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10/12/2007

Role of the pharmacist

Pharmacists & wounds „

„
Dispenser
(Shop keeper)
„ Assessor
„ Advisor
„ ?Clinician
Carmen George „ Referrer
Clinical Nursing Specialist Services „ ?????????

Overview of how wounds heal Wound healing physiology

„ 2 stages of wound „ Inflammation 0- 3 days


healing ‰ Capillaries contract & thrombose to facilitate haemostasis
‰ Haemostasis ‰ Ischaemia in wound causes release of histamine causing
„ Vasoconstriction vasodilation of surrounding tissues
response ‰ More blood to surrounding tissue causing swelling
swelling, heat
heat,
„ Platelet response erythema and discomfort
„ Biochemical response ‰ Polymorphs & macrophages arrive to wound to provide a
‰ Tissue repair defence response
„ Inflammation „ Reconstruction 2- 24 days
„ Reconstruction
„ maturation
„ Maturation 24- 365 days

Wound healing physiology Wound healing physiology

„ Inflammation 0- 3 days „ Inflammation 0- 3 days


„ Reconstruction 2- 24 days
‰ Polymorphs kill pathogens and macrophages digest „ Reconstruction 2- 24 days
bacteria and debris. cleaning up the wound
‰ Macrophages also stimulate fibroblasts to produce collagen „ Maturation 24- 365 days
‰ New vascular network is built by the process of ‰ Remodelling phase
angiogenesis-new capillary development can be seen in
granulation tissue ‰ Tensile strength of wound is increased
‰ Epithelial cell migration occurs from wound edges and from ‰ Decreased vascularity
hair follicles etc. Mitosis thickens epithelium
‰ Wound contraction occurs simultaneously within this period ‰ Scar size decreases

This model is acute wound healing as opposed to


„ Maturation 24- 365 days chronic wound healing

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No person no wound

What characteristics of
A holistic assessment of the client should be the patient and their
undertaken in conjunction with a wound wound should be
assessment, to not only determine why the included in a
wound is present but to also uncover any comprehensive wound
factors that will retard healing assessment?

K.Carville

Wound Assessment Type of Healing

„ Type of wound „ Measurement


„ Type of healing Dimensions
„ Exudate „ Primary intention
„ Tissue loss
„ Surrounding skin „ Secondary Intention
„ Clinical appearance
pp
„ Pain „ Delayed Primary
„ Location
Intention
„ Wound Infection

Type of Wound Tissue loss

„ Surgical incision „ Superficial-epidermis


„ Traumatic-abrasion, „ Partial-epidermis and
laceration, penetrating, dermis
contusion, skin tears „ Full-Epidermis, dermis
„ Burns-minor, major and subcutaneous
„ Lower limb ulcers- tissue
vasculitic ulcer, diabetic
ulcer, venous, arterial
neuropathic etc
„ Pressure ulcer

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Clinical Appearance Location

„ Epithelialising „ Documented as a point of


reference
„ Granulating
„ Identifies problems
„ Contracting associated with access
„ Slough
g „ Ease of dressing gpprocedure
„ Eschar „ Highly movable part
„ Prone to friction and shear
„ Angiogenesis

Measurement Dimensions Exudate

„ Point of reference „ Amount


„ Can be repeated „ Colour
„ Objective
„ Viscosity
„ Length
„ Depth „ Colour
„ Volume replacement „ Odour
„ Undermining „ Type
„ Tracts

Surrounding Skin Pain

Does it need protecting? „ May need addressing


„ Maceration prior to procedure
„ Oedema „ May indicate infection
„ Erythema „ May be related to
„ Denuded wound practices or
„ Lesions products
„ Reactions to tapes or
dressings

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Wound Infection Extra information required usually for

„ Growth of an organism in a „ Skin tears


wound with associated
tissue reaction „ Lower limb ulcers
„ Infection delays wound „ Pressure ulcers
healing
„ Identify patients at risk ie
those with predisposing
conditions

Skin Tears Lower Leg Assessments

„ Presence or absence of
dorsalis pedis and posterior
tibial pulses
„ Ankle and calf
measurements
„ Neurological sensitivity to
touch and pain
„ ABPI

Pressure Ulcer Assessment


Stage 2
Stage 1
Observable pressure-
related alterations of Partial thickness skin loss
intact skin whose involving epidermis
indicators as
compared to the and/or dermis. The
adjacent or opposite ulcer is superficial and
area in the body may presents clinically as an
include changes in one
or more of the abrasion, blister, or
following: Skin shallow crater
temperature,tissue
consistency and/or
sensation
Clinical Practice Guidelines for the Prediction and Prevention of
Pressure Ulcers AWMA 2001

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Stage 3 Stage 4

Full thickness skin loss Full thickness skin loss


involving damage or involving with extensive
necrosis of subcutaneous destruction, tissue necrosis
tissue that may extend or damage to muscle, bone,
down to, but not through, or supporting structures eg
underlying
y g fascia. The ulcer tendon or jjoint capsule.
p
presents clinically as a deep Undermining and sinus
crater with or without tracts may also be
undermining of adjacent associated with Stage 4
tissue pressure ulcers.

