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VITAS Healthcare Corporation. Wound Care Best Practice Guidelines. Goal. To educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients. Objectives. Identify preventative measures

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Wound care best practice guidelines

VITAS Healthcare Corporation

Wound CareBest Practice Guidelines


Wound care best practice guidelines
Goal

To educate healthcare professionals on effective wound care protocols, in order to ensure optimal care for our terminally ill patients.


Objectives
Objectives

  • Identify preventative measures

  • Describe risk factors contributing to skin impairment

  • Describe the parameters of wound assessment including staging of wounds

  • Describe wound types and tissues

  • Describe care planning considerations and the selection of appropriate interventions


Prevention
Prevention

  • Inspect skin

  • Moisture control

  • Proper positioning and transfer techniques

  • Nutrition

  • Avoid pressure on heels and bony prominences

  • Use of positioning devices

  • Monitor and document


Risk assessment
Risk Assessment

  • Alterations in mobility

  • Level of incontinence

  • Nutritional status

  • Alteration in sensation or response to discomfort

  • Co-morbid conditions

  • Medications that delay healing

  • Decreased blood flow to lower extremities when ulceration is present


Contributing factors 1
Contributing Factors1

Friction

Immobility

Shear

Pressure

Ulcers

Pressure

Incontinence

Malnutrition


Assessment and documentation

Location

Stage and Size

Periwound

Undermining

Tunneling

Exudate

Color of wound bed

Necrotic Tissue

Granulation Tissue

Effectiveness of Treatment

Assessment and Documentation


Assessment and documentation1
Assessment and Documentation

  • Wound and Risk Assessment every visit

  • Documentation on Wound Assessment Form every 7 days when 1 or more pressure ulcer exists

  • Physician assessment and documentation on

    Physician Wounds Care Assessment tool


Pressure ulcer staging 2

Stage I

Stage II

Stage III

Stage IV

Pressure Ulcer Staging2


Care planning

Care Planning.

Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound.


Appropriate goals
Appropriate Goals

  • Prevent complications or the deterioration of an existing wound

  • Prevent additional skin breakdown

  • Minimize harmful effects of the wound on the patient’s overall condition

  • Promote wound healing


Interventions
Interventions

Dressing considerations should include:

  • Patient’s condition and prognosis

  • Caregiver ability

  • Ease and continuity of use

  • Ability to maintain moisture balance

  • Frequency of change


Pain management
Pain Management

1) Medicate the resident prior to dressing changes

2) Some treatment regimes may be uncomfortable for the resident

  • Provide maintenance doses of medication for those patients who have pain.

  • Adjuvant therapy may be appropriate

  • Consider non-medicinal approaches


Types of wounds 3
Types of Wounds3

  • Pressure Ulcers

  • Arterial Insufficiency

  • Diabetic Ulcers

  • Venous Insufficiency

  • Surgical Wounds

  • Tumors


Palliative wound care for the imminent patient
Palliative Wound Care for the Imminent Patient

Think:

  • Comfort

  • Quality of Life

    Treatment Choices:

  • Keep Current Treatment

  • Irrigation, Cover with DuoDERM Thin or Bioclusive Dressing

  • Irrigation, Silvadene, Cover with Gauze

    (if infection is suspected)


Basic elements of wound care
Basic Elements of Wound Care

  • Cleanse Debris from the Wound

  • Possible Debridement

  • Absorb Excess Exudate

  • Promote Granulation and Epithelialization When Appropriate

  • Possibly Treat Infections

  • Minimize Discomfort


Wet to dry dressings
Wet to Dry Dressings

Indicated for Mechanical Debridement ONLY

  • Causes Injury to New Tissue Growth

  • Is Painful

  • Predisposes Wound to Infection

  • Becomes a Foreign Body

  • Delays Healing Time


Frequency

Goal is to minimize the frequency of dressing change

Daily dressing changes increase chances of infection and disrupts the healing of tissue

Optimal wear time is 3-7 days

Decrease Frequency

of Dressing Changes

Frequency


Interventions patients at risk or stage i
Interventions:Patients At-Risk or Stage I

  • Assess “Risk for Breakdown”

  • Utilize skin creams and lotions for dry skin

  • Utilize barrier products as needed to minimize irritation from incontinence

  • Reposition frequently

  • Encourage fluids as tolerated and appropriate

  • Use pillows in bed for positioning


Cleansing wounds
Cleansing Wounds..

