lotions, potions and dressings – what do i do?

Lotions, Potions and Lotions, Potions and Dressings – What do I DO?Dressings – What do I DO?

Anna Braden, BSN, RN, CWOCN

ObjectivesObjectives

Have a basic understanding of skin and wound assessment

Have an understanding of basic dressing selection guidelines based on assessment

Have a basic understanding of product categories

AnatomyAnatomy

EpidermisDermisSubcutaneous tissueFascia, Muscle, Bone

Injury

Hemostasis:• Coagulation• Platelet aggregation

Platelets

Inflammation:•Macrophages•Neutrophils•Granulocytes

•Debridement•Resistance to infection

•Neovascular growth•Granulation

Collagen lysis Collagen synthesis

Maturation: remodeling

Healed wound

Proliferation

Epithelialization Proteoglycansynthesis

Contraction

Wound Wound HealingHealing

Wound Care: An Incredible Visual! Pocket guide, 2009

Wound healingWound healing

Wikipedia, the free encyclopedia

Wound HealingWound Healing

Partial Thickness ◦Epidermis, dermis

Full Thickness ◦Can be shallow or deep◦Subcutaneous tissue◦Fascia, Muscle

Factors affecting wound Factors affecting wound healinghealing

Skin AssessmentSkin Assessment

ColorTextureTemperatureTurgorOdor Sensations

Wound AssessmentWound Assessment

1. Location – anatomic landmarks2. Size including

a. Underminingb. Tunneling/sinus track

3. Wound bed appearance4. Exudate

a. Amount & characteristics

5. Odor6. Pain7. Peri wound skin

Infection? – Yes or No?Infection? – Yes or No?

Contamination

Colonization

Critical Colonization

Infection◦Local vs systemic◦Elevated Glucose in diabetics◦Pain in neuropathic extremity

Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 270-273

Skin ProductsSkin Products

AntimicrobialEmollientHumectantPreservativeSkin protectantSurfactant

DimethiconePetrolatumZinc Oxide

◦ <25% = creamy◦ >25% = pasty

Dressing Selection – 1Dressing Selection – 1stst Basic Basic RuleRuleDry

shallow/superficial wound

= Need to ADD moisture

Dry deep/cavity wound

= Need to ADD moisture= Need a Filler in order to pack

undermining/tunneling areas= Need a Cover dressing

Wet shallow/superficial wound

= Need to wick/absorb moisture

***Peri wound skin: Protective barrier film***

Wet deep/cavity wound

= Need to wick/absorb moisture= Need a Filler to pack undermining/tunneling areas= Need a Cover dressing

***Peri wound skin: Protective barrier film***

Then Dressing SelectionThen Dressing Selection

Goes on based on:◦ Does the wound need to be debrided?

Mechanical, enzymatic, autolytic

◦ Is there an infection present?◦ Does the wound bed remain moist or is

it drying up?◦ Do the wound edges need to be

opened?◦ Is the wound bed being protected from

injury, trauma etc.?◦ Is the wound being insulated?

“A dry cell is a dead cell”

ProductsProducts

Terms:◦Primary dressing◦Secondary dressing◦Filler ◦MVTR – Moisture-Vapor Transmission Rate◦Epidermal stripping

Products - Antimicrobial Products - Antimicrobial Antiseptics, iodine, honey, hydrofera blue,

mupirocin ointment, silver Indications:

◦ Partial or full thickness wounds◦ Critical colonization, infection◦ Odorous wound

Primary or secondary dressing Advantages:

◦ Provides broad range of antimicrobial or antibacterial activity

◦ Reduces infection◦ Prevents infection

Disadvantages:◦ Silver - May cause staining◦ May cause stinging or sensitization◦ Nanocrystalline Silver – inactivated by saline

Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292

Products – Calcium Products – Calcium alginatealginateCalled usually ‘alginate’Polysaccharide derived from brown

seaweedPartial or full thickness woundsPrimary dressing/filler

◦Usually needs a secondary/cover dressing

Highly absorbent – moderate to heavily draining wounds

Converts to a viscous/hydrophilic gelHemostatic propertiesChange as needed – usually every

24-48 hoursBryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292

Products - CharcoalProducts - Charcoal

Activated carbon◦Absorbs toxins and wound degradation

productsIndications:

◦Malodorous wounds◦Fecal fistulas

Apply as a ‘filter’ for odor controlIf absorbing drainage, need to

change when saturated


Products – Collagen Products – Collagen Enhances deposition of collagen fibersChemoattractant to granulocytes & fibroblastsBioresorbableHemostatic propertiesProcessed from bovine or porcine sources Indications:

◦ Full-thickness wounds with or without depths◦ Noninfected wounds◦ Minimal to moderate amount of drainage

Apply to wound base◦ Requires a secondary/cover dressing

Packaged as gels, alginates, sheets, powdersContraindicated in bovine sensitivites


