Integumentary - Complex Wounds/Pressure Injuries, Wound Vac, Necrotizing Fascitis, FMS, IV therapy

complex wounds/pressure injuries - what are they?

• complex wounds - wounds that are usually accompanied by comorbidities that complicate healing (such as diabetes, peripheral vascular disease, infections, immune deficiency, poor nutritional status, and burns)

• pressure injury - a localized damage to the skin and underlying soft tissue; usually occurs over a bony prominence and/or is related to improper use of a medical device, such as a tube securement or SCD tubing; a pressure injury may be present with either intact skin or an open ulcer; pain may or may not be present (THEY ARE PREVENTABLE IN MOST CASES!!!)

Pressure injury - PREVENTION

• look for presence of PI upon admission and assess skin surfaces each shift (NOTE THAT NOT ALL WOUNDS ARE DUE TO PRESSURE!!)

• identify high-risk patients with the use of a valid risk assessment tool (Braden Scale or Norton Scale) and those with known risk factors for developing a PI (low body weight, poor nutritional status, inadequate hydration, decreased perfusion, immobility, and/or hypoxemia)

• use strategies to prevent pressure injuries and maintain skin integrity:

  • reposition!!! OFF-LOAD BONY PROMINENCES and lines/tubes

  • use lateral transfer devices rather than pull sheets in order to prevent shearing/friction when moving,

  • moisturize the skin/use skin barriers/protect skin from incontinence

  • maintain clean/dry skin,

  • use paper tape for fragile skin,

  • provide nutritional support;

  • provide special pressure-redistributing surfaces (including mattresses, mattress overlays, and seat cushions);

  • AVOID USE OF DIAPERS, which cause dermatitis in adult patients; use absorbent bed padding instead!!

Pressure Injury - ASSESSMENT (Stages)

• Stage 1 - intact skin with redness of a localized area

• Stage 2 - partial thickness skin loss with exposed dermis; wound bed is PINK or RED and moist and may appear as a blister

• Stage 3 - FULL THICKNESS skin loss; subcutaneous fat is visible

• Stage 4 - FULL THICKNESS SKIN LOSS WITH EXPOSED or DIRECTLY PALPABLE FASCIA, BONE, TENDON, LIGAMENT, or MUSCLE; slough or eschar may be present

• UNSTAGEABLE - PI may be in this classification if there is full thickness skin loss and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; if slough/eschar is removed, the wound may then be classified as Stage 1, 2, 3, or 4

Pressure Injury - TREATMENT

• as soon as identified, notify the provider to discuss a detailed treatment plan; request wound care consult, if available; treatment based on assessment of patient/PI

• keep affected area clean/dry

• provide pressure relief over bony prominences by utilized pressure-reducing surfaces, repositioning the patient at LEAST every 2 hours (even when using pressure-reducing surfaces), and keeping the HOB at 30 degrees while the patient is side-lying

• perform wound debridement to support healing; examples of wound debridement include:

  • enzymatic debridement using proteolytic enzymes

  • nonselective mechanical debridement (whirlpool treatments, forceful irrigation, or wet-to-dry dressings)

  • surgical debridement

• apply dressings as indicated (the type of dressing depends upon the wound assessment)

• ensure adequate nutrition

• apply antibiotic ointment as indicated

• initiate and care for a wound VAC system, if one is ordered by the provider

Negative-Pressure Wound Therapy (Wound Vac Therapy) - what is it?

• wound vac therapy is used for acute or chronic complex wounds (such as diabetic ulcers, surgical wounds, or burns)

• a sealed wound dressing is placed over the wound and connected to a vacuum pump, which provides continuous or intermittent negative pressure (-75 mmHg to -125 mmHg)

  • the continued application of negative pressure promotes healing by increasing blood flow to the area

• this type of therapy is usually applied by a provider or a wound care nurse and is maintained by an acute/critical care nurse

Wound VAC Therapy - MANAGEMENT

• address alarms that may be caused by a full canister, an air leak in the system, a low battery, or blocked or dislodged tubing

• change the evacuation canister when it is full, if there are signs of damage, and according to manufacturer recommendations (generally once per week)

• do NOT allow the therapy to be interrupted for longer than 2 hours; a longer interruption puts the patient at a greater risk for infection

  • if the therapy needs to be interrupted for longer than 2 hours, replace the dressing with a wet-to-damp dressing until the therapy can be resumed

• report any bleeding to the provider

Necrotizing Fasciitis - what is it? causative organisms?