  • Remove Wound Debris

  • Sustain Moist Environment

  • Soften Necrotic Tissue

  • Debride the Wound

  • Reduce the Risk of Bacterial Contamination and Infection

  • Reduce Odor


Goals treatment guidelines
Goals & Treatment Guidelines

  • Dry to Minimal Exudate

  • Moderate Exudate

  • Copious Exudate


Interventions stage i

GOALS:

Maintain skin integrity

Skin to remain clean and odor free

Protect and moisturize skin

TREATMENTS:

Preferred agents (dry skin)

Aloe Vesta skin cream

Preferred agents (at risk for breakdown due to incontinence/pressure)

Aloe Vesta protective ointment

Dermarite Perigaurd barrier ointment

Interventions Stage I


Interventions stage ii iii iv

Dry to Minimal Exudate

GOALS:

Minimize dressing changes

Maintain moist environment

Prevent infection

Prevent additional skin breakdown

TREATMENTS:

Preferred agents:

Hydrofiber (Aquacel)

Viscopaste

Hydrocolloid (DuoDERM Extra Thin)

Follow product guidelines for frequency of dressing change

Interventions Stage II, III, IV


Interventions stage ii iii iv1

Moderate Exudate

GOALS:

Minimize dressing changes

Maintain moist environment

Prevent infection

Prevent additional skin breakdown

TREATMENTS:

Preferred Agents:

Hydrofiber (Aquacel)

Hydrocolloid (DuoDERM Signal)

Follow product guidelines for frequency of dressing change

InterventionsStage II, III, IV


Interventions stage ii iii iv2

Copious Exudate

GOALS:

Minimize dressing changes

Manage Exudate

Prevent infection

Prevent additional skin breakdown

TREATMENTS:

Preferred Agents:

Hydrofiber (Aquacel)

Hydrocolloid (DuoDERM Signal)

Follow product guidelines for frequency of dressing change

InterventionsStage II, III, IV


Interventions1
Interventions

  • Necrotic Tissue in Ulcer Bed

  • Fungating Lesions

  • Infected Wounds

  • Skin Tears

  • Gangrenous Wounds

  • Diabetic Ulcers


Interventions necrotic tissue in ulcer bed
InterventionsNecrotic Tissue in Ulcer Bed

  • Mechanical Debridement

  • Autolytic Debridement

  • Sharp or Surgical Debridement*

  • Enzymatic or Biochemical Debridement*

  • Biological Debridement*

    *Requires Approval


Interventions necrotic tissue in ulcer bed1
InterventionsNecrotic Tissue in Ulcer Bed

  • Prior to debridement interventions, assess whether it will enhance wound healing or promote infection or cause undue pain.

  • Do NOT institute aggressive debridement if the patient is within days/week of death, or if the eschar is stable, dry, non-draining, and wound is not infected.

  • For Intact black heel – relieve pressure – no dressing or debridement – if opens then refer to necrotic treatments.


Interventions fungating lesion

Goals:

Removal of exudate

Odor control

Pain control

Non-Pharmacological measures to control odor include:

Oil of Wintergreen

Charcoal briquettes or Coffee grounds

Dryer Sheets

Treatments:

Preferred Agents

Non-Adherent Gauze Dressing (Telfa)

Zinc Oxide Paste (Viscopaste)

Activated Charcoal Dressing (Carboflex)

Atropine solution may be used to control bleeding

Metrogel cream can be used to control odor

InterventionsFungating Lesion


Interventions infected wounds

Diagnosis of wound infection:

Swab Cultures not recommended

Based on clinical signs (fever, increased pain, friable granulation tissue, foul odor)

Tissue culture or biopsy is not optimal for the hospice patient.

Treatments:

Preferred agents:

Hydrofiber (Aquacel Ag)

Silvadene ointment and non-sterile gauze

DO NOT USE:

Providine Iodine

Iodophor

Dakin’s solution

Hydrogen peroxide

Acetic Acid

InterventionsInfected Wounds…


Interventions skin tears

Goals:

Prevent infection

Healing

Prevent further injury

Minimize dressing change frequency

Treatments:

Preferred Agents:

Non-Sterile Gauze

Transparent Film (Opsite)

InterventionsSkin Tears


Interventions2

Ischemic (Gangrenous) Wounds

Draining wounds

Cover with Telfa or gauze and wrap with Kerlix

No drainage

Cover with gauze and Kerlix

Change QD and PRN

Venous Stasis or Diabetic Ulcers

Draining wounds

Cover with Telfa or Adaptic with a Kerlix wrap changed QD

Cleanse with normal saline using bulb syringe

Non-draining wounds

Cover with gauze and wrap with Kerlix

Apply tape to the Kerlix to prevent further injury to surrounding skin

Change QD

Interventions


Support surfaces

Comfort and Shear Reduction Products:

Pillows

Heel/Elbow Protectors

Foot Cradles

Sheepskin Pads

DO NOT USE DONUT TYPE DEVICES IN WHEELCHAIRS

Support Surfaces


Support surfaces1
Support Surfaces

Multiple Pressure Points (greater than 2 turning surfaces)

  • Standard Mattress

  • 3-4” Eggcrate Overlay on Standard Bed

  • Gel Mattress Overlay

  • Wheelchair Foam Pad

  • Wheelchair Gel Pad

    Multiple Pressure Points (fewer than 2 turning surfaces)

  • Static Air Mattress

  • Alternating Pressure Pad and Pump

  • Low Air Loss Mattress (requires approval)


In summary
In Summary….

  • Determine the plan of care based on the patient’s characteristics

  • Evaluate the wound status every visit and at a minimum of weekly

  • Evaluate the effectiveness of the treatment regime

  • Try to provide consistent wound care among all caregivers

  • Completely document status of wound


Thank you
Thank you

Together, we can make a difference!