Educational Webinar: Advanced Products for Pressure Injuries

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Conference Title: Advanced Products for Pressure Injuries Date: Wednesday, 14th May 2025 Hello, and thank you for joining us today. My name is Brandon Martin, here at McKesson Medical Surgical, and I'm so excited to welcome you to today's Clinical Connections Presentation, Advanced Products for Pressure Injuries. Before we get started, I'd like to direct your attention to our disclaimer. And while you are reviewing that information, I will remind you that this presentation is being recorded. In about a day or two, you can expect to receive a link to re-watch the presentation. And if you have a question, feel free to enter it into the Q&A panel, which is just to the left of your webinar window, at any time. And we will do our best to answer at the end of the presentation. Our speaker today is representing the McKesson Medical Surgical’s newly formed Clinical Center of Excellence, Patricia Howell. Patricia is a registered nurse with over 25 years of experience in the healthcare industry. She has spent ten years working with McKesson Medical Surgical. And she has also held various positions in long-term care, including director of nursing, corporate clinical director, and nursing home consultant. Ms. Howell is an expert in areas such as regulatory compliance, clinical practice, quality improvement, and operational management within the nursing home industry. She also received specialized training in infection control, skin and wound care education. Patricia, thank you so much for joining us today. Thank you, Brandon. And I have to chuckle at myself. I wrote my experience when I joined McKesson 11 years ago, so I now have 36 years of experience. I'm getting – I am aging, is what I am doing. I want to thank you all for joining me today. This should be a good presentation. I'm going to be discussing definition and the definition and impact of pressure injuries, importance of advanced management strategies, and explore advanced products and their benefits. First, we need to understand what are pressure injuries, what causes them, what are the risk factors? I'll talk a little bit about staging of pressure injuries and the impact on patient health and cost. And so causes and risk factors, extrinsic [inaudible], extrinsic factors, is prolonged pressure. That means somebody has been on this bony area for a while, friction and shear force. As you're sitting here, you might be slumping back in your chair, and when you slump back, you can feel shear. That's that bony soft tissue interface. You can feel that movement. For people who are frail, that move that can cause tissue damage. Friction is rubbing, like rubbing your heel on the sheets. Friction injuries can, in addition with pressure, break open the skin and cause a pressure injury. Impact injury, that's somebody who's fallen and can't get up. They had a hard fall, they're laying on a bony area. Heat, moisture, posture, the way they're sitting in a chair, maybe not sitting properly. Intrinsic factors, immobility, the person can't move around well. They can't do any kinds of shifts and turns. Sensory loss, maybe someone who is a diabetic or not, maybe they have neuropathy. They can't feel the bottom of their foot and they put their foot in their shoe and there's a pebble in there and they get an injury from that. Age, the older we get, the more fragile our skin gets and the less adipose tissue we have to help keep us nice and supple and prevent injuries. Disease, people who are diabetics, people who have vascular disease. There's a lot of disease processes that can help cause injuries. Body types, think about somebody who's really thin and bony. They don't have a lot of cushioning and so they can get a pressure injury much quicker. Or somebody who's bariatric, where they have a lot of weight, that's a lot of pressure on them. Somebody who weighs 400 pounds. Malnutrition, they're not getting adequately nourished or have enough fluids. And then incontinence, if someone is not being changed properly or timely or they have briefs that are too big and they leak, or they're not changed – they don't have a regular changing pattern. And they're sitting in a wet brief or a BM for a long time. Any extended period of time, along with pressure, can cause them to have pressure Injuries. Pressure injuries have a variety of names through the years. Pressure ulcers, bedsores, the cubes. And its localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. A pressure injury is a localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense pressure, prolonged pressure, or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. The National Pressure Injury Advisory Panel is – makes the definitions for pressure injuries, and they update them on a regular basis. So, a few years ago, well, probably more than a few years ago, going back, they – The National Pressure used to be called Pressure Ulcer. Now