Dressings and Decision Making in Wound Care PT 632

The ideal wound dressing has what 6 characteristics?

1. maintains a moist, clean, warm environment

2. removes exudate

3. is a barrier to external pathogens

4. easy application and painless removal

5. fills the cavity with no damage to perilesional tissues

6. ensures hydration and gas exchange

List the dressings 8 from most permeable to most occlusive

1. loosely woven gauze (most permeable)

2. finely woven gauze

3. calcium alginate

4. impregnated gauze

5. semipermeable film

6. semipermeable foam

7. hydrogels

8. hydrocolloids (most occlusive)

List the 9 dressings from leas absorptive to most absorptive

1. semipermeable film

2. hydrogel

3. pre-moistened hydrogel or alginate w/ saline

4. hydrocolloid

5. gauze

6. calcium alginate

7. hydrofiber

8. semipermeable foam

9. VAC/NPWT

What are the characteristics of permeable dressings? (3)

- allows for gas exchange to support cell metabolism and healing

- reduces risk of anaerobic infection because O2 is allowedin

- fully permeable to allow fluid to flow out

What are characteristics of occlusive dressings?

- maintain a moist environment with optimal temperature for autolytic debridement and facilitates healing

- protects against external contaminates

- can decrease pain by protecting nerve endings + wound bed

DO NOT USE WITH AN ACTIVE INFECTION! traps bacteria

What type of debridement is used for minimal necrotic tissue?

autolytics

What type of debridement is used for thin/mucinous necrotic tissue?

autolytic OR enzymatic (if theres an increase in amount/thickness)

What type of debridement is used for thick/fibrous necrotic tissue?

sharp (if adequate blood flow)

What wound dressing can be used for no necrotic tissue?

collagen donating dressing

If an infection is present, what 3 things must be considers regarding wound the use of wound dressings?

1. referral for culture and/or oral antibiotics

2. avoid occlusive dressings

3. consider antimicrobial agents/antimicrobial impregnated dressings

If a wound has exposure concerns, what are the options for covering?

hydrocolloid, semi-permeable film, or a composite dressing with an adhesive border

What are the selective types of debridement? (5)

- sharp

- enzymatic

- autolytic

- LFUS (mechanical debridement)

- biologic/maggots

What type of debridement is NOT selective? (2)

- surgical

- PLWS (mechanical debridement)

In the presence/prevention of an infection, avoid ______ and use _____

avoid OCCLUSIVE and use ANTI-MICROBIAL/SILVER dressings

To eliminate dead space....

fill the wound

With incontinence, you need to consider __________ of the dressing

consider the OCCLUSIVITY

In a wound with 100% granulation tissue/no necrotic tissue, consider the use of....

a collagen donating dressing

When considering the protection of the periwound, what should you keep in mind? (2)

- moisture barrier needed for mod/heavy drainage

- fragile skin and type of tape/adhesive secondary dressing

List the characteristics of aterial insufficiency ulcers using the 5PT method.

PAIN: significant pain + increases with elevation

POSITION: toes, foot, lateral malleolus, anterior leg

PRESENTATION: round, regular borders, pale granulation tissue, dry adherent slough, black eschar, may have dependent rubor

PERIWOUND: thin, shiny, hairless, pale, cyanotic, mm atrophy, dependent rubor

PULSE: decreased or absent

TEMPERATURE: cool to touch/diminished

What are the risk/pre-disposing factors for an AIU?

CVD risk factors:

- smoking

- diabetes

- HLD

- HTN

What is the pathophys/etiology of arterial insufficiency?

arterial insufficiency is often caused by atherosclerosis, other cause may be trauma/embolism/thromboangitis

ulcers often develops d/t trauma on the LE, emboli, distal lack of perfusion

Intermittent claudication is a characteristic of what type of ulcer? What else does it cause?

a AIU

can cause in night pain --> legs elevated --> REST PAIN (bad)

The medical management of AIU includes needing to know ABI to determine what? What numbers indicate what? What do you need to worry about with ABI values?

helps to determine diagnosis and severity

What are the PT management needs for AIU?

- address movement dysfunction

- patient education

- direct wound care

With direct wound care for AIUs, debridement may be contraindicated in the presence of....

DRY GANGRENE (d/t PAD with AIUs)

- not enough perfusion

-

What are examples of dressings that you may use for AIUs?

FOR OCCLUSIVITY:

- semipermeable film, semipermeable foam, hydrogel, hydrocolloid

FOR ADDING MOISTURE:

- hydrogel, pre-moistened hydrogels or alginate w/ saline

Explain the characteristics of VIUs using the 5PT method.

