High-Acuity Nursing, 6th Edition

Complex Wound Management Objectives: 1. Describe the anatomic structures and functions of the skin and the effects of wounds on skin integrity. 2. Explain wound physiology, including the physiologic events that occur in each phase of wound repair and the methods of wound closure. 3. Discuss physiologic and environmental factors that affect wound healing. 4. Identify the common clinical assessments used to evaluate wound healing. 5. Discuss treatment modalities used in wound management and their rationale. 6. Explain wound infections, including conditions that predispose a patient to developing an infection, diagnostic criteria, and treatment interventions. 7. Describe necrotizing soft-tissue infections, including pathophysiology, signs and symptoms, risk factors, and treatment strategies for necrotizing fasciitis and Fournier’s gangrene. 8. Discuss enterocutaneous fistula, including pathophysiology, risk factors, clinical presentation, and collaborative management. 9. Review pressure ulcers, including etiology, risk factors, assessment tools, and collaborative management. I. Anatomy and Physiology of the Skin and Effects of Wounds A. Normal Skin anatomy 1. Epidermis, the vascular outermost layer, is composed of stratified squamous epitherial cells and is divided into five sub-layers called stratum. 2. Dermis is the innermost layer of skin, the thickest tissue layer of the skin. It provides support to the epidermis and is made up of two major proteins (elastin and collagen) that provide elasticity and strength to the skin. 3. Hypodermis is a subcutaneous layer below the dermis that consists of adipose tissue and blood vessels. B. Wounds—A disruption of skin functions 1. A wound creates an alteration and disruption of the anatomic and physiologic functions of the skin. A wound can be created intentionally, as with a surgeon’s knife; by accidental trauma, such as occurs in a motor vehicle crash; or by mechanical forces, such as occurs in pressure ulcer formation. a) Partial thickness or full thickness PowerPoint Slides 1. Normal Skin Anatomy Epidermis Dermis Hypodermis 2. Wounds—A Disruption of Skin Functions Partial thickness or full thickness II. Wound Physiology 1. Acute wounds occur suddenly and progress rapidly through a predictable series of repair events that result in wound closure. Acute wounds are usually a consequence of a traumatic injury or surgery. In contrast, chronic wounds fail to proceed through an orderly and timely repair process, resulting in lengthy closure or failure to close. Chronic wounds are often caused by vascular compromise, chronic inflammation, or repetitive injury to an existing wound or ulcer. A. Phases of wound repair 1. Inflammation Phase—This occurs immediately after injury and lasts 3 days. This is a critical phase because the wound environment is being prepared for subsequent tissue development. The major events that occur in this phase are hemostasis (i.e., control of bleeding). 2. Proliferation Phase—begins several days after injury and continues for several weeks. The major processes that occur during this phase are focused on building new tissue to fill the wound space and restoring a functional barrier. a) Angiogenesis—is the formation of new blood vessels to reestablish perfusion to the wound bed. b) Epithelialization. Epithelialization involves the migration of epithelial cells across a wound’s surface. c) Collagen Formation —Fibroblasts produce the major component of new connective tissue. d) Granulation Tissue Formation is a provisional matrix characterized by unstructured collagen and high amounts of fibronectin. e) Contraction—As new granulation tissue is formed, the wound margins begin to contract or pull together toward the center of the wound, and the surface area of the wound decreases. 3. Remodeling/Maturation Phase Usually by the third week after a disruption in skin integrity, the wound has closed and the remodeling phase begins. Remodeling/maturationis the final repair process. This phase can last from months to years. B. Classifications of wound closure–Wound closure is classified as primary, secondary, or tertiary intention (Fig. 9–4). The rate of wound healing depends on the method used to close the wound, which in turn depends on the amount of tissue damage or loss and the potential for wound infection. 1. Primary Intention refers to closing the wound by mechanical means. This method is used when there is minimal tissue loss and skin edges are well approximated. 