Unable to stage pressure ulcers

Factors affecting wound healing External factors affecting wound


„ Diabetes
healing
„ Anaemia „ Availability of Products
„ Smoking „ Medical Officers Orders
„ Vascularity
„ Nursing Knowledge
„ Autoimmune diseases eg
IBD,RA
, and skill
„ Immobility „ ? Pharmacists'
„ Infection knowledge of product
„ Medications performance
„ Nutritional Status
„ Malignancy

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Types of products Principles of wound management

„ No such thing as the ‘ideal dressing’ ie one „ Define/identify the aetiology


dressing wont do for all types of wounds. „ Identify and if possible control or eliminate
„ What are you trying to achieve? factors that can impair or effect wound
healing
„ Short term objectives
„ Set long term and short term objectives
„ Longer term objectives „ Implement a management plan/regime
‰ Refer to appropriate clinician
„ Review and evaluate management regime
„ Nursing, medical, hospital, clinic
regularly
„ Plan for wound healing maintenance

Why dress a wound?? Ideal Dressing


„ To create an environment „ To control and prevent „ Removes excess exudate „ Does not cause sensitivity
conducive to healing odour „ Maintains a moist wound or allergic reaction
„ To promote comfort „ To contain drainage healing environment „ Protects against mechanical
„ To protect the wound and „ To immobilise an injured „ Allows gaseous exchange if trauma
surrounding tissue body part appropriate „ Allows removal without
„ To reduce ppain by
y excluding
g „ To apply
pp y compression
p for „ Provides thermal insulation traumatising the new tissue
air from nerve endings haemorrhage or venous of wound „ Is easy to apply
„ To maintain temperature in stasis „ Provides barrier to „ Is comfortable to wear
the wound „ To prevent and manage pathogens „ Is adaptable to body parts
„ To control and prevent clinical infection in wounds „ Does not promote infection „ Does not interfere with body
haemorrhage „ To decrease distress for „ Does not shed fibres or leak function
client and carers by out toxic substances „ Is cost effective
covering the wound.
K Carville 2005 K Carville 2005

Types of dressings Types of dressings

„ Natural fibre dry dressings-gauze, combine, „ Foam dressings eg Biatain, Hydrasorb,


lint, linen Polymem, Allevyn, Lyofoam. Sheets or cavity
„ Non adherent dry or film coated dressings „ Calcium Alginate dressings eg Kaltostat,
island dressings eg Telfa, Melolin, Melolite Sorbsan, Algoderm, Algisite M. Sheets or
„ Tulle Gras eg Jelonet, Adaptic,Cuticerin rope
„ Tulle Gras with antiseptics eg bactigras, „ Hydrocolloids eg Duoderm Comfeel,
Inadine Cutinova Hydro (sheets, powder & pastes)
„ Semi permeable Film dressings eg Opsite, „ Hydrogels eg Intrasite, Comfeel Purilon
Tegaderm Duoderm. Tube,sheets, impregnated
dressings

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Types of Dressings Modern Wound Dressings


Absorbent exudate managers
„ Hydrofibres- Aquacel. Sheets and filler
„ Multilayer Absorbent dressings eg Alione, Combiderm
„ Charcoal dressings eg Carbonet, Carboflex, Actisorb Plus
„ Hypertonic Saline Inpregnated dressings eg Curasalt, Meslat,
Hypergel
„ C d
Cadexomer Iodine
I di d dressings
i
„ Interactive wet dressings eg Tenderwet
„ Silicone dressings eg Mepitel, Mepilex
„ Silver dressings eg Acticoat, aquacel Ag, Polymem Silver etc
„ Ceramic wound treatment devices egCerdak
„ Capillary wicking dressings eg Vacutex
„ Honey eg medihoney, B Naturals, L Mesitran

Leg Ulcer management Absorbent Wound Fillers


Compression bandaging

Autolytic Debriders Antibacterial

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Anti infective silver dressings Sophisticated products available in


Australia

Silver at the chemists? New Ideas ?

Wound Bed Preparation Includes


What does this mean? „ debridement,
Basically preparing the „ exudate management
wound for healing „ infection control,, and
Usually referring to „ conversion of static
chronic wounds that wounds to active
have stalled in the wounds
healing process

Readings and Resources

„ AWMA 2000 Standards for Wound Management


„ AWMA 2001 Clinical Practice Guidelines for the
prediction and Prevention of Pressure Ulcers
„ Carville K. 2005 Wound Care Manual(5th edition).
Silver Chain.
Chain WA
„ www.worldwidewounds.org
„ SAWMA www.sawma.org.au
„ AWMA www.awma.org.au