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Today’s Presenter:
Albert Goodsell
Nurse Practitioner
VITAS Healthcare
Welcome!
We are glad you are able to join us for today’s presentation on Wound Care 101. The presentation
will begin at 2:00PM EDT. All attendees are muted by default. Any questions may be submitted to the
host via the chat box (open by clicking on the icon at the top right of your screen).
Objectives:
After attending this program you should be able to:
•Review updated Wound Care Guidelines
•Describe special considerations for hospice patients
•List risk factors contributing to skin impairment
•List preventative measures
•Describe the parameters of wound assessment
•Describe basic principles of wound care management
To Connect to Audio select:
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Wound Care 101
CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS
Healthcare Corporation of Florida, Inc/CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home
Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS
Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider
Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois
Respiratory Care Practitioner.
VITAS Healthcare programs in California/Connecticut/Delaware/Illinois/Northern Virginia/Ohio/Pennsylvania/Washington DC/Wisconsin are
provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work
continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE)
program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/15 - 06/06/18). Social Workers
participating in these courses will receive 1-2 clinical or social work ethics continuing education clock hour(s). {Counselors/MFT/IMFT are not
eligible in Ohio}
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered
Nursing, Provider Number 10517, expiring 01/31/2019.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA:
No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois
06-2017
Objectives
• Review updated Wound Care Guidelines
• Describe special considerations for hospice patients
• List risk factors contributing to skin impairment
• List preventative measures
• Describe the parameters of wound assessment
• Describe basic principles of wound care management
Updates to Wound Care Guidelines
• Unpreventable Pressure Ulcer
– LTC facilities must utilize risk, assessment and intervention tools to
prevent formation of new pressure ulcers UNLESS clinical
condition shows they were unavoidable
• New Classifications of Staging
– Addition of ‘Unstageable’ and ‘ Deep Tissue Injury’ to existing
classifications
Factors that contribute to
‘Unpreventable’
• Even with aggressive preventive measures, internal pathophysiology
compromises healing
• Formation of pressure ulcers may be an indicator that the body is now
overwhelmed by the illness
• Emotional concerns of families leading to non compliance with plan of
care- comfort becomes priority
Special Considerations for Hospice
Patients
• Patient perspective
̶ Physical, functional, emotional, spiritual and social
• Dying depend on care from others
• May identify with their illness
• What do they fear most?
̶ Pain
Benefits Of Wound Care
• Goal of hospice is to promote quality of life, focusing on symptoms
• Good wound care still can contribute to comfort, even in final stages of
life
• Poor wound care can be devastating to resident’s death experience
Wounds Common in Hospice
• Pressure ulcers – affect >40% of reported
• Arterial insufficiency
• Diabetic ulcers
• Venous insufficiency
• Fungating or ulcerating tumors
Prevention
• Inspect skin
• Moisture control
• Proper positioning and transfer techniques
• Nutrition as condition tolerates
• Avoid pressure on heels and bony prominences
• Use of positioning devices
• Monitor and document
Risk Factor Assessment
• Accuracy is critical
̶ Alterations in mobility
̶ Incontinence
̶ Pressure, friction and shear
̶ Cognitive deficit
̶ Age
̶ Co-morbids
̶ Steroids
Tools For Risk Measurement
Physical
Condition
Good 4
Fair 3
Poor 2
Very Bad 1
Mental
Condition
Alert 4
Apathetic 3
Confused 2
Stupor 1
Activity
Ambulant 4
Walk Help 3
Chair Bound 2
Bed 1
Mobility
Full 4
Slightly Limited 3
Very Limited 2
Immobile 1
Incontinence
Not 4
Occasional 3
Usually/
Urine
2
Doubly 1
TOTAL SCORE
Norton
Scale
Tools for Risk Measurement (Cont.)
Braden
Scale
Pressure At-risk Sites
Assessment And Documentation
• Type of wound
• Location
• Stage and size
• Periwound
• Undermining
• Tunneling
• Exudate
• Type of tissue
• Effectiveness of treatment
Staging Wounds
Stage 1- At Risk Stage II Stage III
Stage IV Deep Tissue Injury Unstageable
Stage I Stage II
Stage III Stage IV
UnstageableDeep Tissue Injury
Basic Principles of Wound Care
• Overall strategy and scope of the treatment plan depends on
prognosis, condition, and potential for wound healing
Basic Principles of Wound Care (Cont.)
• Set Appropriate Goals
̶ Prevent complications or deterioration of existing wound
̶ Prevent additional skin breakdown
̶ Minimize harmful effects of wound on patient’s overall condition
̶ Promote wound healing
Basic Elements Of Wound Care
• Cleanse debris from the wound
• Possible debridement
• Absorb excess exudate
• Promote healing
• Treat infections
• Minimize discomfort
• Utilize skin creams and lotions for dry skin
• Utilize barrier products as needed
• Monitor and reposition frequently
• Use pillows in bed for positioning
• Convert to bolus feedings
• Raise head of bed 30-60 degrees
• Use lift devices
Interventions: At Risk Or Stage I
• Minimize dressing changes
• Maintain a moist environment
• Prevent infection
• Prevent additional skin breakdown
• Consider condition of patient in choosing treatment
Interventions: Stage II, III, IV
• Benefits:
̶ Remove wound debris
̶ Sustain moist environment
̶ Soften necrotic tissue
̶ Debride the wound
̶ Reduce risk of infection
̶ Reduce odor
Cleanse
• What is it and why is it important?