2. Secondary Intention are usually large wounds characterized by significant tissue loss, damage, or bacterial contamination. These wound cavities close gradually through the normal phases of wound healing. 3. Tertiary Intention is a method of delayed wound closure that uses a combination of primary and secondary intention. PowerPoint Slides 1. Phases of Wound Repair Inflammation phase Proliferation phase Remodeling/maturation phase 2. Proliferation Phase Angiogenesis Epithelialization Collagen formation Granulation tissue formation Contraction 3. Classifications of Wound Closure Primary intention Secondary intention Tertiary intention III. Factors That Affect Wound Healing A. Oxygenation/tissue perfusion 1. Adequate oxygen supply to wounds is required by immune and inflammatory cells to produce proteins, reestablish vascular structure and epithelium, and provide resistance to bacterial invasion. Adequate oxygenation promotes neovascularization and optimizes collagen deposition, which increases the tensile strength of wound beds. 2. The availability of oxygen to tissue and wound beds depends on vascular supply, vasomotor tone, arterial oxygen tension, and the diffusion distance for oxygen to cross the capillary membrane. 3. Many conditions interfere with the delivery of oxygen to the wound (e.g., thrombosis, radiation, obesity, diabetes, cardiovascular disease, cigarette smoking, hypotension, hypothermia, hypovolemia, and the administration of vasoactive drugs). 4. Nursing care for the patient with a wound must include supportive measures to enhance tissue perfusion. B. Nutrition—Wound healing is an anabolic metabolic process; that is, it requires energy to build new tissue. Therefore, adequate nutrition is a critical factor in wound repair. 1. Proteins are the building blocks of collagen, a cellular matrix that forms the basis of tissue granulation. 2. Fats serve as building blocks for prostaglandins, which regulate cell metabolism, inflammation, and circulation. 3. Vitamins and minerals are needed to build new tissues and aid in normal immune function. C. Age 1. Aging affects almost every stage of wound healing; the wound healing process is markedly slower as patients age. D. Diabetes mellitus 1. Wound healing in the patient with diabetes is compromised as a result of macrovascular and microvascular changes, poor glycemic control, and loss of sensation. E. Medications 1. Steroid therapy, used to block the inflammatory component of many diseases, has a well-known inhibitory effect on wound healing. 2. Corticosteroids suppress inflammation and reduce proliferation of keratinocytes and fibroblasts, impairing both granulation and epithelial resurfacing. F. Obesity 1. The obese patient (body mass index of 30 or greater) experiences an increased incidence of dehiscence, herniation, and infection (Rolstad, Bryant, & Nix, 2012). G. Topical therapy 1. Implement best practice dressing strategies to eliminate necrotic tissue and heavy bacterial loads. Use topical therapies that keep the wound surface clean and moist. PowerPoint Slides 1. Oxygenation/Tissue Perfusion Adequate oxygenation promotes neovascularization and optimizes collagen deposition. Availability of oxygen to tissue. Many conditions interfere with the delivery of oxygen to the wound. Nursing care for the patient with a wound. 2. Nutrition Wound healing is an anabolic metabolic process. Proteins. Fats. Vitamins and minerals. 3. Age Aging affects almost every stage of wound healing; the wound healing process is markedly slower as patients age. 4. Diabetes Mellitus Wound healing in the patient with diabetes is compromised as a result of macrovascular and microvascular changes, poor glycemic control, and loss of sensation. 5. Medications Steroid therapy, used to block the inflammatory component of many diseases, has a well-known inhibitory effect on wound healing. Corticosteroids suppress inflammation and reduce proliferation of keratinocytes and fibroblasts, impairing both granulation and epithelial resurfacing. 6. Obesity The obese patient (body mass index of 30 or greater) experiences an increased incidence of dehiscence, herniation, and infection (Rolstad, Bryant, & Nix, 2012). 7. Topical Therapy Implement best-practice dressing strategies to eliminate necrotic tissue and heavy bacterial loads. Use topical therapies that keep the wound surface clean and moist. IV. Clinical Assessment of Wound Healing A. Wound assessment 1. Assessment entails the inspection and collection of data that lead to a comprehensive individualized plan of care. Physical assessment parameters address wound etiology, wound duration, and intrinsic and extrinsic factors impairing wound healing. B. Inspection 1. Wound measurement a) Changes in wound dimensions may indicate improvement or decline in wound status. b) Measure and record the length, width, and depth of the wound. 