The 411 on wound care


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The 411 on wound care

  1. 1. The 411 on Wound Care May 12 2010 Amy Clegg RN, MSN, NP-C, CWOCN Dawn Engels RN, CWOCNQuestions Info
  2. 2. Objectives• Identify Partial and Full Thickness Wounds• List 2 Barriers to Wound Healing• Identify Pressure Ulcer Stages• Identify Measures to Reduce Pressure Ulcers• Verbalize mechanism of VAC• Identify indications/contraindications for VAC• Demonstrate VAC application
  3. 3. Would Healing• Hemostasis – within 60 minutes• Inflammation- 20 minutes –4 days• Proliferation- 3-21 days• Remodeling- 21 days –2 years
  4. 4. Barriers to Wound Healing Lifestyle Pressure Age Health PatientNutrition Status Necrotic Tissue Perfusion Infection
  5. 5. Partial Versus Full Thickness• Partial thickness wound• Wound does not extend through the dermis• Heals by regeneration• Re-epithelization
  6. 6. Partial Versus Full Thickness• Full thickness wound• Wound extends through the dermis may extend to an organ, tendon, muscle bone• Heals by contracting and scar tissue
  7. 7. Partial Thickness•
  8. 8. Full Thickness
  9. 9. What is a Pressure Ulcer?•Localized injury to skin and or underlying tissueusually over a bony prominence due to unrelievedpressure•Can occur under a splint or cast•3 most common locations sacrum, heels, andtrochanter
  10. 10. To Stage or Not to Stage a Wound?• Pressure ulcer staging is only to describe wounds that develop from pressure• Pressure ulcer staging is not used to describe wounds from other causes such as skin tears, tape burns, diabetic foot, venous ulcer, or incontinence
  11. 11. What are the pressure ulcer stages?• Suspected Deep Tissue Injury• Stage 1• Stage 2• Stage 3• Stage 4• Unstageable
  12. 12. Suspected Deep Tissue Injury• Purple or maroon area of discolored skin or blood filled blister• Maybe painful, firm, mushy, boggy, warmer or cooler as compared to adjacent side• The wound may further evolve into full thickness tissue loss
  13. 13. Stage 1• Intact skin with nonblanching redness• Maybe difficult to detect in patients with darker pigment• Maybe painful, firm, soft, warmer or cooler as compared to adjacent tissue
  14. 14. Stage 2• Partial thickness skin loss of dermis• Presents as a shallow open wound with pink or red tissue• Can also be a serum filled blister
  15. 15. Stage 3• Full thickness skin loss. Subcutaneous fat may be visible• Slough may be present but does obscure base of wound• Depth varies by anatomical location
  16. 16. Stage 4• Full thickness tissue loss with exposed bone, muscle or tendon• Depth varies depending on anatomical location
  17. 17. Unstageable• Full thickness tissue loss in which the base of the wound is covered by slough or eschar.• Until enough slough or eschar is removed true depth cannot be determined
  18. 18. Measures to Reduce Pressure Ulcers• Nutrition• Moisture Management• Specialty beds• Chair cushions• Repositioning• Determine risk- Braden Scale
  19. 19. VAC Mechanism of Action• Maintains moist environment• Removes exudate• Promote granulation• Promote perfusion• Reduce edema
  20. 20. Indication/Contraindications VAC• Indications •Contraindications• Dehisced wound •Malignancy in wound• Pressure Ulcers •Untreated Osteomyelitis• Open Abdominal wounds •Necrotic tissue• Traumatic wounds •Directly over vessels• Diabetic wounds •Active Bleeding• Skin grafts
  21. 21. VAC Stations• Apply• Cannister• Y Connect• Bridge• Foams
  22. 22. Thank you!Questions?
  23. 23. References• Google ImagesAyello, E. & Lyder, C. (2008). The new era of pressure ulcer accountability. Advances in Skin & Wound Care, 21(3), 134-139.National Pressure Ulcer Advisory Committee . Pressure ulcer stages revised by NPUAP. Retrieved on 6/5/08 at for Medicare and Medicaid Services, Hospital Acquired Conditions (Present on Admission Indicator): HospAcqCond/01_Overview.asp Retrieved on July 2008