̶ Product of fluid leaking from capillaries into body tissue
• Necessary part of inflammatory process
• Expected to decrease over time in healing wounds
• May remain elevated in non-healing wounds
• Healing may be affected by too much or too little exudate
Exudate
• Achieving a moist but not macerated wound bed is the usual goal
̶ Epithelial cells require moisture to close the wound
̶ In a dry wound, cells move below wound bed to find a moist area
̶ In a moist wound environment, cells migrate directly across wound
bed, resulting in faster healing rates
Moist Wound Healing
Exudate Management
• Desired Moisture Balance:
̶ Consider desired moisture balance
̶ Dressing’s ability to assist healing or prevent wound deterioration
• Retention:
̶ Dressings that maintain structure during use
̶ May reduce risk of periwound maceration
• Sequestration:
̶ Ability to trap bacteria and components of exudate within
dressing
• ‘Removal of dead, damaged, or infected tissue that would otherwise
impair healing of a wound’
• Avoid debridement for:
̶ Wounds on heel covered with dry eschar
̶ Arterial ulcers and diabetic ulcers with dry eschar or gangrene,
without infection, and with insufficient vascular supply for healing,
unless circulation to area can be improved
Debridement
Debridement Methods
• Mechanical
• Autolytic
• Sharp or Surgical
• Enzymatic
• Biological
Goals:
• Removal of exudate
• Odor control
̶ Oil of Wintergreen
̶ Charcoal briquettes or coffee grounds
̶ Dryer Sheets
• Pain Control
Fungating Lesions
Infected Wounds
• Utilize clinical symptoms to determine infection
̶ Fever and elevated WBC may be indicators of systemic infection
• Culture or biopsy not optimal
• Start with localized treatment
• Avoid antiseptics
Promote Comfort
• What may cause pain during dressing change:
̶ Change in positioning
̶ Removing dressing
̶ Cleansing Wound
̶ These can lead to anticipatory pain
Promote Comfort (Cont.)
• How can we help?
̶ Anticipate and pre-medicate
̶ Talk to patient during treatment and explain steps
̶ Use gentle touch when moving patient and changing dressings
̶ Observe and document reactions
• Use pillows
• Heel protectors
• Wheel chair cushions
• Lift devices
• Support surface selection based on pressure points and vendor
availability
Support Surfaces
• Reviewed updated Wound Care Guidelines
• Described special considerations for hospice patients
• Listed risk factors contributing to skin impairment
• Listed preventative measures
• Described the parameters of wound assessment
• Described basic principles of wound care management
In Review
Questions?
References
• Braden B, Bergstrom N. Braden scale for predicting pressure sore risk. Available at:
www.bradenscale.com/braden.pdf. Used with permission April 20, 2010
• Brown, 2003; Eisenberger & Zeleznik, 2003
• Convatec ‘Exudate Management’ www.convatec.com/en/cvtus/exdmngmus/cvt-
portallev1/0/Detail/0/1520/1835/exudate/management.html Accessed Online 4/21,
2010 with permission
• Convatec ‘Debridement’ www.convatec.com/en/cvtus/dbrdmngwus/cvt-
portallev1/0/Detail/0/1518/1831/debridement/.html Accessed Online 4/21, 2010 with
permission
• European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC:
National Pressure Ulcer Advisory Panel; 2009
References (Cont.)
