![Page 1: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/1.jpg)
ManagementofChronicDifficultWoundsintheLongTermCare
Se:ngJaniceLocke,MS,GNP,BC
NursePracBBonerEricksonHealthMedicalGroup–
RenaissanceGardensatFoxRun,Novi
![Page 2: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/2.jpg)
ObjecBves
• AtthecompleBonofthissession,parBcipantswillbeableto:– Describenormalwoundhealingstages– IdenBfywhatconsBtutesachronicwound– DescribewhichpaBentsareatriskfordevelopingchronicwounds
– IdenBfygoalsfortreaBngchronicwounds– DescribetreatmentopBonsformanagingchronicwounds
– IdenBfymethodsforevaluaBngwoundhealing
![Page 3: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/3.jpg)
DisclosureandDisclaimer
• IhavenofinancialrelaBonshipswithanywoundproductcompaniestodisclose.
• Some“off‐label”usesofproductsaswellassomeanecdotalevidencewillbepresented.
• AYemptswillbemadetousegenerictermsforwoundcareproductshoweverbrandnameswillbediscussedandopinionsregardingspecificproductsaremyown.
![Page 4: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/4.jpg)
Normalwoundhealingprocess
• WoundhealingoccursasacellularresponsetoBssueinjuryandinvolvesacBvaBonofseveralcelltypes.
• Acutewoundsusuallyhealinanorderlyandefficientmanner.
• RestoraBonofskinintegrityfollowinganacutesurgicalwoundin“normal”individualsisusuallycompletewithin2‐4weeks.
![Page 5: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/5.jpg)
Normalwoundhealing
• Hemostasis–immediateresponsetoinjury– Smallvesselscontracttoprovidesomehemostasis
– Plateletsaggregatetotriggerclo:ngcascadeandreleaseessenBalgrowthfactorsandcytokines
– ResulBngfibrinmatrixstabilizesthewoundandprovidesaprovisionalscaffoldforthewoundhealingprocess
![Page 6: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/6.jpg)
Normalwoundhealing
• Inflamma,on– Keycomponentsofthisphaseareincreasedvascularpermeabilityandcellularrecruitment.
– Cellsarerecruitedthatwill• Createstructuralproteins• MediatevasodilaBonandcellmigraBon• CausevesselpermeabilityresulBnginaccumulaBonofplasmaandcellularelements(edema)
• Digestbacteria,foreigndebrisandnecroBcBssue.– Thisisusuallythephasewherechronicwoundsbecomearrested
![Page 7: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/7.jpg)
Normalwoundhealing
• EpithelializaBon– ProliferaBonandmigraBonofepithelialcellsunBlindividualcellsaresurroundedbycellsofasimilartype.
– ChallengedbywoundsthatarenotclosedbyprimaryintenBon.
– Presenceofbiofilmandsenescentcellsonwoundedgeorbasealsochallengesthisstage.
![Page 8: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/8.jpg)
Normalwoundhealing
• Fibroplasia– Makethegroundsubstanceofthewoundbase
– ProducecontracBleproteinsthatworktopulltheedgesofthewoundtogether.
• MaturaBon– Disorganizedcollagenisdegradedandreformedtoenhancethetensilestrengthofthewound.
![Page 9: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/9.jpg)
Chronicwounds
• Achronicwoundisonethatdoesnothealwithina“reasonable”Bme–usually3months.
• A“stalledwound”doesnotdecreaseinsizeby30%in3weeksorby50%in4‐5weeks.
• Astalledwoundisn’tnecessarilygoingtobeachronicwound–mayjustneeda“kickstart”toresumehealingprocess.
![Page 10: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/10.jpg)
Chronicwounds
• Oeenstalledintheinflammatoryphase– ThepresenceofnecroBcBssue,foreignmaterial,andbacteriaresultintheabnormalproducBonofmetallloproteaseswhichalterthebalanceofinflammaBonandimpairthefuncBonofthecytokinesinvolvedininiBaBonandprogressionofwoundhealing(growthfactors).
