Wound care: Difference between revisions
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− | == |
+ | ==Assessment== |
− | * |
+ | *MEASURE acronym |
− | ** |
+ | **Measure (length, width, depth, and area) |
− | ** |
+ | **Exudate (quantity and quality): serous, serosanguineous, sanguineous, seropurulent, purulent |
− | ** |
+ | **Appearance (wound bed, including tissue type and amount): granulation, fibrin, slough, eschar |
− | ** |
+ | **Suffering (pain type and level) |
− | ** |
+ | **Undermining (presence or absence) |
− | ** |
+ | **Reevaluate (monitoring of all parameters regularly) |
− | ** |
+ | **Edge (condition of edge and surrounding skin) |
− | == |
+ | ==Management== |
− | === |
+ | ===Care Plan=== |
− | * |
+ | *Appropriate management includes patient factors, local wound factors, and environmental measures, and requires regular reassessment |
− | ==== |
+ | ====Patient Factors==== |
− | * |
+ | *Manage comorbidities (e.g. diabetes, arterial disease, etc) |
− | * |
+ | *Address risk factors when possible |
− | * |
+ | *Optimize nutrition and hydration |
− | * |
+ | *Manage other infections |
− | * |
+ | *Treat symptoms |
− | * |
+ | *Provide psychosocial support |
− | * |
+ | *Prescribe appropriate antibiotics |
− | * |
+ | *Create and individualized management plan |
− | * |
+ | *Educate the patient and family |
− | ==== |
+ | ====Local Wound Factors==== |
− | * |
+ | *See below for more information |
− | * |
+ | *Prevent infection using aspetic technique and universal precautions |
− | * |
+ | *Drain wounds |
− | * |
+ | *Ensure good wound hygiene and protection |
− | * |
+ | *Manage exudate |
− | * |
+ | *Optimize wound bed |
− | ** |
+ | **Debride non-viable tissue |
− | ** |
+ | **Disrupt biofilm |
− | ** |
+ | **Clean with each dressing |
− | ** |
+ | **Use appropriate antimicrobial dressings |
− | ** |
+ | **Use appropriate antiseptic therapy (each should have at least a 2 week trial) |
− | ==== |
+ | ====Environmental Factors==== |
− | * |
+ | *Ensure a clean environment for wound care |
− | * |
+ | *Store equipment safely |
− | * |
+ | *Educate patient and caregivers |
− | * |
+ | *Review policies and procedures |
− | ==== |
+ | ====Regular Reassessment==== |
− | * |
+ | *Follow wounds over time for changes |
− | * |
+ | *Make adjustments as necessary to management plan |
− | === |
+ | ===Local Wound Care=== |
− | ==== |
+ | ====Wound Cleansing==== |
− | * |
+ | *Saline, sterile water, tap water, or liquid antiseptics (povidone-iodine, etc) |
− | ** |
+ | **The antiseptic solutions often disrupt or penetrate biofilm |
− | ** |
+ | **Antiseptics include povidone-iodine, PHMB, OCT, HOCl/NaOCl |
− | * |
+ | *If infection suspected, use antiseptic or surfactant |
− | * |
+ | *Irrigate with gentle pressure; do not scrub |
− | ==== |
+ | ====Debridement==== |
− | * |
+ | *Removing necrotic or devitalized tissue, including slough, pus, debris, etc, can help healing |
− | ** |
+ | **Moist necrotic tissue is an excellent medium for bacteria |
− | * |
+ | *'''Selective''' (only non-viable tissue) generally preferred over '''non'''-selective debridement |
− | * |
+ | *Specific techniques include: |
− | ** |
+ | **'''Mechanical:''' most common. Physically removes the tissue. |
− | *** |
+ | ***Wet-to-dry dressing: apply wet tissue, allow to dry, then remove. This causes pain and is discouraged |
− | *** |
+ | ***Irrigation: with 4-15 psi can dislodge bacteria and debris. Can be done with syringe and 18-19 gauge needle |
− | *** |
+ | ***Polyacrylic microfibre pads: now out of favour |
− | *** |
+ | ***Low-frequency ultrasound |
− | ** |
+ | **'''Autolytic''': allows body's own immune system to get rid of dead tissue (e.g. liquefaction of eschar) |
− | *** |
+ | ***Scoring or crosshatching the eschar with a scalpel |
− | *** |
+ | ***Using dressings that promote autolysis |
− | *** |
+ | ***Must keep wound clean |
− | ** |
+ | **'''Enzymatic:''' the use of exogenous proteolytic substances such as collagenase |
− | *** |
+ | ***Dry eschar must be kept moist for the enzymes to work |
− | ** |
+ | **'''Surgical:''' converts a chronic non-healing wound into an acute wound by a surgeon in an OR |
− | ** |
+ | **'''Conservative sharp:''' removal of devitalized tissue with a scalpel or scissors |
− | ** |
+ | **Chemical: e.g. sodium hypochlorite (NaOCl), but is non-selective and can damage healthy tissue |
− | ** |
+ | **Hydrosurgical: uses specialized tools and a surgeon |
− | ** |
+ | **Biological/biosurgical: maggots |
− | ==== |
+ | ====Bacterial Balance==== |
− | * |
+ | *Antimicrobial includes both antibiotics and antiseptics |
− | * |
+ | *Bacterial burden ranges from contamination to colonization, local infection, spreading infection, and finally systemic infection |
− | ** |
+ | **Intervention is required for any infection |
− | ** |
+ | **Biofilm should be considered for any infection |
− | ===== |
+ | =====Topical Antimicrobials===== |
− | * |
