Risk factors
• Evaluate posture, activities, mobility, lifestyle and current support surfaces (sleeping and
sitting surfaces) for potential sources of pressure
• Communicate risks with all team members and clearly identify residents who are at risk
120120©2019 Medline Industries, Inc.
SHEAR
• Definition: Deformation of tissue by two oppositely directed parallel forces
• Dragging, sliding over sheets, slipping down bed and having head of bed > 30°
increases shearing force
• The addition of shear doubles the impact of pressure
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FRICTION
• Definition: Friction is the force of rubbing two surfaces against one another
• may contribute to or exacerbate pressure injury development
• usually accompanies shear
• friction alone is not a direct cause of a pressure injury
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NUTRITION
• Lack of optimal nutrition and hydration may interfere with wound healing
• Identify those at risk for poor healing due to inadequate nutritional intake using a validated
screening tool
• Develop a nutrition plan with the goal of optimizing nutritional status
• Refer those at risk to a registered dietitian
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SKIN MOISTURE
• Urinary and fecal incontinence increases the probability of pressure injury development
– Strateum corneum is macerated – softer
– Skin becomes more alkaline
– Friction & wet skin more easily damaged
• Incontinence Associated Dermatitis = higher risk of developing ulcers
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LOCAL WOUND CARE 125
Wound management strategies should be part of the
plan of care and fit with the overall goals
• Wound cleansing – should be used at body
temperature and should be nontoxic
• Debridement – removal of necrotic tissue
• Bacterial balance – managing bioburden with
antimicrobial dressings
• Moisture balance – use of dressings that absorb or
donate moisture to help create the optimal
environment
125©2019 Medline Industries, Inc.
PREVENTION IN PRACTISE
• Only 10.8% of the patients at risk received some pressure ulcer prevention while lying or
sitting (Vanderwee et al, 2011)
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PREVENTION STRATEGIES 127
• Use a validated risk assessment tool
• Provide regular skin assessment
• Manage pressure, friction and shear
• Positioning and repositioning
• Manage moisture
• Monitor nutritional intake
127©2019 Medline Industries, Inc.
Prevention strategies
• Risk Assessment:
• Conduct a risk assessment using a
validated pressure injury risk assessment
tool (e.g. Braden, Norton)
• Develop a care plan based on the
subscale scores put the person a risk
• Prevention plan should include
interventions that minimize the factors
identified
128128©2019 Medline Industries, Inc.
Prevention strategies
Skin Assessment:
•A head‐to‐toe skin assessment should be
carried‐out for those identified at risk for skin
breakdown
•Assess areas of vulnerability such as bony
prominences, skin folds, perineal and
perigenital area and under medical devices (ie
tubing)
•Differentiate pressure injuries from other
wound etiologies (IAD, skin tears)
129129©2019 Medline Industries, Inc.
Prevention strategies
Manage pressure, friction & shear:
•Maintain mobility while focusing on
reduction of pressure, friction and shear
•Use wedges or heel boots to suspend heels
off the bed
•Utilize support surfaces on wheelchairs and
beds – make sure staff continue to reposition
•Staff should be knowledgeable about the
maintenance and operation of the devices
130130©2019 Medline Industries, Inc.
Prevention Strategies 131
• Positioning and repositioning:
• Position every two to four hours while in bed
• Weight shift every 15 minutes when sitting
• Minimize head of bed elevation and utilize
turning sheets
• 30° side‐lying position with a pillow or wedge
behind the trunk and pillow between legs
• Positioning and repositioning can be assessed by
a PT/OT
131©2019 Medline Industries, Inc.
Prevention Strategies 132
• Manage Moisture:
• Implement a skin‐fold hygiene program to keep
skin dry
• Implement a structured and consistent skin care
program that includes:
– Cleansing with a pH balanced skin cleanser after each incontinence
episode
– Application of a topical barrier to protect skin
– Moisturizing skin using a fragrance free moisturizer to maintain
supple, hydrated skin
132©2019 Medline Industries, Inc.
Prevention Strategies 133
• Nutritional Intake:
• Assess weight changes over time
• Assist at mealtimes to increase oral intake
• Offer snacks and fluids between meals
133©2019 Medline Industries, Inc.