2. Presence of exudate or drainage a) The fluid produced by wounds is called exudate. Assess wound exudate for volume (none, light, moderate, or heavy), type (clear, serosanguineous, sanguineous, purulent), and odor (absent, faint, moderate, or strong). The amount of exudate generally varies with the type of wound. 3. Appearance of wound tissue a) Wound tissue characteristics are an indication of the state of healing. Normal progression from the inflammatory phase to proliferation in a full-thickness wound results in a vascular granulating wound surface. b) Bioburden refers to the degree of foreign material and debris resulting from bacteria and tissue injury that cause a delay in the wound healing process. c) Nonviable tissue known as eschar is a black, gray, or yellow-tan necrotic tissue, thick and leathery, that appears even with the skin margin but extends more deeply. d) Nonviable tissue known as slough is a moist, slimy, gray, tan, or yellow necrotic tissue attached to the wound base. 4. Inspection of wound edges a) The wound edges should be attached (approximated) to each other without undermining. b) Edges should be moist and flush with the wound base, allowing epithelial cells to migrate from the edges across the surface once granulation and wound contraction are complete. 5. Inspection of periwound skin a) Periwound assessment provides information about the effectiveness of the treatment plan and topical therapy (Nix, 2012). b) Impaired periwound skin integrity compromises and complicates wound healing. c) Periwound skin integrity can also be altered by frequent tape removal. 6. Palpation of Periwound Area a) Palpation of the wound and surrounding areas assists in recognizing changes in size, consistency, moisture, and texture. C. Assessment of tissue perfusion/oxygenation status 1. Adequate tissue perfusion/oxygenation is the most important factor to assess for in wound healing. 2. To assess circulation into and from a wound, assess the proximal and distal pulses by palpation or by Doppler ultrasound. D. Assessment of immunologic status 1. An intact immunologic response to injury, regardless of the cause of injury, is a key factor in proper wound healing. 2. The patient is assessed for the three predisposing elements for wound infection: susceptible host, compromised wound, and infectious organism. E. Assessment of nutritional status 1. A complete and thorough nutritional assessment for all patients with altered skin and tissue integrity is imperative. 2. The assessment must include baseline height and weight, serial weight monitoring, and regular assessment of intake and output. PowerPoint Slides 1. Wound Assessment Wound etiology Wound duration Intrinsic and extrinsic factors impairing wound healing 2. Inspection Wound measurement Presence of exudate or drainage Appearance of wound tissue Inspection of wound edges Inspection of periwound skin Palpation of periwound area 3. Assessment of Tissue Perfusion/Oxygenation Status Adequate tissue perfusion/oxygenation Assess the proximal and distal pulses 4. Assessment of Immunologic Status Intact immunologic response to injury Three predisposing elements for wound infection: susceptible host, compromised wound, and infectious organism 5. Assessment of Nutritional Status Complete and thorough nutritional assessment for all patients. Assessment must include baseline height and weight, serial weight monitoring, and regular assessment of intake and output. V. Principles of Wound Management 1. There are three important principles of wound management: controlling or eliminating the etiology or causative factors, providing systemic support to reduce existing and potential cofactors, and maintaining an optimal physiologic local wound environment. A. Wound cleansing 1. Wound cleansing involves removing debris, microorganisms, contaminants, exudate, and devitalized tissue, usually by flushing the surface of the wound with a nontoxic irrigating solution such as normal saline. 2. The effective and safe range for wound cleansing is 4 to 15 psi. A large wound with a significant amount of necrosis requires high-pressure (8 to 15 pounds per square inch [psi]) irrigation with enough solution to adequately remove the debris. 3. The goal of cleansing proliferative, granulating wounds is to remove inorganic debris from the wound using a gentle flushing technique. B. Debridement 1. The removal of nonviable tissue, foreign matter, and debris from the wound bed is a naturally occurring event in the wound repair process. 