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Adam's Weak Spots > Wound Care and Lymphedema > Flashcards

Wound Care and Lymphedema Flashcards

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1
Q

Prevalence of wounds in PC

A
  • 60% have 1+ wound at presentation
  • Average 1.8 wounds/pt at presentation
  • Average 1.5 new wounds before death
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2
Q

Prognostic significance of malignant wounds

A

1966: 3 months’ avg. survival
1993: 11 months’ avg. survival
Today: no impact on survival
:. Treat wounds!
:. Don’t write off wound patients

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3
Q

Prognostic significance of
pressure ulcers

A

Correlated w. poor prognosis rather than causative

Nonmalignant patients: death HR 2.42
Malignant patients: death HR 1.48
Worse for women

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4
Q

5 primary goals of wound mx

A
  1. Wound healing
  2. Wound maintenance (i.e. stop growth)
  3. Wound palliation
  4. Wound prevention
  5. Achieving patient GOC

In PC setting, 5 > 4 > 3 > 2 > 1

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5
Q

What is a pressure wound?

A

Ischemic necrosis d/t to arterial, venous, lymphatic stasis.

The stasis is caused by prolonged pressure over hard surface +/- friction/shearing.

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6
Q

Patient risk factors for pressure wounds

A
  • Advanced age
  • Multimorbidity
  • Cachexia
  • Neuropathy
  • Peripheral vascular disease
  • Paralysis
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7
Q

What is the primary pressure ulcer risk assessment scale?

A

Braden Risk Assessment

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8
Q

Describe the Braden Risk Assessment

A

24-point scale, lower = higher risk
<17 is considered at-risk

6 items, rated 1-4 each
1. Sensory function
2. Moisture
3. Activity (out of bed)
4. Mobility (in bed)
5. Nutrition
6. Friction/shear

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9
Q

What score does the Braden score correlate with in palliative pts?

A

Palliative Performance Scale

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10
Q

NPUAP Stages 0-I of Pressure Injury

A
  1. Healthy skin
  2. Nonblanchable erythema + intact skin
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11
Q

NPUAP Stage II of Pressure Injury

A

Exposed dermis or intact blistering
- Visible tissue is healthy/viable
- No visible fat/deeper tissue
- No granulation tissue or slough

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12
Q

NPUAP Stage III of Pressure Injury

A

Full thickness skin loss to subq tissue
- Fat + granulation tissue present
- Depth depends on anatomical loc’n
- No muscle/fascia/bone visible
- +/- slough that may make it unstageable

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13
Q

NPUAP Stage IV Pressure Injury

A

Full-thickness skin + tissue loss
- Exposed connective tissue, incl. Bone
- +/- slough that may make it unstageable

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14
Q

NPUAP Stage X Pressure Injury

A

Wound is too obscured to stage
- Slough and/or eschar
- Debridement will reveal stage III-IV
- Stage I-II don’t make slough
- Don’t debride dry stable eschar

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15
Q

What mnemonic reflects a sample approach to wound healing?

A

“DIME”

(D)ebridement/(D)ownloading
(I)infection/(I)nflammation management
(M)oisture balance
(E)dge management

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16
Q

Describe debridement approaches

A

Sharp debridement of dead tissue
- Reduces infx risk
- Promotes healing
- At bedside or in OR

Debriding wound products
- Hydrocolloids, hydrogels, alginates

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17
Q

Describe wound downloading

A

AKA offloading, pressure redist’n
- Goal is maximum surface area exposed
- Repositioning
- Soft surfaces and/or moving surfaces
- Lifting affected areas (esp. heels)

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18
Q

Describe bacterial flora of
Acute vs. chronic wounds

A

Acute: gram+ aerobes

Chronic: gram- and anaerobes

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19
Q

4 “stages” of wound infection

A
  1. Colonised without infection
  2. Superficial tissue infection
  3. Deep tissue infection
  4. Sepsis
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20
Q

What are some complications
of wound infections?

A
  • fistulae/sinuses
  • Abscess formation
  • Osteomyelitis
  • Compartment syndrome
  • Sepsis
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21
Q

What is the first sign/symptom
of wound infection?

