Care of the Wound Bed Assessment and Management Algorithm
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Arterial Leg Ulcer Clinical Pathway
Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Arterial Leg Ulcer Clinical Pathway 0-7 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) Refer patient to ‘Care Connects’ if no responsible practitioner currently involved with patient identified/informed Determine if MRP/NP is part of Family Health Team (FHT) or Community Health Centre (CHC) and consider additional supports available Medical/surgical history and co-morbidity management Risk factors include: Chronic renal disease considered within care plan Smoking Congestive heart failure Diabetes mellitus Impaired liver function Hyperlipidemia Use of systemic steroids, Hypertension immunosuppressive and chemotherapy Coronary artery disease >70 years of age History of cerebral vascular accident Age 50-69 years with history of diabetes (CVA) or smoking Low hemoglobin < 50 years with diabetes and one other Obesity atherosclerotic factor Poor nutrition History of vascular surgery or deep vein Decreased thyroid function thrombosis Psoriasis Bleeding disorders Autoimmune diseases Family history of arterial disease Medication reconciliation and their impact on wound healing Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, reviewed inhaled substances and nicotine replacement therapy) Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs Other -
Wound Bed Preparation: TIME in Practice
Clinical PRACTICE DEVELOPMENT Wound bed preparation: TIME in practice Wound bed preparation is now a well established concept and the TIME framework has been developed as a practical tool to assist practitioners when assessing and managing patients with wounds. It is important, however, to remember to assess the whole patient; the wound bed preparation ‘care cycle’ promotes the treatment of the ‘whole’ patient and not just the ‘hole’ in the patient. This paper discusses the implementation of the wound bed preparation care cycle and the TIME framework, with a detailed focus on Tissue, Infection, Moisture and wound Edge (TIME). Caroline Dowsett, Heather Newton dependent on one another. Acute et al, 2003). Wound bed preparation wounds usually follow a well-defined as a concept allows the clinician to KEY WORDS process described as: focus systematically on all of the critical Wound bed preparation 8Coagulation components of a non-healing wound to Tissue 8Inflammation identify the cause of the problem, and Infection 8Cell proliferation and repair of implement a care programme so as to Moisture the matrix achieve a stable wound that has healthy 8Epithelialisation and remodelling of granulation tissue and a well vascularised Edge scar tissue. wound bed. In the past this model of healing has The TIME framework been applied to chronic wounds, but To assist with implementing the he concept of wound bed it is now known that chronic wound concept of wound bed preparation, the preparation has gained healing is different from acute wound TIME acronym was developed in 2002 T international recognition healing. Chronic wounds become ‘stuck’ by a group of wound care experts, as a framework that can provide in the inflammatory and proliferative as a practical guide for use when a structured approach to wound stages of healing (Ennis and Menses, managing patients with wounds (Schultz management. -
The Triangle of Wound Assessment a Simple and Holistic Framework for Wound Management
The Triangle of Wound Assessment A simple and holistic framework for wound management Wound bed WOUND Wound edge Periwound skin We asked healthcare professionals around the world about their priorities ? for wound care We found that most people Respondents said that treating wounds are not protecting the periwound specialists in a hospital1 skin is very important1 Approximately Up to 79% of wounds are 70% of being treated in wounds are the community2 surrounded by unhealthy skin3 2 ...none However, in a recent met all of the study of 14 wound criteria for assessment tools ... optimal wound assessment4 The Triangle of Wound Assessment is a holistic framework that allows practitioners üto assess and manage all areas of the wound, including the periwound skin. It is a simple and systematic approach that guides the user Wound bed from complete wound WOUND assessment to setting management goals, and Wound edge Periwound skin selecting the optimal treatment. 3 The Triangle of Wound Assessment offers a systematic approach to wound management Optimal wound management starts with a holistic wound assessment. This will help to more efficiently set management goals, which will increase the potential for better treatment outcomes. Assessment Management Goals Treatment 4 This is achieved through a holistic framework The Triangle of Wound Assessment provides a framework to assess all three areas of the wound while remembering the patient behind the wound within their social context. Patient Wound bed Social context WOUND Wound Wound edge Periwound skin 5 It’s not just about the wound but also the patient behind the wound Optimal management of the wound starts with assessing the patient behind the wound, and the social context in which the patient lives. -