![Page 11: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/11.jpg)
Factorsassociatedwithnon‐healingwounds
• Intrinsic– ImpairedcirculaBon
– Diseaseprocesses(inflammatory,metabolic,malignancy)
– MalnutriBon– Age– Obesity– InfecBon
![Page 12: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/12.jpg)
Factorsassociatedwithnon‐healingwounds
• Extrinsic– Mechanicalforces(pressure,shear,fricBon)
– Pharmacology– Foreignbodies
• Psychosocial– PaBent/familypreferences,beliefs,goals,expectaBons
– Caregiver/paBentrelaBonship
![Page 13: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/13.jpg)
Factorsassociatedwithnon‐healingwounds
• Access/implementaBon– Availabilityofcare– Financialresources– Abilitytounderstandandperformcare
![Page 14: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/14.jpg)
Individualwoundfactorsassociatedwithdelayedhealing
• Lackofacute“trigger”forhealing• Extendedinflammatoryphase• Presenceofmatrixmetalloproteases(MMPs)• LowlevelsofBssueinhibitorsofproteases(TIMPs)
• Deficiencyofgrowthfactorreceptorsitesand/orgrowthfactordestrucBonbyMMPs
• Inefficient/senecentcells• Biofilm
![Page 15: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/15.jpg)
Whoisatriskfornon‐healingwounds
• PaBentswith:– Vascularimpairment
– Impairedimmunestatus– MetastaBccancer– Advancedage– Diabetes– Neuropathy/SCI– MalnutriBon
![Page 16: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/16.jpg)
IdenBfygoalsoftreatment
• ConsistentwithpaBent/familyvaluesandlifestyle
• Cure/healing• PalliaBon/comfort
![Page 17: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/17.jpg)
TreatmentopBons‐Systemic
• Illnessmanagement– Bloodsugarcontrol– ManagementofoxygenaBon
• CirculaBonmanagement– ImprovecirculaBontoarea
• Offloading
• RevascularizaBon• Edemamanagement
![Page 18: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/18.jpg)
TreatmentopBons
• Reduce/eliminatecausaBvefactors– ManagementoffecalandurinaryinconBnence
• Useoffecalbags/condomcathetersorindwellingcathetersforshortperiodsofBme.
– PressureredistribuBon/reducBon– ControlfricBon/shear
![Page 19: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/19.jpg)
Treatment‐NutriBon
• Complexissue–lotsofconflicBngdataandlackofstrong(levelAandBevidence)tosupportspecificrecommendaBonsforsupplementaBon
• Albumin,TotalProtein,TotalLymphocyteCount,Pre‐albumin,Transferrinlevels.
![Page 20: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/20.jpg)
Treatment‐NutriBon
• Proteinrequirements– Healthyadult=0.8gmprotein/Kg/24hours– 1.5‐2.1gm/KgormorecouldberequireddependingonindividualmetabolicandclinicalcondiBon
• Micronutrients– Zinc,Copper,Iron,VitaminA,VitaminC,VitaminE,Arginine,Glutamine
• ConsultRD
![Page 21: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/21.jpg)
InfecBon
• Cultures–– Swabculturesmostfrequentlyused–theyreflectthesurfacecolonizaBonratherthaninfecBon.AHQRGuidelinerecommendsagainstusingswabculturestodefinemicrobiologyofapressureulcer.
– ForinfecBoncontrolpracBces,aswabculturemaybeusefulinidenBfyingpaBentscolonizedwithMRSAorotherresistantbacteria.
– BloodcultureordeepBssuebiopsycultureismoreclinicallysignificant.
– CulturingdeepBssuespecimensfromasurgicallycleanedanddebridedulceristhegoldstandardforwoundculture.
![Page 22: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/22.jpg)
ColonizaBonvsInfecBon
• Bothcandelay/impairhealing• SuperficialinfecBonislocalizedwithoutsystemicsigns,non‐healingulcer– Localwoundcare
• DebridementofnecroBcBssue
• Moistwounddressing• NutriBonalsupportandpressurereducBon
– TrialoftopicalanBbioBctoreducelocalbacterialcounts
![Page 23: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/23.jpg)
TopicalanBmicrobialagents
• Silversulfadiazine1%cream• CombinaBonanBbioBcointments• Silver‐containingdressings• Avoidcytotoxicagents– Hydrogenperoxide– Povidone‐iodine
• AHQRrecommends2weektrialoftopicalabxforcleanwoundsthatfailtohealaeer2‐4weeksofopBmalcare.
![Page 24: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/24.jpg)
DeepinfecBon
• CelluliBs–paBentswithneuropathymaynothavepain.Leukocytosisandfevermayormaynotbepresent.