CONCLUSION
• Clearly IDENTIFY who is at risk
• REPORT & DOCUMENT reddened areas ASAP and REVIEW care plan regularly
• COMPLETE assessment tools to determine if goals have been met
• INSPECT skin regularly
• BE KNOWLEDGEABLE about the devices and equipment being used
• Effectively MANAGE moisture on the skin
• Keep PRESSURE OFF pressure points
• ENCOURAGE resident to eat well and drink fluids
• KEEP MOVING – encourage movement of limbs when possible
134134©2019 Medline Industries, Inc.
REFERENCES
• BC Provincial Nursing Skin and Wound Committee website (Connecting Learners with Knowledge) 2014. Accessed on Dec. 29,
2018: https://www.clwk.ca/buddydrive/file/braden‐scale‐interventions‐algorithm/
• Foundations of Best Practice for Skin and Wound Management. Best Practice Recommendations for the Prevention and
management of Pressure Injuries. Sue Rosenthal (Ed). Canadian Association of Wound Care (Wounds Canada). 2017
• Chan et al. Net costs of hospital‐acquired and pre‐admission PUs among older people hospitalised in Ontario. Journal of Wound
Care. Vol 22, Issue 7, 2013
• Gray, M & Giuliano, K. Incontinence‐Associated Dermatitis, Characteristics and Relationship to Pressure Injury. Journal of Wound
Care Nursing, Jan/Feb 2018, pg 63‐67.
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance.
Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Emily Haesler (Ed.). Cambridge Media: Perth, Australia:
2014
• Pieper B. Pressure Ulcers: Impact, etiology and classification. In Bryan R & Nix D (Eds): Acute & Chronic Wounds: Current
management concepts (4th Ed), Philadelphia, 2012, Mosby.
• Vanderwee et al. Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey: A nationwide
prevalence survey. BMJ Quality and Safety.2011; 20(3):260‐267
• Woodbury G, Houghton, P. Prevalence of Pressure Ulcers in Canadian Healthcare Settings. Ostomy/Wound Management.
2004;50(10):22‐38, Norton, L. et al. Best practice recommendations for the prevention and management of Pressure Injuries.
Wounds Canada 2017.
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ASSESS THE WOUND
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Deep Tissue Injury
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Stage 1
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Unstageable
139©2019 Medline Industries, Inc.
Stage 3
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Skin Tear
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Stage 2
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Leg Ulcer
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Tip of bone
Stage 4
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Incontinence Associated Dermatitis
145©2019 Medline Industries, Inc.
Section 10:
Diabetic Foot Ulcer
Prevention and
Management
Medline Canada
5150 Spectrum Way, Suite 300
Mississauga, ON L4W 5G2
Lower ExtremityWound I.D.
Know what to look for when identifying
Diabetic Foot Ulcers
Where is the wound located?
Anywhere below the knee, but usually on the bottom of the foot.
How is the wound shaped?
Likely round and with a calloused edge.
What is the color of the wound bed?
Pink, red, well granulating, all depending on circulatory status.
What is the volume of exudate?
Varies, depending on the size and location.
What does the area around the wound look like?
Calloused edges, dry skin, might be flaky or macerated, depending
on the drainage level.
How bad does it hurt?
Varies, but might be dull and achy. Might also be completely painless
due to neuropathy.
Did you know?
A diabetic foot wound might look like a callus at first, but then reveal
a full thickness wound once all the callus tissue is debrided and removed.
Find more skin health insights and expertise at MedlineSkinHealth.com
2019 Medline Industries, Inc. All rights reserved. Medline is a registered trademark of Medline Industries, Inc. MKT19121922 / 69
Lower Leg
Assessment &
Compression
• “The most common underlying etiologic factors responsible for chronic delayed healing
among lower extremity wounds encountered in the outpatient clinic are chronic venous
insufficiency (CVI), diabetic neuropathy, and arterial insufficiency”
42 42©2019 Medline Industries, Inc.
Arterial Insufficiency
• PAD – peripheral arterial disease
• Decreased blood flow through arteries
– Narrowed arteries d/t plaques formation – atherosclerosis
– end result a Ischemic wound
43 43©2019 Medline Industries, Inc.
• Coronary artery disease co existing
• Diabetics – 4x more likely to have PAD
• Correctable by surgery only!
44 44©2019 Medline Industries, Inc.