Guideline: Wound Bed Preparation for Healable and Non Healable Wounds
British Columbia Provincial Nursing Skin and Wound Committee Guideline: Wound Bed Preparation for Healable and Non Healable Wounds Developed by the BC Provincial Nursing Skin and Wound Committee in collaboration with Wound Clinicians from: / TITLE Guideline: Wound Bed Preparation for Healable and Non-Healable Wounds in Adults & Children1 Practice Level Nurses in accordance with health authority and agency policy. Conservative sharp wound debridement (CSWD) is a restricted activity according to the Nurse’s (Registered) and Nurse Practitioner Regulation. 2 CRNBC states that registered nurses must successfully complete additional education and follow an established guideline when carrying out CSWD. Biological debridement therapy is a restricted activity according to the Nurse’s (Registered) and Nurse Practitioner Regulation. 3 CRNBC states that registered nurses must follow an established guideline when carrying out biological debridement. Clients 4 with wounds needing wound bed preparation require an interprofessional approach to provide comprehensive, evidence-based assessment and treatment. This clinical practice guideline focuses solely on the role of the nurse, as one member of the interprofessional team providing care to these clients. Background Factors affecting wound healability include the presence of adequate circulation in the area of the wound, wound related factors such as the size and duration of the wound, the ability to treat the cause of the wound and the presence of risk factors impacting wound healing. While many wounds heal, others are determined to be non-healing or slow-to-heal based on the presence or absence of these factors. Wound healability must be determined prior to debridement and moist wound healing. Although wound healing normally occurs in a predictable fashion, wound healing trajectories can be heterogeneous and non- uniform resulting is delayed wound healing for some clients. -
VII. Wound and Fracture Healing
Journal of Rehabilitation Research and Development Rehabilitation R & D Progress Reports 1986 VII. Wound and Fracture Healing VII . Wound and Fracture Healing Electrical Stimulation for Augmentation of Wound Healing Scott R. Crowgey, M.D., and Steven M. Sharpe Veterans Administration Research and Development, Decatur, GA 30033 Sponsor: VA Rehabilitation Research and Development Service Purpose—This project will attempt to identify ing that could be influenced by electrical stimu- aspects of the wound healing process that may lation. Efforts will then be directed toward de- be augmented by the exogenous influence of veloping mathematical models of the possible electromagnetic fields. A theoretical analysis of electrical interaction of electromagnetic fields the possible effects of electromagnetic fields on with cells and cell structures to determine how wound healing will include analyses of the these interactions could be optimized to im- interaction of electromagnetic fields with cellu- prove wound healing. It is anticipated that the lar structures and of the deposition of heat in literature will not contain all the information damaged tissue via exogenously applied energy necessary to develop these models . Any gaps in fields. This analysis will then be used as a basis necessary information and data will be filled, if for developing a plan for future investigations practical, using tissue phantom modeling mate- into the potential application of electrical stim- rials, blood, and possibly even primitive tissue ulation for the augmentation of wound healing. culture exposed to a variety of known electro- The initial research will involve a review of magnetic environments, using easily construct- the literature to identify aspects of wound heal- ed exposure chambers. -
For Wound Bed Preparation Among Diabetic Patients
Negative pressure therapy (vacuum) for wound bed preparation among diabetic patients: case series Terapia por pressão negativa (vácuo) no preparo do leito da ferida em pacientes diabéticos: série de casos Marcus Castro Ferreira1, Viviane Fernandes de Carvalho2, Fábio Kamamoto3, Paulo Tuma Junior4, André Oliveira Paggiaro5 Case series Plastic Surgery Division, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil KEY WORDS: ABSTRACT Diabetic foot. Skin transplantation CONTEXT: Complications from diabetes mellitus affecting the lower limbs occur in 40 to 70% of such patients. Neuropathy is the main cause of ulceration Surgical flaps. and may be associated with vascular impairment. The wound evolves with necrosis and infection, and if not properly treated, amputation may be the end Negative-pressure wound therapy. result. Surgical treatment is preferred in complex wounds without spontaneous healing. After debridement of the necrotic tissue, the wound bed needs to Wound healing. be prepared to receive a transplant of either a graft or a flap. Dressings can be used to prepare the wound bed, but this usually leads to longer duration of hospitalization. Negative pressure using a vacuum system has been proposed for speeding up the treatment. This paper had the objective of analyzing the effects of this therapy on wound bed preparation among diabetic patients. CASE SERIES: Eighty-four diabetic patients with wounds in their lower limbs were studied. A commercially available vacuum system was used for all patients after adequate debridement of necrotic tissues. For 65 patients, skin grafts completed the treatment and for the other 19, skin flaps were used. Wound bed preparation was achieved over an average time of 7.51 days for 65 patients and 10 days for 12 patients, and in only one case was not achieved. -