Products - CompositeProducts - Composite

Combine distinct dressing components into a single dressing◦Absorptive part is different than alginate,

foam, hydrocolloid, hydrogelBacterial barrierPartial or full thickness wounds

without depthDry to heavy drainage – depending

on dressing componentsPrimary or secondary dressingCan be used with topical medications


Products – Contact layerProducts – Contact layerProtects the wound from direct

contact with other agents/dressingsConforms to wound shapePorousIndications:

◦Partial or full thickness wounds with or without depth

◦Infected wounds◦Donor sites◦Split-thickness skin grafts

Not intended to be changed with every dressing change


Products – Fiber gellingProducts – Fiber gelling

Hydrofiber Moderate to heavy drainageConverts to gel - “snot”-like

appearancePartial or full thickness woundsUsually needs a secondary

dressing


Products - FoamProducts - Foam

Absorptive and non-adherentIndications:

◦Partial or full thickness wounds with or without depth

◦Moderate to heavily drainageContraindicated with dry escharFrequently used as a secondary

dressing after medication and/or primary dressing

If used as primary dressing, apply appropriate secondary dressing

Change every 24 hours or as neededBryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

Products - HydrocolloidProducts - Hydrocolloid Contains gel-forming agents

◦ Forms a gelatinous mass Impermeable to contaminants = reducing risk of

infection Promotes autolysis Indications:

◦ Partial or full thickness wound with or without depth◦ Minimal to moderate drainage

Avoid acutely infected wounds and dry eschar Use cautiously in diabetics Low MVTR Change every 3-5 days as needed Select dressing 1-2” larger than the wound Use light pressure of hands to allow body heat

promote adhesion


Products - HydrogelProducts - Hydrogel

Adds moisture to dry wound bedNon-adherent Little or no absorptionCool & soothingVarious formulations:

◦Gel, sheets, impregnated gauze, with silver

Apply according to instructionsUse appropriate secondary dressing


Products – Transparent Products – Transparent filmfilmIndications:

◦Shallow partial thickness◦Dry to minimal drainage = nonabsorbent

Low MVTRCan promote autolysisCreates “second” skinApply without tension/stretchingAllow for 1-2” border around woundUse skin sealant around wound edgesNot for infected woundsChange every 4-7 days or as needed


Products – MedicationsProducts – Medications Collagenase/=Santyl

◦ Enzymatic debrider Collagenase derived by fermentation of Clostridium histolyticum

◦ Need physician order◦ Need some ‘contact’ with moist wound bed

Around edges or cross-hatching by physician ‘Xenaderm’ = BCT

◦ Balsam Peru◦ Castor oil

Improve epithelialization Protective covering Aids in reduction of pain

◦ Trypsin – mild debrider Dakin’s solution

◦ 1/16 strength – odor control◦ 1/25 strength – pseudomonas infection

Metronidazole/Flagyl◦ Crushed - odor control

Thomas Hess, C. Clinical Guide to Skin and Wound care. 2013, 7th Edition, p 557-559

Peri wound protectionPeri wound protectionPrevent epidermal stripping

◦Avoid tapes if possible◦Roll gauze, tubular stockinette,

Montgomery straps◦Skin sealants

Maceration◦Skin sealants◦Zinc oxide◦Re-evaluate current dressing and/or

frequencyInfection

◦Candidiasis Crusting technique with antifungal powder


Special Consideration:Special Consideration: Palliative Wound Palliative Wound

CareCareS = Stabilize the woundP = Prevent new woundsE = Eliminate odorC = Control painI = Infection prophylaxisA = Advanced absorbent wound dressingsL = Lessen dressing changes

Haas. M.L., Moore-Higgs, G.J. Principles of Skin Care and the Oncology Patient.2010. p 105.

DocumentationDocumentation

Today – EMR/Electronic Medical Record◦Order◦Assessment◦Actual dressing change◦Teaching

Must meet certain criteria for reimbursement

Accurate and consistent◦Monitoring◦Legal


Presentwoc.com

Worldwidewounds.com

ReferencesReferencesBryant, R., Nix, D. Acute and Chronic

Wounds. Current Management Concepts. 4th Edition. 2012.

Hass, M.L., Moore-Higgs, G.J. 2010. Principles of Skin Care and the Oncology Patient, p 105,

Milne, C.T., Corbett, L.Q., Dubuc, D.L., Wound, Ostomy, and Continence Nursing Secrets, Questions and Answers Reveal the Secrets to Successful WOC Care. 2003

Thomas Hess, C. Clinical Guide to Skin and Wound care. 7th Edition. 2013.

Wound Care: An Incredibly Visual! Pocket Guide. 2009. Wound healing, p 21.

Questions?

lotions, potions and dressings – what do i do?

Documents

wound healingwikipedia

wound edges

wet deepcavity wound

moisturedry deepcavity

basic understanding

dermisfull thickness

protective barrier film

underminingtunneling