it's Pressure Injury. Why did they change the name? If you look at this picture, a stage one is an injury, it's not an ulcer. A stage four is an ulcer. So if you say an injury, that covers everything. So, what is a stage one? A stage one is going to be intex skin non-blanchable erythema. I'm not going to read the entire definition. You can go to the National Pressure Injury Advisory panel, if you don't know what the actual definitions are. You can go there and download free information. You can also go, and I'll mention this website a couple of times, the Wound Education Institute, WCEI. And they are a partner of McKesson's and we have a lot of complimentary, resources from them. And you can go to their website. They have a great free blog that has really good information. Stage-two pressure injury, partial sickness skin loss with exposed dermis. It also could be a fluid-filled blister. A stage-three pressure injury is full thickness skin loss. You might see some fat visible in the ulcer. If you are reading documentation and somebody says it's a stage-two pressure injury and there's beefy rug granulation tissue, no, that can't possibly be a stage two. It would have to be a full thickness skin loss. So somebody mis-staged that. Stage-four pressure injury, full thickness skin and tissue loss. Then there is un-stageable and that's where the bottom of the wound bed is totally obscured by slough necrotic tissue eschar. Once that eschar is removed, you will be able to see the bottom of the wound bed and it will be either a three or a four-pressure injury or pressure ulcer. Deep tissue pressure injury is a dark maroon non-blanchable deep red or purple. It could be a purple fluid-filled blister. Difference between a stage two and three blisters, stage two is going to be clear, and deep tissue is going to be purple. And then there's a mucosal membrane injury. Mucosal membrane injuries cannot be staged, and they're caused by medical devices. It could be from a Foley catheter, it could be from any device in the nose, in the mouth. Impact on patient health and healthcare costs. When somebody has a pressure injury, it can affect their socialization. It can put them at risk for infection. There can be delayed wound healing, reduced mobility. If they have something on their foot there, they may not be able to walk very well. I've seen heel ulcers and then the person tries to put their shoe on, and they can't get it on and they can't walk, they can't go outside. It's a problem, reduced mobility. It can have a great psychological impact. And then there's risk of loss of limb. I'll talk about diabetic foot ulcers a little bit later, but anywhere in the lower extremity, it can put them at risk for losing that limb. If we can prevent the pressure injury, all the better. That's going to cost – save you a lot of money by prevention, by putting good systems and protocols in place. Impact on healthcare, very expensive to treat pressure injuries. Billions of dollars. I find – I have a very difficult time wrapping my head around $96.8 billion. It is a huge strain on the healthcare system. It's a big strain on caregivers. We have limited clinician capacity. But prevention is much better than having some – than not taking care of the people and then having pressure injuries and not having the time to then take really well care of them. It will cost readmissions. People who have infections, they're probably going to be readmitted. It's a big risk for readmissions. Loss of productivity related to changes in condition, related to dressing changes. And it has an effect on their – the person's quality of life. Prevention strategies. Traditional versus advanced approaches – Excuse me. Regular positioning and skin assessments and then use of advanced products to enhance, prevention. So some approaches, levering technology, telehealth. During – I had to make a move recently and I didn't have a doctor, and I used telehealth. It was a lifesaver. I felt that way. Telehealth is great if you have a rural community to utilize telehealth. Digital imaging. And then total wound solutions. There are solutions that provide pressure mapping. There's wearable sensors for real-time monitoring. And you can use that data to drive your decision making. Repositioning, do's and don'ts, don't drag lift. Sometimes you think, well, there's only me here. If there's only you there, have the patient help you as much as possible. Make sure the bed is flat. Have them bend their legs so they can help push. Use draw sheets so that you can help – lift them instead of pulling them. Do a tissue tolerance test. Not everybody's tissue can tolerate the same amount of pressure, everybody is different. Don't position the individual on bony prominences with existing non plantable erythema. Do use pressure relieving devices for at risk patients and patients with pressure injuries. It could be a multi-podus boot for somebody who is high risk of a heel. Wheelchair cushions, all sorts of pillows to help get