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Lotions, Potions and Dressings – What do I DO?

Lotions, Potions and Dressings – What do I DO?. Anna Braden, BSN, RN, CWOCN. Objectives. 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. Anatomy.

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Lotions, Potions and Dressings – What do I DO?

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  1. Lotions, Potions and Dressings – What do I DO? Anna Braden, BSN, RN, CWOCN

  2. Objectives • 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

  3. Anatomy • Epidermis • Dermis • Subcutaneous tissue • Fascia, Muscle, Bone

  4. Wound Healing Injury • Hemostasis: • Coagulation • Platelet aggregation Platelets • Inflammation: • Macrophages • Neutrophils • Granulocytes • Debridement • Resistance to • infection • Neovascular growth • Granulation Proliferation Epithelialization Proteoglycan synthesis Collagen lysis Collagen synthesis Maturation: remodeling Contraction Healed wound Wound Care: An Incredible Visual! Pocket guide, 2009

  5. Wound healing Wikipedia, the free encyclopedia

  6. Wound Healing • Partial Thickness • Epidermis, dermis • Full Thickness • Can be shallow or deep • Subcutaneous tissue • Fascia, Muscle

  7. Factors affecting wound healing • Perfusion/oxygenation • Nutritional status!!!! • Infection • Corticosteroids/medications • Aging • Nicotine!!! Smoking • Denervation • Obesity • Diabetes!!!! • Most of all – patient’s cooperation

  8. Skin Assessment • Color • Texture • Temperature • Turgor • Odor • Sensations

  9. Wound Assessment • Location – anatomic landmarks • Size including • Undermining • Tunneling/sinus track • Wound bed appearance • Exudate • Amount & characteristics • Odor • Pain • Peri wound skin

  10. 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

  11. Skin Products • Antimicrobial • Emollient • Humectant • Preservative • Skin protectant • Surfactant • Dimethicone • Petrolatum • Zinc Oxide • <25% = creamy • >25% = pasty

  12. Dressing Selection – 1st Basic Rule Dry 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***

  13. Then 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”

  14. Products • Terms: • Primary dressing • Secondary dressing • Filler • MVTR – Moisture-Vapor Transmission Rate • Epidermal stripping

  15. 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

  16. Products – Calcium alginate • Called usually ‘alginate’ • Polysaccharide derived from brown seaweed • Partial or full thickness wounds • Primary dressing/filler • Usually needs a secondary/cover dressing • Highly absorbent – moderate to heavily draining wounds • Converts to a viscous/hydrophilic gel • Hemostatic properties • Change as needed – usually every 24-48 hours Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292

  17. Products - Charcoal • Activated carbon • Absorbs toxins and wound degradation products • Indications: • Malodorous wounds • Fecal fistulas • Apply as a ‘filter’ for odor control • If absorbing drainage, need to change when saturated Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292

  18. Products – Collagen • Enhances deposition of collagen fibers • Chemoattractant to granulocytes & fibroblasts • Bioresorbable • Hemostatic properties • Processed 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, powders • Contraindicated in bovine sensitivites Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292

  19. Products - Composite • Combine distinct dressing components into a single dressing • Absorptive part is different than alginate, foam, hydrocolloid, hydrogel • Bacterial barrier • Partial or full thickness wounds without depth • Dry to heavy drainage – depending on dressing components • Primary or secondary dressing • Can be used with topical medications Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

  20. Products – Contact layer • Protects the wound from direct contact with other agents/dressings • Conforms to wound shape • Porous • Indications: • 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 Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

  21. Products – Fiber gelling • Hydrofiber • Moderate to heavy drainage • Converts to gel - “snot”-like appearance • Partial or full thickness wounds • Usually needs a secondary dressing Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

  22. Products - Foam • Absorptive and non-adherent • Indications: • Partial or full thickness wounds with or without depth • Moderate to heavily drainage • Contraindicated with dry eschar • Frequently 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 needed Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

  23. Products - 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 Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 294

  24. Products - Hydrogel • Adds moisture to dry wound bed • Non-adherent • Little or no absorption • Cool & soothing • Various formulations: • Gel, sheets, impregnated gauze, with silver • Apply according to instructions • Use appropriate secondary dressing Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

  25. Products – Transparent film • Indications: • Shallow partial thickness • Dry to minimal drainage = nonabsorbent • Low MVTR • Can promote autolysis • Creates “second” skin • Apply without tension/stretching • Allow for 1-2” border around wound • Use skin sealant around wound edges • Not for infected wounds • Change every 4-7 days or as needed Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293

  26. Products – 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

  27. Peri wound protection • Prevent 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 frequency • Infection • Candidiasis • Crusting technique with antifungal powder Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301

  28. Special Consideration:Palliative Wound Care • S = Stabilize the wound • P = Prevent new wounds • E = Eliminate odor • C = Control pain • I = Infection prophylaxis • A = Advanced absorbent wound dressings • L = Lessen dressing changes Haas. M.L., Moore-Higgs, G.J. Principles of Skin Care and the Oncology Patient.2010. p 105.

  29. Documentation • Today – EMR/Electronic Medical Record • Order • Assessment • Actual dressing change • Teaching • Must meet certain criteria for reimbursement • Accurate and consistent • Monitoring • Legal Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301

  30. Presentwoc.com

  31. Worldwidewounds.com

  32. References • Bryant, 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.

  33. Questions?

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