Wound Care: the Basics
Wound Care: The Basics Suzann Williams-Rosenthal, RN, MSN, WOC, GNP Norma Branham, RN, MSN, WOC, GNP University of Virginia May, 2010 What Type of Wound is it? How long has it been there? Acute-generally heal in a couple weeks, but can become chronic: Surgical Trauma Chronic -do not heal by normal repair process-takes weeks to months: Vascular-venous stasis, arterial ulcers Pressure ulcers Diabetic foot ulcers (neuropathic) Chronic Wounds Pressure Ulcer Staging Where is it? Where is it located? Use anatomical location-heel, ankle, sacrum, coccyx, etc. Measurements-in centimeters Length X Width X Depth • Length = greatest length (head to toe) • Width = greatest width (side to side) • Depth = measure by marking the depth with a Q- Tip and then hold to a ruler Wound Characteristics: Describe by percentage of each type of tissue: Granulation tissue: • red, cobblestone appearance (healing, filling in) Necrotic: • Slough-yellow, tan dead tissue (devitalized) • Eschar-black/brown necrotic tissue, can be hard or soft Evaluating additional tissue damage: Undermining Separation of tissue from the surface under the edge of the wound • Describe by clock face with patients head at 12 (“undermining is 1 cm from 12 to 4 o’clock”) Tunneling Channel that runs from the wound edge through to other tissue • “tunneling at 9 o’clock, measuring 3 cm long” Wound Drainage and Odor Exudate Fluid from wound • Document the amount, type and odor • Light, moderate, heavy • Drainage can be clear, sanguineous (bloody), serosanguineous (blood-tinged), -
Suturing with U-Technique Versus Un
Official Title of the Study: Suturing with U-Technique versus Un- Reapproximated wound Edges during removal of Closed Thoracostomy-tube drain - A single centre Open-label randomized prospective trial (SUTURE TRIAL) NCT NUMBER: Not Yet Assigned DATE OF DOCUMENT: January 16, 2019 1 STUDY SUMMARY Title: Suturing with U-Technique versus Un-Reapproximated wound Edges during removal of Closed Thoracostomy-tube drain - A single centre Open-label randomized prospective trial (SUTURE TRIAL) Background: Closed thoracostomy tube drainage or chest tube insertion is one of the most commonly performed procedures in thoracic surgery. There are several published evidence-based guidelines on safe performance of a chest tube insertion. However, there is absence of prospective controlled trials or systematic reviews indicating the safest technique of closing the wound created at the time of chest tube insertion and that best guarantees good wound and overall outcomes, post-chest tube removal. The use of a horizontal mattress non-absorbable suture or U- suture which is placed at the time of chest tube insertion and used to create a purse-string wound re-approximation at the time of tube removal has been an age-long and time-honored practice in most thoracic surgical settings. It has been established by a recent study that an occlusive adhesive-absorbent dressing can also be safely used to occlude the wound at the time of chest tube removal with good wound and overall outcomes though the study focused on tubes inserted during thoracic surgical operations. -
Prontosan®Wound Irrigation Solution and Gels
Prontosan® Wound Irrigation Solution and Gels WOUND BED PREPARATION TAKEN SERIOUSLY What is a Biofilm? The prevention and management of biofilm in chronic wounds is rapidly becoming a primary objective of Bacteria protected from wound care, with the presence of topical agents in a biofilm biofilm acknowledged having a role in delayed wound healing.1 Impaired migration and proliferation of keratinocytes Biofilm forms when bacteria adhere to surfaces by excreting a thick, slimy, Bacteria protected from glue-like substance known as the systemic antibiotics Extracellular Polymeric Substance (EPS). This substance forms a protective layer, where the bacteria are no longer free to move (planktonic), but adhere to the wound bed. New bacteria are produced and the colony grows under CONTAMINATION the protection of the EPS. Free floating bacteria attach to a surface within minutes. Initial attachment is reversible. Biofilms are often difficult to detect visually but delay wound healing.2 COLONIZATION Bacteria multiply and become firmly HOW DO BIOFILMS attached within DEVELOP?2 2 – 4 hours. BIOFILM CYCLE SPREADING LEADS TO SYSTEMIC INFECTIONS Mature biofilm releases bacteria within 2 – 4 days causing recolonization, which results in a never ending biofilm cycle. BIOFILM DEVELOPMENT AND INFLAMMATORY HOST RESPONSE Develop initial EPS and become increasingly tolerant to within 6 – 12 hours. The use of surfactant-based wound dressings in a clinical setting may help to disrupt existing biofilm from wound tissue.3 Prontosan® with Betaine (Surfactant) and -
