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Atypical Wound Care

Atypical Wound Care. LEE Wai-kuen Nurse Specialist Queen Mary Hospital. Atypical Wound. Wounds due to uncommon etiologies are called atypical wounds.

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Atypical Wound Care

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  1. Atypical Wound Care LEE Wai-kuen Nurse Specialist Queen Mary Hospital

  2. Atypical Wound • Wounds due to uncommon etiologies are called atypical wounds. • The most commonly encountered etiologies for an atypical wound include inflammatory causes, infections, vasculopathies, metabolic and genetic causes, malignancies and external causes. (Baranpski & Ayello, 2004)

  3. Potential etiologies • Inflammatory causes • Vasculitis • Puoderma gangrenosum • Infections • Atypical mycobacteria • Deep fungal infections Araujo & Kirsner, 2004

  4. Metabolic and genetic causes • Calciphylaxis • Sickle cell anemia • Malignancies • Squamous cell carcinoma • Basal cell carcinoma • Lymphoma • Kaposi’s sarcoma Araujo & Kirsner, 2004

  5. Vasculopathies • Cryoglobulinemia • Cryofibrinogenaemia • External causes • Bites • Radiation Araujo & Kirsner, 2004

  6. Scleroderma • A widespread connective tissue disease that involves changes in the skin, blood vessels, muscles, and internal organs.

  7. Alternative Names • CREST syndrome • Progressive systemic sclerosis • Systemic sclerosis • Localized scleroderma

  8. Affect 300,000 people in USA • Female : Male = 4:1 • Population • Infant elderly • Average age 22-55

  9. Causes • Unknown • Not directly inherited • Over production of collagen in the skin and other organs • Risk factors • Occupational exposure to silica dust and polyvinyl chloride

  10. Skin symptoms • Blueness or redness of fingers and toes in response to heat and cold • Ulcerations on fingertips or toes • Skin hardness / thickening • Skin is abnormally dark or light • Shiny hands and forearm • Small white lumps beneath the skin • Tight and mask-like facial skin • Hair loss

  11. Other organs involvement • Bone, joint and muscle • Digestive system • Lung • Kidney • Gallbladder • Heart • Eye

  12. Complications • Heart failure • Kidney failure • Malabsorption • Pulmonary fibrosis • Pulmonary hypertension

  13. Medication • Decrease activity of immune system • Corticosteroids • Immunosuppressants (Methotrexate, Cytoxan) • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Symptomatic control

  14. Prognosis • In most patients, the disease slowly gets worse. • Death may occur from gastrointestinal, heart, kidney, or lung involvement. • Pulmonary sclerosis - most common cause of death.

  15. Epidermolysis Bullosa (EB) • A rare inherited disease • The skin is very fragile and blisters formed in response to friction and to every day trauma • May also affect multiple systems of the body

  16. Epidermolysis Bullosa • Epidermolysis simplex • Junctional epidermolysis bullosa • Dystrophic epidermolysis bullosa

  17. Epidermolysis simplex • Largest group • Dominantly inherited disorder • One copy of the gene is faulty • Not life threatening • Blistering mainly limited to the hands, elbows, knees and feet • Reduce in severity as the child becomes older

  18. Junctional epidermolysis bullosa • Recessively inherited disease • Both copies of the gene are faulty • The most serious type of EB, infants usually die during the first year of life • Generalized lesions • Affect mucous membrane

  19. Dystrophic epidermolysis bullosa • Can be either dominant or recessive • Dominant – only mildly affected • Recessive – severely affected • Continuing blistering and ulceration of the skin follows everyday trauma

  20. Lesions heal with scarring • result in strictures and contractures • limitation in mobility and eating • Predispose to skin cancer

  21. Handling of the children • Small infants should never lift up under arms as painful blisters may result. • Older children should be encouraged to be independent in his / her early age so as to avoid trauma by others.

  22. Aims of wound care • Encourage wound healing • Maintain daily activities • Social acceptability

  23. Dressing choice • Wound contact layer dressing • eg. Mepitel, Urgotul • Non adherent dressing • eg. Melolin, Tricose, Mepliex • Alginate dressing

  24. Clothing • Fine material clothing • Can be worn inside out to avoid rough seams • Remove internal labels • Padded footwear

  25. Oral care • Affect mucous membrane • eg. oral blistering, bleeding, oral submucous fibrosis, oesophageal strictures • Dental decay • Due to fragility of oral mucosa • Fluoride supplement • Oral hygiene • ?? Tooth brushing • ?? Dentures

  26. Nutrition • Dysphagia - gastrostomy feeding • Constipation – soluble fibre supplement

  27. Mobility • Digital fusion • Results from repeated blistering and scarring • Plastic surgery • Splintage

  28. Pyoderma Gangrenosum (PG) • An inflammatory process resulting in ulceration of unknown etiology. • It was an immune-mediated inflammatory condition characterized by ulcerative skin lesions. • Affect about 5 percent of people with ulcerative colitis Regueiro, et al, 2003 Papageprgiou, Mathew, Kaniorou-Larai, & Yiakoumetis, 2007

  29. Systemic diseases associated with PG • Associated with other conditions in up to 75% of patients. • Inflammatory bowel disease • Arthritis • Hemotologic abnormalities • Lymphoma • Myeloma • Leukemia • Immunologic abnormalities • SLEAraujo & Kirsner, 2005

  30. Appear as a blister, red bump, or pustule • Appear alone or in a group • Pustules progress rapidly and develop into the ulcer • Commonly found on the extremities • More frequently on the legs than on the arms Nkrumah, Addo, & Tachi, 2005 Papageprgiou, et al, 2007

  31. Diagnosis • No single diagnostic test available for PG • It is a clinical diagnosis of exclusion • Based on excluding other causes and evaluating the patient for underlying systemic disease. Trent & Kirsner, 2001

  32. Treatment • Treat underlying disease • Corticosteroid • Immunosuppressant • Cyclosporine • Systemic antibiotics • Anaesthetic

  33. Wound management • Control pain • Necrotic tissue • surgical debridement is contraindicated as it may result in even worse ulceration • Avoidance of trauma at dressing removal • disturbance can generate an even greater inflammatory response and stimulate deterioration Araujo, & Kirsner, 2004

  34. Negative pressure therapy • may be used to assist debridement when the disease is stable • Debridement and skin grafting • can be considered when condition is under controlled • surgery may reactive the disease Moffatt, Martin, Smithdale, 2007

  35. The End !!

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