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Guest Lecture Pres
Wounds Guest Lectures
| Question | Answer |
|---|---|
| What is Governor Brownback's new reform of Medicaid & when does it go into action? | KanCare; 1/1/2013 SRS will be Dept for Children & Families Dept of Aging will be Dept for Aging & Human Services |
| 3 MCOs under KanCare | United HC Sunflower Amerigroup |
| Insurance Requirements for Wounds | Physician's order with wound location, size of wound (LxWxD), wound type, exudate amount, type of debridement, freq. of dressing change, type(s) dressing used, description of wound care |
| When is a new wound assessment required? | If still ordering same supplies after a month Expect wounds to change within 2 weeks |
| Medicare doesn't pay for what? | Hospital-acquired pressure ulcers |
| Long-term care reimbursement for Medicare | EBP for prevention & treatment of pressure ulcers & LE wounds are in place. Penalties for non-compliance are severe. Home care, CMS requires reporting on wound care published on a public website. |
| Preventing Pressure Ulcers- Pressure | Regular re-positioning & pressure re-distribution (pillows or devices) |
| Preventing Pressure Ulcers- Sheer/Friction | Apply skincare products to lubricate- such as Aloe Vesta Skin Conditioner or moisturizing body cream (not lotion); or Apply moisture-retentive dressings to reduce friction (hydrocolloid extra thin or transparent dressings) |
| Preventing Pressure Ulcers- Excess Moisture | Protect with skin barrier products- ointments, desitin, zinc, InterDry Ag |
| Preventing Pressure Ulcers- Dryness | Use moisturizing bathing- such as Aloe Vesta; AND Conditioning creams |
| Preventing Pressure Ulcers- Expected Outcome | Skin stays intact without signs of hyperemia |
| Skin Care & Prevention- Protective Ointments | Help treat & prevent rash associated with diaper use or continued exposure to feces, urine or both. Help treat skin tears & sheering, stage I ulcers |
| What to use protective ointments on | Intact, clear skin; Red, dry skin; Mild dermatitis; Denuded skin; Adheres to macerated skin- be careful not to cause shear wounds Don't apply over deep or puncture wounds, infections or lacerations |
| Protective Ointment Properties | Usu. petrolatum based; Vits A&E help sooth/condition skin; Some have clove oil (helps mask odor, slightly numbing); Karaya absorbs moisture, adheres to weepy/macerated skin; Doesn't wash away when exposed to urine/feces; Can see through some |
| Dimethicone | Silicone oil that softens the skin without contributing to the lipids, or making the skin feel greasy |
| Anti-Fungal Cream | Tx: Tinea cruris (jock itch), Tinea corporis (ringworm), Tinea pedis (athlete's foot) Water based, absorbs quickly Don't use in areas exposed to urine/feces Contains Vitamin E & skin conditioners |
| Guidelines | Decide which type of wound you're treating Determine what you want tx to accomplish Create a plan & choose products to help If it's dry, wet it; If it's wet, dry it If wound has both characteristics, wet AND dry |
| What to do prior to treatment | Assess for infection (increased/purulent exudate, inflammation, delayed healing, odor, discolored granulation tissue) Obtain measurements weekly Cleanse- wound cleanser/sterile water/saline |
| Moisture Balance- Dry Wounds | Dry wounds-hydrate Need- moisture to help dissolve dead tissue. Reduce dead space in cavity wounds. Wound gel/gauze filled w/ wound gel/hydrogel wafer Transparent dressing if no exudate Thin hydrocolloid if none--slight exudate Soft silicone contact |
| Should you fill the wound bed? | Line the wound, don't fill. If you fill, gel comes out & will macerate wound edges. With lining, it will seep back into wound bed & hydrate it. |
| Moisture Balance- Wet Wounds | Manage exudate; Need- dressing that can keep moist environment, remove exudate, permit moisture vapor transmission, avoid wound trauma at dressing changes |
| Products to use in wet wounds | Foam- thick/thin Alginate- hydrofiber (manmade), calcium alginate (seaweed) or collagen alginate (animal based) Composite- protect, absorb, adhere (3 layers) InterDry AG- skin to skin moisture |
| Secondary Dressings- Cover & Protect | Bordered gauzes, Island dressings, Woven/non-woven gauze, Wraps, ABD dressings, Hydrocolloids, Foams, Composite Dressings |
| Dry Wound-- Hydrogel- 3 forms | Tube Wafer Impregnated Gauze |
| Hydrogel | Gently rehydrates necrotic tissue; Effectively de-sloughs; Creates moist environment; Non-adherent; Keeps gel in close contact with wound surface; Non-cytotoxic Change daily! Use 2ndary dressing |
| Wound Gel Application (Dry Wounds) | Cleanse & pat wound dry. Measure. Apply by positioning pt so gel can go directly into wound. Line wound bed (don't fill); If necrotic, line edges of necrotic tissue. Cover with 2ndary dressing. |
| Wound Gel impregnated gauze application (Dry wounds) | Clean, pat dry, measure. Cut or fold gauze to fit wound bed. Place over wound bed. Cover with 2ndary dressing. |
| Hydrogel Wafer application (dry wounds) | Clean, pat dry, measure. Doesn't have to be cut to fit wound bed, cover wound & surrounding skin. Cover with 2ndary dressing. |
| Transparent Dressing- Dry Wounds | Breathable, high vapor permeability, allows moisture to pass from wound & surrounding skin. Barrier to bacteria. Waterproof (can't be submerged). Easy to apply. Conforms to body contours. Can view wound through dressing. Remove with LATERAL STRETCH! |