• Hadley & Hinds, 2002; Peerless, Davies, Klein, & Yu, 1999; Williams & Harding, 2003
• Hughes RG, Bakos AD, O'Mara A, Kovner CT. Palliative Wound Care at the End of
Life. Article originally published in Home Health Care Management & Practice
2005;17(3):196-202. Copyright© 2005 by Sage Publications. Agency for Healthcare
Research and Quality, Rockville, www.ahrq.gov/about/nursing/palliative.htm
Retrieved online April 19, 2010
• Source:Skin Safety Protocol: Risk Assessment and Prevention of Pressure Ulcers
Second Edition/March 2007 www.icsi.org
• Wounds Research www.woundsresearch.com/article/3951 Retrieved online April 23,
201
• Wound Ostomy and Continence Nurse’s Society
www.wocn.org/pdfs_aboutus/News/wocn-avoidable-unavoidable_position-3-25.pdf
Accessed online April 15, 2010
CEU Instructions
• Fill out Evaluation
– Link to evaluation will be emailed to the email address used to login
to WebEx
– Evaluation will be open for only 5 days post event
• Certificate will be emailed to you
– 1 week after the event

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Wound Care 101

  • 1. Connecting to Audio There is no dial in number. You must use your computer’s speakers. Please select “yes” when prompted at either of the following: If you missed either of these, at the top, To Connect to Audio select: Communicate  Join Conference
  • 2. To Connect to Audio select: Audio  Audio and Video Connection
  • 3. To Connect to Audio select: Audio  Audio and Video Connection
  • 4. Today’s Presenter: Albert Goodsell Nurse Practitioner VITAS Healthcare Welcome! We are glad you are able to join us for today’s presentation on Wound Care 101. The presentation will begin at 2:00PM EDT. All attendees are muted by default. Any questions may be submitted to the host via the chat box (open by clicking on the icon at the top right of your screen). Objectives: After attending this program you should be able to: •Review updated Wound Care Guidelines •Describe special considerations for hospice patients •List risk factors contributing to skin impairment •List preventative measures •Describe the parameters of wound assessment •Describe basic principles of wound care management To Connect to Audio select: Audio  Audio and Video Connection
  • 6. CE Provider Information VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc/CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner. VITAS Healthcare programs in California/Connecticut/Delaware/Illinois/Northern Virginia/Ohio/Pennsylvania/Washington DC/Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/15 - 06/06/18). Social Workers participating in these courses will receive 1-2 clinical or social work ethics continuing education clock hour(s). {Counselors/MFT/IMFT are not eligible in Ohio} VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2019. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois 06-2017
  • 7. Objectives • Review updated Wound Care Guidelines • Describe special considerations for hospice patients • List risk factors contributing to skin impairment • List preventative measures • Describe the parameters of wound assessment • Describe basic principles of wound care management
  • 8. Updates to Wound Care Guidelines • Unpreventable Pressure Ulcer – LTC facilities must utilize risk, assessment and intervention tools to prevent formation of new pressure ulcers UNLESS clinical condition shows they were unavoidable • New Classifications of Staging – Addition of ‘Unstageable’ and ‘ Deep Tissue Injury’ to existing classifications
  • 9. Factors that contribute to ‘Unpreventable’ • Even with aggressive preventive measures, internal pathophysiology compromises healing • Formation of pressure ulcers may be an indicator that the body is now overwhelmed by the illness • Emotional concerns of families leading to non compliance with plan of care- comfort becomes priority
  • 10. Special Considerations for Hospice Patients • Patient perspective ̶ Physical, functional, emotional, spiritual and social • Dying depend on care from others • May identify with their illness • What do they fear most? ̶ Pain
  • 11. Benefits Of Wound Care • Goal of hospice is to promote quality of life, focusing on symptoms • Good wound care still can contribute to comfort, even in final stages of life • Poor wound care can be devastating to resident’s death experience
  • 12. Wounds Common in Hospice • Pressure ulcers – affect >40% of reported • Arterial insufficiency • Diabetic ulcers • Venous insufficiency • Fungating or ulcerating tumors
  • 13. Prevention • Inspect skin • Moisture control • Proper positioning and transfer techniques • Nutrition as condition tolerates • Avoid pressure on heels and bony prominences • Use of positioning devices • Monitor and document
  • 14. Risk Factor Assessment • Accuracy is critical ̶ Alterations in mobility ̶ Incontinence ̶ Pressure, friction and shear ̶ Cognitive deficit ̶ Age ̶ Co-morbids ̶ Steroids
  • 15. Tools For Risk Measurement Physical Condition Good 4 Fair 3 Poor 2 Very Bad 1 Mental Condition Alert 4 Apathetic 3 Confused 2 Stupor 1 Activity Ambulant 4 Walk Help 3 Chair Bound 2 Bed 1 Mobility Full 4 Slightly Limited 3 Very Limited 2 Immobile 1 Incontinence Not 4 Occasional 3 Usually/ Urine 2 Doubly 1 TOTAL SCORE Norton Scale
  • 16. Tools for Risk Measurement (Cont.) Braden Scale
  • 18. Assessment And Documentation • Type of wound • Location • Stage and size • Periwound • Undermining • Tunneling • Exudate • Type of tissue • Effectiveness of treatment
  • 19. Staging Wounds Stage 1- At Risk Stage II Stage III Stage IV Deep Tissue Injury Unstageable
  • 23. Basic Principles of Wound Care • Overall strategy and scope of the treatment plan depends on prognosis, condition, and potential for wound healing
  • 24. Basic Principles of Wound Care (Cont.) • Set Appropriate Goals ̶ Prevent complications or deterioration of existing wound ̶ Prevent additional skin breakdown ̶ Minimize harmful effects of wound on patient’s overall condition ̶ Promote wound healing
