Pressure ulcer Discover the world of BSN medical.

Therapy approach

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Assortment folder

NEW Cutimed® Advanced wound care

Therapy approach: Venous leg ulcer

Therapy approach: Diabetic foot ulcer

Therapy approach: Pressure ulcer

For further information contact: BSN Medical (Pty) Ltd, South Africa Tel. +27 (31) 710 8111, Fax. +27 (31) 710 8225 • 30 Gillitts Road, Pinetown, 3610, PO Box 526, Pinetown, 3600 TollFree (orders) 0800 202 858/9 • TollFree (fax) 0800 203 555 • www.bsnmedical.co.za

Advanced wound care

A guide for the successful therapy of pressure ulcers.

Pressure ulcers can cause much suffering for patients. Treatment often takes several months and requires that a holistic approach be adopted to the patient and his or her circumstances.

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Infected wounds Critical colonisation and wound infection pose serious barriers to the healing process. Antimicrobial dressings reduce the bacterial load, preferably without using Sloughy substances that impair wound healing or promote the development of bacterial wounds resistances. Slough is a mixture of fibrin, pus, cellular debris and bacteria. Gel products gently help Granulating remove the slough. Antimicrobial dressings additionally reduce the wounds bacterial load. Heavily exuding wounds require professional exudate management. Highly absorbent wound dressings Epithelialising support the natural wound healing wounds process by maintaining an ideal Atraumatic moist environment. dressings provide protection of fragile skin and the newly formed epithelium. Medical skin care prevents the new skin from drying out and keeps it flexible and smooth.

exudate

management

preparation

Necrotic tissue inhibits wound healing. As an alternative to the surgical removal of necrosis, hydrogels provide a gentle method of debridement by donating moisture and supporting autolysis.

bed

This booklet focuses on the appropriate treatment of pressure ulcers, a wide-spread indication associated with numerous complications and suffering for patients. The therapy approach outlined was developed together with wound specialists and aims to provide a guide for all those involved in wound management. It demonstrates the principle of wound bed preparation, i.e. wound cleansing, preparing the wound bed for later stages of wound healing. It also offers information on the recommended treatment of pressure ulcers.

Necrotic wounds

wound

No two wounds are the same, yet every wound needs the best possible conditions to allow for its healing. The new Cutimed® advanced wound care range helps physicians and caregivers to create ideal conditions for wound healing – from autolytic debridement and antimicrobial therapy to exudate management.

Pathogenesis and Therapy

Pressure ulcers – particular characteristics.

How do pressure ulcers develop? Immobility is the most serious risk factor which may result in a pressure ulcer. If a certain part of the body is exposed for more than 2 hours to pressure, local ischaemia followed by cell damage can be the consequence. Continuous pressure could result in a blister, followed by loss of skin and tissue in a matter of hours. What are the stages and how are they recognised? Stage 1: visible reddening of the skin

Stage 2: formation of a blister

Manage the cause as well as the wound. A holistic approach needs to be taken when treating pressure ulcers. In addition to wound management, successful treatment should also involve further therapeutic measures. Pressure relief A variety of aids are available which help reduce the pressure on the affected skin areas. Soft positioning systems, for example, serve to enlarge the contact area. The distribution of pressure over the largest possible area or intermittent pressure relief is key. Today, the use of “traditional” aids such as furs, water mattresses, sitting rings and cotton dressings is no longer recommended. Positioning techniques The pressure can be relieved via various positioning techniques. Make use of the classic 30° oblique position and ensure frequent changes.

Stage 3: loss of skin areas

Stage 4: loss of deeper tissue, possibly affecting bones or tendons

(Classification ref: National Pressure Ulcer Advisory Panel, 1989 (NPUAP)

Pain treatment The majority of pressure ulcers are a source of pain which must be treated. It is recommended to keep a record of the pain, for example by keeping a diary. Restoring circulation An essential goal of treatment is restoring circulation to the skin area affected. This is achieved by systematically relieving the pressure on the area and by mobilising the patient, if possible. Nutrition Patients with pressure ulcers have increased energy and protein requirements and need a special diet. A diet containing sufficient vitamins and minerals clearly supports the healing process.

Where do pressure ulcers develop? Areas at highest risk for the devlopment of pressure ulcers are areas where there is only a thin layer of tissue present, between the skin and underlying bones. Common examples are:

sacrum

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heel

back of the head, shoulder blades 5

Wound bed preparation

Necrotic wounds: How to achieve gentle yet effective debridement.

Wound bed preparation step by step.

Important: what is the wound status? Necrotic Black, dry necroses form a barrier to wound healing. Large necroses are often surgically removed. A gentle alternative is autolytic debridement.

