F314 Follow-up Clinical Training January 23, 2006

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F314 Follow-up Clinical TrainingJanuary 23,
2006

• Presented by
• Jeri Lundgren, RN, CWS, CWCN
• Wound Care Consultant
• Pathway Health Services

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Training Objectives

• Know what a comprehensive risk assessment should
  include
• Discuss individualized turning and repositioning
• Understand the treatment for lower extremity
  wounds
• Describe the causes of pressure ulcers
• Differentiate between pressure reduction verses
  pressure relief
• Discuss the application of pulsatile lavage in
  wound management

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Risk Assessment

• Regulation states
• Although the requirements do not mandate any
  specific assessment tool, other than the RAI,
  validated instruments are available to assess
  risk for developing pressure ulcers

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Risk Assessment ToolsBRADEN SCALE

• Mobility
• Activity
• Sensory Perception
• Moisture
• Friction Shear
• Nutrition
• Please note Using the Braden scale requires
  obtaining permission at
• www.bradenscale.com or [phone]

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Risk Assessment Tools

• Regardless of any residents total risk score,
  the clinicians responsibility for the residents
  care should review each risk factor and potential
  cause(s) individually
• an overall risk score indicating the resident is
  not at high risk of developing pressure ulcers
  does not mean that existing risk factors or
  causes should be considered less important or
  addressed less vigorously than those factors or
  causes in the resident whose overall score
  indicates he or she is at a higher risk of
  developing a pressure ulcer.

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Risk Assessment Tools

• A COMPREHENSIVE risk assessment should be done
• Upon admission
• Weekly for the first four weeks after admission
• With a change of condition
• Quarterly

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Comprehensive Risk Assessment

• Overall skin condition - including tissue
  tolerance
• Medical diagnosis and co-morbidities
• Medications or Treatments
• Degree of Mobility
• Incontinence of Bowel and/or Bladder
• Scarring over bony prominences
• Contractures
• Bedfast or Chair-bound

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Comprehensive Risk Assessment

• Cognitively impaired
• Resident choice
• Restraints
• Unrelieved pain
• Slouching in a chair
• Repeated hospitalizations or ER visits with-in 6
  months
• Nutrition and hydration

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Comprehensive Risk Assessment

• The overall goal of the risk assessment is to
  ensure that individualized interventions are
  attempted to stabilize, reduce or remove the
  underlying risk factors

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Prevention InterventionsProvide appropriate
pressure reduction or relief
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Prevention Interventions Choose appropriate
pressure reducing surfaces while in bed and
sitting

• Pressure Reduction Is the reduction of
  interface pressure, not necessarily below
  capillary closure pressure
• Pressure Relief Is the reduction of interface
  pressure below capillary closure pressure
• Capillary closing pressure is also individual to
  the resident

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Support Surfaces

• There is no standardize testing or requirements
  for support surfaces
• There is no set mandate or recommendation as to
  when a specific type of support surface should be
  used.
• Regulation states
• Appropriate support surfaces or devices should
  be chosen by matching a devices potential
  therapeutic benefit with the residents specific
  situation for example, multiple ulcers, limited
  turning surfaces and ability to maintain
  position.

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Support Surfaces

• Surveyors should consider the following pressure
  redistribution issues
• Static devices (e.g., solid foam or gel
  mattresses) may be indicated when a resident is
  at risk or delayed healing. A specialized
  reduction cushion or surface might be used to
  extend the time a resident is sitting in a chair
  however, the cushion does not eliminate the
  necessity for periodic repositioning

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Support Surfaces

• pressure redistribution issues continued
• Dynamic pressure reduction surfaces may be
  helpful when
• The resident cant assume a variety of positions
  without bearing weight on a pressure ulcer
• The resident completely compresses a static
  device
• The pressure ulcer is not healing as expected,
  and it is determined that pressure may be
  contributing to the delay in healing

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Prevention Interventions
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Support Surfaces

• Use of recliners, regulation states
• The care plan for a resident who is reclining
  and is dependent on staff for repositioning
  should address position changes to maintain the
  residents skin integrity...Elevating the head
  of the bed or the back of a reclining chair to or
  above a 30 degree angle creates pressure
  comparable to that exerted while sitting, and
  requires the same considerations regarding
  repositioning as those for a dependent resident
  who is seated.

