Pediatric Wound Care: It Sucks - Cox College
11/9/2017ObjectivesPediatric Wound Care:It Sucks Appropriate use and application of NPWT in pediatric trauma patients Special skin considerations of the pediatric population Choosing wound care appropriatelyWhat definesPediatrics? Aren’tkids just little adults? I have no conflicts of interest to disclose.Kris Torgerson, MSN, CHRNC, CWS, FNP-C1
11/9/2017What are challenges in Pediatrics?Building a TeamDevice Pressure ulcers in PediatricsPain controlCauses/RisksPressure ulcers are most common in patients requiring management in an intensive care unit.Adapting adultproducts forchildrenAdhesives on fragileskinSmaller sizeFragile patients, EBand Hem/Oncpatients, traumapatientsNPWTEvaluationCommon sites: sacrum/coccyx (most common site in children), occiput (most common site ininfants), and heels.The Braden Q Scale and Modified Braden Q Scale were developed to allow for standardizedassessment of pressure ulcer risk in pediatric patients. These scales are based on assessment ofmobility, activity, sensory perception, moisture, friction/shear, nutrition, and tissueperfusion/oxygenationMore than 50% of pressure ulcers in hospitalized children are related to pressure from devices andequipment,ALL equipment should be considered as potential injury creatingInterventionRelated to immobilityDifferent skin asphysiology maturesPressure ulcers in PediatricsIn children, Most frequently located in 3 areas:1)2)3)on the head and neck in association with the presence of a tracheostomy or noninvasive positivepressure ventilation interfaceon the torso in association with placement of electrocardiography leadson the digits in association with use of pulse oximeter probes.Appropriate padding of bony prominences and devices that come in contact with the skin; use ofage-appropriate specialty mattress such as an alternating pressure mattress, low-air loss, or foamor gel overlay; frequent repositioning; and frequent assessment and rotation, when possible, ofmedical devices.2
11/9/2017What are challenges in Pediatrics?Building a TeamDevice RelatedPressureUlcersDifferent skin asphysiology maturesAdapting adultproducts forchildrenHeightenedawarenessofcosmesisAdhesives on fragileskinAdhesives/Epidermal strippingPain controlSmaller sizeFragile patients, EBand Hem/Oncpatients, traumapatientsNPWTEpidermal stripping is a common form iatrogenic skin injury in neonatesand in any pediatric patient with compromised skin integrity, despite theuse of an adhesive remover prior to removal of adhesive dressings Inaddition, adhesive removal is painful and often a source of fear and anxietyin the hospitalized child.The use of dressings with soft silicone adhesive technology significantly reducedpain during dressing changesUse of a skin barrier product prior to the application of the dressing may minimizeepidermal stripping; use of a skin protectant under a product with a soft siliconeadhesive may interfere with dressing adherenceSelected Percutaneous Toxicities in ChildrenCompoundAlcoholToxicityElevated blood alcohol, cutaneous necrosisAdhesive remover solventsCutaneous necrosisChlorhexidineSystemic absorption, no known toxicitiesNeomycinNeural hearing lossPovidone-iodineHypothyroidismSilver sulfadiazineKernicterus, agranulocytosis3
11/9/2017What are challenges in Pediatrics?Building a TeamDevice RelatedPressureUlcersDifferent skin asphysiology maturesAdapting adultproducts forchildrenHeightenedawarenessofcosmesisAdhesives on fragileskinSpecial Considerations for Wound Care in InfantsPain controlSmaller sizeFragile patients, EBand Hem/Oncpatients, traumapatientsNPWT Children can develop irritant or allergic reactions to dressing andwound care products Minimize epidermal stripping Important to use special dressings Tubular net or stretchy overwrap to secure dressingsPain control-soft silicone based “sticky” dressingsDressings that require less frequent changesUse alcohol free skin preparation barrier Minimize cold stress in infants Special attention to NPWTSpecial considerations in children Infants and Toddlers –Mobility –Stool and urinary incontinence –Drooling –Stripping Adequate nutritional reserves Developmentally delayed children –Pain management, comfort and distraction during woundcare –Child Life specialists/play therapy Teenagers mobility and restriction of activity Increased risk for wound contamination Psychological factors Manipulation of dressings4