Infected A high bacterial load may lead to wound stagnation and infection. Antimicrobial therapy supports the healing process.

Sloughy It is advisable to remove slough and fibrin, which form a barrier to wound healing and may increase the risk of bacterial colonisation or infection.

Donate moisture to dry necroses: Necroses should be removed from the wound bed as they impair wound healing and hinder the assessment of wound size and depth. Autolytic debridement can be effectively supported by hydrogels. Cutimed® Gel shows high moisture donation and contributes to dissolving necroses – gently and effectively. Care must be taken not to over-apply so that maceration is prevented. Cutimed® Gel may be applied by the applicator provided, with a spatula or directly from the tube.

Dissolve necrotic areas: If a hydrogel is applied, a secondary dressing (film or foam dressing) needs to ensure the gel remains in place in order to dissolve necroses effectively.

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Film dressings (e.g. Leukomed® T or Fixomull® transparent) • prevent the hydrogel from drying out • help to maintain a moist wound environment Chronic wounds: Moist wound healing is the first choice! Today, the traditional, dry treatment of chronic, secondary healing wounds is widely seen as inappropriate as this would considerably compromise the wound healing process. Moist wound management, in contrast, provides an ideal physiological environment and allows nutrients, enzymes and growth factors to spread in the wound bed. These are the best conditions for the formation of new granulation tissue and epithelium.

Foam dressings (e.g. Cutimed® Siltec® B) • prevent the hydrogel from drying out • absorb wound exudate if present in other wound areas

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Wound bed preparation

Infected wounds: How to reduce the bacterial load.

Bind and inactivate wound pathogens: Cutimed® Sorbact® has proved effective in colonised and infected pressure ulcers. By a unique mode of action the microbial load is effectively reduced without using a chemically active agent, such as silver. Cutimed® Sorbact® is not linked to undesirable side effects or bacterial resistance and supports the natural wound healing process. Choose from a wide range of products depending on: • wound size • wound depth and • exudate level.

Manage various amounts of exudate: Depending on the levels of exudate, either • cover Cutimed® Sorbact® ribbon gauze or swabs with a transparent film dressing (Leukomed® T or Fixomull® transparent) • choose Cutimed® Sorbact® absorbent pads held in place by Fixomull® stretch or • apply Cutimed® Siltec®/Cutimed® Cavity as secondary dressings to absorb higher amounts of exudate.

Sloughy wounds: How to cleanse the wound bed.

Dissolve slough and fibrin: Autolytic debridement is an effective yet gentle method to dissolve fibrinous or sloughy tissue. Cutimed® Gel shows superior moisture donation which contributes to an effective therapy. Care should be taken not to over-apply the gel to avoid any risk of maceration. For your convenience, Cutimed® Gel allows various ways of application: • directly from the tube • via a sterile spatula (due to it’s viscosity even upside down, which is a major advantage in daily practice) • or by its sterile applicator (for deeper parts of wounds) For best results cover Cutimed® Gel with a sterile film dressing (e.g. Fixomull® transparent or Leukomed® T) Cleanse and prevent or manage infection: Cutimed® Sorbact® gel is a ready-to-use combination of an antimicrobial dressing and hydrogel. Wound pathogens are bound and inactivated by the unique Sorbact® method while the hydrogel component helps cleanse the ulcer of slough and fibrin. • Fold back overlapping egdes in direction of the wound to avoid maceration of skin or wound margins. • Use a secondary dressing that manages the moisture in the wound, e.g. Leukomed® T or Cutimed® Siltec® B.

Skin Care The surrounding skin of a pressure ulcer may be fragile, sensitive or dry. In addition, incontinence may compromise skin conditions. Skin care products with a neutral pH value are effective cleansing agents and could be used to maintain the natural skin barrier properties of the skin.

Important:

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• There is no wound healing without treating the underlying disease or avoiding the risk factors: make sure that adequate pressure relief is provided. 9

Exudate management

Granulating wounds: How to promote and protect the formation of new tissue.

Keyword: Granulation tissue. Today, the principle of moist wound healing is well accepted as the therapy approach of choice for chronic wounds. Clinical evidence confirms that moisture has various beneficial effects in the wound bed: • nutrients, growth factors, enzymes can easily spread across the wound • moisture facilitates the proliferation of new cells • epithelialisation is much quicker than in dry wounds

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7.0 5.2

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The major requirement for modern wound dressings is to support a balanced level of moisture in the wound bed.