them off their area at risk. Don't use the 90-degree side length position, do use the rule of 30. So you don't want to have the head of the bed all the way up and having that person sit at that 90-degree ankle. It's better if they're more at a 30 degree. So using the 30-degree rule, that's no more than 30 degrees, and that they're tilting their body in the 30-degree lateral position. Don't ignore patient discomfort. If they complain that this is – I don't – this doesn't feel right, this hurts, readjust them so that they are more comfortable. Ask them. And if they can't talk and tell you exactly, look at any facial expressions or wincing. There's always some kind of signs. If somebody's feeling good than if they're not feeling good. Use pillows and cushions for support. There's all sorts of, even little stuffies, little stuffies can help. Sometimes you only need a little bit of movement to get them tilted so that they're not on that pressure area all the time. And do communicate with the patient. It's very important to talk about the plan with them. I know you don't like laying on your left side, but let's try this for ten minutes, five minutes. Can you do it for five minutes? Even five minutes will help them getting off that area. Repositioning and mobilization when possible encourage mobility. Even if they just stand up. Okay, I know you can't walk, but let's push yourself up out of the chair. Or have them put their hands on the wheelchair arms and push up a little bit. Turn and reposition all at-risk patients, unless contraindicated. Schedule frequency based on the support surface and use the tolerance of skin for pressure and the patient's preferences. Gone are the days of routinely turning people queue two hours. That's very antiquated and that was developed back in the early 1900s. Now you do a tissue tolerance test and turn and reposition based on that. When turning, place the patient in that less than 30-degree sideline position and ensure the sacrum is off the bed. Assess the level of immobility, their exposure to shear, skin moisture, perfusion, body size, and weight. We talked about, or I talked about that earlier. Of the patient when choosing a support surface. There are great mattresses that have special cushioning for somebody that has a risk of heel injuries or other areas. That, depending on the person, you can select the right mattress for them. The right prevention. Features of a wound assessment. When you are assessing a wound, the first thing you need to know is etiology. What caused this wound to occur in the first place? Is it a pressure injury? Is this an acute injury from a skin tear, a fall? And what is the size of this injury? So, when you measure, always measure the longest length by the widest width using the face of a clock in centimeters. We don't describe it in the size of a quarter nickel or dime. Tissue type. Is the tissue granulation tissue, necrotic tissue, eschar, peri wound and skin condition. Is the skin dry and clear? Is it macerated, dish pan-hand looking? What is the amount of exudate? Is it copious amount, small amount? Odor. Always check the odor after the dressing's removed and the wound is cleansed. Is there pain associated with dressing changes or pain in the wound? Wound edges, are they open or closed? Wound tissue type. And then changes since the previous assessment. Even if you were the clinician that did the last assessment, still read that last assessment and look for the little nuances. You see a lot of patients during the week, you're never going to be able to remember everything. Where was that undermining and tunnelling? The tunnelling is at – towards the right hip. And that will help you then when you go in to do this assessment, that you're going to look in the right place for that tunnelling. Products used in modern wound care. There's a lot of different ideas in that wheel and spoke, different types of dressings there. Negative pressure wound therapy is an example. There's traditional, with the canisters, and then there's disposable. And there are a lot of different disposable negative pressure wound therapy devices on the market that can fit the need for every agency, every organization, and every patient's wound. There are bio-engineered skin substitutes, growth factors and cytokines, hyperbaric oxygen therapy, cell-based therapy. I'm amazed with 3D printing and what that can do for people, bioprinting. Smart dressings that can conform – that can, pardon me, that can inform the clinicians of the wound condition. If the wound's too wet, if it's too warm, usually it's too cold. Nanotechnology, an example of nanotechnology is a three-dimensional formulation for the dressing treatment and the hydrogel-based dressing. So, the technology is just bursting at the seam. It gets better every day. Advanced dressings and wound care products promote a moist wound healing environment. So we want to promote a moist wound healing environment versus dry and scabby. When I, a very long time