11/9/2017Evidence Based Pediatric Wound Care—what product should I choose?Wound Care Dressings in PediatricsThe Building Blocks of theFoundation for Wound Care Fundamentals of Dressings in Wound Care Types of Wound Care DressingsDebrideMoistureOff-loadTopicals5
11/9/2017Successful Wound HealingDebridementMoisture ControlTopical applicationsSuccessful Wound Care All You Need Is One Good Off-loadSurgical vs mechanicalBalance is importantDesigned aroundmoisture balancePressureEnzymatic vs autolyticLess painMoist wound healing iskeyAntimicrobial propertiesNPWTTopicalsNutrition Protein very important malnourishmentCirculation Trauma Congenital Alginate Melgisorb, melgisorb plus, aquacel, Antimicrobial Plethora of silvers, methylene blue/gentianviolet, HMBControl ofComorbidities May be disease related: DM, autism, down syndrome, etc May be birth defect, with mechanical issues, ie CP Hydrocolloid Hydrogel Matrix More advanced wound care used at WoundCenters Foam Transparent dressing NPWT system To heal 95% of wounds, it is the other5% you have to worry about6
11/9/2017Transparentpolyurethane filmContact layerMay containadhesiveSome containsoft-siliconeadhesiveSkin tearsSuperficial wounds withlittle to no exudateSecondary dressingSecure devices to skinSuperficial tearsSuperficial wounds withlittle to no exudateFirst- andsecond-degree burnsMinimal to moderateexudative woundsPressure ulcersPartial andfull-thickness woundsPrevents woundcontaminationProvides moist woundhealingPromotes autolyticdebridementNonabsorptiveSemipermanent; not intended forfrequent dressing changesMay result in epidermal stripping(if adhesive present)Prevents woundcontaminationProvides moist woundhealingAllows transfer of exudateinto absorbant dressingNonabsorptiveRequires secondary estoreContactRestoreContact SilverVersatelAdapticXeroformConformantWound VeilHydrocolloid (gelatin, pectin,and/or carboxymethylcellulose)MaycontainadhesiveMinimal tomoderateexudative woundsPressure ulcersPartial andfull-thicknesswoundsPromotes autolyticdebridementPressureredistributionPrevents wound contaminationPromotes autolytic debridementMinimal absorptionEase of useCaution in infected woundsMay cause maceration ofperiwoundMay result in epidermal stripping(if adhesive present)DuodermTegasorbMedihoneyPolyurethane foam andcompositeMaycontainadhesiveModerate to heavyexudative woundsPartial and full-thicknesswoundsPeristomalPressure redistributionInfected woundsbEase of removal (only ifnonadherent or containing softsilicone adhesive)Ease of useModerate absorptionPressure redistributionComfortableNot for use in dry woundsRequires a secondary dressing(unless HydrosorbHydrogelNonadherentMinimal exudate ordry woundsPartial andfull-thicknesswoundsBurnsPressure redistributionReduce painPromotes autolytic debridementPromotes epithelializationMay over-hydrate woundMay macerate periwound;consider applying skin sealantfirst as protectionAdds moistureMinimal to moderate absorptionFills dead spaceRequires secondary dressingSheet: Solosite Intrasite Normlgel Hypergel Carrasynwound gelHydrofiber (sodiumcarboxymethyl cellulose)NoneModerate to heavyexudative woundsPartial and full-thicknesswoundsWound dehiscenceInfected woundsbWounds requiring packingPromotes autolyticdebridementModerate to markedabsorptionAlginateNoneModerate to heavyexudative woundsPartial and full-thicknesswoundsWound dehiscenceInfected woundsbWounds requiring packingPromotes autolyticdebridementModerate to markedabsorptionBarrierNoneDiaper dermatitisPeristomalProtects againstmoisture-associated skindamageProtects against epidermalstrippingProtects against irritationfrom adhesivesRequires secondary dressingAquacelAquacel-AgRequires secondary dressingKaltostatMedihoneyMaxorb extraMaxorb extra-AgMay be difficult to assess wound withopaque preparationsResidual cream or ointment should notbe removed prior to reapplicationStomahesive waferStomahesive powderColoplast waferSensicare creamCriticaid ointmentWhite petrolatumZinc oxide ointmentCavilon No-StingbarrierEase of removalEase of removalMarathonEase of removal7