  • 25. Basic Elements Of Wound Care • Cleanse debris from the wound • Possible debridement • Absorb excess exudate • Promote healing • Treat infections • Minimize discomfort
  • 26. • Utilize skin creams and lotions for dry skin • Utilize barrier products as needed • Monitor and reposition frequently • Use pillows in bed for positioning • Convert to bolus feedings • Raise head of bed 30-60 degrees • Use lift devices Interventions: At Risk Or Stage I
  • 27. • Minimize dressing changes • Maintain a moist environment • Prevent infection • Prevent additional skin breakdown • Consider condition of patient in choosing treatment Interventions: Stage II, III, IV
  • 28. • Benefits: ̶ Remove wound debris ̶ Sustain moist environment ̶ Soften necrotic tissue ̶ Debride the wound ̶ Reduce risk of infection ̶ Reduce odor Cleanse
  • 29. • What is it and why is it important? ̶ Product of fluid leaking from capillaries into body tissue • Necessary part of inflammatory process • Expected to decrease over time in healing wounds • May remain elevated in non-healing wounds • Healing may be affected by too much or too little exudate Exudate
  • 30. • Achieving a moist but not macerated wound bed is the usual goal ̶ Epithelial cells require moisture to close the wound ̶ In a dry wound, cells move below wound bed to find a moist area ̶ In a moist wound environment, cells migrate directly across wound bed, resulting in faster healing rates Moist Wound Healing
  • 31. Exudate Management • Desired Moisture Balance: ̶ Consider desired moisture balance ̶ Dressing’s ability to assist healing or prevent wound deterioration • Retention: ̶ Dressings that maintain structure during use ̶ May reduce risk of periwound maceration • Sequestration: ̶ Ability to trap bacteria and components of exudate within dressing
  • 32. • ‘Removal of dead, damaged, or infected tissue that would otherwise impair healing of a wound’ • Avoid debridement for: ̶ Wounds on heel covered with dry eschar ̶ Arterial ulcers and diabetic ulcers with dry eschar or gangrene, without infection, and with insufficient vascular supply for healing, unless circulation to area can be improved Debridement
  • 33. Debridement Methods • Mechanical • Autolytic • Sharp or Surgical • Enzymatic • Biological
  • 34. Goals: • Removal of exudate • Odor control ̶ Oil of Wintergreen ̶ Charcoal briquettes or coffee grounds ̶ Dryer Sheets • Pain Control Fungating Lesions
  • 35. Infected Wounds • Utilize clinical symptoms to determine infection ̶ Fever and elevated WBC may be indicators of systemic infection • Culture or biopsy not optimal • Start with localized treatment • Avoid antiseptics
  • 36. Promote Comfort • What may cause pain during dressing change: ̶ Change in positioning ̶ Removing dressing ̶ Cleansing Wound ̶ These can lead to anticipatory pain
  • 37. Promote Comfort (Cont.) • How can we help? ̶ Anticipate and pre-medicate ̶ Talk to patient during treatment and explain steps ̶ Use gentle touch when moving patient and changing dressings ̶ Observe and document reactions
  • 38. • Use pillows • Heel protectors • Wheel chair cushions • Lift devices • Support surface selection based on pressure points and vendor availability Support Surfaces
  • 39. • Reviewed updated Wound Care Guidelines • Described special considerations for hospice patients • Listed risk factors contributing to skin impairment • Listed preventative measures • Described the parameters of wound assessment • Described basic principles of wound care management In Review
  • 41. References • Braden B, Bergstrom N. Braden scale for predicting pressure sore risk. Available at: www.bradenscale.com/braden.pdf. Used with permission April 20, 2010 • Brown, 2003; Eisenberger & Zeleznik, 2003 • Convatec ‘Exudate Management’ www.convatec.com/en/cvtus/exdmngmus/cvt- portallev1/0/Detail/0/1520/1835/exudate/management.html Accessed Online 4/21, 2010 with permission • Convatec ‘Debridement’ www.convatec.com/en/cvtus/dbrdmngwus/cvt- portallev1/0/Detail/0/1518/1831/debridement/.html Accessed Online 4/21, 2010 with permission • European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009
  • 42. References (Cont.) • Hadley & Hinds, 2002; Peerless, Davies, Klein, & Yu, 1999; Williams & Harding, 2003 • Hughes RG, Bakos AD, O'Mara A, Kovner CT. Palliative Wound Care at the End of Life. Article originally published in Home Health Care Management & Practice 2005;17(3):196-202. Copyright© 2005 by Sage Publications. Agency for Healthcare Research and Quality, Rockville, www.ahrq.gov/about/nursing/palliative.htm Retrieved online April 19, 2010 • Source:Skin Safety Protocol: Risk Assessment and Prevention of Pressure Ulcers Second Edition/March 2007 www.icsi.org • Wounds Research www.woundsresearch.com/article/3951 Retrieved online April 23, 201 • Wound Ostomy and Continence Nurse’s Society www.wocn.org/pdfs_aboutus/News/wocn-avoidable-unavoidable_position-3-25.pdf Accessed online April 15, 2010
  • 43. CEU Instructions • Fill out Evaluation – Link to evaluation will be emailed to the email address used to login to WebEx – Evaluation will be open for only 5 days post event • Certificate will be emailed to you – 1 week after the event

Editor's Notes

  1. Length: 60 minutes 50 minute presentation 10 minute question & answer Continuing Education Credit: Approved for one credit. Target Audience: Healthcare Professionals who care for terminally ill patients and their families. Recommended Presenter: Presenter must be a Nurse or Physician Facilitator: Welcome to this training entitled: Wound Care 101. Allow me to introduce myself I am (Facilitator: state your name and position). As you know, wound management is one of the most frequent issues we deal with in hospice. It is important to have an understanding of some of the challenges and solutions in dealing with these sometimes unpreventable wounds.