ago, when I started working in the nursing home industry, sadly we did not have the technology or the studies like we have now to tell us that moisture and healing environment's the best way to heal the wound, other than taking off the pressure. You always want to remove the pressure. But when I was growing up in the nursing home industry, we used dry healing. And dry healing meant, you'd go to jail if you used this now, a heat lamp, milk of magnesia, Maalox. No, it's very bad. Who thought of that? We are much better now. When you know better, you do better. We have innovative dressings. Hydrocolloid and foam dressings are great go-to’s. And the foam dressings are now silver impregnated and antimicrobial. And there's blue dressings and green dressings that have all sorts of great things impregnated into them. I did mention negative pressure wound therapy. And the benefits is that it's promotes healing. You will have quicker healing and reducing the infection risk. And we want to maintain optimal moisture levels. A little bit about support surfaces and the benefits. Dynamic air mattresses. I think these have come a long way also. Always make sure that air mattress is functioning. Check it. If you are in a nursing home, check it a couple of times per shift to make sure everything's connected. If you're in home health or hospice, when you are there, if the person is sitting up and they're not in bed, still go back to the bed where that mattress is and check to make sure it's functioning properly. There's air – low air loss beds, alternating pressure mattresses, and their benefits are pressure redistribution, moisture management, and enhanced comfort. We want people to be comfortable. If the person's comfortable, they're going to be happy. Position the individual in such a way as to reduce the risk of pressure injury. Pad between, if they're lying and their legs are together, put some padding between their legs. The pressure injury develops – oh, and for surgery, their special ways to distribute pressure over a larger body surface area and offloading bony prominences. So, we even have to speak to people going into surgery, make sure that they're protected. Select a support surface that meets the individual's need for pressure redistribution based on these factors, level of mobility, immobility, and inactivity. Need to influence microclimate control and shear reduction. Microclimate could be kind of moist and hot in those areas where the rest of the body's fine. Size and weight of the individual is important. Number and severity and location of existing pressure injury is paramount. You need to know, if they have it on the heel, you're not going to have their heel on the bed. Risk for developing new pressure injuries. For individuals with obesity, select a support surface with enhanced pressure redistribution. They're going to need a special mattress, not the everyday mattress for somebody that only weighs 100 or 150 pounds. And for shear reduction in microclimate features. There's a lot to think about. For individuals with stage three or greater heel pressure injury, elevate heels using a specifically divine heel suspension device, offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the achilles tendon and the popliteal vein. Sometimes people will use waffle boots, quilted boots, that might provide comfort, but that is not going to relieve pressure. If they have a pressure injury, it has to have no – it has to have nothing touching the heel. There should be space, airspace, between the heel and whatever device is on their foot, to keep it suspended. Keep the pressure off. For individuals with a pressure injury, consider changing to a specialty support surface when the individual cannot be positioned off the existing pressure injury. Has pressure injuries on two or more turning surfaces, the sacrum ventral cancer, that will limit repositioning options. Has a pressure injury that fails to heal or the pressure injury deteriorates despite appropriate comprehensive care. Is at high risk for additional pressure injuries. Has undergone slap or grip surgery. Is uncomfortable or bottoms out on the current support surface. Do you know how to test for bottoming out? If you don't, you're not sure. The best way to test for bottoming out is when the person is sitting, for example, in their wheelchair and they have a cushion in their chair. Put your hand between the seat and the bottom of that cushion. Can you feel the bony areas? If you can, that's bottoming out. And then do the same thing for the mattress on the bed. Put your hand between the bed frame, the bed, and then that mattress. And if you can feel their heel or any bony areas, then that's bottoming out. Seating surface. Select a seat and seating support surface that meets the individual needs for pressure redistribution, with consideration to body size and configuration. I've said this a couple of times, because it's really important to remember. Effects of posture and deformity on pressure