VENOUS INSUFFICIENCY
• “failure of the veins to adequately circulate the blood, especially from the lower
extremities”
• valve incompetence – valve reflux
• Calf muscle pump failure
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Wound Differences
•• Venous • arterial
Gaiter area: distal 1/3, • lower calf – ankle –toes
• ABSENT PEDAL PULSE
ankle • Minimal exudate
• ++ pain
• Palpable pedal pulse • “punched out”
• ++ exudating appearance
• Healing slow if at all
• Achy, tired feeling
– surgery
• Irregular borders
46
• Bench mark healing 12wks
chronic, reoccurring
46©2019 Medline Industries, Inc.
Ve•noTheu disffe rvencse . Arterial • Arterial
• Venous
47©2019 Medline Industries, Inc. 47
Which is it?
• Ankle Brachial Pressure – part of lower leg assessment
– VLU Uncomplicated – 0.8‐ 1.15
• High compression
– Mixed Arterial & venous – 0.65 – 0.8
• Low – moderate compression
48©2019 Medline Industries, Inc. 48
• Arterial – 0.5 ‐0.65
– Severe arterial ‐ <0.5
– NO COMPRESSION
49©2019 Medline Industries, Inc. 49
Assessment ‐ Arterial
• Bilateral
• Punched out appearance – well defined margins
• Wound base ‐ poorly perfused, dusky, dry
• Minimal discharge, minimal bleeding, minimal edema
50 50©2019 Medline Industries, Inc.
• Cool feet/legs
• Dependent rubor
• Pale, shiny, taunt skin
• Minimal hair growth
• PAIN PAIN – with ambulation, when supine, when elevated‐ danglers
51 51©2019 Medline Industries, Inc.
52 52©2019 Medline Industries, Inc.
treatment
• Manage blood pressure
• Smoking cessation ‐ gradual
• No restrictive stockings
• Avoid tight foot wear
• Avoid sitting for long periods
• Avoid cold temps
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• Manage wound – decrease risk of infection
• SURGERY to revascularization
54 54©2019 Medline Industries, Inc.
Venous Insufficiency
• Abnormal blood flow through veins
• Slowed return of blood from legs to heart
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Stand up!
56 56©2019 Medline Industries, Inc.
VENOUS INSUFFICIENCY
57©2019 Medline Industries, Inc. 57
Assessment ‐VLU
Bilateral!
• Edema
• Varicose veins
• Ankle flare: tinny varicose vessels inner ankle
• Woody fibrosis : Hyperkeratosis – over proliferation of keratin layer, woody texture to
touch
58 58©2019 Medline Industries, Inc.
• Atrophie blanche –scarring from injury i.e. VLU; poor blood flow to area
59 59©2019 Medline Industries, Inc.
ASSESSMENT
• Induration: hardening of the skin due to surround inflammation
• Hemosiderein staining: break down of blood cells under the skin
60 60©2019 Medline Industries, Inc.
assessment
• Minimal hair growth from mid calf downward
• Ask how client sleeps – “lazy boy” venous wounds will be relieved with elevation
61 61©2019 Medline Industries, Inc.
Risk factors ‐ VLU
• History:
• Age ‐ mean 60‐80 yrs
• Sex – women at slightly higher risk
• Family history – varicosities
• Past VLU
• Lifestyle: smoking, obesity, poor nutrition
62 62©2019 Medline Industries, Inc.
• # of pregnancies – out flow
• Occupation – long periods of standing/sitting
• Trauma
• Arthroscopic surgery – fixation at hip/ankle leads to decreased calf pump effectiveness
• History of DVT
• Congenital venous system anomalies
63 63©2019 Medline Industries, Inc.
Compression
• “…compression works by squeezing the limb, thereby reducing oedema and aiding venous
return to the heart”
• gold standard for treating Venous wounds
• Activation of calf muscle pump
64 64©2019 Medline Industries, Inc.
• Mild compression ‐<20mmHg
• Moderate compression > 20‐30mmHg,
• High compression > 30‐40mmHg
• Single layer, 2 layer, 3 layer, 4 layer
65 65©2019 Medline Industries, Inc.
Right wrong
66 66©2019 Medline Industries, Inc.
Points to remember!
• Don socks before getting out of bed in AM
• Removal at night – if possible
• Can be off max 2hrs – drsg change, bathing
• Moisturize, moisturize, moisturize!
