Skin and Wound Care: Introduction (06:26)
Heidi Huddleston Cross is certified wound ostomy nurse practicing at Upstate University Hospital and long term care facilities. Cross introduces herself and gives a brief overview of her credentials.
Evidence Based Practice (10:18)
Standard of care can be defined as what any reasonable practitioner would do under similar circumstances. AHRQ books have been archived, but guidelines continue to be listed on the website. WOCN updates guidelines regularly.
Skin: A Vital Organ (15:30)
Functions of the skin include protection, metabolism, temperature regulation, absorption, and excretion. Skin is the largest organ in the body composed of three layers: epidermis, dermis, and subcutaneous. Cross outlines preventative steps to keep aging skin healthy in healthcare environments.
Phases of Wound Healing (06:57)
Wounds heal in four phases—hemostasis, inflammation, proliferative, and remodeling. Acute wounds are mitotically competent while chronic wounds are senescent. MMPs of chronic wounds prevent the wound from advancing into the proliferative phase.
Systemic Factors Impacting Wound Healing (10:04)
Cross outlines systemic factors that impact wound healing. Tissue hypoxia, nutritional deficiencies, comorbidities, and obesity impede healing. Care plans should take psychosocial factors into consideration.
Skin and Wound Assessment (52:03)
Physical assessments include systemic factors and patient history. The Braden scale evaluates risk and outlines care plans. Comprehensive skin assessments examine skin color, texture, and temperature. Wound assessments evaluate the location, physical properties such as color and size, odor, drainage, undermining, and periwound skin. Cross answers questions from the audience.
Biofilms are protective bacterial mechanisms that make wounds impervious to external threats. Biofilms form in three stages: reversible surface attachment, permanent surface attachment, and formation of a protective matrix. Treatment includes debridement followed by an antimicrobial covering.
Wound Infection (07:46)
Chronic wounds show symptoms of increased pain, failure of progression and increased biofilm formation. Topical and systemic antibiotics can be used to treat chronic wounds. Tissue biopsies determine culture insensitivity. Wound infections are defined as 10 to the fifth colonies of bacteria per gram of tissue.
Swab Results for Infected Wounds (07:08)
Chronic wounds are polymicrobial and initial treatment target gram positive organisms. Cipro, Doxycycline, Levaquin, and Clindamycin are common antibiotics used to treat wounds. MRSA is resistant to Oxacillin.
Threat of Post-antibiotic Era (09:11)
2 million people in the U.S are sickened with antibiotic-resistant infections per year. Carboplatin enterobacteriaceae, drug resistant gonorrhea, and C. diff are urgent infections resistant to antibiotics. MRSA, non-typhoidal salmonella, and necrotizing fasciitis are particularly dangerous.
When diagnosing osetomyelitits x-rays, MRIs or three phase bone scans can be used. A culture and sensitivity (C&S) of the bone leads to the most accurate results and treatment.
Types of Wounds: Pressure Injuries (30:30)
Pressure injuries are localized regions of damaged skin of underlying soft tissue caused by prolonged pressure with various stages of severity. Pressure injuries from medical devices conform to the pattern or shape of the device and use the normal staging scale.
Mucosal membrane pressure injuries are not staged like normal pressure injuries.
Wound Treatment (05:32)
Cross explains the three-legged stool analogy for treating pressure injuries which include controlling the cause, wound care, and nutrition. Controlling the cause relates directly to offloading pressure, stringent turning and positioning, and improves surface quality. Wound care regulations advocate for debridement with some expectations. Increase protein and calorie consumption as well as micronutrients.
Avoidability versus Unavoidability (04:00)
F-tag 314 is a specific guide to pressure ulcers. To prove unavoidability a facility must evaluate residence clinical condition, pressure ulcer risk factors, implement interventions consistent with standards of practice, and monitor the impact of said interventions.
Kennedy terminal ulcer (07:15)
Terminal ulcers occur at the end of a patient's life and result from skin failure. This type of ulcer is located on the coccyx or sacrum, has the shape of a pear, occurs suddenly, varies in color from red, yellow, or black, and death is imminent. Cross addresses pressure injury prevention practices.
