wound breakdown, fungating lesions, pressure sores, fistulae rebecca owen
TRANSCRIPT
Wound Breakdown, Fungating Lesions, Pressure Sores, Fistulae
Rebecca Owen
Objectives Stages of Wound Healing
Fungating Lesions overview
Types of wound + dressing suggestions
Pressure Sores – common areas and treatment pathway
Fistulae overview
Summary
Stages of Wound Healing Haemostasis
Clotting cascade
Inflammatory Bacteria and debris phagocytosed and removed Release of factors causing migration +
proliferation
Proliferative Angiogenesis, collagen deposition, granulation
tissue formation, epithelialisation, wound contraction
Remodelling Collagen remodelled and realigned along tension
lines and unneeded cells removed by apoptosis
Wound Healing Phases
Wound Healing – Primary Intention “Involves epidermis and dermis
without total penetration of dermis healing by process of epithelialization”
When wound edges are brought together so that they are adjacent to each other (re-approximated)
Minimizes scarring Most surgical wounds Wound closure is performed with sutures (stitches),
staples, or adhesive tape Examples: well-repaired lacerations,well reduced
bone fractures,healing after flap surgery
Wound Healing – Secondary Intention
The wound is allowed to granulate Granulation results in a broader scar Healing process can be slow due to
presence of drainage from infection Wound care must be performed daily to
encourage wound debris removal to allow for granulation tissue formation
Surgeon may pack the wound with a gauze or use a drainage system
examples:gingivectomy,gingivoplasty,tooth extraction sockets, poorly reduced fractures.
Wound Healing – Tertiary Intention
(Delayed primary closure or secondary suture):
The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure.
The wound is purposely left open examples:healing of wounds by use of tissue
grafts.
Fungating Lesions Can be associated with
Pain Pruritis Exudate Malodour Bleeding Infection
Consider topical morphine, NSAIDs (pruritis), abx,
Treat exudate + infection with appropriate dressing
Fungating Lesions
Malodour Clense and debride surface Topical/systemic metronidazole Live Yoghurt (topically) Manuka Honey (Activon) (topically) Mask odour with camphor, herbs,incense
Psychological Support
Skin Tear
Occurs when friction + shearing forces cause tissue layers to slide across each other breaking blood vessels
Caused by sliding patients in bed,agitated patients moving in bed, removal of adhesive dressings
Skin Tear Management
Remove dressings using “lateral pull” technique
Mepitel dressing + dry gauze Change Mepitel every 5-7 days Change gauze when saturated
Wet Wound with Granulating Tissue
Aims Minimise dressing changes Relieve the pressure that caused the ulcer If increasing exudate then consider infection Maximise nutrition and hydration
Suggested dressing – Aquacel Place sheets in wound bed and cover with dry
dressing Cover dressing depends on wetness
Daily – Gauze; 2-3/7 – Alldress, 3-5/7 – Allevyn/Mepilex
Multiple layers of aquacel can minimise dressing changes
Change Aquacel when it has turned into a gel
Cellulitis Local infection of dermis and
subcutaneous tissue characterised by spreading redness, pain and swelling.
Monitor demarcation by marking and dating the skin
Consider systemic/topical antibiotics Use Mepitel on wound bed to reduce
surface pain Change every 7/7 or PRN
Sacral Ulcer
Remove/prevent pressure on area Observe for infection If problems with incontinence –
consider barrier cream i.e. Cavilon Sacral Shaped Tegasorb – dressing
of choice
Fold sacral dressing in half Pinch the fold to form a crease "Bookmarking"
Peel off the entire backing
Insert "bookmark" into the patient's fold, above the rectum and secure the dressing up the middle
Secure the dressing out the sides using the heat of your hand and slight
pressure to help it adhere
Slowly peel away the border while securing the tegaderm with your fingers
Applying a Sacral dressing
Clean Wound with Granulating Tissue
Remove/prevent pressure on affected area
Maximise nutrition and hydration Sugessted foam dressing such as
Mepilex Dressings can remain on wound for
7/7
Wound with Yellow Slough Stage X as wound bed cannot be visualised Pain management with dressing changes
2 options of treatment: Option 1 - cut silver dressing, such as Acticoat to fit into the
wound bed and moisten with sterile water. Cover with a light dressing (gauze and tape or “island dressing” such as Alldress). Ensure daily that Acticoat dressing is moist. Change Acticoat 3/7.
