Lotions, Potions and Dressings

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Lotions, Potions and Dressings What do I DO?

• Anna Braden, BSN, RN, CWOCN

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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

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Anatomy

• Epidermis
• Dermis
• Subcutaneous tissue
• Fascia, Muscle, Bone

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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
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Wound healing
Wikipedia, the free encyclopedia
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Wound Healing

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

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Factors affecting wound healing

• Perfusion/oxygenation
• Nutritional status!!!!
• Infection
• Corticosteroids/medications
• Aging
• Nicotine!!! Smoking
• Denervation
• Obesity
• Diabetes!!!!
• Most of all patients cooperation

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Skin Assessment

• Color
• Texture
• Temperature
• Turgor
• Odor
• Sensations

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Wound Assessment

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

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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
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Skin Products

• Antimicrobial
• Emollient
• Humectant
• Preservative
• Skin protectant
• Surfactant

• Dimethicone
• Petrolatum
• Zinc Oxide
• lt25 creamy
• gt25 pasty

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Dressing Selection 1st Basic Rule

• Dry deep/cavity wound
• Need to ADD moisture
• Need a Filler in order to pack
  undermining/tunneling areas
• Need a Cover dressing

• Dry shallow/superficial wound
• Need to ADD moisture

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
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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

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Products

• Terms
• Primary dressing
• Secondary dressing
• Filler
• MVTR Moisture-Vapor Transmission Rate
• Epidermal stripping

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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
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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
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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
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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
• Dakins 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
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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
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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.
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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
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Presentwoc.com
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Worldwidewounds.com
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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.

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Questions?