  2. We will review the updated Guidelines for Wound Care, which include 2 new stages for pressure ulcers. We will describe special considerations in wound care for hospice patients. We will list the risk factors that contribute to skin impairment. We will list measures to prevent skin breakdown. We will describe the basic parameters of wound assessment, focusing primarily on pressure ulcers. And finally, we will describe the basic principles of wound care management.
  3. CMS has already maintained that pressure ulcers are not all preventable, at least in long-term care settings. CMS states that long-term care facilities must ensure that "a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable.” Unavoidability means "the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of interventions; and revised the approaches as appropriate The National Pressure Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The WOCN Society's position paper identifies several clinical situations that can severely impair efforts to prevent pressure ulcers. Among these are patients with preexisting deep tissue injury (but no visible ulceration), patients in whom prevention interventions are medically contraindicated, nonadherent patients, and patients who are nearing the end of life. Source: Wound Ostomy and Continence Nurse’s Society www.wocn.org/pdfs_aboutus/News/wocn-avoidable-unavoidable_position-3-25.pdf Accessed online April 15, 2010
  4. Evidence suggests that even in the presence of aggressive preventive measures, critically ill individuals will have alterations in tissue perfusion, immune functioning, and coagulation, which compromise muscle cells and the overall healing response. Source: Hadley & Hinds, 2002; Peerless, Davies, Klein, & Yu, 1999; Williams & Harding, 2003. Pressure ulcer formation may be a visual biomarker that the critical illness has totally overwhelmed the body and that skin breakdown is neither preventable nor treatable. Emotional concerns for family members of terminally ill patients arise because they may view pressure ulcer formation as a failure on the part of the health care staff caring for the patient or even as their own failing if they are responsible for providing care. Hospice staff may feel that turning a patient frequently may contribute to an increase in pain, so standard preventive measures such as turning a patient every 2 hours may be suspended. Studies have revealed that when patients are more comfortable in one position due to advanced illness, overall comfort becomes of greater importance. I n fact, some staff felt that prevention and treatment could potentially compromise the overall hospice philosophy of providing comfort care. Source: Brown, 2003; Eisenberger & Zeleznik, 2003
  5. It is important to consider unique factors facing a patient who is terminally ill. These factors will impact the plan of care: What is the patient’s perspective? Are they making their own medical decisions? If they are impacted by wound care to the point that they refuse care, we must comply with their wishes. We must remember that dying patients are generally weak and dependent on care from others – Consider who will be providing wound care and what type of education may need to be provided, if so. Always remember that the terminal patient has become accustomed to defining their sense of self with their disease. Much time up to this point has been spent defining treatments, medications and outcomes. Help them by personalizing their care. We are dealing with a person, not ‘my cancer patient’ or ‘my stage IV’ What is one of the biggest fears of a terminal patient? ‘ Pain. ‘ We must remember to incorporate the principle of pre-medicating prior to treatment. Advocate for your patient by clarifying the medications and administering pre-treatment to ensure comfort.
  6. Although wounds can be an indicator of body system breakdown, and impending death, good wound care can be of benefit. Consider this : The goal of hospice is to promote quality of life, focusing on symptoms. We know that skin breakdown, itself, is a symptom. Even in the final stages of life, good wound care can contribute to comfort. Wound care performed poorly can be devastating to the resident and family’s experience of death. Wounds can generate feelings of fear, aversion, and suspicion of neglect. Source: Hughes RG, Bakos AD, O'Mara A, Kovner CT. Palliative Wound Care at the End of Life. Article originally published in Home Health Care Management & Practice 2005;17(3):196-202. Copyright© 2005 by Sage Publications. Agency for Healthcare Research and Quality, Rockville, MD. ahrq.gov/about/nursing/palliative.htm Accessed online April 19, 2010.
  7. Let’s review the types of wound problems common in hospice. Pressure ulcers result from the unrelieved pressure, shearing, and skin irritation and result in damage to underlying tissue --they usually occur over bony prominences. Studies done on hospice patients have revealed that this type of wound occurs in greater than 40% of wounds seen, as high as 70% in some cases. Wounds Research http://www.woundsresearch.com/article/3951 Arterial Insufficiency often appears as ulcers with black eschar on the lower leg and foot --the skin surrounding the wound appears to be very thin, shiny and usually hairless --the foot may feel cold and appear dusky red or pale in color--typically they occur on the lateral aspect more frequently than medial. They are the result of arterial disease. They are often painful which is often worse at night. Diabetic ulcers are typically on the plantar surface of the foot and the 2nd metatarsal head. Neuropathy associated with diabetes results in a decreased sensation which increases susceptibility. They are usually painless. Venous Ulcers result from venous disease. They occur in the so-called gaiter area--halfway up the calf and down to just below the ankle. The skin will likely feel itchy and appear mottled brown or have black staining and may appear crusty in the gaiter area. The legs may become painful with sitting. Tumors or Fungating Lesions onto the skin surface occurs most often in CA of the breast, but may occur with other types of cancers including head and neck CA, malignant melanomas, and sarcomas. The lesion may be a small crusted area or a large ulcerated area with profuse exudate and capillary bleeding. They are often disfiguring, distressing and isolating. Odor and exudate management may be a particular problem in this type of wound.