2. The five methods of debridement are: a) Sharp debridement is the removal of necrotic areas using a scalpel or scissors. b) Mechanical debridement is accomplished with wet-to-dry gauze dressings, irrigation, or hydrotherapy. c) Chemical debridement involves the removal of necrotic tissue using enzymes or sodium hypochlorite. d) Autolytic debridement is a selective, painless form whereby usual body processes effectively remove nonviable necrotic tissue. e) Biosurgical (maggot) debridement was first used to remove necrotic tissue in the wounds of soldiers on the battlefield. C. Dressings 1. Dressings are placed over wounds for multiple purposes: debridement; protection from the external environment; provision of a physiological environment conducive to wound healing; and provision of immobilization, support, and comfort. 2. Dressings assist in the assessment of quality and quantity of drainage, pressure reduction, and absorption. D. Negative pressure wound therapy 1. Negative pressure wound therapy (NPWT) is the application of subatmospheric pressure to the wound bed using suction to enhance granulation and contraction and collect wound fluid. 2. NPWT has been effective in treating Stage III and IV pressure ulcers, leg ulcers, diabetic foot ulcers, and dehisced incisions. 3. The wound filler dressing may be changed every 12 hours for infected wounds or every 72 hours in the absence of infection. a) Patients may experience pain from the interaction of the wound filler. b) Pain etiology should be assessed and interventions employed to alleviate the pain. (1) Changing the type of dressing (2) Adding a no adherent contact layer prior to the wound filler dressing (3) Using lower pressure (75–80 mmHg) (4) Switching from intermittent to constant suction (5) Instilling normal saline to moisten the dressing prior to removal (6) Instilling with topical Xylocaine (without epinephrine) (7) Changing the type of NPWT system PowerPoint Slides 1. There are three important principles of wound management: Controlling or eliminating the etiology or causative factors Providing systemic support to reduce existing and potential cofactors Maintaining an optimal physiologic local wound environment 2. Wound cleansing involves: Removing debris Microorganisms Contaminants Exudate Devitalized tissue 3. The five methods of debridement are: Sharp debridement Mechanical debridement Chemical debridement Autolytic debridement Biosurgical (maggot) debridement 4. Dressings are placed over wounds for multiple purposes: Protection from the external environment Provision of a physiological environment conducive to wound healing Provision of immobilization, support, and comfort 5. Negative Pressure Wound Therapy Pain etiology should be assessed and interventions employed to alleviate the pain. Changing the type of dressing Adding a nonadherent contact layer prior to the wound filler dressing Using lower pressure (75–80 mmHg) Switching from intermittent to constant suction Instilling normal saline to moisten the dressing prior to removal Instilling with topical Xylocaine (without epinephrine) Changing the type of NPWT system. VI. Wound Infection: Etiology, Diagnosis, and Treatment 1. Intact skin provides a barrier to microorganism invasion and infection. Once epidermal integrity is disrupted, the wound quickly becomes contaminated by body fluids and normal skin flora (Acinetobacter, Streptococcus, and Staphylococcus). a) Bioburden, on the wound is vast and complicated. All wounds have some level of microorganism burden; most do not become infected. b) The presence of nonreplicating microbes is called contamination. c) Critical colonization describes a level of microorganism burden that affects skin cell proliferation and tissue repair, altering wound healing but not invading the wound tissue. d) Biofilm—As microorganisms adhere to the wound, they develop a biofilm. e) Wound infection occurs when the microorganisms multiply and invade body tissues A. Predisposing factors for wound infection 1. Susceptible Host—the patient who is a has some degree of local or systemic impairment of resistance to bacterial invasion a) The causes of systemic impairment may include diabetes, immune deficiency, acute or chronic use of steroids, renal disease, malnutrition, cardiovascular disease, pulmonary disease, extremes of age, obesity, cancer, and the use of immunosuppressive therapies. 2. Compromised Wound—One that contains devitalized tissue, which is tissue that has been separated from the circulation and the body’s antimicrobial defenses. 