Absorb wound exudate from the wound bed: • Fold or cut the dressing to the shape of wound. • Loosely fold Cutimed® Cavity into the wound. • As Cutimed® Cavity will swell at fluid uptake, only 60% of the wound should be filled. • For best results cover the wound either with a sterile film dressing (Leukomed® T) or with a foam border dressing (e.g. Cutimed® Siltec® B).

Absorption (g/cm2)

Biatain® Cavity

4.4

Allevyn® Plus Cavity

4.8

Permafoam® Cavity

Cutimed® Cavity

In-vitro tests confirm superior absorption. (DIN EN 13726-1: 2002, data on file).

Why absorption capacity is so important? State-of-the-art foam dressings are designed to maintain a moist wound environment which means that they are able to handle high amounts of exudate. Caregivers can rely on the high absorption capacity of Cutimed® Cavity dressings. The effect: superior fluid handling = longer wearing time = fewer dressing changes = less nursing time required = cost effective therapy!

Remove the dressing: The appropriate interval for dressing changes depends on the healing stage and the exudate level of the individual wound. In later stages of wound healing (after the wound bed is free from necroses, slough or infection) the frequency of dressing changes can be reduced. Cutimed® Cavity will not disintegrate after exudate uptake and can be removed as one piece.

Depending on wound depth: In case the granulation progresses and the wound bed fills with new tissue it may be appropriate to switch from Cutimed® Cavity dressings to Cutimed® Siltec® B which is designed to cover superficial wounds.

Cutimed® Cavity dressings are designed to provide superior fluid handling. • Carefully explore the wound depth. • Choose the appropriate size and shape. • Cutimed® Cavity dressings can be cut to size when needed.

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Moist wound environment

Epithelialising wounds: How to protect new tissue.

Protect new, fragile skin: Once the wound has filled with granulation tissue and epithelium begins to grow from the wound margins, dressings for superficial wounds can be recommended, preferably with a silicone layer for atraumatic dressing changes.

Ongoing therapy: How to keep the new skin intact.

Prevent skin from drying out: Once the wound is healed and newly formed skin covers the former wound bed, care must be taken to protect this new, fragile tissue. Waterin-oil products help the skin to become smooth and flexible and resistant to the mechanical stress (friction and shear) of day-to-day activities. In addition, mild cleansing products should be preferred as they maintain the natural pH value and prevent the skin from drying out.

Ensure atraumatic dressing changes: When larger parts of the wound are covered with epithelial cells the amount of exudate is likely to decrease. In this stage of wound healing using a thin border dressing is appropriate. As all dressings of the Cutimed® Siltec® range come with a silicone layer on the wound contact side they provide most gentle adherence to the dry peri-wound skin – and there is no adherence at all to the moist wound bed.

Provide medical skin care: Products with a skin-friendly pH value and the absence of colorants and fragrance provide optimal care for stressed, problematic and mature skin. Newly healed and dry skin needs to be stabilised by providing sufficient amounts of moisture and lipids to maintain the barrier function of skin.

The benefits of Cutimed® Siltec®’s silicone layer: • gentle adherence to fragile epithelium • undisturbed healing progress • pain-free dressing changes. In case of dry, healed wounds, impregnated sterile dressings (e.g. Cuticell® Classic) can be used in order to protect the fragile skin. As a secondary fixation film dressings are recommended (e.g. Fixomull® transparent).

Important:

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• There is no wound healing without treating the underlying disease or avoiding the risk factors: make sure that adequate pressure relief is provided.

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Product overview

All you need for the successful therapy of pressure ulcers. Primary dressing Necrotic wounds

Infected wounds

Sloughy wounds

Granulating wounds

Secondary dressing / fixation

Cutimed® Gel Donates moisture to dry necrotic or sloughy wounds.

Depending on level Cutimed® Sorbact® gel Reduces the bacterial load while providing a moist wound environment, cleanses from slough and fibrin layers.

of exudate: Cutimed® Sorbact® Binds and inactivates microbes in colonised and infected wounds.

Cutimed® Cavity Maintains a moist environment in deep wounds with moderate to high levels of exudate. Requires secondary fixation.

Cutimed® Siltec B Can be used as a secondary fixation and allows atraumatic dressing changes.

or

Leukomed® T or Fixomull® transparent The waterproof, fully adhesive transparent dressing. Allows wound inspection.

Cutisorb® LA A low adherent wound contact layer with excellent absorption.

Epithelialising wounds

Recurrence prevention

Cuticell® Classic Impregnated sterile dressing. Protects fragile skin and keeps a moist wound environment. Cleansing and moisturising products Help to improve the skin status of sensitive skin and severely dry and stressed skin on hands, feet and joints.

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Fixomull® stretch The economic temporary solution as long as highest exudate levels require frequent dressing changes.