  8. Preventing wounds from occurring is the best practice that we can offer our patients when it comes to wound care. Prevention measures include, but are not limited to, inspecting the skin and monitoring for proper moisture control. Of course, proper positioning, transfer techniques, and nutrition are essential for the comfort of the patient. Do your best to avoid pressure on the heels and bony prominences of the body, and use positioning devises whenever feasible. As always, remember to document the condition of the skin after your assessments.
  9. Risk Assessment upon admission is crucial and must be an accurate and complete body check. Pressure ulcers are caused by intrinsic and extrinsic factors. The intrinsic factors include immobilization, cognitive deficit, and inability to verbalize discomfort or numbness, chronic illness (for example, diabetes mellitus is known to compromise skin integrity), poor nutrition, use of steroids-(which delays healing), and aging, which in itself can compromise healing. Incontinence retains moisture on the skin and there is also a possibility for fecal contamination. Immobility is the most significant risk factor for pressure ulcer development. Patients who have any degree of immobility should be closely monitored for pressure ulcer development . Source: Wound, Ostomy, and Continence Nurses Society, 2003 Pressure over a given area which is greater than the capillary profusion pressure, compresses blood vessels leading to tissue ischemia (‘tissue death’). Just 2 hours of pressure on a bony prominence can cause a wound. Shear forces occur when patients are positioned in such a way that they tend to slide. For example, when the head of the bed is elevated without elevating the feet as well. Shear forces plus pressure cause stretching and kinking of capillaries and tissue, resulting in more tissue ischemia than would have occurred with pressure alone. Friction affects only the outermost skin layers by movement of the epidermis against an external surface. Clinically, friction presents as a superficial abrasion or blister. For example, a blister may form from the heel rubbing on sheets. Shear and friction often go hand in hand. Source: Skin Safety Protocol: Risk Assessment and Prevention of Pressure Ulcers Second Edition/March 2007. www.icsi.org
  10. Several scales are available to provide the nurse with measurable ways to assess potential for development of skin problems. These scales are routinely used in LTC. We are displaying a sample of the ‘Norton Scale’ for this presentation. Others are available, such as the ‘Braden Scale.’ Whatever scale is used, consistency is important to gauge the actual risk. Hospice residents are usually at high risk for breakdown. The Norton Scale rates the resident’s mental capacity, mobility, physical condition, activity level and degree of incontinence. Each assessment risk factor is given a value from 1 to 4, based on the degree of risk. In the Norton Scale, a higher score represents a better condition. For example, assess the patient’s physical condition. Choices for physical condition are: Good = 1, Fair = 3, Poor = 2, and Very Bad = 1. You will then continue through each risk assessment factor, assigning a score for each from 1 to 4; 1 being the highest risk. This subjective tool provides a means of anticipating and planning for skin integrity. It is important to note that many of the underlying risk factors for terminally ill patients are not listed on traditional risk scales. Facilitator ask: What factors may be present for terminal patients? Answers: Inability to eat or drink, other disease processes, compromised circulation.
  11. The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Risk areas to be scored include sensory perception, moisture, activity, mobility, nutrition, and friction and shear Total scores range from 6-23 The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, thus, higher levels of risk for pressure ulcer development. Source: Braden B, Bergstrom N. Braden scale for predicting pressure sore risk. Available at: http://www.bradenscale.com/braden.pdf Accessed April 20, 2010
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  13. Assessment both upon admission and ongoing is crucial to both wound care prevention and treatment. Documentation must be completed in a timely manner, with attention to details. This should also include the notification of the physician regarding wound status. All of the following information provides data that will support current treatment or require a change in means of management: The type of wound must be identified first – it a pressure ulcer, venous, arterial, or diabetic ulcer? Physician consultation and documentation is recommended for all skin ulcers. Where is the wound located? Each wound should be documented separately. What is the stage and size? Measurements are always given in the metric system. Describe the periwound - this is the area surrounding the wound. Is there any undermining? Document both location and size. Is there any tunneling? Document the location. Does exudate exist? If so, is it minimal, moderate, or excessive? What type of exudate do you see? Describe the odor. Describe the type of tissue. Is it granulation, epithelial, slough, or necrotic? How effective is the current treatment?
  14. The National Pressure Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. A pressure ulcer is defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Pressure Ulcer Stages include: I, II, III, IV, Deep Tissue Injury, and Unstageable – The following describe the new categories of staging: Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compares to adjacent tissue. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined The WOCN Society's position paper identifies several clinical situations that can severely impair efforts to prevent pressure ulcers. Among these are patients with preexisting deep tissue injury (but no visible ulceration), patients in whom prevention interventions are medically contraindicated, non-adherent patients, and patients who are nearing the end of life. Source: Wound Ostomy and Continence Nurse’s Society www.wocn.org/pdfs_aboutus/News/wocn-avoidable-unavoidable_position-3-25.pdf
  15. Here are some examples of the stages that may be seen. In a Stage I wound, the skin is intact with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark pigmented skin tones. This may indicate an “at risk” person (a heralding sign of risk). In a Stage II wound, there will be partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The wound presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
  16. With a Stage III wound we will see full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. There may be undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, back of the head, and the bony protrusions of the ankles do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant fat can develop extremely deep stage III ulcers. Bone/tendon is not visible or directly palpable. Stage IV wounds will have full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. This wound often includes undermining and tunneling. The depth of a stage IV pressure ulcer varies by location. Stage IV ulcers can extend into muscle and/or supporting structures (for example, fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
  17. Deep tissue injury presents as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compares to adjacent tissue. An unstageable wound presents as full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
  18. The first determination in a successful wound plan of care involves the patient’s prognosis, condition, and potential for wound healing. A less aggressive approach will be necessary for someone in the final days of life, or when it is evident that healing is not realistic.