3. Infectious Organism —Many different organisms are capable of initiating a wound infection. Organisms come from endogenous or exogenous sources. a) Endogenous sources arise within the patient. b) Exogenous organisms enter the body from the external environment. B. Diagnosis and treatment of wound infection 1. In diagnosing wound infection, it is important to consider the patient’s physical assessment and individual risk factors for wound infection along with the clinical presentation of the wound. 2. Local wound management for infection refers back to the three principles of wound management discussed in the prior section. 3. Systemic signs of wound infection require treatment with systemic antibiotics that are sensitive to the causative microorganism. 4. Wound assessment, diligent management of wound bioburden, providing individual patient system support, administering antibiotics, and monitoring therapeutic drug levels when indicated are important in supporting wound healing and avoiding sepsis in this population. C. Prevention of wound infections 1. Prevention begins with recognizing the three elements that predispose the patient to a wound infection, as described above: susceptible host, compromised wound, and infectious organism. 2. For elective surgical procedures, prevention begins preoperatively with skin preparation, mechanical and antibiotic bowel preparations, timely prophylactic administration of antibiotics, and sterile operative site draping. 3. For patients with traumatic injury, resuscitation and lifesaving measures often take priority over the immediate treatment of wounds. 4. Hand washing is still considered one of the most important methods of preventing wound infections. PowerPoint Slides 1. Wound Infections: Etiology, Diagnosis, and Treatment Bioburden Contamination Critical colonization Biofilm Wound infection 2. Predisposing Factors for Wound Infection Susceptible host Causes of systemic impairment Compromised wound Infectious organism 3. Diagnoses and Treatment of Wound Infection Diagnosing wound infection Local wound management Systemic signs of wound infection Wound assessment 4. Prevention of Wound Infections Prevention begins with recognizing the three elements that predispose the patient to a wound: Susceptible host Compromised wound Infectious organism Elective surgical procedures Patients with traumatic injury Hand washing VII. Necrotizing Soft-Tissue Infections 1. Necrotic tissue is dead, devitalized tissue. It is an impediment to wound healing and provides an environment for microorganism growth and infection. A. Necrotizing fasciitis (NF) is a severe deep soft tissue infection that leads to necrosis of the subcutaneous tissue and fascia without involvement of the underlying muscle. 1. Signs and symptoms a) NF is difficult to diagnose in the beginning stage because symptoms mimic nonsevere soft-tissue infections. Early signs include those associated with the inflammatory process: erythema, edema, and pain in the affected area. b) In later stages, crepitus may be palpated in the affected area or may be seen radiographically. Crepitus results from gas-forming organisms and anaerobic infection (Morgan, 2010). c) The underlying disease process is common to all types of NF, but the speed of development and associated clinical features differ greatly depending on the causative microorganism(s). d) Depending on the causative organism, NF is categorized as: (1) Type I is caused by a synergistic mixture of aerobic and anaerobic bacteria and is the most common form (Morgan, 2010). (2) Type II is a monomicrobial infection caused by GAS, either alone or with Staphylococcus aureus. (3) Type III is caused by marine organisms, mainly Vibrio. (4) Type IV is a fungal infection related to Candida and is rare, mainly affecting immunocompromised patients (Morgan, 2010). 2. Pathogenesis of NF a) The pathogens causing NF invade the subcutaneous tissue and proliferate rapidly. 3. Treatment includes: a) Antibiotics b) Intravenous administration of broad-spectrum antibiotics c) Wound management d) Aggressive surgical debridement e) Dressing changes 4. NF antibiotic therapy typically consists of: a) Intravenous administration of penicillin for gram-positive cocci b) Aminoglycoside for gram-negative aerobes c) Metronidazole for anaerobes 5. Surgical debridement is only effective treatment (lack of antibiotic penetration). a) All nonviable tissue, including fascia, must be surgically debrided. b) Patient might require debridement in operating room every couple of days. c) NPWT may be used. d) Amputation might be required (not healing, septic shock). 