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Support Surfaces

• Recliners continued
• Remember off-loading is one full minute of
  pressure relief
• Is the turning schedule in the best interest for
  the resident or per their wishes or is it in the
  best interest for staff
• Foam vs. Gel vs. Air wheelchair cushions Overall
  ensure it is the best for the individual resident

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Prevention Interventions

• Develop an INDIVIDUALIZED turning repositioning
  schedule
• Tissue tolerance is the ability of the skin and
  its supporting structures to endure the effects
  of pressure with out adverse effects
• There is no standard/mandated Tissue Tolerance
  Test
• A skin inspection should be done, which should
  include an evaluation of the skin integrity and
  tissue tolerance, after pressure to that area,
  has been reduced or redistributed

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Prevention Interventions

• After skin integrity and tissue tolerance has
  been assessed the resident then should be put on
  an appropriate INDIVIDUALZED turning and
  repositioning program
• Ongoing monitoring of tissue tolerance and skin
  integrity should be done
• Recommend assessing skin integrity and tissue
  tolerance upon admission and with a significant
  change of condition

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Lower Extremity Wounds

• Arterial Insufficiency
• Venous Insufficiency
• Peripheral Neuropathy/Diabetic
• Referred to F309 Tag

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Arterial Insufficiency
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Arterial Insufficiency Ulcers

• Location
• Toe tips and/or web spaces
• Phalangeal heads around lateral malleolus
• Areas exposed to pressure or repetitive trauma
  (shoe, cast, brace, etc.)

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Arterial Insufficiency
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Arterial Insufficiency Interventions

• Measures to Improve Tissue Perfusion
• Revascularization if possible
• Lifestyle changes (no tobacco, no caffeine, no
  constrictive garments, avoidance of cold)
• Hydration
• Measures to prevent trauma to tissues
  (appropriate footwear at ALL times)
• Aspirin in doses of 75-325 mg oral/day

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Arterial Insufficiency Interventions

• Nutrition
• Consider niacin niacin has been shown to ? HDL-C
  ? Triglycerides in oral dosages of 3,000mg/d
• L-Arginine (vasodilator properties) oral intake
  of 6.6 g/day for 2 weeks improved symptoms of
  intermittent claudication
• Provide nutritional support with 2,000 or more
  calories preoperatively and postoperatively, if
  possible this has been benefited patients
  undergoing amputations

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Arterial Insufficiency Interventions

• Pain Management
• Recommend walking to near maximal pain three
  times per week.
• Administer Cilostazol, 100mg BID, orally
• Topical Therapy
• Dry uninfected necrotic wound KEEP DRY
• Dry INFECTED wound Immediate referral for
  surgical debridement/aggressive antibiotic
  therapy (Topical antibiotics are typically
  in-effective for arterial wounds)

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Arterial Insufficiency Interventions

• Topical Therapy (continued)
• Open Wounds
• Moist wound healing
• Non-occlusive dressings (e.g. solid hydrogel)
• Aggressive treatment of any infection
• Adjunctive Therapies
• Hyperbaric oxygen therapy
• Intermittent pneumatic compression
• Topical autologous activated mononuclear cells,
  twice per week (Autologel)

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Arterial Insufficiency Interventions

• Adjunctive Therapies (continued)
• High-voltage pulsed current (HVPC) electrotherapy
• Patient Education

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Venous Insufficiency
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Venous Insufficiency Ulcers

• Location
• Medial aspect of the lower leg and ankle
• Superior to medial malleolus

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Venous Insufficiency Treatment

• Surgical obliteration of damaged veins
• Elevation of legs
• Compression therapy to provide at least 30mm Hg
  compression at the ankle
• Short stretch bandages (e.g. Setopress,
  Surepress)
• Therapeutic support stockings
• Unnas boot
• Profore layer wrap
• Compression pumps
• ensure compression therapy in not contraindicated

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Venous Insufficiency Treatment

• Topical Therapy
• Absorb exudate (e.g. alginate, foam)
• Maintain moist wound surface (e.g. hydrocolloid)
• Chronic or non-responding wounds
• Small Intestinal SubmucosaTechnology (Oasis Wound
  Matrix Healthpoint)
• Bi-layered cell therapy (Apligraf Organogenesis,
  Inc.)
• Patient Education
• Appropriate antibiotics to treat infection

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Peripheral Neuropathy/Diabetic Signs Symptoms

• Relief of pain with ambulation
• Parasthesia of extremities
• Altered gait
• Orthopedic deformities
• Reflexes diminished
• Altered sensation (numbness, prickling, tingling)

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Peripheral Neuropathy/Diabetic Signs Symptoms

• Intolerance to touch (e.g., bed sheets touching
  legs)
• Presence of calluses
• Fissures/cracks, especially the heels
• Arterial insufficiency commonly co-exists with
  peripheral neuropathy!