• a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues; early identification of and treatment for this infection are the keys to decreasing morbidity and mortality

  • CAUSATIVE ORGANISMS: group A Streptococcus, Clostridial myonecrosis (gas gangrene), salt water that contains a Vibrio species, or multiple organisms may be the cause; at times, the cause of it may be unknown

Necrotizing Fasciitis - RISK FACTORS? Signs/Symptoms?

• Risk factors - presence of open skin (such as site of an injection, abrasion, insect bite, or surgical procedure), more often seen in those who are immunocompromised, such as those with diabetes, cancer, alcoholism, vascular insufficiency, organ transplants, HIV infection, or neutropenia

• Signs/Symptoms - intense pain over involved skin and underlying muscle, minor redness, infection quickly spreading out onto normal skin, developing dusky or purplish discoloration, and necrosis; subsequent systemic signs of an infection (such as a fever and malaise) will occur (MAY PROGRESS TO SEPTIC SHOCK, MODS, and/or LIMB LOSS)

Necrotizing Fasciitis - TREATMENT

• SURGICAL EMERGENCY!! (early and aggressive implementation of a regimen of surgical debridement (until the spread of necrosis is resolved) is associated with a decrease in morbidity/mortality; however, patient may require surgical reconstitution

  • treat hemodynamic instability with fluids/pressors

  • provide antibiotic therapy (that will initially be empiric, but will subsequently be guided by the blood culture results)

  • provide nutritional support to address the catabolism that is caused by large necrotic wounds

  • consider using hyperbaric oxygen and IV immunoglobulin for select cases

Fecal Management System (FMS) - what is it?

• FMS is used for a patient with involuntary, liquid diarrhea in order to prevent skin excoriation and breakdown and to prevent contamination of a surgical site, wounds, or invasive lines

• an internal device is inserted into the rectum and is held in place by a balloon catheter; the balloon is then inflated, and the device is flushed as directed by the manufacturer

  • a provider order is needed to use an internal device

  • an internal FMS is CONTRAINDICATED for patients with rectal injury, patients with recent lower large bowel surgery, fecal impaction, and severe hemorrhoids or formed stool

• an external device is applied externally around the anus

  • external device is indicated when internal device cannot be used; do NOT apply over excoriated skin

• provide frequent monitoring of device patency, stool quality/amount, and condition of the skin

Management of IV Therapy - INFILTRATION

• the inadvertent infusion of a medication or solution into the surrounding tissue rather than into the intended vascular system; medication or solution may OR may not be a vesicant

• STOP INFUSION!!

• assess/document infiltration using infiltration scale:

  • 0 = no symptoms

  • 1 = blanched skin, edema < 1 inch in any direction

  • 2 = blanched skin, edema 1-6 inches in any direction

  • 3 = blanched and translucent skin, edema > 6 inches in any direction; possible numbness

  • 4 = blanched and translucent skin, tight skin that’s leaking fluid, deep pitting edema, moderate to severe pain; NOTE: an extravasation of blood product, irritant, or vesicant is a grade 4 infiltration, REGARDLESS of site assessment

• if infiltration occurs, elevate extremity and apply a warm, moist compress, or provide whatever treatment is indicated for that specific type of irritant/vesicant

• reinsert the IV using opposite extremity

Management of IV Therapy - Phlebitis

• a venous inflammatory reaction that is caused by an irritant drug or mechanical device and results in a local inflammatory reaction such as redness, red streaks, pain, burning, or swelling

  • use strategies to prevent phlebitis: use smallest gauge catheter indicated, avoid placing catheter near joints or vein valves, use more diluted agent if indicated, use a central line for medications known to have a high osmolality or low pH

• STOP INFUSION and elevate extremity

• attempt to identify cause of reaction and address as able; restart IV

Management of IV Therapy - EXTRAVASATION

• an INFILTRATION of a VESICANT drug that may cause severe and/or irreversible tissue injury and necrosis; this may result in blisters, pain, tissue sloughing, a loss of mobility, and/or an infection

  • more serious cases require surgery

• consult pharmacist/hospital procedures to determine which drugs are vesicants, since there are MANY agents used that are non-cytotoxic agents that will cause tissue damage, and determine:

  • whether an antidote is available

  • whether warm or cold compresses are indicated and the frequency/duration of application

    • most vesicant agents are treated with cold compresses, although warm compresses are indicated when the antidote hyaluronidase is used or when phentolamine (Regitine) is used; always double check!

• provide antidote, as indicated, AS SOON AS POSSIBLE!!

• examples of antidotes:

  • hyaluronidase (used for non-cytotoxic agent extravasations (amiodarone, calcium gluconate, mannitol) OR for cytotoxic extravasations (teniposide)

  • phentolamine (Regitine), terbutaline, or 2% nitroglycerin ointment (used for vasopressor extravasations (such as norepinephrine, dopamine))