  19. Appropriate care planning goals for hospice patients may include: Preventing complications of the wound, such as infection or odor Of course, you will work to prevent additional breakdown of the skin We want to do our best to minimize harmful effects of the wound on the patient’s overall condition. Wounds can initiate depression, social isolation or general discomfort. In many of our hospice patients, we know that promoting wound healing may be unrealistic. Therefore, let’s take a look at some specific interventions for wound care that might be more feasible.
  20. Basic elements of wound care include cleansing, possible debridement, exudate management, promotion of healing, treating infections, and minimizing discomfort. Each resident’s plan of care will likely differ. There are many different methods of caring for a wound and all would be considered appropriate. Our goal is to define what makes sense in light of the resident’s status and desires. Additionally, each intervention should be re-evaluated every 2 weeks to determine whether the plan is still appropriate. It does not mean that a change is indicated, even if the wound is not responding to the current regime, but that it is the best option for this patient at this time. Failure of a wound to heal does not mean that all possible approaches should be exhausted, nor does it imply an alternate plan of care was more appropriate. Again, the physician assessment is necessary for a number of reasons. They will be able to help us identify appropriate interventions and realistic goals for each wound. They will also be able to document why the development of a wound or lack of healing was an unavoidable outcome. Source: European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.
  21. Standard approaches in all residents to minimize the potential for skin breakdown and prevent the incidence of further deterioration in residents with existing wounds include: Lotions will help reduce friction and moisturize dry skin. Do not massage bony prominences, as this is painful. Incontinence can be better managed by using a petroleum-based product which we usually see called “ointments”. They work to seal out wetness and irritants. We need frequent monitoring of the skin. It is important to relieve pressure every 2 hours or more often. You can float the heels when in bed with pillows and position the resident in bed so bony prominences are not in direct contact with each other. It is helpful to convert tube feedings over to bolus feedings so the resident is not required to sit upright in bed for long periods. It is better for the head of bed to be raised only between 30-60 degrees to minimize shear. Lifting devices can help reduce friction. Only use lifting devices if you have been properly trained.
  22. The main goals for treatment of Stage II, III, and IV pressure ulcers with a hospice resident include: We want to minimize dressing changes. Research has shown that the prolonged period that the modern dressings remain in place speeds up the healing time and decreases the chance of infection. We need to maintain a moist environment. We will work to prevent infection. We will want to prevent additional skin breakdown. When choosing wound care interventions, some of the things to consider are: What is the patient’s condition and prognosis ? If the resident has poor potential for healing or has a prognosis of less than 1 week, then aggressive measures may not be appropriate.
  23. Cleansing wounds should be part of any wound care regime. Irrigation will remove wound debris. Cleansing helps to sustain a moist environment, and soften any necrotic tissue. Cleansing can debride the wound and reduces the risk of bacterial contamination and infection. Finally, it helps to reduce the odor. Normal saline is the cleansing agent of choice because it is not cytotoxic and has no side effects. Antiseptics are known to be cytotoxic and also have some untoward effects. These include Betadine, Dakins, Acetic Acid, and Hydrogen Peroxide. Keep in mind that cleansing with harsh agents can be painful to the patient. Current research suggests that the use of a 35 milliliter syringe with a 19 gauge needle produces the correct pressure to achieve removal of surface contaminants and debris in the wound. This is a good method of debridement with hospice patients.
  24. What is exudate and why is it important? Wound exudate is the product of fluid which leaks from capillaries into body tissue. In the early stages of healing, inflammation will increase the permeability of capillaries, leading to an excess level of fluid entering the wound. This is expected to decrease over time in healing wounds, but in non-healing wounds, which may be stuck in the inflammatory phase, exudate may remain at elevated levels. Healing may be affected if there is too much or too little exudate. Source: Convatec ‘Exudate Management’ convatec.com/en/cvtus/exdmngmus/cvt-portallev1/0/Detail/0/1520/1835/exudate/management.html. Accessed Online 4/21, 2010
  25. The usual goal in wound care is moist wound healing without maceration. Epithelial cells require moisture to move from the wound edges to re-epithelialize or close the wound. In a dry wound, these cells move below the wound bed to find a moist area. In a moist wound environment, however, the cells are able to migrate directly across the wound bed, which results in faster healing rates. Maceration of the skin occurs when it is consistently wet - the skin softens, turns white, and can easily get infected with bacteria or fungi.
  26. When you think about selection of a product, keep in mind that any cavities should be filled. It is not necessary to pack a wound tightly, but gently place the primary dressing in the wound bed. The frequency of dressing changes will depend on the amount of drainage. The area surrounding the wound is at risk for maceration when heavy exudate occurs. The area may be skin prepped to provide easy removal of dressings and also prevention of skin irritation from drainage.
