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

4

Stage 3
Full thickness skin loss
involving damage or
necrosis of subcutaneous
tissue that may extend
down to, but not through,
underlying
y g fascia. The ulcer
presents clinically as a deep
crater with or without
undermining of adjacent
tissue
Unable to stage pressure ulcers
Factors affecting wound healing
„ Diabetes
„ Anaemia
„ Smoking
„ Vascularity
„ Autoimmune diseases eg
IBD,RA
, and skill
„ Immobility
„ Infection
„ Medications
„ Nutritional Status
„ Malignancy
10/12/2007
Stage 4
Full thickness skin loss
involving with extensive
destruction, tissue necrosis
or damage to muscle, bone,
or supporting structures eg
tendon or jjoint capsule.
p
Undermining and sinus
tracts may also be
associated with Stage 4
pressure ulcers.
External factors affecting wound
healing
„ Availability of Products
„ Medical Officers Orders
„ Nursing Knowledge
„ ? Pharmacists'
knowledge of product
performance
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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
conducive to healing
„ To promote comfort
„ To protect the wound and
surrounding tissue
„ To reduce ppain by
y excluding
g „ To apply
air from nerve endings
„ To maintain temperature in
the wound
„ To control and prevent
haemorrhage
„ To control and prevent
odour
„ To contain drainage
„ To immobilise an injured
body part
pp y compression
p for
haemorrhage or venous
stasis
„ To prevent and manage
clinical infection in wounds
„ To decrease distress for
client and carers by
covering the wound.
K Carville 2005
„ Removes excess exudate
„ Maintains a moist wound
healing environment
„ Allows gaseous exchange if
appropriate
„ Provides thermal insulation
of wound
„ Provides barrier to
pathogens
„ Does not promote infection
„ Does not shed fibres or leak
out toxic substances
„ Does not cause sensitivity
or allergic reaction
„ Protects against mechanical
trauma
„ Allows removal without
traumatising the new tissue
„ Is easy to apply
„ Is comfortable to wear
„ Is adaptable to body parts
„ Does not interfere with body
function
„ Is cost effective
K Carville 2005

Types of dressings Types of dressings

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

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