PAIN: significant, decreases with elevation

POSITION: lower leg, medial malleolus, areas of trauma

PRESENTATION: large amounts of exudate, irregular wound edges, red ruddy granulation tissue

PERIWOUND: edema, hemosiderin staining**, cellulitis, lipodermatosclerosis

PULSE: normal or decreased d/t edema or AI

TEMPERATURE: normal to mild warmth

What are the risk/predisposing factors for VIUs?

- LE edema

- hx of DVT/varicose veins

- immobility/prolonged standing

- obesity

- heart failure

- advanced age

What is the pathophys/etiology of VIUs?

sustained venous HTN and incompetent valves

- typically develop d/t minor trauma like a bug bite or scratch

Medical management for VIUs include... (2)

- venous ablation (surgical consult needed)

- management of contributing conditions like DM, CHF, AI

What is the PT management needs to for movement dysfunction with VIUs?

to maximize mobility and independence AND exercise for the mm pump with short-stretch bandages donned

What is the PT management needs for patient education with VIUs?

NEED for adherence to long term compression and to elevate the LEs

Regarding wound care for VIUs, what is he most important thing to provide? What ABI values correspond to this?

need to provide COMPRESSION to control edema

What type of dressings may be used for VIUs?

absorptive dressings, need to also protect the periwound d/t the excessive drainage

debride as needed (may need to use PLWS, LFUS, e-stim (>30 days), and NPWT)

Explain the characteristics of a neuropathic ulcer using the 5PT method.

PAIN: absent or little pain

POSITION: hallux, MT heads, lateral midfoot, areas of pressure

PRESENTATION: round/oval, callus rim, necrotic base uncommon, low exudate (can vary)

PERIWOUND: dry, cracked, callus

PULSES: diminished or absent (unreliable ABIs)

TEMPERATURE: warm with edema with autonomic dysfxn, decreased temperature if PAD

What are risk/predisposing factors of neuropathic ulcers?

DMI/II, poor glucose control, neuropathy, loss of protective sensation, CKD, charcot foot deformity

What is the pathophys/etiology of neuropathic ulcers?

caused by neuropathy d/t motor, sensory, and autonomic changes

- callus forms --> turns into ulcer --> poor healing d/t poor blood flow and immune fxn

What standardized scale do you use to classify neuropathic ulcers?

the Wagner 0-5 scale

0: pre-ulcerative lesion

1: superficial ulcer localized to skin

2: deep ulcer to subcut. layer

3: deep ulcer through subcut. layer (OSTEOMYELITIS RISK!! sepsis, abscess)

4: partial gangrene effecting foot

5: gangrene of entire foot

What medical management is needed for neuropathic ulcers?

- diabetes management/medications

- blood glucose control, NEED A1C

What movement dysfunction needs to be addressed by the PT with neuropathic ulcers?

need to maximize mobility and independence

- decreased balance + foot/ankle ROM

- need physical activity to prevent diabetic complication

- need gait training to decreased WB for plantar ulcer

What patient education is need for neuropathic ulcers?

- proper glucose control

- importance of adherence to offloading/WBing recommendations

What is the best way for direct wound care with neuropathic ulcers? (5)

NEED OFFLOADING!

- total contact cast is the gold standard (can also use CROW boot, CAM boot, walker, etc)

- saucerization

- dressing depends on necrotic tissue/drainage (granulation tissue can use collagen dressing)

- debridement as needed (may use PLWS, LFUS, e-stim (>30 days), NPWT)

Explain the characteristics of a pressure injury using the 5PT method.

PAIN: varied, often deceased sensation

POSITION: sacrum, GT, ischial tub, heels, lateral malleoli, (any area of pressure)

PRESENTATION: round, cater-like, tunneling/undermining, mod/heavy drainage, slough + eschar common

PERIWOUND: can be macerated, rolled (epibole), hyperkeratosis

PULSES: normal

TEMPERATURE: increased

What are the risk/predisposing factors for pressure injures?

- braden score

What is the pathphys/etiology of pressure injuries?

pressure (localized area of tissue compression between a firm surface and bony prominence)

stage them I-IV (no reverse staging)

What movement dysfunction needs to be addressed with pressure injures?

PRESSURE RELIEF! (evaluate proper support with cushions + mattresses)

What patient education needs to be addressed for an individual with a pressure injury?

- the need for consistent pressure relief

- protection to prvent a pressure injury in other areas

For a pressure injury, what type of dressing are you likely to use?

- HIGH ABOSPRTIVE DRESSING

- HIGH IN OCCLUSION like a semipermeable foam or wound vac (will likely need to protect wound from incontinence use, moisture barrier)

- may need PFWS, LFUS e-stim (stage III/IV OR >30 days), or NPWT