  27. Debridement is the removal of dead, damaged, or infected tissue that would otherwise impair the healing of a wound. There are some instances where debridement is not appropriate and close monitoring of the wound is essential. When pressure ulcers are located on the heel and are covered with a dry eschar, they should not be debrided. Debridement is also generally not recommended for arterial ulcers and diabetic ulcers with dry eschar or gangrene, without infection, and with an insufficient vascular supply for healing, unless circulation to the area can be improved. Source: Convatec ‘Debridement’ convatec.com/en/cvtus/dbrgmngmus/cvt-portallev1/0/Detail/0/1518/1831/debridement/.html Accessed Online 4/21, 2010
  28. Although several methods for debridement exist, 3 common methods are detailed here: Surgical removal of necrotic tissue by a qualified practitioner may be done by sharp or surgical debridement. The practitioner removes necrotic tissue with the use of sterile instruments including scissors, forceps, and scalpel. Autolytic refers to removal of necrotic tissue by the body’s own enzymes (liquefaction of necrotic tissue). Moisture-retentive dressings remove necrotic tissue while maintaining a moist wound-healing environment that supports proliferation of granulation tissue and re-epithelialization. Enzymatic refers to removal of necrotic tissue through the application of prescription enzymatic debriding agents that break down the tissue through a chemical process. Source: Convatec ‘Debridement’ www.convatec.com/en/cvtus/dbrgmngmus/cvt-portallev1/0/Detail/0/1518/1831/debridement/.html Accessed Online 4/21, 2010 with permission
  29. Because rapid healing of fungating lesions in hospice patients are unrealistic, our goals should be three-fold: To remove the exudate, To control the odor; and most importantly… To control the pain There are agents that can be used to control odors, however, there are some non-pharmacological interventions that we can use, such as: Oil of Wintergreen – Saturate a cotton ball and place in patient’s room Charcoal briquettes or coffee grounds in a container placed under the patient’s bed. Dryer sheets placed over a vent in patient’s room. We will discuss pain control in detail shortly
  30. The current thinking suggests that wound infection should be diagnosed primarily on the basis of clinical signs (fever, increased pain, friable granulation tissue, foul odor). Necrotic tissue is not necessarily a sign of infection; however necrotic tissue does support microorganism growth. Start with a localized treatment such as a triple antibiotic cream or silver sulfadiazine. Oral antibiotics are not indicated unless the wound is clearly infected. It can be appropriate to utilize a two-week trial of a topical antibiotic to a wound with clinical symptoms suspicious of a local infection. Tissue culture or biopsy would not be optimal for a hospice patient. Avoid the use of antiseptics such as povidone iodine, hydrogen peroxide, and acetic acid. These agents have been shown to be cytotoxic to granulation tissue and can actually delay the healing process. Again, they can be painful upon application.
  31. We know that hospice patients have a fear of pain, already. Wound care can compound that fear. Dressing changes can represent a very painful experience for a patient, who is already weak and afraid. Consider the following factors that can cause or aggravate pain: Position changes – we sometimes have to move the patient very aggressively to reach the wounds, and many times, there are several wounds. This can be very painful. Removing dressings can hurt, especially if the wound has become dry. Consider a time when you have had an adhesive dressing pulled off. Cleansing a dry wound can hurt, or the cleansing product, itself may sting. All of these factors that take place during wound care may lead to ‘anticipatory pain.’
  32. We can help make this a more comfortable experience by anticipating these painful experiences. Advocate for the patient by ensuring that there is an order for pain medication on the chart, and that it is written so the patient will be pre-medicated prior to treatment. Monitor the effects of the medication and use a pain scale or non-verbal pain assessment to gauge and document the patient’s reaction. Talk to the patient before, during, and after wound care, explaining what you are going to do. Remember, this is a person with wounds, not ‘a wound.’ Be as gentle as possible when moving and changing the dressings. Get help if you need a second person.
  33. Many products exist that will alleviate pressure points, to be used both preventatively and to promote comfort on existing wounds. Here is a list of some of the products that can be utilized: Special mattresses. Egg crate devices. Heel protectors. Bunny boots. Lift devices if you have been properly trained. Wheel chair cushions. Supportive pillows. Always utilize the principles of pressure points and remember that a pressure sore can occur in as little as 2 hours. Advocate for your patients.
  34. In review, we: Reviewed the updated Wound Care Guidelines. Described special considerations for hospice patients. Listed the risk factors that contribute to skin impairment Listed measures to prevent skin breakdown. Described the parameters of wound assessment, focusing primarily on pressure ulcers. Described the basic principles of wound care management.
  35. Ask the group to visualize the residents that they are caring for with these same risk factors/symptoms that are not currently benefiting from VITAS services and encourage them to discuss (in general terms) the challenges that they face each day in caring for them. Drill down to develop explicit needs. Due to time constraints, you may want to narrow down the list of needs to the few that create the biggest impact. Based upon the needs identified, discuss the benefits that VITAS can provide to meet those needs. Before we conclude, do you have any questions?
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