distribution, mobility, and lifestyle needs. So, think about somebody who has contractures, somebody who has scoliosis, things like that. They're – they have special needs. Re-evaluate after patient's change in condition. So, if someone has significant weight loss, you may want to take a look at the specialty devices and cushions that they are using to make sure it still meets their needs. Advanced dressings and wound care products, we're going to talk about these dressings. Got a whole long list here, from A to Z. Actually, it's A to X. Calcium alginate and hydro fibres. Antimicrobials, there's so many different antimicrobials on the market. You always want to keep in mind when you are selecting, addressing, or considering dressing selection. Think about the patient's wound, where it's located, and preventing the risk of infection. And you may want to choose an antimicrobial dressing initially. For example, honey dressing, a honey gel over plain gel. Use the honey gel to help prevent that infection. And then once the symptoms or the signs or the fluff is cleaned up, then switch to the regular gel. You could do the same thing for calcium alginate. Start with silver, and then after a couple of weeks, that wound should be cleaned up enough to go to the plain. Collagen, composite dressings, compression, contact layers, foams. Foams come in thin foam, thick foam, antimicrobial foam, film back foam, border foam, silicon adhesive, non-adhesive. The list goes on and the technology continues to improve. Film honey, hydrocolloids. Hydrocolloids have been around for a very long time, but they continue to improve, and they are good cost-effective dressing to use. Hydrogels are great, super absorber, skin protection. I say protect the skin with no stink. Peri-wound skin, every time you have a dressing change. And sometimes you might need to use an adhesive remover for certain types of dressings. Don't use those non-stink skin prep with silicone used in dressings. They don't need the extra adherence because they're not supposed stick, they're not super stickers. Tapes, they're silicone tapes. Transparent films, the nice thing about transparent films is that they're conformable and they're see-through. So, if you need to see what's happening, instead of peeling back and peaking, you can see through the transparent dressing. But just keep in mind that if it – the wound is in an area where someone will see it and expose others to it, you might want to protect it. Because you don't – transparent films will soften up that tissue, it gets to be a soupy mess, and it can't – it's not pretty. It can be pretty ugly. But it's great for friction too. So, the heel, you can use a transparent film protection. Lots of waterproof dressings. Wound cleansers, I recommend using wound cleansers, especially for pressure ulcers with any slough versus normal saline or sterile water wound cleansers. I believe this is the world according to Patricia. The first step and the most important step in wound bed prep is cleaning the wound with the wound cleanser. Clean from the inside to the outside of the wound. And don't forget about the peri wound. And zero foam is a specialty dressing. It has 3% bismuth in it, antimicrobial, and it has a lot of uses. Wound healing is like an orchestra. It is complex and has multiple players and they all have to be playing in harmony for the wound to heal. And so, we're talking about the phases of wound healing. The first phase, hemostasis phase – I was just checking my time, excuse me. That stops the leak five to 15 minutes after injury, clotting. These are the things that occur, blood vessel constriction, platelets stick together, coagulation occurs. Plug forms with fibrin occurs quickly in a matter of seconds, clot forms, and keeps the platelets and blood cells trapped. And then the clean-up crew comes in. This happens 24 to 48 hours and can last up to two weeks. Injured blood vessels leak, localized swelling occurs, neutrophils and macrophages release cytokines and growth factors. All these create swelling, heat, pain, and redness that are common in the inflammatory phase. And this is a natural part of wound healing. And then we have the proliferative phase where we're rebuilding. This takes – start is in the two to three days and lasts up to 20 days. Collagen and extracellular matrix are deposited to help rebuild the tissue. Granulation tissue starts filling up the cup. This phase of wound healing can be seen as an abundant formation of granulation tissue. We don't want the granulation tissue to be so happy across, up and out of the wound. Contraction starts and finally epithelialization occurs. And that's when we put the lid on it. Now it's time to reinforce the remodelling phase. It continues for up to two years. It's a long time. New epithelium is final scar tissue formation. The temporal strength is – it's never going to be the same as what it was in the beginning. And the scar tissue will have only a 50% to 80% original strength