6. Given the high rate of systemic toxicity, decrease mortality by: a) Intensive monitoring b) Hemodynamic resuscitation c) Nutritional support B. Fournier’s gangrene 1. Fournier’s gangrene (FG) is a form of necrotizing fasciitis that develops in the perineal, genital, and perianal regions. It is more common in males than females (Czymek et al., 2010). 2. Treatment is similar to that for patients with NF: administration of broad-spectrum antibiotics for polymicrobial infections, aggressive surgical debridement, and wound management. C. Nursing care 1. Nursing care for NSTIs: Patients require complex, specific wound management. a) Dressing changes usually done several times a day. (1) Often complex and time consuming. (2) Dressing changes can be extremely painful. b) Administration of antibiotics in a timely fashion is imperative. (1) Peak and trough levels should be drawn accurately. (2) Antibiotic doses adjusted for maximal effect. PowerPoint Slides 1. Signs and Symptoms NF is difficult to diagnose in the beginning stage. In later stages, crepitus may be palpated in the affected area or may be seen radiographically. The underlying disease process is common to all types of NF. Depending on the causative organism. 2. NF is categorized as: Type I Type II Type III Type IV 3. NF Surgical Debridement—Only Effective Treatment All nonviable tissue must be surgically debrided. Patient might require debridement every couple of days. NPWT may be used. Amputation might be required. 4. Ways to Decrease Mortality Given high rate of systemic toxicity, decrease mortality by: Intensive monitoring Hemodynamic resuscitation Nutritional support 5. NF Possible Adjunct Therapies Hyperbaric oxygen therapy Intravenous immunoglobulins 6. NF Healing Process Systemic manifestations of infection disappear. Organisms reduced or eradicated. Transudate decreases in volume. Healthy granulation tissue appears. 7. Nursing Care for NSTIs Dressing changes several times a day Administration of antibiotics Aggressive pain management Monitor for septic shock and multisystem organ dysfunction Psychological support VIII. Enterocutaneous Fistulas A. Risk factors 1. Enterocutaneous fistula (ECF): passageway between GI tract and the skin a) Abdominal surgery b) Bowel anastomosis c) Repair of an enterotomy d) Unrecognized bowel injury 2. Management of ECFs is complex, challenging. Requires multidisciplinary team: a) Surgeons b) Enterostomal therapy nurses c) Nutritionists d) Physical therapists e) Occupational therapists 3. Conditions that increase the risk of enterocutaneous fistulas a) Hypoalbuminemia (albumin less than 3 mg/dL) b) Malnutrition at the time of surgery c) History of steroid use d) History of chemotherapy or radiation therapy to the abdomen e) Inflammatory bowel disease f) Trauma to the abdomen, abdominal compartment syndrome 4. Risk: malnutrition at the time of surgery a) Tissue repair and regeneration are compromised b) Bowel anastomoses are more likely to fail c) Allows GI contents to leak into the peritoneum 5. Risk: history of steroid use a) Long-term and/or high-dose steroids b) Poor wound healing 6. Risk: history of chemotherapy or radiation therapy to the abdomen a) Decreased tissue integrity b) Interferes with wound healing 7. Risk: trauma to the abdomen; abdominal compartment syndrome a) Bowel injury missed at the initial operation. b) Patient developed abdominal compartment syndrome. c) Abdomen was left open to heal by secondary intention. (1) Exposed bowel receives mechanical debridement from dressing changes. (2) Epithelial cells removed with the dressing changes. (3) Thinning of bowel wall; eventually breaks open. (4) Protect bowel with Vaseline gauze until sufficient epithelialization. B. Clinical presentation 1. First sign of an ECF is a local wound infection. 2. Abdominal incision healing by primary intention. a) Skin around the sutures or staples can become erythematous. b) Skin becomes shiny and tight. c) Appearance and odor of GI contents noted. d) Small amount of drainage might seep out of the sutures. 3. Open abdomen healing by secondary intention. a) Drainage might not be visible in the wound bed. b) Drainage apparent on the dressings as they are removed. c) Drainage changes from serosanguinous to green/brown. d) Drainage can have a fecal odor. e) Nurse must notify health care provider immediately. f) Early recognition crucial to prevent life-threatening complications. 