A

Escalating pain–always look for infx

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22
Q

Approaches to superficial vs. deep wound tissue infections

A

Superficial: topical treatments
e.g. topical antibiotics
e.g. silver- or iodine-infused dressings

Deep: systemic antibiotics

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23
Q

Primary inflammatory mediator
in chronic wounds

A

Matrix metalloproteinases (MMPs)
* Released by neutrophils/macrophages
* Released by cancer cells
* Released 2* interleukins + TNF-a

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24
Q

How do MMPs impair healing?

A

Hyperinflammatory state:
* Damage extracellular matrix
* Kill fibroblasts and epithelial cells
* Inactivate growth factors

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25
Name 2 dressings designed to inactivate MMPs
Promogran© Prisma© (= Promogran© with Ag+)
26
How does excess moisture impair wound healing?
* Excessive tissue maceration * Reduces tissue tensile strength * Damage from toxic exudate products
27
What components of exudate can impair wound healing?
* Proinflammatory mediators * MMPs * bacteria/bacterial toxins * Necrotic products
28
What is the pathophysiology of exudate formation?
* High capillary permeability * Vascular perm. Factors from cancer * Increased venous/lymphatic pressure * Iatrogenic (creams, hydrogels)
29
Dressing approach to Highly exudative wounds
1. High absorbency dressings (see below) 2. Noncontact layer underneath 3. Consider plastic on top to protect clothing/fabrics 4. Consider abdo pads (not in contact) to save expensive absorbent dressings 5. Don’t change contact layer too often
30
What is an option for extreme exudate accumulation?
Negative pressure wound therapy (i.e. suction) Ostomy bags
31
What are “edge effects” in the DIME approach to wounds?
Refers to failure in wound to “edge” inward (i.e. heal). * Can be managed with NPWT, hyperbaric O2, skin grafts * Remember that malignant wounds don’t heal
32
What are 2 mnemonics for signs of deep and superficial wounds infx?
Superficial: NERDS Deep: STONES
33
“NERDS” Mnemonic
⅗ predictive of superficial wound infx NERDS: * Nonhealing (or worsening) * Exudate * Red wound bed * Debris * Smell worsening
34
“STONES” Mnemonic
4/6 predictive of deep wound infx STONE(EE)S: * Size increasing * Temp increasing (use IR thermometer) * Osteum exposed * New breakdown * Exudate/Erythema/Edema * Smell worsening
35
How common are malignant wounds?
15% of advanced cancer patients * 60% are exophytic/fungating * 40% are erosive
36
What 4 cancers are most associated with malignant wounds?
* Breast * Lung * Head/Neck * Primary skin
37
What are approaches to treating malignant wounds?
Malignant wounds are unlikely to heal, And will not heal w/o cancer treatment * Systemic chemo/hormonal/immunotx * Local radiation * 6% miltefosine topically (single small study)
38
List approaches to wound pain mx
regular/prn opioids, incl. Fentanyls Topical opioids EMLA Nonadherent base dressings Avoid gauze
39
List options for wound odour mx
1. Systemic/topical metronidazole 2. Charcoal-containing dressing 3. Wound cleansing 4. Topical antiseptics 5. Debridement 6. Environmental management - Aromatherapy - Ventilation - Pet litter/charcoal under bed - Baking soda
40
What are 2 “natural” options for debridement and wound odour mx?
Sugar pastes Honey Both create hyperosmotic env’t Honey may have some added effects
40
What is the risk of bleeding from malignant wounds?
<10%
41
List local options for wound bleeding mx
* Reduce freq. of dressing changes * Calcium alginate * ORC collagen * Silver nitrate cautery * Thromboplastin * Zinc chloride paste (Mohs’ paste) * topical/po TXA
42
What is the main contraindication for compression tx in VENOUS leg ulcers?
Inadequate arterial supply (per ABI)
43
List the main categories of wound care products
Absorbents Hydrating agents Protease inhibitors Antimicrobials Anti-odour Nonadherent layers
44
