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2015: Wounds in the Geriatric Population-Salas

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Wounds in the Geriatric Population

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2015: Wounds in the Geriatric Population-Salas

  1. 1. WOUNDS IN THE GERIATRIC POPULATION Adriana Salas, MSN, RN, CNS, ANP-BC Ingrid Kruse, DPM VA San Diego Healthcare San Diego, CA 1
  2. 2. Outline WHY WOUNDS ARE IMPORTANT RISK FACTORS ASSESSMENT STANDARD WOUND MANAGEMENT REASSESSMENT ADVANCED WOUND CARE 2
  3. 3. Wounds are Common ANY ULCER 12% of the population >65yrs 1 VENOUS STASIS ULCERS 1% of US population 2 PRESSURE ULCER 0.4 – 38% 70% of pressure ulcers occur in the elderly 3,4,5 3 1. U.S. Census Bureau. Statistical abstract of the United States. 2012. http://www.census.gov/compendia/statab/2012/tables/12s0009.pdf. Accessed 9/15/14. 2. Gillespie DL. Venus ulcer diagnosis, treatment, and prevention of recurrences. J Vasc Surg. 2010: 52:8S-14. 3. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston VA: National Pressure Ulcer Advisory Panel; 2001. 4. https://www.soa.org/news-and-publications/newsroom/press-releases/society-of-actuaries/default.aspx 5. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington,DC: National Pressure Advisory Panel; 2009.
  4. 4. Wounds are Expensive Foot infections are the most common reason for hospitalization in Diabetics PRESSURE ULCER COST $43,180 - $151,500 per hospital stay $9.2 -$15.6 billion total U.S. cost 1,5 LEGAL COST 2nd leading cause for litigation in long term care4 Medicare and Medicaid services stopped reimbursing acute care facilities for treatment of pressure ulcers in 2008 4 Diabetes Care 1998;21:2161-2177 and JAPMA 98:166,2008
  5. 5. Morbidity Physical decline Delayed rehabilitation Infection Amputation Depression Financial burden Death 5 NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org
  6. 6. Risk Factors Modifiable Tobacco Incontinence Malnutrition Diabetes Hypertension Vascular Disease 6 Non-Modifiable Skin Muscle Fat Mobility Cognition
  7. 7. Assessment of Wounds Location Stage/Size Base Tissue Exudate Perimeter Pain Infection Odor 7
  8. 8. Venous Stasis Ulcers TREATMENT Compression & Elevation Perforator Ligation Phlebectomy Stripping Sclerotherapy Laser Therapy 8 1. Falanga, V., Fujitani, R. M., Diaz, C., et al (1999), Systemic treatment of venous leg ulcers with high doses of pentoxifylline: efficacy in a randomized, placebo-controlled trial. Wound Repair and Regeneration, 7: 208–213. doi: 10.1046/j.1524-475X.1999.00208.x 2. Image: http://3.bp.blogspot.com/-ye1j4BSJ5VA/Ud9-93LC0qI/AAAAAAAABx8/IBDXEDmjhHA/s1600/Chronic+Ulcers+2.jpg
  9. 9. Neuropathic/Diabetic Ulcer TREATMENT Pressure Relief Proper shoes 9
  10. 10. Arterial Ulcers STUDIES: Ankle Brachial Index (ABI) Toe-Brachial Index (TBI) Segmental Pressures Waveform Analysis TCPO2, Angiogram 1 10 1. D Holtman, V Gahtan. Peripheral Arterial Perfusion: is it adequate for wound healing? Wounds. 2008: 20(8): 230-235. 2. Image: http://www.angiologist.com/wp-content/uploads/2010/08/Rutherford_6.jpg TREATMENT: Balloon angioplasty, stent, or bypass surgery1
  11. 11. Pressure Ulcers TREATMENT: Pressure relief Temperature control Moisture control 11 1. Image: http://1.bp.blogspot.com/--f1gXWksxF0/TxUdgP8iwtI/AAAAAAAAA-I/O_4nc6O_CIU/s1600/IMG_0418.JPG
  12. 12. Common Sites For Pressure Ulcers 12 http://img.docstoccdn.com/thumb/orig/41604968.png
  13. 13. Stage I Pressure Ulcer: Non-blanchable Erythema 13 NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org
  14. 14. Stage II Pressure Ulcer: Loss of Epidermis and Dermis 14 NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org
  15. 15. Stage III Pressure Ulcer: Subcutaneous Fat Layer 15 NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org
  16. 16. STAGE IV PRESSURE ULCER: Exposed Bone, Tendon Or Muscle 16 NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org
  17. 17. Unstageable: Full Thickness, Depth Unknown 17 NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer Prevention Points. NPUAP.org
  18. 18. Deep Tissue Injury: Intact Skin Or Blister 18 1. Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stNPUAP agescategories/Pressure Ulcer Prevention Points. NPUAP.org 2. http://woundeducators.com/wp-content/uploads/2014/01/suspected-deep-tissue-injury.jpg
  19. 19. Mechanical Debridement 19 http://www.curezone.org/upload/_N_Forums/Natural_Heali/Wound_Packed.jpg
  20. 20. Enzymatic Debridement 20http://in.hartmann.info/534.php
  21. 21. Sharp Debridement 21 1.http://www.podiatry.com/images/desertfootsite/images/Debridement-1.jpg
  22. 22. Wound Maceration TREATMENT Paint wound edges with betadine, avoid occlusive dressings. 22 https://wocn.confex.com/wocn/2007AM/techprogram/images/2414-0.jpg