4. Determine exact anatomic location of ECF—an important prognostic factor. a) Upper GI contrast study b) CT scan 5. Small bowel ECF vs. colon ECF a) Small bowel ECFs (proximal GI tract) (1) Associated with worse outcomes (2) Take longer to heal (3) Require longer courses of treatment and hospitalization (4) Higher output of GI drainage b) Colon ECFs (distal GI tract) (1) Do not have as much drainage (2) Stool from ECF more formed C. Collaborative management 1. Treatment includes: a) Correction of fluid and electrolyte imbalances. b) Nutritional support. c) Complex wound management. 2. Monitor and measure: a) Accurately measure ECF drainage for replacement. b) Monitor the patient for signs of hypovolemia. c) Monitor for the development of hypokalemia, hypocholoremia, and acidosis. 3. Nutritional support may include enteral or parenteral nutrition. a) Enteral nutrition b) Maintenance of GI mucosal integrity c) Improved immunologic host response d) Parenteral nutrition e) Allow administration of full nutritional requirements f) Aid in wound healing by decreasing ECF drainage 4. Nutritional support decisions are individualized based on: a) Location of the ECF b) Output from the ECF c) Patient’s overall metabolic and nutritional requirements 5. Management of skin integrity is extremely complex and challenging. a) Wound ostomy nurse can help manage these complex wounds. b) Developing the plan of care for these patients. c) Skin protection. d) Drainage quantification. e) Drainage containment. 6. Skin care: application of ostomy appliances (protect skin and contain drainage) a) Alteration in skin integrity around the fistula b) Enzyme content of the ECF drainage c) Prolonged exposure of the perifistula skin to moisture d) Prevents spontaneous closure of the ECF e) Predisposes the patient to infection 7. Decrease ECF output a) Reducing fluid and electrolyte imbalances. b) Promotes wound healing. c) Reduces GI secretions. d) H2 receptor antagonists. e) Proton pump inhibitors. f) Bowel transit may be slowed with anti-motility agents. 8. Anti-secretory agents are controversial (somatostatin, octreotide). a) Reduce secretion of GI hormones (gastrin and cholecystokinin). b) Decrease gastric and pancreatic secretions. c) Reduce fistula drainage. d) Decrease time to closure of ECFs. PowerPoint Slides 1. Enterocutaneous Fistula (ECF) Abdominal surgery Bowel anastomosis Repair of an enterotomy Unrecognized bowel injury 2. Multidisciplinary Team to Manage ECFs Surgeons Enterostomal therapy nurses Nutritionists Physical therapists Occupational therapists 3. Conditions That Increase Risk of ECFs Hypoalbuminemia Malnutrition at the time of surgery History of steroid use History of chemotherapy/radiation Inflammatory bowel disease Trauma to the abdomen 4. Risk: Malnutrition at Time of Surgery Tissue repair/regeneration compromised. Bowel anastamoses are more likely to fail. Allows GI contents to leak into peritoneum. 5. Risk: History of Steroid Use Long-term and/or high-dose steroids Poor wound healing 6. Risk: Chemotherapy/Radiation Therapy to Abdomen Decreased tissue integrity Interferes with wound healing 7. Other Risks Bowel injury missed at initial operation. Patient develops abdominal compartment syndrome. Abdomen left open to heal by secondary intention. 8. First sign of an ECF is a local wound infection. 9. Abdominal incision healing by primary intention Skin around the sutures or staples can become erythematous. Skin becomes shiny and tight. Appearance and odor of GI contents noted. Small amount of drainage might seep out of the sutures. 10. Open abdomen healing by secondary intention Drainage might not be visible in the wound bed. Drainage apparent on the dressings as they are removed. Drainage changes from serosanguinous to green/brown. Drainage can have a fecal odor. Nurse must notify health care provider immediately. Early recognition crucial to prevent life-threatening complications. 11. Determine exact anatomic location of ECF—an important prognostic factor. Upper GI contrast study CT scan 12. Small bowel ECF vs. colon ECF Small bowel ECFs (proximal GI tract) Associated with worse outcomes Take longer to heal Require longer courses of treatment and hospitalization Higher output of GI drainage Colon ECFs (distal GI tract) Do not have as much drainage. Stool from ECF more formed. 