A Focus on the Triangle of Wound Assessment — Addressing the Gap Challenge and Identifying Suspected Biofilm in Clinical Practice
Clinical practice A focus on the Triangle of Wound Assessment — addressing the gap challenge and identifying suspected biofilm in clinical practice Authors: Wound assessment should be comprehensive, systematic and evidence- Caroline Dowsett, Terry Swanson and Tonny Karlsmark based (World Union of Wound Healing Societies [WUWHS], 2016a). The Triangle of Wound Assessment offers clinicians a framework to assess the patient and their wound, taking into consideration the wound bed, wound edge and periwound skin (Dowsett et al, 2015). The framework can be adapted to incorporate new developments and new challenges in wound care such as the ‘gap challenge’ and biofilm prevention and management. Using the framework can assist in determining the status of the wound bed and support clinical decision making to prevent problems associated with exudate pooling at the wound bed and the potential for biofilm formation. he Triangle of Wound Assessment This article will discuss how the Triangle of was established in 2014 and provides Wound Assessment identifies infection and T a systematic approach to wound biofilm, tackles the gap challenge, and how assessment and in setting management goals, this framework can be developed for new to guide optimal treatment choice (Dowsett et challenges in wound care. al, 2015), ensuring that the periwound skin is incorporated into the assessment. Periwound The importance of holistic assessment skin can be a significant problem in patients Wounds are a significant source of cost to with chronic wounds, with between 60–70% patients, as well as to the health economy. of wounds found to be surrounded by either Chronic wounds are often hard to heal problematic or unhealthy periwound skin resulting in a cycle of pain, anxiety and (Cartier et al, 2014). -
Ewma Document: Negative Pressure Wound Therapy
EWMA DOCUMENT: NEGATIVE PRESSURE WOUND THERAPY OVERVIEW, CHALLENGES AND PERSPECTIVES Jan Apelqvist,1, 2 (editor) MD, PhD, Associate Professor Christian Willy,3 (co-editor) MD, PhD, Professor of Surgery Ann-Mari Fagerdahl,4 RN, CNOR, PhD Marco Fraccalvieri,5 MD Malin Malmsjö,6 MD, PhD, Professor Alberto Piaggesi,7 MD, Professor of Endocrinology Astrid Probst,8 RN Peter Vowden,9 MD, FRCS, Professor 1. Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden 2. Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden 3. Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany 4. Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden. 5. Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy 6. Clinical Sciences, Lund University, Lund, Sweden. 7. Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy 8. Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany 9. Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom Editorial support and coordination: Niels Fibæk Bertel, EWMA Secretariat Corresponding author: Jan Apelqvist, [email protected] The document is supported by unrestricted educational grants from: Acelity, BSN medical, Genadyne, Mölnlycke Health Care, Schülke & Mayr GmbH, Smith & Nephew and Spiracur. The document is published as a deliverable for the SWAN iCare project, www.swan-icare.eu, which is partially funded under the ICT Smart components and smart systems integration programme (FP7-ICT) as part of the Research and Innovation funding programme by the European Commission. -
Biology of Bone Repair
Biology of Bone Repair J. Scott Broderick, MD Original Author: Timothy McHenry, MD; March 2004 New Author: J. Scott Broderick, MD; Revised November 2005 Types of Bone • Lamellar Bone – Collagen fibers arranged in parallel layers – Normal adult bone • Woven Bone (non-lamellar) – Randomly oriented collagen fibers – In adults, seen at sites of fracture healing, tendon or ligament attachment and in pathological conditions Lamellar Bone • Cortical bone – Comprised of osteons (Haversian systems) – Osteons communicate with medullary cavity by Volkmann’s canals Picture courtesy Gwen Childs, PhD. Haversian System osteocyte osteon Picture courtesy Gwen Childs, PhD. Haversian Volkmann’s canal canal Lamellar Bone • Cancellous bone (trabecular or spongy bone) – Bony struts (trabeculae) that are oriented in direction of the greatest stress Woven Bone • Coarse with random orientation • Weaker than lamellar bone • Normally remodeled to lamellar bone Figure from Rockwood and Green’s: Fractures in Adults, 4th ed Bone Composition • Cells – Osteocytes – Osteoblasts – Osteoclasts • Extracellular Matrix – Organic (35%) • Collagen (type I) 90% • Osteocalcin, osteonectin, proteoglycans, glycosaminoglycans, lipids (ground substance) – Inorganic (65%) • Primarily hydroxyapatite Ca5(PO4)3(OH)2 Osteoblasts • Derived from mesenchymal stem cells • Line the surface of the bone and produce osteoid • Immediate precursor is fibroblast-like Picture courtesy Gwen Childs, PhD. preosteoblasts Osteocytes • Osteoblasts surrounded by bone matrix – trapped in lacunae • Function