as compared to the un-wounded tissue. And the original strength of the tissue will never be the same. The goldilocks effect, I mentioned moisture and healing environment. So we don't want the wound to be too wet, not too dry, just the right amount. And advanced wound care products help manage moisture very well. Make sure that you consider skin and barrier protection. I'll just talk a little bit about lotions, notions, and potions. Lotions are light non-greasy; they're mostly made of water and provides cooling effect. Easy to apply and there's lots of different choices on the market. Creams are great, they're thicker. They have oleum properties to them, and they are less occlusive and hydrating more so than ointments. So, using a great cream every day, an ounce every day, is going to help keep that person's skin hydrated and supple. Ointments are thick and greasy. So, think about petrol latum or something with lanin in it. That is going to be a little like Vaseline, that's thick and greasy. It has the place. But think about when you are applying something, a barrier cream to a person who's incontinent, you don't want to apply too much. We're not frosting a cake. If you put on too much barrier cream, you're thinking, wow, it's really going to protect the skin from that moisture. But if they're wearing a brief, it's going to rub off on the brief and it's going to block the brief from doing its job. And then people are going to say, oh, there's – those briefs are terrible, they're leaking. Well, it's probably because they're overcompensating putting too much cream on. This is just a nice little picture to show you how much goes where. We've talked about broken, failed skin. What is healthy skin? You need to know. Skin is composed of two main layers, the epidermis and the dermis. The epidermis is the outermost layer, which acts as a barrier to pathogens and helps regulate water loss. So, we need to have intact skin to protect us. You want an even skin color, we want it supple and soft and clean, at a normal temperature, and well hydrated. Speaking of, thank you, I needed a drink of water. Monitoring and assessment technology. Every day, there are new innovative technologies on the market. And I talked about wearable sensors earlier for real time monitoring. These sensors inform the healthcare professionals of the wound's temperature, the moisture level, presence of bacteria. Some can detect pressure and that is great. It's a great benefit. They can significantly improve the person's outcomes. WCEI, that I talked about earlier, The Wound Care Education Institute, they just wrote a blog a couple of weeks ago, April 28th, 2025, about smart bandages. So, if you want to learn more, you can go, it's free, you can go to wcei.org. I'm going to talk about some case studies as we wind things down here. And so, the first one is a stage-four pressure injury. And this pressure injury person is a 52-year-old paraplegic. I'm not going to read everything on the left. I'm going to talk about the things on the right. And so, he is a 52-year-old paraplegic. He's had this pressure injury wound for three years. He has a lack of support. He doesn't have significant comorbidities. He has had negative pressure wound therapy two times and he had a failed flap. He doesn't have any support surfaces in place. He should have a chair cushion and a specialty mattress. He is a paraplegic. And he needs support. he's probably not 100% in compliance because he's having difficulties caring for his wound. He's had it for three years, that's a long time. His wound assessment measures – or wound assessment, his wound measures three centimeters by two centimeters by two centimeters. He is undermining from six o'clock to 12 o'clock. Half his wound has undermining this pretty significant two and a half centimeters. There's no odor, there's 80% dusky, some bruising, and possible deep tissue – oh, because of this bruising, I'm thinking you can kind of see it at the bottom of the picture, the bruising. So, I'm thinking there might be a possible deep tissue pressure injury. He has 20% left, so he does need to have debridement done. And a dressing, you can choose a dressing that will provide autolytic debridement for this wound. He has had an infection, so we have to keep that in mind. He had a history of osteomyelitis a year ago, so we have to make sure we're choosing a dressing that will help prevent infection. We have to keep that top of mind. The moisture level is moderate serous drainage. Serous drainage is not a good thing. His edges are rolled, rolled edges are called epibole. And epibole prevents the epithelial cells from migrating across the wound surface. Epibole is – the wound thinks it's finished doing its job. It's closed and we're good to go now. But no, that wound will never heal because those – the wound edges are rolled. So, we need to do something about that. He may need a little bit of help with nutrition. He's had this wound for three years, so you might want