+ | *Includes gential violet, methylene blue, honey, iodine, PHMB, silver, and hydrophobic agents |
− | ** |
+ | **These reduce bacterial burden or disrupt biofilm |
− | *** |
+ | ***May be used prophylactically, as well |
− | **** |
+ | ****Iodine is contraindicated in breastfeeding and pregnant women, and in renal disease, and should be used with care in patients with thyroid disease |
− | ==== |
+ | ====Moisture Balance==== |
− | * |
+ | *The goal is for the wound to be moist enough to promote healing without being so wet as to promote maceration and irritation |
− | * |
+ | *Primarily done using occlusive dressings |
Revision as of 22:16, 8 January 2021
Assessment
- MEASURE acronym
- Measure (length, width, depth, and area)
- Exudate (quantity and quality): serous, serosanguineous, sanguineous, seropurulent, purulent
- Appearance (wound bed, including tissue type and amount): granulation, fibrin, slough, eschar
- Suffering (pain type and level)
- Undermining (presence or absence)
- Reevaluate (monitoring of all parameters regularly)
- Edge (condition of edge and surrounding skin)
Management
Care Plan
- Appropriate management includes patient factors, local wound factors, and environmental measures, and requires regular reassessment
Patient Factors
- Manage comorbidities (e.g. diabetes, arterial disease, etc)
- Address risk factors when possible
- Optimize nutrition and hydration
- Manage other infections
- Treat symptoms
- Provide psychosocial support
- Prescribe appropriate antibiotics
- Create and individualized management plan
- Educate the patient and family
Local Wound Factors
- See below for more information
- Prevent infection using aspetic technique and universal precautions
- Drain wounds
- Ensure good wound hygiene and protection
- Manage exudate
- Optimize wound bed
- Debride non-viable tissue
- Disrupt biofilm
- Clean with each dressing
- Use appropriate antimicrobial dressings
- Use appropriate antiseptic therapy (each should have at least a 2 week trial)
Environmental Factors
- Ensure a clean environment for wound care
- Store equipment safely
- Educate patient and caregivers
- Review policies and procedures
Regular Reassessment
- Follow wounds over time for changes
- Make adjustments as necessary to management plan
Local Wound Care
Wound Cleansing
- Saline, sterile water, tap water, or liquid antiseptics (povidone-iodine, etc)
- The antiseptic solutions often disrupt or penetrate biofilm
- Antiseptics include povidone-iodine, PHMB, OCT, HOCl/NaOCl
- If infection suspected, use antiseptic or surfactant
- Irrigate with gentle pressure; do not scrub
Debridement
- Removing necrotic or devitalized tissue, including slough, pus, debris, etc, can help healing
- Moist necrotic tissue is an excellent medium for bacteria
- Selective (only non-viable tissue) generally preferred over non-selective debridement
- Specific techniques include:
- Mechanical: most common. Physically removes the tissue.
- Wet-to-dry dressing: apply wet tissue, allow to dry, then remove. This causes pain and is discouraged
- Irrigation: with 4-15 psi can dislodge bacteria and debris. Can be done with syringe and 18-19 gauge needle
- Polyacrylic microfibre pads: now out of favour
- Low-frequency ultrasound
- Autolytic: allows body's own immune system to get rid of dead tissue (e.g. liquefaction of eschar)
- Scoring or crosshatching the eschar with a scalpel
- Using dressings that promote autolysis
- Must keep wound clean
- Enzymatic: the use of exogenous proteolytic substances such as collagenase
- Dry eschar must be kept moist for the enzymes to work
- Surgical: converts a chronic non-healing wound into an acute wound by a surgeon in an OR
- Conservative sharp: removal of devitalized tissue with a scalpel or scissors
- Chemical: e.g. sodium hypochlorite (NaOCl), but is non-selective and can damage healthy tissue
- Hydrosurgical: uses specialized tools and a surgeon
- Biological/biosurgical: maggots
- Mechanical: most common. Physically removes the tissue.
Bacterial Balance
- Antimicrobial includes both antibiotics and antiseptics
- Bacterial burden ranges from contamination to colonization, local infection, spreading infection, and finally systemic infection
- Intervention is required for any infection
- Biofilm should be considered for any infection
Topical Antimicrobials
- Includes gential violet, methylene blue, honey, iodine, PHMB, silver, and hydrophobic agents
- These reduce bacterial burden or disrupt biofilm
- May be used prophylactically, as well
- Iodine is contraindicated in breastfeeding and pregnant women, and in renal disease, and should be used with care in patients with thyroid disease
- May be used prophylactically, as well
- These reduce bacterial burden or disrupt biofilm
Moisture Balance
- The goal is for the wound to be moist enough to promote healing without being so wet as to promote maceration and irritation
- Primarily done using occlusive dressings