Venous Ulcers (17:46)
Venous ulcers are the most common leg wound typically found in the lower leg or ankle. Ulcers develop as venous valve systems fail and fluid extravasates into the soft tissue bringing with it red blood cells.
Treatment of Venous Ulcers (03:36)
Compression, limb elevation, and anti-platelet aggregates treat hypertension- the main cause of venous ulcers. Using a dressing with exudate absorption enhances proper moisture balance. Nutrition plays a critical role in wound healing.
Compression Therapy: Inelastic (04:29)
Inelastic therapy provides a therapeutic level of pressure only during ambulation using non-elastic garments, boots, and short stretch wraps.
Compression Therapy: Elastic (11:55)
Long stretch and recoil orthotics are used in elastic compression to adapt to changes in limb volume. This type of therapy is used for non-ambulatory patients. Cross reviews guidelines for compression therapy.
Diagnosis and Treatment: Venous Ulcers (01:40)
Duplex ultrasounds will identify the pathway of reflex and incompetent vessels. Subfascial endoscopic perforator surgery obliterates effecter perforators to prevent flow from deep to superficial veins. Endovenous oblation and phlebotomy scleral therapy are effective treatments.
Most often occurs with impaired lymphatic transport in the lower extremities as a result of obesity and surgery. Treatment includes congestive deep therapy involving massage, manual lymph drainage, and compression. Ulcers associated with lymphedema are considered palliative.
Arterial Ulcers (05:49)
Risk factors include age, smoking, arterial atherosclerosis, hyperlipidemia, diabetes, and homocysteinemia. Cross describes the characteristic of arterial ulcers.
Acute Limb Verses Critical Limb Ischemia (08:13)
Acute limb ischemias are embolism characterized by pain, pulselessness, pallor, paralysis, paresthesia, polar, and purplish color. Critical limb ischemia is chronic ischemic rest pain, wounds, and gangrene leading to amputation. Cross recalls her experience with a gangrene patient.
Vascular Evaluation (01:40)
Magnetic resonance angiography, duplex angiography, ultrasounds, and arteriography map out the arterial system to locate occlusions for intervention. Transcutaneous oxygen flow measures the flow of oxygen to tissues.
Treatment of Arterial Ulcers (04:44)
Arterial ulcers can be treated by improving blood flow to the leg through revascularization, walking programs, balanced nutrition, and dry wound healing.
Diabetic Ulcers (15:03)
Lower extremity neuropathic disease impacts sensory, motor, and autonomic nerves. Osteoclast to osteoblast ratio leads to bone degradation and foot malformation. Cross explores the description of diabetic ulcers.
Diabetic Ulcer Treatment (04:46)
Offloading pressure, controlling blood glucose, and weight loss control the cause of diabetic ulcers. Debridement, moist wound healing, and the use of antimicrobials treat diabetic wound beds. Increase in protein consumption and reduction of glucose control diabetic ulcers.
Wound Debridement and Wound Bed Preparation (19:35)
A clean-up of the wound bed and the surrounding skin by reducing bacteria load and stimulates healing. Autolytic debridement uses moisture retentive dressings. Enzymatic wound treatment is limited to collagenase SANTYL. Mechanical debridement uses wet to dry dressings, pulse lavage, Debrisoft, and sharp wound debridement.
Maggot Therapy (07:10)
This is an inexpensive, painless, and selective means of wound debridement. The secretions of the maggots inhibit the growth of bacteria, virulent, and pathogenic organisms.
Wound Dressings (23:15)
Cross explores wound dressing basics and various products. Moist wound healing stimulates collagen synthesis, growth factors, and decreases infection rate. Proper wound processing includes maintaining healthy tissues, removing the infection, and maintaining periwound.
Negative Pressure Wound Therapy (04:30)
The primary goal is to increase fibroblast migration and granulation tissue production. Wound vacs clean the wound and remove damaged tissue.
Refractory Wounds (26:14)
This type of wound is classified by a lack of improvement during evidence-based therapy. Additional wound therapy includes antimicrobial dressings.
Skin and Wound Care: Conclusion (04:04)
Cross concludes the lecture by reviewing the essential points of skin and wound care.
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