• OsteomyeliBs–hasbeenreportedin17‐34%ofpaBents
• Bacteremia
• Basetreatmentonbacterialcultureswheneverpossible
![Page 25: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/25.jpg)
LocalCareofthewound
• TIME• T=Bssue(nonviable/deficient).– Debridement–episodicorconBnuous
• I=InfecBonorInflammaBon– Topicaland/orsystemicanBbioBcs
• M=moistureimbalance– Applymoisturebalancingdressings
• E=edge– EvaluateandcorrectimpedimentstoepithelialmigraBon
![Page 26: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/26.jpg)
Cleansing
• pHbalancedcleansers• Normalsaline
• Soapandwater• Psi
![Page 27: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/27.jpg)
Debridement
• EnzymaBc• Sharp/surgical• Mechanical
• Biologic
![Page 28: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/28.jpg)
Debridement
![Page 29: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/29.jpg)
Post‐debridement
![Page 30: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/30.jpg)
Debridement
TheimageaboveisacopyrightedproductofAACW(www.aawconline.org)andhasbeenreproducedwithpermission
![Page 31: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/31.jpg)
Moisturecontrol
• MaintainingappropriateamountofmoistureinwoundbediscriBcal.– toomoist=maceraBon/denuding,increasedbreakdown• Hydrofibers• Calciumalginates
• Foams• CombinaBonproducts
![Page 32: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/32.jpg)
Moisturecontrol
• Toodry=dessicaBon.DrywoundslackwoundfluidsthatprovidetheBssuegrowthfactorstofacilitatereepithelializaBon– Salinemoistenedgauze
– Transparentfilms– Hydrocolloids– Hydrogels
![Page 33: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/33.jpg)
Moisturecontrol
![Page 34: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/34.jpg)
Edges
• Examineedgesofthewound• Epibole=theupperedgesoftheepidermisrolltoenvelopthebasementmembraneorloweredgesoftheepidermissothatepithelialmigraBondoesnotoccuratwoundedges.
• TheedgescurlunderandepithelialmigraBonstops.
![Page 35: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/35.jpg)
Epibole
![Page 36: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/36.jpg)
Topicaltreatments
• Dressings– Films– Foams
– Hydrocolloids– Hydrogels– Hydrofibers– Composites
• Othertopicals– CollagenMatrix– Growthfactor– Xenaderm– Barriercreams
– Silverproducts– Honey
![Page 37: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/37.jpg)
TopicalTreatments
• Filmdressings–– willnotmanageexcessmoisture.Avoidusingifthereisanydrainagefromthewound.
– Douseifthewoundistoodry.– CancombinewithSantylointmenttohelpsoeeneschar
– Also,canapplyoverescharthathasbeencrosshatched.
![Page 38: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/38.jpg)
UseoffilmdressingforautolyBcdebridement
TheimageaboveisacopyrightedproductofAAWC(www.aawconlin.org)andhasbeenreproducedwithpermission.
![Page 39: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/39.jpg)
FoamsandHydrofibers
• UsewithwoundsthataremoreheavilyexudaBngtohelpwithmanagementofwoundfluid.
![Page 40: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/40.jpg)
HydrogelsandHydrocolloids
• UsefulinpromoBngautolyBcdebridementandaddingmoisturetoawound
TheimageaboveisacopyrightedproductofAAWC(www.aawconline.org)andhasbeenreproducedwithpermission.
![Page 41: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/41.jpg)
PainControlinchronicwounds
• Twotypesofpainassociatedwithopenwounds:– NocicepBvepainfromtheBssuedamagecreaBngthewound
– Neuropathicpainfromdamagedperipheralnervesatthesiteofthewound
![Page 42: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/42.jpg)
Painassessment
• The“usual”painassessmentwillhelpdeterminethemostappropriatetreatment– LocaBon– Timing– Severity– AggravaBng/alleviaBngfactors– Quality
![Page 43: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/43.jpg)
Topicaltreatmentofpain
• Dressingchoice–avoiddressingsthatadheretothewoundbedandinessencedomechanicaldebridementwitheverydressingchangeacausepain.– Protectskinsurroundingthewound– Premedicatewithsystemicpainmedpriortodressingchanges
![Page 44: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/44.jpg)
TopicalTreatmentsforpain
• TopicalmedicaBonpriortodebridement– EMLA(EuteBcMixtureofLocalAnestheBcs,2.5%lidocaineand2.5%prilocaine,AstraZeneca,Wilmington,Del)
– 2%Lidocainegel
![Page 45: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/45.jpg)
Topicaltreatmentsforpain
• Topicalopioids:– Morphineinawater‐basedgel
– Methadoneinaninertwoundpowder– TheusualconcentraBoninthestudiesis1%concentraBonoftheopioid.
