Wound Care Presentation

• Measuring a wound


  Length, width and depth are measured as well as areas of tunneling or undermining
• General Wound Care Principles

  • If wound bed is: Red = protect, Yellow = clean, Black = debride
• Débridement


  The removal of nonviable tissue
• Types of débridement


  • Autolytic (uses the body's own digestive enzymes to break down necrotic tissue)
  • Enzymatic (commercial products that contain the same enzymes the body produces naturally)
  • Mechanical (wet to dry dressings – rarely used anymore)
• Categories of Wound Dressings

  • Passive/Primary (protective function only)
  • Interactive/Secondary (modify the physiology of the wound, modify & stimulate cellular activity & release growth factor, absorb exudate, maintain moist environment & allows surrounding skin to remain dry, hydrocolloids, alginates, & hydrogels)
  • Active (improve the healing process & decrease healing time, skin grafts or biologic skin substitutes)
• Types of Dressings


  • Occlusive dressings
  • Transparent films
  • Moisture retention dressings
  • Hydrogels
  • Hydrocolloids
  • Foam dressing
  • Calcium alginates
  • Antimicrobial
  • Collagen dressings
• Goals Related to Burns

  • Prevention
  • Institution of lifesaving measures for the severely burned person
  • Prevention of disability and disfigurement through early specialized and individualized care
  • Rehabilitation through reconstructive surgery and rehabilitation programs
• Factors to Consider in Determining Burn Depth

  • How the injury occurred
  • Causative agent
  • Temperature of agent
  • Duration of contact with the agent
  • Thickness of the skin
• Burn Depth


  • First degree (superficial) - Skin intact, red
  • Second degree (Partial thickness) - Skin with blisters, red
  • Third degree (Full thickness) - Skin white, black, edges painful, burn itself may not be painful
  • Fourth degree - Major fluid and electrolyte shifts, skin debridement (surgical), skin grafts necessary
• Physiologic Changes


  • Burns less than 25% TBSA produce primarily a local response
  • Burns more than 25% may produce a local and systemic response, and are considered major burns
  • Systemic response includes release of cytokines and other mediators into systemic circulation
  • Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction
• Effects of Major Burn Injury

  • Fluid and electrolyte shifts
  • Cardiovascular effects
  • Pulmonary injury
  • Upper airway
  • Inhalation below the glottis
  • Carbon monoxide poisoning
  • Restrictive defects
  • Renal and GI alterations
  • Immunologic alterations
  • Effect upon thermoregulation
• Methods to Estimate Total Body Surface Area (TBSA) Burned

  • Rule of nines (various areas=9%)
  • Lund and Browder method (more precise division of body parts with corresponding percentages)
  • Palm method (patients palm approximately 1%)
• A 20 y/o patient comes to the ER with burns to the front of their chest and the entire arms (anterior) bilaterally. Using the rule of nines their burn percentage would be estimated as 27%
• A 37 y/o patient comes to the ER with burns to their entire back, and both legs (posterior) bilaterally. Using the rule of nines their burn percentage would be estimated as 36%
• A 57 y/o patient comes to the ER with burns from a house fire. The burns are from their waist down anteriorly and posteriorly. Using the rule of nines their burn percentage would be estimated as 55%
• Types of Ulcers


  • Pressure
  • Arterial
  • Venous
  • Neuropathic
• Pressure Ulcers


  Involve breakdown of the skin due to prolonged pressure, friction and shear, and insufficient blood supply
• Pressure ulcers are a "NEVER EVENT"
• Assessment for the Prevention of Pressure Ulcers

  • Assessment of skin
  • Evaluate mobility
  • Evaluate circulatory status
  • Evaluate neurologic status
  • Evaluate nutrition, hydration
  • Braden scale
• Patients with a total Braden scale score of 16 or less are considered to be at risk of developing pressure ulcers
• Stages of pressure ulcers

  • Deep tissue injury - Immediate pressure relief to affected area
  • Stage I - Intact skin with nonblanchable erythema of a localized area, usually over a bony prominence - Remove pressure, prevent moisture, shear, friction, promote proper nutrition, hydration
  • Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, with slough - Clean with sterile saline, use semipermeable occlusive dressings, hydrocolloid dressings, or wet saline dressings
  • Stage III - Full-thickness tissue loss
  • Stage IV - Full-thickness tissue loss with exposed bone, tendon, or muscle - Debridement, wet-to-damp dressing, enzyme preparations, surgical debridement, topical treatment to promote granulation of tissue, surgical interventions may be required
• Arterial Ulcer


  Chronic arterial disease characterized by intermittent claudication, typically small, circular, deep ulcerations on the tip of the toes or in the web spaces between the toes, minimal exudate
• Venous Ulcer