Option 2 - Spread a thin layer of Iodosorb on a gauze and place in wound bed.Cover with island dressing (such as Alldress) or foam. Change dressing q 3 days, when Iodasorb changes to a creamy colour.
(NB) make sure patient doesn’t have thryroid issues—Iodosorb has iodine & contraindicated if thyroid condition or breast-feeding mother).
Diabetic/Neuropathic Ulcer Most common on plantar aspect of
foot,heels and over metatarsal heads Dry,warm, cracked, fissured skin,
thickened nails Usually no oedema/exudate Causes – peripheral neuropathy,arterial
insufficiency, poor microvascular circulation, inadequate blood glucose control
Treatment – debridement plus mepilex/Allevyn + Intrasite gel
Pressure Sores
Several factors that increase risk of developing a pressure sore: Mobility problems Poor nutrition Underlying health condition Age >70 yrs Urinary &/or bowel incontinence Serious mental health conditions
Treatment of Pressure Sores Changing position Mattresses and cushions Dressings Creams and ointments Antibiotics Nutrition Debridement Maggot therapy Surgery
Fistulae Abnormal communication between 2
hollow organs or between a hollow organ and the skin
Aetiology Anastomotic leaks Trauma - often iatrogenic post surgery Inflammatory bowel disease Malignancy Radiotherapy
Fistulae Types Rectovaginal/Rectovesical fistulas
Conservative/Surgical
Enterocutaneous fistulas Simple
Single orifice with intact abdominal wall Multiple
Multiple orifices in abdominal wall Disrupted
Fistula caused by dehiscence or surgical wound/scar
Imaging Important to determine anatomy of
fistula
Fistulography will define tract
Small bowel or barium enema will define state of intestine or distal obstruction
US and CT will define abscess cavities
Management of Fistulae• Usually conservative management - at least initially
- consisting of:• Skin protection
• Upper GI contents are very corrosive
• Correction of fluid and electrolyte loss• Require careful fluid balance & restoration of blood
volume
• Correction of acid-base imbalance• H2 Antagonist, proton pump inhibitor to reduce gastric
secretions• Somatostatin analogues (e.g. Octreotide) to reduce GI and
pancreatic secretions
Management of Fistulae Tissue viability review Nutritional support
Restrict oral intake and possibly an nasogastric tube Malnutrition corrected with either parenteral or enteral
nutrition Total parenteral nutrition given via Dacron-cuffed
tunneled feeding line Radiological screening to ensure tube in correct site Enteral nutrition can be given distal to fistula
Control of sepsis Abscess cavities should be drained Antibiotics
Enterocutaneous fistulas will not close if: There is total discontinuity of bowel
ends There is distal obstruction Chronic abscess cavity exists around
the site of the leak Mucocutaneous continuity has occurred
Fistulas are less likely to close if: They arise from disease intestine (e.g.
Crohn's Disease) They are end fistulae The patient is malnourished They are internal fistulas
60% will close in one month once sepsis has been controlled with conservative treatment
Mortality associated with fistula is still at least 10%
Surgery should be considered if fistula does not close by 30-40 days
Summary Fully assess area and cleanse thoroughly
Use appropriate dressing – if in doubt ask
Treat malodour
Be aware need of ongoing psychological support
Any Questions?
References Symptom Management in Advanced Cancer; (2009) Twycross,
Wilcock, Toller. http://www.google.co.uk/imgres?imgurl=http://
www.lhsc.on.ca/Health_Professionals/Wound_Care/ Blowers A L Irving M. Enterocutaneous fistulas. Surgery
1992; 10.2: 27 – 31 Dubrick S J, Maharaj A R, McKelvey A A. Artificial nutritional
support in patients with gastrointestinal fistulas. World J Surg 1999; 23: 570-576.
Mcintyre P B. Management of enterocutaneous fistulas: a review of 132 cases. Br J Surg 1984; 71: 293 -296.