– UseofpowderorgeldependsonthecondiBonofthewound.
• Foam/IbuprofencombinaBondressings.
![Page 46: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/46.jpg)
OthertreatmentmodaliBes
• NPWT• HyperbaricOxygentreatments
• Compression
• EsBmulaBon
• Ultrasound• ContactcasBng/offloading
• Maggottherapy
![Page 47: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/47.jpg)
TheaboveimagesarecopyrightedproductsofAAWC(www.aawconline.org)andarereproducedwithpermission.
![Page 48: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/48.jpg)
Complementary,alternaBveandintegraBvetherapy
• Accupuncture• Yoga/meditaBon• Biofeedback• Guidedimagery
• Massage• TherapeuBctouch
• Herbs/dietarysupplements
• Aromatherapy
• Exercise• EmoBonalhealth/stressmanagement
• Spiritualhealth
![Page 49: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/49.jpg)
Managingthehardtohealwound
• Assessment– Misseddiagnosis?
– CofactorscontribuBngtothelackofhealing• Woundfactors
– Edges– Base– Biofilm
– Localtreatment–appropriatechoice,beingdoneappropriately?
![Page 50: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/50.jpg)
Managinghardtohealwounds
• PaBentfactors– CooperaBng/parBcipaBngincare?(“compliant”)
– Illnessprogression– Mentalhealth/social/spiritual
• Establishgoalsforcare– Healing– Maintenance/palliaBon– Symptomcontrol
![Page 51: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/51.jpg)
Treatmentofhardtohealwounds
• AddresseBologyandcofactorsaffecBnghealingbasedongoalsoftreatment– Debride/cauterizeedgesofwoundifepibolepresent
– TreathypergranulaBon/exuberantgranulaBon– Treat/managebiofilminwoundbed– Treat/managelocalandsystemicinfecBon
– Treat/managesystemicillnessasable.
![Page 52: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/52.jpg)
HypergranulaBon
ImageaboveisacopyrightedproductofAAWC(aawconline.org)andhasbeenreproducedwithpermission
![Page 53: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/53.jpg)
ManaginglocalinfecBon/biofilm
• Topicalagents– Silversulfadiazine– TopicalanBbioBcs– Topicalsilver–hydrofiber,gels– Flagyl500mgtabcrushed,mixedinSantylointmentandapplieddailytotwicedailyfor7days*
*Note:thisisan“offlabeluse”ofFlagyl.WorkswellinwoundswithfoulodorindicaBnghighlocalbacterialcountinwoundbed
![Page 54: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/54.jpg)
Diphenylhydantoinsodium(phenytoin)
• Capacitytoaccelerateulcerhealingwasreportedover40yearsagoandhasbeenusedinmanydifferentkindsofwounds.
• PossiblemechanismsofacBon:– DecreaseinserumcorBcosteriod
– AcceleraBonofassemblyandpresenceofcollagenandfibrinintheulcerarea
– SBmulaBonofalkalinephosphatasesecreBon
![Page 55: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/55.jpg)
OthertreatmentopBonsunderstudy
• OralPentoxifyllinealongwithcompressiontotreaBngvenousulcers
• Effectsofstressresponse(epinepherine)andtheimpactonwoundhealing=AnewuseforBetablockertherapy?
![Page 56: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/56.jpg)
Assessforhealing
• PressureUlcerScaleforHealing(PUSH)• PressureSoreStatusTool(PSST)• SessingScale• WoundHealingScale.
![Page 57: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/57.jpg)
PressureUlcerScaleforHealing(PUSH)
• LengthxWidth(incm2)=scoreof0‐10(0cm2‐>24cm2)
• Exudateamount=scoreof0‐3(none,light,moderate,heavy)
• Tissuetype=scoreof0‐4(closed,epithelialBssue,granulaBonBssue,slough,necroBcBssue)
• Totalthe3sub‐scores.IfthetotalscoregoesdownoverBme,thewoundishealing.
![Page 58: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/58.jpg)
WoundsBllnothealing?
• Reassessgoalsofcare• Changethelocaltreatment
• Refertowoundcareclinic,vascularsurgeon,infecBousdiseasespecialist
![Page 59: Management of Chronic Difficult Wounds in the Long …enp-network.s3.amazonaws.com/Great_Lakes_GAPNA/… · · 2012-10-29– Describe treatment opons for managing chronic ... infecon](https://reader033.vdocuments.mx/reader033/viewer/2022051601/5ad7042e7f8b9af9068bb13a/html5/thumbnails/59.jpg)