11/9/2017NPWTNPWTThe clinical goals of treating traumatic injuries include:Controlling any life-threatening eventPain managementStabilization of the patientTransport to surgery: initial damage repair, debridement, closureWhat if we can’t close?The safety and efficacy of these devices in neonates, infants, and children, has not been establishedand there are no devices that are approved by the U.S. Food and Drug Administration for use in thesepopulationsReduces Tissue edemaIncreases tissue perfusionRemoves exudatesFacilitates granulation formationDecreases frequency of dressing changesReduced need for use of pain medsDecreased length of hospital stay.NPWT cont.Several retrospective studies safe, cost effective (27-68 subjects)Types of injuries used on:LawnmowerOpen fracturesOpen abdominal/dehiscedPilonidal sinusPressure ulcers post debridementSTSG bolstering8
11/9/2017Building A Pediatric Wound Team Surgeons Pediatric Hospitalist Wound Specialist Pediatric Nurses Dietician Child life specialists Pediatric pharmacists9
Pediatric Wound Care: It Sucks Kris Torgerson, MSN, CHRNC, CWS, FNP-C Objectives Appropriate use and application of NPWT in pediatric trauma patients Special skin considerations of the pediatric population Choosing wound care appropriately I have no conflicts of interest t
board-certified wound care nurse from 8am–5pm Central Standard Time Monday–Friday. 1-888-701-SKIN (7546) » The NE1 Wound Assessment Tool This proprietary wound assessment tool is designed to dramatically increase accuracy, consistency and transparency in wound assessment. » WoundRounds Wound Management System This unique wound management
Sloughy Wound (Pale layer of dead or fibrinous tissue over all or part of the wound bed) Macerated Skin (Soft, pale/white, wet or soggy skin surrounding wound) Granulating Wound (Wound bed filled with highly vascular, fragile tissue) Determine if present dressing regime is Goal of Treatment Keep woundRemove non-vital tissue and management of
Wound edges open Not healing Wound with 25% avascular tissue (eschar and/or slough) OR Signs/symptoms of infection OR Clean but nongranulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appro-priate comprehensive wound management Note. Data from WOCN (2009).
Podiatrists provided the majority of wound care services (for the selected wound types) in office-based settings (Table 8). In outpatient facilities, a mix of specialties (e.g., podiatrists, surgeons, internists) provided wound care. The mean episode length for a wound care episode was 15.5 days (for the selected wound types), with a
Triad was applied to the wound bed and periwound skin. Wound as presented on Day 2. Triad is applied to the wound bed. Wound as presented on Day 2. Triad is applied to wound bed and periwound skin. "After 1 application of Triad, wound was progressing and the patient was able to continue to use Triad at home for wound treatment."
Wound Management Procedure (Tissue Viability and Wound Care (TVWC) Manual) Page 2 of 19 1. INTRODUCTION A systematic approach to holistic wound care is essential for the delivery of high quality wound care. Holistic wound assessment considers the
Communication Skills Learning Tools for the Pediatric Clerkship 37 Pediatric History Taking Approach to the Pediatric Patient 38-39 Explanation of Pediatric H&Ps/Pediatric Database 40-43 Example H&Ps (older child and infant) 44-52 Pediatric Physical Examination Benchmarks for Pediatric Physical Examination 53 54-65
Unit 14: Advanced Management Accounting Unit code Y/508/0537 Unit level 5 Credit value 15 Introduction The overall aim of this unit is to develop students’ understanding of management accounting. The focus of this unit is on critiquing management accounting techniques and using management accounting to evaluate company performance. Students will explore how the decisions taken through the .
