Alternative smells. vanilla, vinegar.
Topical metronidazole
Pain management
narcotics before dressing changes
can sometimes give topical morphine, methadone, dilaudid, lidocaine.
Morphine infused hydrogel (compounded) 8 mg MS in 8 mg hydrogel (or metronidazole gel can be used as carrier).