to take a look at his nutrition. This is a chronic wound, and it won't heal until that epibole is resolved. So, what treatment options would you consider? Well, the treatment options I would consider, if possible, sharp debridement of those rolled edges, or you could use silver nitrate. Either one of those choices, you have to have training for. Or you could use something to scrub the edges, scrub them with maybe gauze to open it up and to have it bleed. And that will open it up. We need to fill that dead space. You can use calcium alginate or hydro fiber to fill that dead space in the foam dressing. This is a stalled wound. It's been there for a while. He could probably benefit from collagen as well. Our next wound is a leg ulcer. This is Mrs. Jones, and she is an 80-year-old lady, and she has an attitude. I kind of thinks she does, by her assessment here. Etiology of this wound, what caused it? It is a traumatic injury. She bumped her leg on the wheelchair. She's – her history and assessment is that she is wheelchair bound. She's 80-years old. Vascular studies, I would recommend them, because in this description, she says she's not going to wear those horrible tight stockings. Are they horribly tight because she has more swelling than she used to have or does she just not like the stocking? I'm not quite sure. You need to evaluate that. Compliance, she's not compliant with the compression and she really needs the compression. She's got vascular issues, she has edema, and that will help heal the wound. Her wound assessment, it measures – her wound measures two by two by 0.1, so it's kind of shallow. There's 50% yellow slough in it and it's 50% pink. It looks a little bit on the dry side, although she says a lot of drainage fluid comes out. And that's from the edema probably. I don't see any size of symptoms of infection. She has hemosiderin staining. I think her leg looks pretty good. Her edges, wound edges are open. She does need management of that edema, maybe vascular testing. I would refer her to nutrition. She puts a band aid. She really can't see her wound very well, that's why she's getting help. She puts a band aid on it. This was – started out as an acute wound but it turned chronic, because it's non-healing. Some treatment options, in addition to vascular studies and compression, I would suggest collagen and a foam dressing. Collagen and foam are indicated pretty well for helping these types of like ulcers. But there's other choices as well. Diabetic foot ulcers. Diabetic foot ulcers are leading cause of hospitalization, infection, and amputation. This person is at great risk for amputation. The etiology is, it's a diabetic foot ulcer and he's had it for eight months. His history and assessment say that he sees a podiatrist every other week. His HbA1c is 8.5 and the goal for most adults with diabetes is seven. So that's a little on the high side. No signs and symptoms of infection. There's some yellow and that's probably dressing residue. He has a large callous there. The wound itself, there is quite a bit of swap. It's thin, the wound that has some nice pink granulation tissue in there. His nutrition and diabetic management, I think there's an opportunity to educate him raise his awareness of his condition and the consequences of his behavior. The bottom of this description, it says he has a special orthotic shoe that he doesn't wear. He answered the door in his socks. You know that people who have diabetic foot ulcers, they're on the bottom of the foot, and they have to be totally offloaded and suspended. Otherwise, that will never heal, and it will only get worse. Treatment options. The key to successful wound management is maintaining his blood sugar levels. I think that's paramount. Removing the pressure, monitor for infection, and choose a dressing, based on infection prevention. Develop strategies to comply with orthotic use and how it will help him and improve his quality of life. I think this is our last – our last wound is the surgical wound. The surgical wound etiology obviously is a surgical wound. The history is the wound responded well to negative pressure, but now it's stalled. The assessment is there's a really fragile wound bed with hyper granulation. Granulation tissue shouldn't get happy and grow out – up out of the wound. So, some – but something needs to be done with that granulation tissue. And there's a lot of reasons why it can occur. It could be from too much moisture. And so, we'll need to re-evaluate the treatment plan. The surgical wound is – was acute, it's now chronic. And some treatment options to consider is using a foam dressing, firmly pressed onto the wound to help manage the hyper granulation and moisture. You could use silver nitrate, but I think I'd go low and slow and use the foam dressing. It will be most comfortable for that person. Implementation of best practices. Training your staff, educating them. If you don't have a person certified in wound care, I would get someone certified