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ADVANCED TOPICAL WOUND CARE by Megan Leach, BSN, RN, CWOCN

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ADVANCED TOPICAL WOUND CARE by Megan Leach, BSN, RN, CWOCN 2/17/2020 ADVANCED TOPICAL WOUND CARE By Megan Leach, BSN, RN, CWOCN Disclosure Statement • Presenter has no financial disclosure. • I mention brand names of products, however this does not imply an endorsement by myself or UAB of any particular brand. These products are simply the items on our formulary at this time based on multiple factors including contracts & pricing. • All product and company names are trademarks™ or registered® trademarks of their respective holders. Use of them does not imply any affiliation with or endorsement by them. Objectives • Participant will be able to describe advanced solutions for use with Wet to Wet dressings. • Participant will be able to choose between topical antifungal therapies for management of Perineal Candidiasis and Intertriginous Candidiasis • Participant will be able to describe topical options for debridement, mechanism of action, advantages/disadvantages • Participant will be able to describe options for wicking fluid from tunnels • Participant will be able to describe packing options for infected surgical incisions s/p debridement 1 2/17/2020 What is a CWOCN? • Certified Wound, Ostomy, and Continence Nurse • Specialty Nurse trained in the assessment and management of wounds, ostomies, and incontinence conditions. • Requirements: • RN Licensure with > 1 year clinical experience post licensure • Current, clinical nursing experience OR proof of an acceptable nurse refresher course OR proof of a clinical performance examination • Bachelors Degree or Higher • Completed one of the following education/practice pathways • Graduate from an accredited WOC (or WCET international) Nursing Education Program for each desired specialty • Complete 50 CE/CME credits (or an equivalent in college course work) for each certification specialty as well as 1500 direct patient clinical hours • Pass Board Certification for each specialty Brief Overview of Tissue & Wound Types Tissue Types Slough Eschar Ecchymosis Granulation Mucus Membrane 2 2/17/2020 Pressure Ulcer Stages • Pressure ulcers typically either have round wound edges (not irregular), or they match a device imprint • They are located over boney prominences or beneath devices. • Important to pad at risk sites during surgeries (Silicone Adhesive Foam/gel cushions), be aware of OR surface (gel pad), and positioning. Pressure Ulcers: Suspected Deep Tissue Injury • Area of ecchymosis resulting from tissue damage caused by pressure. • For sites ABOVE THE KNEE: Usual first line of defense is to start trypsin‐balsum of peru‐castor oil (Venelex) Q12hrs.This increases circulation to the area. • For sites BELOW THE KNEE: Paint with Betadine Solution and leave open to air. Will help to maintain dry stable wound bed while also helping to reduce bioburden. DO NOT use Betadine Ointment –this is not the same product (it a gel‐like consistency and will add moisture to the wound bed rather than keeping the site dry)! • Do NOT cover with occlusive dressings • Turn side to side or offload injured area. • These wounds typically evolve to a Stage III, IV, or Unstageable. At which time topical wound care should be adjusted accordingly. Moisture Associated Skin Damage • MASD: Skin breakdown d/t moisture (perspiration/exudate). Seen below with trapping within folds. • Yeast: Red maculopapular rash with satellite lesions. May present as grey flaking rash in darker skin tones. • Fissure: Linear crack in the skin. Often seen in the base of a skin fold d/t moisture trapping. MASD with Yeast MASD MASD with Fissure 3 2/17/2020 Incontinence Associated Dermatitis, Yeast • IAD: Skin breakdown d/t exposure to urine/stool. • Yeast: Red maculopapular rash with satellite lesions. May present as grey flaking rash in darker skin tones. IF with skin loss, may have rounded edges. IAD IAD with Yeast Yeast Dressings/Pastes/Ointments Pastes/Powders/Creams How to Choose??? Antifungals: • Nystatin/Miconazole Powder: Can use for crusting yeast to peristomal/perifistular/periwound skin. ‐ ex) Perineal Yeast in a CONTINENT patient. ‐ IF treating yeast to skin fold order Interdry Ag instead! Powder clumps up in fold as it absorbs moisture (sweat/drainage) & will compound the problem. • Nystatin Cream: Thin cream that comes in tiny tube (infant size) ‐ ex) Infant Perineal Yeast (our tube is too small to be practical for adults) ‐ IF treating yeast to skin fold order Interdry Ag instead! Cream will add moisture to fold and compound the problem. • Miconazole 2% Cream: • Miconazole 2% PASTE: Antifungal barrier paste (THICK) ‐ ex) IAD with Yeast, Perineal Yeast in an INCONTINENT patient 4 2/17/2020 Pastes/Powders/Creams How to Choose??? Barrier Products: • Barrier Cream: Petrolatum/Emollient