What are 5 considerations in choosing a wound care product
* Wound shape/depth * Wound moisture * Patient preference * Availability * Cost
45
What is lymphedema?
Protein-rich insterstitial fluid (and sequelae) ALMOST ALWAYS ASYMMETRICAL
45
Specific causes of Lymphedema
* Cancer treatment (sx, XRT) * Chronic venous insufficiency * Tropical illnesses * Primary lymphedema (congenital)
46
General cause of lymphedema
Damage to lymph vessels/nodes Congenital absence/abn of same
47
Oncology-Associated lymphedema features
* Associated w. Node dissection / XRT * 1-2 year latency from tx → onset * Can also mark cancer recurrence
48
Which 4 cancers are most associated with lymphedema?
* Breast ca (20-30%) * Gyne Cancer (5-50%) * Prostate ca (5-30%) * Melanoma + Sarcoma (5-30%)
49
List 5 lymphedema sequelae
* High protein → fibrosis * Abnormal fat distribution * Skin changes * Fibrosis can trap nerves/vessels → pain * Infection ←→ worse lymphedema
50
List 4 chronic skin changes in lymphedema
1. Hyperkeratosis 2. Thickened skin folds 3. Hyperpigmentation 4. Inflammation
51
List the 3 stages of lymphedema progression
1. Spontaneously resolves w. Elevation 2. No spontaneous resolution a. Will progress to fibrosis if untx 3. Skin changes develop
52
DDx of unilateral limb swelling consistent with lymphedema (i.e. alternative dx) (3)
* Cancer recurrence * DVT * Cellulitis
53
Skin care in lymphedema (4)
1. Fastidious skin hygiene 2. Low-pH moisturiser 3. Avoid extremes of temperature a. Heat → hyperemia → swelling b. Cold → rebound vasodilation 4. Avoid punctures if at all possible
54
General patient advice for lymphedema patients.
1. Skin care (see slide 55) 2. Ongoing exercise a. Resistance exercise can improve LE b. Cardio can prevent obesity c. Obesity worsens LE
55
What is the basis of lymphedema tx?
Combined Decongestive Therapy (CDT)
56
Describe combined decongestive therapy (CDT)
Physical therapy for lymphedema (a) increase current drainage routes (b) develop collaterals * Intensive phase to reduce edema * Maintenance phase to preserve * Patient responsible for maintenance
57
Describe CDT in lymphedema Stage I
* Compression garments * Elevation as able
58
CDT in Stage II lymphedema
* Initial non-elastic bandaging * Skin care * Manual lymphatic drainage * Followed by chronic compression garment use
59
Describe Manual Lymphatic Drainage (MLD)
* Goal is to enhance lymphatic vessel contractility/volume * Proximal → distal massage * Requires trained professional * About 45 minutes * Followed by bandaging * “Simplified lymphatic drainage” can be done at home
60
CDT in Stage III lymphedema
1. 2-4 week intensive treatment a. education/psychological support b. Skin care / cellulitis precautions c. Multilayer bandaging d. exercise/weight management 2. Full-time maintenance per patient 3. Aim to repeat in 1 year
61
What are the principles and advantages of bandaging in lymphedema?
* Inelastic—not ACE/tensor type * Remain on 24h day; off only for tx * remain on at night indefinitely * Replaced by custom compr’n garment * Benefit 20-60% reduction in edema
62
List 4 exercise goals/tips in lymphedema
* Weight control * Abdominal breathing to enhance thoracic duct flow * Weight training safe/healthy * Over-vigorous exercise can be counterproductive
63
Mechanisms of compression tx in lymphedema.
* Reduce pressure gradient * Mimic flow created by muscle contraction * Ultimately improve volume/elasticity of lymph vessels
64
Contraindications to limb compression
1. Acute DVT 2. Fragile CHF (can shift fluid to chest) 3. Arterial insufficiency 4. Wounds 5. Pain
65
Drug classes that may worsen lymph/edema (4)
1. NSAIDs 2. CCBs 3. Alpha antagonists 4. Diuretics (more complicated)
66
How can diuretics interact with lymphedema?
1. Likely to reduce edema a. Especially if comorbid venous edema 2. Increase tissue [protein] and :. fibrosis a. This is a long-term issue b. Less of a concern <1 year use

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