• New socks Q6 mos
• Hand wash & hang to dry
• Base of toes 2 fingers below knee ALWAYS!!!
• Assistive devices available for donning
67©2019 Medline Industries, Inc.
Compression
• High compression 30‐40 mmhg ‐ >0.8 – Fourflex, Coflex TLC
• Moderate compression 20‐30 mmhg – 0.6‐0.8 – Threeflex, Coflex lite
• Low compression 15‐20 mmHg ‐ socks
• Graduated compression – higher @ ankle tapering to ½ knee
68 68©2019 Medline Industries, Inc.
Contraindications
• Uncontrolled CHF
• Poorly controlled Diabetes – caution & observation
• Arthritis in ankle – poor dorsiflexion
• Elderly w cognition issues
• Infection
69 69©2019 Medline Industries, Inc.
Compression is on going
Socks:
– OTC – 15mmHg
– Prescription – over 15mmHg – certified fitter
– Change q 6 mos
– Hand wash, hang to dry
– LIFE LONG
70 70©2019 Medline Industries, Inc.
REFERENCES
• Lymphoedema Framework. Best Practice for the Management of Lymphoedma;
International Consensus. London: MEP Ltd, 2006
• Pain and health‐related quality of life in people with chronic leg ulcers: W. M. Hopman, MA
(1, 2); M. Buchanan, PHCNP, MSc (3); E. G. VanDenKerkhof, RN, DrPH (4, 5); M. B. Harrison,
RN, PhD (4)
• Best Practice Recommendations for the Prevention and Treatment of venous Leg Ulcers:
Update 2006; Cathy Burrows, RN, BScN; et all
• Assessment & Management of Venous Leg Ulcers: RNAO Nursing Best Practice Guidelines:
March 2004
71©2019 Medline Industries, Inc. 71
• reference: World Union of Wounds Healing Societies (WUWHS), Principals of best practice
– Compression in Venous leg ulcers: A consensus document. London MEP 2008“Author(s):
• William Marston, MD; Wounds; Volume 23 ‐ Issue 12 ‐ December 2011
72©2019 Medline Industries, Inc. 72
Compression Low working pressure
High resting pressure
Long stretch/Inelastic No calf pump involvement
Poor edema containment
• Short stretch Can be dangerous for PAD
High working pressure • Fourflex, Threeflex
Low resting pressure
Encourages calf pump involvement 73
Good edema containment
Improves venous & arterial flow
Coflex TLC, Comprilan
73©2019 Medline Industries, Inc.
ABPI
• >0.9 – 1.2 = normal
• 0.8 – 0.9 = mild ischemia
• 0.5 – 0.79 = moderate ischemia – mixed ulcer
• 0. 35 – 0.49 = moderate – severe ischemia
• 0.20 – 0.34 – severe ischemia
• < .2 – critical
• > 1.2 – probably calcification
• CAWC‐ RNAO – Best Practice Recommendations for the Prevention and Treatment of
Venous Leg Ulcers: Update 2006
74 74©2019 Medline Industries, Inc.
Section 11:
Lower Leg Assessment and
Compression Therapy
Medline Canada
5150 Spectrum Way, Suite 300
Mississauga, ON L4W 5G2
Lower ExtremityWound I.D.
Know what to look for when identifying
Arterial Wounds
Where is the wound located?
Usually on the distal portion of the leg, often on the heels and/or toes.
How is the wound shaped?
Usually round, “punched out” shape with well-defined borders.
What is the color of the wound bed?
Likely pale, non-granulating. May also contain necrotic tissue.
What is the volume of exudate?
Wound may appear dry due to minimal drainage.
What does the area around the wound look like?
Dry. Skin may be fragile, sometimes erythema is present.
How bad does it hurt?
This wound may be very painful due to inadequate
level of blood flow.
Did you know?
Walking may improve the symptoms of arterial disease by helping
to develop better collateral circulation.
Find more skin health insights and expertise at MedlineSkinHealth.com
2019 Medline Industries, Inc. All rights reserved. Medline is a registered trademark of Medline Industries, Inc. MKT19121923 / 69
Lower ExtremityWound I.D.
Know what to look for when identifying
Venous Wounds
Where is the wound located?