  Caused by venous insufficiency, venous stasis, pain described as aching or heavy, ulcerations are in the area of the medial or lateral malleolus, typically large, pink, superficial and highly exudative, surrounding brown pigmentation
• Neuropathic Ulcers


  Located on plantar surface over metatarsal heads, moderate to large exudate, wound bed is typically red, edges well defined
• Medical Management of Ulcers

  • Anti-infective therapy dependent upon infecting agent
  • Oral antibiotics usually prescribed
  • Debridement of wound
  • Dressings
  • Other may require surgery
• Mobility with Leg Ulcers

  Activity is usually initially restricted to promote healing, gradual progression of activity, activity to promote blood flow, encourage patient to move about in bed and exercise upper extremities, diversional activities, pain medication prior to activities
• Skin cancers are frequently related to sun exposure, prevention involves use of sunscreen and avoiding sun exposure
• Types of Malignant Skin Tumors

  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Malignant melanoma
  • Kaposi's sarcoma
  • Metastatic skin tumors
• Basal Cell Carcinoma (BCC)


  Most common type, sun exposure major risk factor, small waxy nodule with rolled, translucent borders, rarely metastasizes but does erode contiguous tissues, prognosis is good
• Squamous Cell Carcinoma (SCC)

  Appears on sun damaged skin but may arise from normal or preexisting skin lesions, greater concern than BCC because it is invasive carcinoma and may metastasize, metastases account for 75% of deaths from SCC, prognosis depends on incidence of metastases
• Malignant Melanoma


  • Most lethal of all skin cancers, risk factors include fair skinned, blue eyed, light haired people of Celtic or Scandinavian origin, people who burn and don't tan, environmental exposure to intense sunlight, history of melanoma, skin with congenital nevi, worldwide incidence is increasing and mortality rate is increasing, peak incidence 20-45 years of age, types include superficial spreading, lentigo-maligna melanoma, nodular melanomas, acral-Lentiginous
• Scabies


  Caused by the mite Sarcoptes scabei, itching is severe, symptoms begin about 4 weeks after contact, mite frequently involves fingers and hands, contact may spread infection, health care personnel should wear gloves when providing care until infection is ruled out
• Patient Teaching for Scabies

  • Take a warm, soapy bath, allow skin to cool, thoroughly dry skin and apply prescription scabicide lindane, crotamiton, or 5% permethrin to entire body, not including the face or scalp, leave on for 12–24 hours, wash clothing and bedding in hot water and dry in a hot dryer, treat all contacts at the same time, pruritus may continue for several weeks and does not mean retreatment is required
• Gerontologic Considerations for Scabies


  Long term care facilities are susceptible to outbreaks, scabies may not be recognized and itching may be contributed to dry skin, more sensitive to side effects of scabicides
• Shingles (Herpes Zoster)


  Treatment with antiviral acyclovir (zovirax, valacyclovir (valtrex), or famciclovir (Famvir) must be started within first 72 hours to be effective, best within 24 hours, goal of treatment is to treat pain and reduce or avoid complications (infection, scarring, post herpetic neuralgia and eye complications, such as blindness)
• Psoriasis


  A chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate, affects about 2% of the population, primarily those of European ancestry, improves and recurs, a life-long condition, may be aggravated by stress, trauma, seasonal and hormonal changes
• Medical Treatment for Psoriasis

  • Biologicals- Enbrel (injection weekly alters immune function)
  • Topical steroids- Clobetasol (temovate - severe)
  • Vitamin D3 derivatives- Dovonex
  • Coal tar products- T-derm, Psori gel
  • Systemic therapy- Methotrexate (chemo)
  • Photochemotherapy- UVA or UVB light with out topical meds, PUVA (UVA and oral psoralens)
• Stevens-Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)


  Severe adverse reactions to medication, almost any medication including over-the-counter drugs, such as Ibuprofen, can cause SJS, most commonly implicated drugs are anti-convulsants, antibiotics (such as sulfa, penicillin and cephalosporin) and anti-inflammatory medications
• Symptoms of SJS


  • Early - Swelling of eyelids, red eyes, conjunctivitis, flu-like symptoms, persistent fever
  • Late - Blisters in mouth, eyes, ears, nose, genital area, rash, blisters, or red splotches on skin, recent history of having taken a prescription or over-the-counter medication
• Treatment for SJS


  Stop taking the offending drug immediately to prevent complications, good supportive care, IV fluids and high calorie formulas are given to promote healing, antibiotics are given when necessary to prevent secondary infections such as sepsis, pain medications such as morphine are administered, most SJS patients can be managed in medical ICU or pediatric ICU, patients with TENS should be treated in a burn unit