13. ECF Treatment Correction of imbalances Nutritional support Complex wound management 14. Monitor and Measure Accurately measure ECF drainage Monitor patient for: Hypovolemia Hypokalemia Hypocholoremia Acidosis 15. Nutritional Support Enteral nutrition Maintenance of GI mucosal integrity Improved immunologic host response Parenteral nutrition Full nutritional requirements Aid wound healing by decreasing drainage 16. Nutritional Support Decisions Are Individualized Location of the ECF Output from the ECF Patient’s overall metabolic/nutritional requirements 17. Management of Skin Integrity Wound ostomy Developing the plan of care Skin protection Drainage quantification Drainage containment 18. Skin Care: Application of Ostomy Appliances Alteration in skin integrity around fistula Prevents spontaneous closure of the ECF Predisposes the patient to infection 19. Decrease ECF Output Reducing fluid and electrolyte imbalances Promotes wound healing Reduces GI secretions Bowel transit slowed with anti-motility agents 20. Anti-Secretory Agents Controversial Reduce secretion of GI hormones Decrease gastric and pancreatic secretions Reduce fistula drainage Decrease time to closure of ECF IX. Pressure ulcers 1. A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence that occurs when blood circulation to an area is decreased due to compression of the skin between the bone and another surface. A. Etiology of pressure ulcers 1. Intrinsic factors that contribute to the development of pressure ulcers are those internal conditions that relate to the patient’s physical or mental health, such as nutritional status, mobility, incontinence, age, and skin condition. 2. Extrinsic factors are those that derive from the immediate environment, such as skin hygiene, medications, shear, and friction, and place the patient at increased risk. B. Risk factors for pressure ulcer development 1. Patients whose activity is restricted 2. Malnourished patients 3. Patients who are incontinent or whose skin is exposed to moisture C. Predicting risk for pressure ulcers 1. A widely used, clinically validated tool that allows nurses to score a high-acuity patient’s risk for development of pressure ulcers is the Braden Scale for Predicting Pressure Sore Risk (Table 9-5) D. Pressure ulcer staging 1. Pressure ulcers are staged according to the depth of injury using a staging classification system developed to ensure consistency in the assessment and documentation of these wounds. E. Collaborative management of pressure 1. Preventive measures are the best strategy to prevent or reduce the development of pressure ulcers 2. Treatment Decision Are Guided By the Stage of the Ulcer a) In Stage I, frequent turning and removal of pressure can prevent progression of the ulcer. b) Stage II and III ulcers need a moist healing environment. c) Stage IV wounds may require debridement, which can be accomplished surgically or by using specialized dressings or enzymes as well as packing to fill dead space and/or absorb exudate. F. Nursing management 1. Once a pressure ulcer develops, the nurse is responsible for assessing the wound at periodic intervals for improvement and response to treatment. G. Evaluation of pressure ulcer healing 1. The National Pressure Ulcer Advisory Panel (NPUAP) developed a tool to document the healing of ulcers known as the Pressure Ulcer Scale for Healing (PUSH). PowerPoint Slides 1. Pressure ulcer Skin and/or underlying tissue Usually over a bony prominence 2. Etiology of Pressure Ulcers Intrinsic factors Extrinsic factors 3. Risk Factors for Pressure Ulcer Development Patients whose activity is restricted Malnourished patients Patients who are incontinent or whose skin is exposed to moisture 4. Treatment Decision Are Guided by the Stage of the Ulcer Stage I Stage II and III Stage IV X. Chapter Summary XI. Clinical Reasoning Checkpoint XII. Post-Test XIII. References Suggestions for Classroom Activities Using the Internet and an image search engine (e.g., Google images), search for images of “necrotic wounds.” Study the various examples. Discuss in class. Using the Internet, visit the websites of the two commercial negative-pressure wound therapy systems mentioned in this section. Read the manufacturer’s website to see pictures of the equipment and see how their devices work:Vacuum-assisted closure® (VAC) by Kinetic Concepts, Inc., at www.kci1.com/82.asp. Blue Sky Medical Verstaile-1 Wound Management System at www.whatisbluesky.com. Suggestions for Clinical Activities Take the clinical group to tour a wound care clinic. Invite a guest speaker to meet with the class. The speaker could be one who has had a history of a longstanding wound. Ask the speaker to discuss the impact of the wound on his or her daily life. Review the health history of patients on the nursing unit who have wounds. What characteristics do they have in common? Are their treatment plans similar? What trends are noted? Wagner et al., Instructor’s Resource Manual for High-Acuity Nursing, 6th Edition ©2014 by Education, Inc.