NRSG 301: complex dressings irrigation and packing

category 1 pressure ulcer

- non-blanchable erythema of intact skin

- discoloration of skin, warmth, or hardness also may be indicators

category 2 pressure ulcer

- partial thickness skin loss involving epidermis and/or dermis

- presents as an abrasion, blister or shallow crater

category 3 pressure ulcer

full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

category 4 pressure ulcer

full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (tendon, joint capsule)

category x or n

unable to determine depth of the wound due to the presence of thick eschar

suspected deep tissue and injury

- usually intact skin

- purple or maroon localized area of discoloured intact skin or blood-filled blister that indicates DEEP tissue damage

- painful; firm or mushy/boggy

- can deteriote rapidly

category 1 treatment

- relieve pressure

- protect (barrier creams)

- prevent from becoming worse

category 2 treatment

- relieve pressure

- no dressing (barrier cream)

- dressing to absorb drainage

- debride slough if present

- protect

category 3 treatment/category 4 treatment

- relieve pressure

- debride slough/eschar if present

- pack sinus tracts and undermining if present

- dressing to absorb drainage

- decrease bacterial colonization

- protect

category x treatment

- surgical debridement to remove eschar

- if non-surgical, keep dry, and prevent infection

products used:

- iodine swab or liquid with cotton swab

- iodasorb ointment

- inadine (antimicrobial povidone impregnated guaze)

SDTI pressure ulcer treatment

- depends on presentation and when/if wound becomes open

- may become stage III or IV ulcer

- air-fluidized therapy

- non-contact low frequency ultrasound therapy

wound irrigation

application of fluid to a wound to remove exudate, debris, bacterial contaminants and dressing residue without adversely impacting celllular activity to the wound healing process

irrigation fluids

- sterile normal saline

- sterile water

- potable water

- commercial cleansing agent

- topical antiseptic agents

fluid should be at room temperature. if fluid needs to be warmed to meet client needs, using a bowl of warm water is preferred

why is packing used in a wound?

- packing material absorbs any drainage from the wound, which allows for faster healing from the inside out

- packing material also protects the wound

- without the packing, the wound might close at the top, without healing at the deeper areas of the wound

- wound needs to heal from the bottom upwards

sinus tract/tunneling

a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation

undermining in a wound

wounds that extend into the subcutaneous tissue under the skin

- because the undermining extends under the skin, the actual amount of damaged tissue is much bigger than it appears by just looking at the surface of the wound

causes of undermining

- infection

- pressure ulcers due to lack of blood flow and pressure being applied to the wound

- improper wound treatment such as allowing the wound to become dried out or dehydrated

V. A. C. therapy

- a non-invasive, active therapy combining localized negative pressure and moist wound healing to promote wound healing

- what does V. A. C. stand for?

V. A. C. therapy indications

- acute/traumatic wounds

- abdominal wounds

- cardiothoracic wounds

- orthopedic wounds

- chronic wounds (eg. ulcers)

- burns

benefits of V. A. C. therapy

- improved wound bed preparation and enhanced granulation tissue growth

- removal of excess interstitial fluid

- increased local vascularity

- decreased bacterial colonization

- accurate wound drainage assessment

- maintenance of moist wound environment

- increased rate of epithelialization

- cost-effective

V. A. C. therapy contraindications

- insufficient vascularity

- necrotic wounds

- untreated osteomyelitis

- malignancy in the wound

- wound bed more than 20-25% non-viable tissue

- sinus tracts unexplored or un-packable

- fistula: unexplored enteric or non-enteric

- allergy to dressing supplies

- high risk for bleeding

V. A. C. therapy complications

- infection/sepsis

- foam retention in wound

- tissue adherence

- bleeding

- pain

wound care products

a) non-adherent

b) absorbant

c) antimicrobial

d) debridement

e) hydrocolloids

f) gels/hydrogels

g) bleeding wound

h) gauze dressings

i) occlusive/transparent film dressings

j) odour control

non-adherent

a) mepitel

b) adaptic

c) allevyn

d) alldress

e) inadine

f) restore Ag

g) iodasorb

mepitel

silicone layer

adaptic

cellulose acetate fabric impregnated with petroleum

allevyn

hydrocellular foam dressing

alldress

composite dressing

inadine

viscose fabric impregnated with iodine

restore Ag

fine polyester mesh and petroleum-based formula with silver layer

iodasorb

cadesomer iodine ointment

absorbant

a) allevyn with mepilex border

b) nuderm alginate

c) aguacel

d) silvercel

e) mesalt

f) mesorb

g) gauze

allevyn with mepilex border

hydrocellular foam dressing/non-adherent

nuderm alginate

calcium alginate (made from seaweed; has hemostatic properties)

aguacel

hydrofiber (carboxymethylcellulose fibers)

silvercel

fine polyseter mesh and petroleum-based formula with silver

mesalt

hypertonic guaze (salt-impregnated gauze)

mesorb

absorant material/fluid-repelling backing

gauze

cotton fabric

antimicrobial

a) silvercel or seasorb

b) aquacel Ag

c) acticoat flex 3 or 7

d) restore

e) inadine

f) povidine-iodine solution

g) iodasorb

silvercel or seasorb AG

calcium alginate with silver

aquacel Ag

hydrofiber with silver

acticoat flex 3 or 7

knitted polyester with silver

restore

fine polyester mesh and petroleum-based formula with silver layer

inadine (antimicrobial)

viscose fabric impregnated with iodine

iodasorb (antimicrobial)

cadesomer iodine ointment

debridement

- hypertonic gauze

- iodasorb ointment

- gels

- moistened hydrofiber or calcium alginate

hydrocolloids (absorbs only small amount)

nuderm or tegaderm hydrocolloid

gels/hydrogels

gels (eg. intrasite gel)

bleeding wound

calcium alginate

gauze dressings

- gauze packing

- mepore strip dressing

- gauze roll - cotton

occlusive/transparent film dressings

tegaderm IV

odour control

activated charcoal dressing

how do you choose an appropriate wound care product based on wound assessment?

1. is the wound healable?

2. is the wound flat or deep?

3. do you need to add moisture or remove moisture

4. are there signs of infection or bacterial colonization? if so, do you need an antimicrobial?

5. what is the main colour of the wound? (red/yellow/back)