Most often appears around the inner side of the ankle joint
(medial malleolus).
How is the wound shaped?
Wound may appear large and shallow, with irregular sloping edges.
What is the color of the wound bed?
Ruddy red and may appear swollen, possibly with yellow slough.
What is the volume of exudate?
May appear “wet” with a moderate to heavy amount.
What does the area around the wound look like?
It could be macerated, crusted and scaled. May be edematous,
have discoloration of skin or be hyperpigmented.
How bad does it hurt?
Often dull to severe, requiring medication before assessing change.
Did you know?
Most venous wounds do not heal without compression, as it is necessary
to improve venous blood flow return from the legs, ankles and feet.
Find more skin health insights and expertise at MedlineSkinHealth.com
2019 Medline Industries, Inc. All rights reserved. Medline is a registered trademark of Medline Industries, Inc. MKT19121921 / 69
Diabetic Foot
Ulcer
Management
Agenda
• What is Diabetes
– Type 1
– Type 2
• Diabetes Facts Canada
• Assessment
– History
– Feet
– Peripheral Neuropathy
– Management
– Foot Care/Wear
– Offloading
– Holistic Management
– Dressing Selection
– Case Study
76 76©2019 Medline Industries, Inc.
Diabetes – what is it?
• “ A chronic disease that occurs when the body is either unable to sufficiently produce or
properly use insulin. Insulin, a hormone secreted by beta cells in the pancreas, enables the
cells of the body to absorb sugar from the bloodstream and use it as energy source.”
• Canadian Diabetes Association; www.diabetes.ca
77©2019 Medline Industries, Inc.
Diabetes Type 1
• Immune system attacks the pancreas
• Pancreas makes no insulin
• Usually diagnosed in childhood or adolescence
• Insulin dependent
• Accounts for 10% of diabetics
78 78©2019 Medline Industries, Inc.
DIABETES Type 2
• Pancreas does not make enough insulin or the body cannot use the insulin
• Accounts for 90% of diabetics
• Controlled by lifestyle change i.e. weight loss, exercise
• Progressive without lifestyle changes
79 79©2019 Medline Industries, Inc.
Diabetic Foot Ulcers ‐ Canada
• 2016 – 11 million living with pre‐diabetes, Type 1 and Type 2
• 15‐25% will develop a DFU
• 85% of amputations are related to DFUs
• 5 year mortality rate is 50% post amputation
80 80©2019 Medline Industries, Inc.
Diabetic Foot Ulcers ‐ Canada
• Health care costs:
• Acute DFU ‐ $21,347
• Chronic DFU ‐ $52,360
• Total direct cost $547 million (2011)
81 81©2019 Medline Industries, Inc.
ASSESSMENT
• Resident history:
• Current and past health history
• Recent HbA1C
• Past diabetic complications
• Identification of peripheral vascular disease risk factors (50% of patients with a DFU, also
have PVD)
• Complications – cardiac, renal, retinol, neuropathy
–
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ASSESSMENT
• Both Feet:
• Structural deformities – claw or hammer toes, Charcot foot, limited joint mobility
• Skin and nail changes – dry, cracked, callous, fungus
• Areas of pressure
• Vascular – colour, temperature, pulse (consider ABPI or TBI doppler)
• Sensation ‐ monofilament test
• Pain
• Footwear ‐ wear and tear on shoes, sizing
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hammertoe
84 84©2019 Medline Industries, Inc.
Charcot Foot
• Rocker bottom
• Significant neuropathy and loss of sensation
• Multiple fractures
• Signs and symptoms of infection
– Warmth, redness, pain, swelling
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Charcot Foot
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Peripheral Neuropathy
• Motor – structural changes to the foot
• Sensory – loss of sensation (starts with tingling and burning, feet will eventually become
numb)
• Autonomic – loss of sweat gland production
87 87©2019 Medline Industries, Inc.
Foot Care
• Check both feet daily – redness, dry skin, cracks, callous
• NO foot soaks
• Bath and dry thoroughly ‐ don’t forget between toes
• Moisturize whole foot avoiding between the toes
• Seek professional help for nail care
88 88©2019 Medline Industries, Inc.