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Peripheral NeuropathyDiabetic Location

• Plantar aspect of the foot
• Metatarsal heads
• Heels
• Altered pressure points
• Sites of painless trauma and/or repetitive stress

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Peripheral NeuropathyDiabetic Treatment

• Pressure relief for heal ulcers
• Offloading for plantar ulcers (bedrest, contact
  casting, or orthopedic shoes)
• Appropriate footwear
• Tight glucose control
• Aggressive infection control
• orthopedic consult for exposed bone and
  antibiotic therapy
• Zyvox approved for MRSA
• Treatment for co-existing arterial insufficiency

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Peripheral NeuropathyDiabetic Treatment

• Topical Treatment
• Cautious use of occlusive dressings
• Dressings to absorb exudate
• Dressings to keep dry wound moist
• Chronic or non-responding wounds
• Recombinant human platelet-derived growth factors
  (Regranex Gel Johnson Johnson)
• Human fibroblast-derived dermal substitute
  (Dermagraft Smith Nephew)
• Bi-layered cell therapy (Apligraf Organogenesis,
  Inc.)

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Peripheral NeuropathyDiabetic Treatment

• Adjunctive Therapy
• Hyperbaric Oxygen
• MIRE - nitric oxide and monochromatic infrared
  photo energy (Anodyne Therapy LLC, Tampa, FL)
• The V.A.C (KCI)
• Patient Education

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Mixed Etiology
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Mixed Etiology

• Use reduced compression bandages of 23-30 mm Hg
  at the ankle. Compression therapy should not be
  used in patients with ABI lt 0.5
• Keep extremities in neutral position
• Protect from trauma

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Pressure Ulcers
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Pressure Ulcers
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Contributing factors Friction
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Contributing factors Friction
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Contributing factors Shear
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Contributing factors Shear
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Contributing factors Moisture
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Contributing factors Moisture
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Topical Treatment

• Wound Debridement
• Removal of devitalized tissue is considered
  necessary for wound healing
• Exception Stable heel ulcers with a protective
• eschar covering with no signs or symptoms of
• edema,erythema, fluctuance, or drainage, do NOT
• need debridement

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Wound Debridement

• Mechanical Use of wet-to-dry, hydrotherapy and
  wound irrigation to remove devitalized tissue
• Disadvantage non-selective, painful and can
  lead to excessive bleeding
• NOTE A wet-to-dry dressing should be used for
  debridement purposes ONLY

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Wound Debridement

• Pulsatile Lavage
• It is a form of mechanical debridement to
  facilitate removal of larger amounts of debris
• Irrigation pressure should not exceed 15psi
• It is best discontinued once the wound is clean

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Pulsatile Lavage

• It can cause dissemination of wound bacteria over
  a wide area, exposing the resident and care
  provider to potential contamination (JAMA Vol.
  292 No. 24, December 22/29, 2004 Nursing 2005,
  January 2005 Issue)
• Study at John Hopkins University School of
  Medicine, traced 11 patients infected with
  acinetobacter baumannii, back to the use of
  pulsatile lavage equipment. 3 of the patients
  required ICU care for sepsis and respiratory
  distress

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Pulsatile Lavage

• Precautions must be used
• Use continuous suction
• Keep splash shield in contact with the
  wound/periwound
• Empty suction waste container after each use
• Dispose of all single-use pulsatile lavage
  components, then sterilize or disinfect all
  reusable items
• Always perform pulsatile lavage in a private room
  enclosed with walls and doors
• Thoroughly clean and disinfect environmental
  surfaces

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Pulsatile Lavage

• Precautions continued
• Wear fluid proof gown, mask/goggles or face
  shield and hair cover
• Resident should consider the use of a droplet
  barrier, such as a surgical mask
• Use a drape or towel to cover all resident lines,
  ports and wounds that arent being treated

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THANK YOU!!!

• Jeri Lundgren, RN, CWS, CWCN
• Wound Care Consultant
• Pathway Health Services
• 612-805-9703
• jlundgren_at_centurytel.net