  23. 23. Hypertrophic Granulation Tissue • TREATMENT: non occlusive dressing, steroid cream low potency x 5-7 days, topical antibiotic, compression with foam dressings, Silver nitrate sticks. 23 1. Sephen-Haynes, J., Hampton S. Achieing effective outcomes in patients with over granulation: wound care alliance UK. www.wcauk.org/downloads/booklet_overgranulation.pdf retr9eved 9/23/14 2. Image:https://woundcare-today.com/news/special-report/wound-care-today-special-report-overgranulation
  24. 24. Peri-wound Yeast Infection Treatment: topical or oral antifungal 24 1. image: http://www.oley.org/lifeline/TubetalkMA07.html 2. http://www.monarchlabs.com/mdtdressings
  25. 25. Wound Infection • SIGNS/SYMPTOMS: induration, redness, warmth, purulent discharge, increased pain, fever, leukocytosis, elevated CRP • STUDIES: MRI, bone biopsy, bone culture • TREATMENT: topical, oral or intravenous antibiotics 25 http://healthh.com/wp-content/uploads/2014/06/diabetic-foot-ulcer- pictures-3.jpg
  26. 26. Wound Odor TREATMENT: • Dressing with activated charcoal • Metronidazole 0.75% gel • Frequent dressing changes • Dakins Solution 26 Image: http://s.hswstatic.com/gif/smelly-feet-1200x800.jpg
  27. 27. Reassessment MEASUREMENTS: – Pressure Ulcer Scale for Healing (PUSH) tool 1 – Bates-Jensen Wound Assessment Tool (BWAT) 2 PICTURES: Obtain consent per facility protocol FREQUENCY: Daily until a working dressing change is established, then at least weekly 27 www.npuap.org Pressure Ulcer Scale for Healing (PUSH) PUSH Tool 3.0 http://www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf
  28. 28. Sheehan et al. Diabetes Care 2003;26:1879-1882. 28
  29. 29. Wound Healing Prediction • New Wounds that do not become 50 % smaller in 4 weeks will likely fail to heal and turn into a Chronic Wound! 29
  30. 30. The Chronic Wound • “Non-healing Wound” • “Stalled Wound” • “Problem Wound” 30
  31. 31. The Chronic Wound 1.Infection – Biofilm, Osteomyelitis 2.Hypoxia – Edema, Vascular disease, Nicotine 3.Poorly controlled Diabetes, Malnutrition 4.Trauma – Too much Pressure!! 31
  32. 32. Chronic Wound  All risk factors addressed and corrected  But wound still not healing : Consider using Advanced Wound Care 32
  33. 33. Advanced Wound Care Technologies 1. Negative Pressure Wound Therapy 2. Growth Factors: Regranex 3. Bioengineered Skin Substitutes: Apligraf, Dermagraft, Grafix 4. Extracellular Matrix :Oasis, Integra 33
  34. 34. Negative-Pressure Wound Therapy (Wound Vac) Introduced in the US in 1997 produced faster wound-healing and faster granulation tissue formation than standard wound care Armstrong et al:Lancet366:1704,2205 34
  35. 35. Negative Pressure Wound Therapy , KCI 35
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  38. 38. Growth Factors: Regranex 38
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  40. 40. Bioengineered Skin Substitutes Products with living cells as functional skin equivalents Recruitment of stem cells Production of growth factors Stimulation of angiogenesis Re-epithelialization: Substrate for keratinocyte migration Modification of inflammatory processes: Recruitment of neutrophils, prevention of biofilms Mansbridge J. J Biomater Sci Polymer Edn 2008;19:955-968.40
  41. 41. Apligraf® Organogenesis  Living bi-layered dermal-epidermal skin substitute  Dermal layer: fibroblasts in bovine type I collagen  Epidermal layer: keratinocytes  Cells from human neonatal foreskin tissue  FDA-approved for venous leg ulcers, diabetic ulcers  Shipped overnight, viable for 2-3 days 41
  42. 42. Dermagraft® Shire  Bioengineered Dermal substitute  Fibroblasts seeded on a bio-absorbable mesh  Cells derived from human neonatal foreskin tissue  FDA-approved for diabetic ulcers  Preserved at -70°C with 6-month shelf-life 42
  43. 43. Dermagraft® Apligraf® Bioengineered Skin Substitutes 43
  44. 44. Grafix Osiris • Cryopreserved Placental Membrane • Contains extracellular matrix rich in collagen, growth factors, stem cells, epithelial cells 44
  45. 45. Dermagraft • Leg ulcer for over 1 year's duration 45
  46. 46. Dermagraft 46
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  49. 49. Surgical Debridement • In case of an abscess, incision and drainage is ESSENTIAL with debridement of all abscessed tissue. Consensus Development Conference on Diabetic Foot Care, 1999,Boston,MASS Diabetes Care, 1999:22:1354-60 49
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  61. 61. Summary 1.Diagnose and correct reversible risk factors 2.Manage wound bed 3.Assess healing after 4 weeks of standard wound care 4.If healing<50% consider Advanced Wound Therapies 61
  62. 62. Questions???? 62

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