based barrier creams (THIN) ‐ ex) Prevention of IAD • Zinc/Dimethicone Barrier Spray: ‐ ex) Prevention of IAD, Treatment of IAD • Barrier Paste: Zinc barrier pastes (THICK) ‐ ex) incontinence with superficial wound depth –MASD, IAD, Friction/Shear, Stage I, II, Unstageable (with limited depth). • Hydrophillic Wound Paste: zinc‐oxide based hydrophilic paste for light‐to‐ moderate levels of wound exudates. Helps maintain an optimal wound healing environment and facilitates natural autolytic debridement. ‐ ex) incontinence with superficial wound depth in which there is difficulty with Barrier Paste adherence –MASD, IAD, Friction/Shear, Stage I, II, Unstageable (with limited depth). Antimicrobial Wicking Material • For use to treat yeast, superficial wounds, and provide moisture management within skin folds/beneath devices/etc. • Moisture wicking fabric with antimicrobial silver. • Reduces friction between skin folds • Silver – Antimicrobial, reduces itching and odor caused by bacteria. • Ex) Interdry Ag • Use: Cut Interdry Ag so that at least 2 inches of fabric is exposed beyond folds to wick moisture. DO NOT USE CREAMS, POWDERS, OR OINTMENTS with Interdry and use only 1 layer of fabric. Replace fabric every 5 days or if visibly soiled. Assess skin daily. Antimicrobial Hydrogel Gauze • Silver, Alginate, and Maltodextrin. Woven gauze –does not lint or fray. • Provides sustained broad antimicrobial coverage for up to 7 days. • Inhibits bacterial cell division which prevents development of resistance. • Promotes autolytic debridement • Decreases wound odor • Adds some moisture to dry wounds, but not appropriate for most completely dry wound beds. • Ex) Algidex Ag 5 2/17/2020 Antimicrobial Hydrofiber • Gelling dressing • Conforms to wound bed to reduce dead space in which microorganisms can grow. • Locks in exudate to minimize maceration –material develops gell‐like texture when wet • Locks in bacteria to minimize cross infection • Promotes a moist wound heling environment • Helps decrease pain with dressing changes. • Ex) Aquacel Ag Advantage • Advantage Technology: • Ethylenediaminetetraacetic Acid (EDTA) –improves the transfer of silver from the dressing to microorganisms. Helps to break up biofilm and prevent formation/reformation. • Ionic Silver –Provides sustained broad antimicrobial coverage to kill microorganisms within the dressing for up to 7 days. • Benzethonium chloride (BEC) – Surfactant that reduces the surface tension of biofilm and exudate. This reduced surface tension increases the mobility of the EDTA and Ionic Silver improving the efficiency of the antimicrobial activity. Hydrophobic Gauze • Hydrophobic dressing that irreversibly binds to microorganisms within the wound bed which are then physically removed with each dressing change. • Effective against all bacteria and fungi (they are all also hydrophobic and bind through principle of hydrophobic interaction). • No bacterial resistance (no antibiotic/antiseptic substances used) • Does not kill bacteria, thus there are no bacterial endotoxins released from dead bacteria. • Non cytotoxic • No risk of allergies • No contraindications –safe for use during pregnancy, while breast feeding, and on children. • Ex) Cutimed Sorbact Hypochlorous Acid Examples: Vashe & Puracyn Vashe Puracyn • pH 3.5 –6.75 per MSDS • pH 6.2‐7.2 per MSDS • Contains the highest concentration of • Solution comprised of Hypochlorous Acid Hypochlorous Acid. and Sodium Salt, Hypochlorite. • Cleanses, debrides, removes microorganisms • Cleanses, debrides, removes from the wound bed. microorganisms from the wound bed, • Non Cytotoxic, Non Sensitizing, Non inhibits growth of microorganisms. Irritating, No Oral Toxicity, No Clinical • Non Cytotoxic, Non Sensitizing, Non Contraindications Irritating, No Oral Toxicity • Biocompatible • “Additional testing has demonstrated • Reduces odor no oral toxicity, ocular irritation, or genotoxicity” per manufacturer. • Cleansing Contact Time: • Cleansing Contact Time: ‐ Normal Use 3‐5 min ‐ Apply saturated gauze x 3‐5 min ‐ Heavy Necrotic Tissue/Slough 5‐10 min with generous amount of solution prior to debridement 6 2/17/2020 Sodium Hypochlorite • A broad spectrum antimicrobial solution. It is also helpful in management of wound odor. • Quarter Strength = 0.125% • bactericidal while still being minimally toxic for good cells/fibroblasts. • Di‐Dak‐Sol= 0.0125% • bactericidal while being very safe to fibroblasts. • Ex) Dakin’s Collagenase • An enzymatic debrider for use on slough/eschar. Discontinue use once wound bed clean of necrotic tissue so as not to be wasteful of resources/capital (it is $200 for ~ travel toothpaste size tube)! • NOT compatible with all cleansers/solutions/dressings. Always check compatibility before use! • MUST have a source of moisture to activate –wound must be sufficiently exudative or secondary dressing must
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