in wound care. If you love wounds, I think that would be a good thing. Get a mentor, someone who is certified in wound care. If you can't get certified, have someone mentor, have a consultant help you. Integrate advanced products into your care protocol. So, evaluate what you are currently using. Are you using gauze and tape that you shouldn't? You should be using advanced products. And then monitor and evaluate the product effectiveness for each person every week. The wounds will hopefully improve, and as they improve, you'll have to change the type of dressing you're using. This is the conclusion. It's important to use advanced products for managing pressure injuries. Look at innovative products, it changes every day. And adopt best practices. The National Pressure Injury Advisory panel is a great place to go to. WOCN, Wound Ostomy Continence Nurse Association has good practices, best practices as well. Here's some references that I used. Questions if you have any. I hope I didn't run over because I don't see a clock. Brandon, thank you very much. And that's it. Brandon Martin: That was great, Pat. And in fact, we do have a question. Someone asks, when we have a deep tunnel or undermining that's not observable, does that lead to staging as unstageable pressure injury categorization? Patricia Howell: That is a great question. So, undermining and tunneling is a complex adverse effect of a pressure ulcer that is at a stage three or stage four. You – if you cannot see the base of the wound bed, undermining and tunneling is horizontal or could be not horizontal. So it's lateral, down into the wound bed. Look at the bottom of the wound bed, can you see the bottom of the wound bed? What you should see is adipose tissue. You should see – you don't want to see it really, but if it's a stage three or four, you're going to – you should be able to see the tissue, you might see cartilage, you might see tendons. If all you see is fluff, that would be an unstageable wound, if you can't see the base of the wound bed. Brandon Martin: And then someone made a comment about bringing an unstageable wound back to – that you could bring back a stage. Patricia Howell: Backstage? Brandon Martin: Is that backstage? Patricia Howell: So, an unstageable is, you're not back-staging. Back staging fight[?], that's correctly. Back staging is you have a stage three pressure injury, it's – or full thickness, and then it goes to partial thickness. You don't go backwards. You don't say stage three, not to stage two. It never can be a stage two again. A deep tissue pressure injury, or unstageable rather, was unstageable, an unstageable pressure injury's the wound that is obscured and you cannot see what stage it's at until that dead material is removed and then it will reveal itself as a stage three or four. Brandon Martin: Okay. Going back to the portion on the creams and ointments and stuff, is there anything that you should try to avoid? So, like things with – I know a lot of creams and things can sometimes have alcohol in there. Can that slow recovery or is there anything we should avoid there? Patricia Howell: I would – there's a lot of great products on the market. The less ingredients, the better. Some people are very sensitive to alcohol and so I would avoid alcohol. Hyaluronic acid is in better higher quality products. So, you're going to – if you see hyaluronic acid as an ingredient, you're probably not going to see alcohol. I would choose something that has silicone, dimethicone, hyaluronic acid is a barrier treatment. Creams are going to have oils and waxes in them. So, if you look at that chart, creams have 20%, about 20% water, about 50% oils and waxes. They're emollient and they're not real occlusive. So, choosing something with hyaluronic acid, dimethicone, silicone. It doesn't have to be high percentages. There are, I would love to say names of products, but I probably shouldn't. Brandon Martin: That's okay. Well, I'll tell you as we're in – coming up on the end of the hour, I'm going to keep my eye on the Q&A, just in case we get a couple more questions that come in. But I do want to take this opportunity to thank you so much for your time today. Patricia, it was a great presentation. And thank you to everyone in our audience who joined us today. I've got our contact information up on the screen. I'll give you just a second there. And then also I'd like to show you that you can access a full list of our upcoming webinars and events at mms.mckesson.com/learning-webinars. There you can register for a future webinar as they become available, share events with your colleagues, and of course, sign up to receive regular updates on our webinar schedule. Once again, thank you so much, Patricia, for joining us today and sharing your time and expertise. Patricia Howell: Thank you for having me. Brandon Martin: Absolutely. And thank you again to our audience for taking the time to join us today. Hope you have a great day, everybody. Patricia Howell: Bye-bye.