Foot Wear
• Check footwear inside/outside for pressure points regularly
• Check inside of shoe for objects before applying the shoe
• Properly fitted foot wear – wide toe box ideal
• Shop for shoes in afternoon/evening
• Wear socks and shoes at all times
• Socks – breathable, no elastic banding
89 89©2019 Medline Industries, Inc.
Holistic Management
• Support coordination of care
• Appropriate referral –dietician, endocrinology, ophthalmology, chiropody, vascular surgeon
• Provide patient education to modify behavior
– Canadian Diabetes Association: website, blogs
• OFFLOAD; OFFLOAD; OFFLOAD!!
90 90©2019 Medline Industries, Inc.
Offloading
• Offloading is the removal or redistribution of pressure to the foot
• Continued pressure decreases blood flow to wound – circulation is vital to wound healing
• Begins with callous formation
• Treat early to prevent deterioration
91 91©2019 Medline Industries, Inc.
OFFLOADING
• Total Contact Casting – gold standard
• Offloading: MUST be consistent
• “One unprotected step erases days of worth of healing” – Dr. Perry Mayer, 2016
92 92©2019 Medline Industries, Inc.
Dressing selection
• Based on nursing assessment of wound
• Primary Dressing:
• Assess for S&S of infection
• Antimicrobial dressings include silver, iodine, PMHB, honey
• Assess level of drainage
• too much moisture consider an alginate or gelling fiber
• dry wound bed, consider a hydrogel or surfactant gel
93 93©2019 Medline Industries, Inc.
DRESSING SELECTION
• Secondary Dressing:
• Small to moderate drainage – composite dressing, or thin foam
• Moderate to heavy drainage – foam, or superabsorbent
• Heavy drainage ‐ superabsorbent
94 94©2019 Medline Industries, Inc.
Case study
• 59 yr old male
• DM x 5yr
• At diagnosis met with dietician no other “education”
• HbA1C 9.9 @ last testing, 2 months earlier – says his BS is usually 7 in the morning ‐
doesn’t test at night
• Insulin x2/day – hasn’t spoken to MD since HbA1C done
• Wound 1yr:
– Saw GP x2
– Used Fucidin x3mos
– Used Ag Sulfadiazine x3mos – same tube
95 95©2019 Medline Industries, Inc.
Case Study
• Does dressing himself 2x/day – gauze & tape
• Wound:
– 10 x 5 x 3.3
– Callous surrounding – cuts it himself with exacto knife
– no odor, no redness, no pain
• Employed in construction, supervisory position
• Wear construction boots daily
• Married, 3 kids
• Good insurance plan
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97 97©2019 Medline Industries, Inc.
Case Study Questions
• What referrals should you send?
• What health teaching would be most important?
• What dressings would you select for topical management?
• Does the patient require debridement? If yes, what type of debridement?
• What kind of offloading footwear would you recommend?
98 98©2019 Medline Industries, Inc.
References
• Botros, M., Kuhnke, J., Embil, J., Goettl, K., Morin, C., Parsons, L., ..Evans, R. (2017).
Foundations of best practice for wound management: Best practice recommendations for
the prevention and management of diabetic foot ulcers. Retrieved from
https://www.woundscanada.ca/docman/public/health‐care‐ professional/bpr‐
workshop/895‐wc‐bpr‐prevention‐and‐management‐ of‐diabetic‐foot‐ulcers‐1573r1e‐final/file
• Canadian Diabetes Association. (2019). Types of diabetes. Retrieved from
https://www.diabetes.ca/about‐diabetes/types‐of‐diabetes
• Driver, V.R., LeBretton, J.M., Allen, L., Park, N.J. (2016). Neuropathic wounds: The
diabetic wound. In R.A. Bryant and D.P. Nix (Eds.), Acute and Chronic Wounds: Current
Management Concepts (359‐397). St. Louis, MO: Elsevier.
• Wounds Canada. (2017). The burden of wounds in Canada. Retrieved from
https://www.woundscanada.ca/leader‐change‐maker/overiew/burden‐ of‐
wounds‐in‐canada
99 99©2019 Medline Industries, Inc.
Section 12:
Allied Health Care Worker
Module
Medline Canada
5150 Spectrum Way, Suite 300
Mississauga, ON L4W 5G2
AM1
Prevention
and
Management
of MASD
Agenda
• Skin structure
• MASD: IAD & Intertrigo
25©2019 Medline Industries, Inc.