| Thin Hydrocolloid- Dry Wounds | Activates enzymes through moisture; microbial barrier/waterproof; Adheres to slightly moist skin, not wound bed. Can be primary or secondary dressing. Facilitates autolytic debridement of fibrin & necrotic tissue. 1 hand application, self adhesive. |
| 30 second rule | Once applied, hold hand over it for 30 sceonds b/c it has to get to body temperature to adhere to the skin Hydrocolloids are often used for coccyx wounds |
| Applying Hydrocolloid | Clean, pat dry, measure. Place dressing centering wound in middle of dressing. Spend 1-1.5 mins working dressing down after applying. Work from center out. Can use skin prep/tape for edges. |
| When should you change out a hydrocolloid? | When exudate reaches within 1/2" dressing edge or leaking- usually lasts at least 3 days. |
| Contact Layers | Prevents damage to new tissue Enables less frequent dressing changes Doesn't adhere to moist wound beds, only dry tissue Atraumatic to wound/surrounding skin, minimizing trauma & pain on dressing changes Transparent for inspection |
| Contact Layers continued | Conforms to contours Designed for wide range of wounds, dry & wet, including 2nd deg burns, grafts Open mesh for application of topical tx Can line deep wound before application of packing materials |
| How long can contact layers be worn? | Up to 10 days, just change secondary dressing |
| Foam Dressings | Lite, Regular, Bordered- depends on exudate amount Hydrophilic Polyurethane Dressing sandwiched b/t nono-adherent wound contact layer & waterproof outer film S/sx infectoin- use only if proper infection tx initiated |
| More foam dressings | Fast fluid uptake & absorption that xfers exudate away from wound- reduces maceration Can be cut to shape Bacteria & waterproof Breathable Don't use with oxidizing agents (Dakins, Hydrogen Peroxide, enzymatic) |
| Application of Foam | Clean, dry, measure. Clip excess hair. Cut to fit awkward areas. Apply non-waterproof side to wound bed. Non-bordered, secure with tape/bandage. Remove by lifting dressing away from wound. |
| Alginates- Hydrofiber Dressings | Alginates absorb 20x their weight Hydrofiber absorbe 5-6x more than gauze Insulate wound, fill dead space Non-adherent as exudate diminishes Controlled wicking Converts to clear gel/gel-fiber matrix Strong- simple application/removal |
| What would you use an alginate on? | Deep or shallow wounds with or without undermining/tunneling-moist to wet wounds Only put alginate where there is moderate to heavy exudate. If it is put on good skin, you will just suck out moisture. |
| Thick Hydrocolloids | Moist environment. Absorbs exudate, allows fluid to evaporate, avoiding maceration. Hydrophobic outer layer resists fluid penetration. Doesn't adhere to wound base. Primary or 2ndary dressing. 1-hand app 30 second rule & remove with lateral stretch! |
| Composite Dressings | All in one Contact layer- exudate passes to absorbent pad Absorbent pad- absorbs exudate minimizing risk of maceration Protective film- semi-permeable, prevents fluids passing through dressing, protecting wound bed from contamination |
| InterDry AG | Textile w/ Antimicrobial Silver Complex Treats intertrigo Wicks moisture from skin Reduces skin to skin friction 5-day therapy 5 cm interdry exposed to ensure skin folds remain dry |
| InterDry AG | Candidiasis non-resolving in 5 days, antifungal powder (microguard) may be used Don't use creams, ointments, or pastes with interdry Refer if skin doesn't improve in 5 days Can use with compression bandages May be placed over wound dressings |
| Silver Dressings | Wound gel; Foams; Alginates; Secondary dressings Wouldn't use silver on wounds changed daily or more b/c it's very expensive. Wound has to be infected for silver to work on it. |
| Silvery 2ndary Dressings | Sustained release of Ag usually 3-7 days- purpose: kill bacteria Silver begins inactivating pathogens within 30 mins of applying Reduction of micro-organisms reduces odor Cost effective- 3x> other dressing- use Ag w/ cross infection/colonization |
| Prisma | Collagen matrix that looks like styrofoam, can cut it & place in wond; reduces bacterial burdens; cut to fit wound bed, then cover with semi-occlusive dressing so moisture can exit Not for 3rd degree burns or patients sensitive to Ag |
| Prisma | Sterile, freeze dried oxidized regenerated cellulose, collagen, & Ag. Transforms into soft, conformable gel. Reduction of bacterial burden = reduced risk of infection Collegen fibers- biodegradable matrix for cell invasion & capillary growth |
| Prisma | Effective with- pseudomonas, staph, e coli, strep Cut to fit, cover with semi- or non-occlusive 2ndary dressing Used on dry wound-use saline to hydrate matrix |
| Prisma | May be used under compression therapy Don't be concerned if any matrix residual left in wound, will be naturally absorbed into the body over time |
| Medihoney | Resistant to degradation by wound fluid Sterilization doesn't decrease product effectiveness Debrides, lower wound pH moisture balance, natural & potential for extended wear times |
| Medihoney | Uses: non-healing post-op, venous leg ulcers, Crohn's disease ulcerations, diabetic foot ulcers; Gel form, impregnated into calcium alginate dressing, Honeycolloid |
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