Educational Webinar: What am I looking at? Determining Wound Causality to Define Treatment

Hello and good afternoon everyone and welcome to the mason Clinical connection webinar series. I'm Patricia Howell on the MS. Clinical Resource team. Our program today is sponsored by the Mason Clinical Resource Team. This series has been created to provide an opportunity for education and discussion related to clinical topics affecting the post acute care market. following the call, attendees will receive a copy of the presentation and recording via email. Um and to ask a question, locate the chat box at the bottom of your screen, I'm pleased to share with you that our featured speaker today is Doctor Michelle Carr, who is a member of our clinical resource team Dr. Carr is a registered dietician and podiatrist. She's certified in Oasis as well as wound care for more than 15 years. Michelle has worked in the home health and hospice space as an educational consultant, helping clinicians improve patient outcomes and helping administrators to improve their bottom line. So please sit back and enjoy the show and I'll know now turn the program over to you Michelle. Thank you and thanks for joining us. I'm so happy to be able to talk to you about something that I love and that is wounds and wound care. Um, so I was really excited when I got the opportunity to speak to you today. This is the disclaimer from Um the one and this is my disclaimer, I have no conflicts of interest for this presentation. So, the goals for today, what I'm hoping to do with you is to review the probably most common wound ideologies that you might see and um help you use those clues that are gonna help you determine that ideology to decide. um the healing potential for for those wounds. And also we're gonna really explore some of the unique wound characteristics, what what makes one wound different from another wound because sometimes that's really confusing, especially for clinicians, and so, you know, people um and clinicians have come to me over many years and asked me the same types of questions and it's often uh what do I put on this wound? You know, give me a treatment regimen for this particular wound, and I don't really think that's where we should start. I really think we need to start by looking at what causes a wound or what caused that particular wound. That is really to me the first principle of wound care now in a perfect world, Uh a patient would come to you number one and they would say I have a wound, you know, you would know going in ok, they have a wound and some provider or physician would tell you what kind of wound it is that they have, but I would guess it looks like there's about 100 people on this call right now, um out of these clinicians on the call, I would guess that um many of you don't have that in your real real world scenario. That's not the world you live in, right? If you're a home health nurse, for example, I bet many times you just go out to see a patient no mention of a wound on the documentation, right? And you walk in and do a skin check and realize that there's a problem and you need to put it into your system, into your E. M. R. Or E. HR. Or something, right? You have to to say that there's a wound and and say, I think it's this, kind And so even though you might not be officially making the diagnosis, you need to know enough to get an idea of what you think the ideology is. You need that for your documentation. You also need it because sometimes you're following orders right on room care, but what happens when it's not working? you know, do you have enough knowledge to say, you know what, this isn't working? Maybe we're going down the wrong path And so even though you might not be making the diagnosis, I do think it's still important for anybody who has their hands on a wound to understand some basic principles about wound ideology. So I'm glad you're here and I hope this helps you I think, determining the ideology is an important first step because the second step needs to be to reverse the ideology. So again, people come to me all the time or send me um information all the time and say, what do I put on this wound? Well, the very first thing we actually need to do before putting some type of dressing on there is to undo what's causing the ideology because if you don't, then no matter what product you're using, it's not gonna work right? For example, if you are treating a pressure injury and you're so worried about absorbing the extra that you do nothing to remove the pressure then, is that one gonna get better? No. So again, first figure out what's causing it. Then we're gonna try to reverse that and then we can work on the rest of our our treatment plan, right. and part of that treatment plan is determining. what our goals are for that wound. Do we think that this wound is heal? Do we think we're just gonna have to maintain it? It's not heal, but maybe we can prevent it from getting much worse. Or maybe we're gonna focus on palliation. So, let's go to what causes wounds. What are the most common causes and you're gonna see them in that blue box on the left. There's arterial insufficiency, Burns cancer, diabetic or, I like to say, neuropathic wounds. Different disease states can have wombs, infections can cause wounds, but it normally doesn't. Um Normally, what happens is infection will piggyback on one of these other ideologies, but it can it can be its own ideology, pressure injuries, radiation sores, surgical wounds, traumatic wounds and venous stasis ulcers. We're gonna go through the top ones in that list. The most common ones in that list? in a little bit more detail, but it's important to realize that sometimes in your patient, there are multiple ideologies. Sometimes it's not just one. For example, something that's pretty common is to have patients have both arterial insufficiency and venus stasis. Sometimes we call these mixed right mixed vascular disease. It's they have the inflow problem and the outflow problem and that's fairly common. So that can they can both contribute or sometimes the wounds can have a complicating factor for example. Um Let's say they had a surgical wound and it became infected, right? So these aren't just discrete. You know single ideologies. A lot of your patients are a little more complex and might have multiple issues playing in at the same time But whatever is affecting this wound, it's really important to identify so that you can treat it appropriately, so you can get the outcomes that you're hoping for and that you also can code and build appropriately right, Now before we go much further into each ideology, I want to level set just a second here because I use a lot of terms and sometimes I take for granted the terms I use. I just wanna make sure we're all talking the same language. Number one. I'm gonna use the terms granulation and epithelization a lot. I like to use the analogy when I'm talking about um granulation and epithelization of a hot liquid cup with a lid. If I had a hot chocolate or coffee cup or tea cup, um with a lid, the first thing I would do is fill up my cup. And then I would put on my lid, right? Well that's very similar in a wound that has a deficit or defect. The first thing we need to happen is we need that wound to fill in And that process of filling in is called granulation. And it happens with specific cells that are called fibroblasts. Fibroblasts are responsible for granulation. And so they fill up that wound base with that granulation tissue. and then analogous to the lid. Is the skin formation, right? Or epithelization? And those are other cells. Those are caros. And so um those are two separate processes that granulation versus epithelization. We call that whole process of when you had to have a wound that fills in like that. And then epithelialize, we call that healing by secondary intention. So you'll sometimes he hear that term in contrast to primary intention which is what happens typically for like a surgical wound. So, that's one set of terms that I want to make sure we all understand. And then the second set is a partial versus a full thickness wound. Partial thickness wound is gonna be a wound. But the only thing missing is the skin. So, it's like that cup that you see without a lid. Right? And a full thickness wound means a wound that goes past that skin down into the deeper tissue. Doesn't really tell us exactly how far it goes. You could just go down to the sub Q. Fat or it could go all the way down right to bone tendon muscle. But it just means it's past the skin So, just to make sure that you're understanding. I'm just gonna ask you to think about in your head um does a partial thickness wound graduate And the right answer to that would be no. Because a partial thickness wound by definition is only missing skin. So what does it need to do? It only needs to epithelialize. That's actually a common mistake that I see on documentation. All right. So, I think we're we're we have enough information to dive in here to these different ideologies. So, let's start with arterial insufficiency It if you think about it uh it takes arterial blood flow or inflow right to maintain healthy tissue. So just you and I to have healthy skin and muscle and fat even it takes that arterial blood flow bringing in the oxygen bringing in the nutrients just to maintain. And if you have tissue damage, like a wound. Then it actually takes more blood flow to repair. And that's gonna be important when we go a little bit further into this, So wounds that happen because there's not enough blood flow are sometimes called vascular wounds, but more definitive would be the term arterial wounds because vascular vasculature, that could be a vein or an artery, right blood vessels. So, to really define that it's an inflow problem, arterial wound or arterial insufficiency is probably better terminology these can occur suddenly. like with uh, an right. Um that that could happen really suddenly. Or it could happen over time. And sometimes what I see? is that perhaps somebody has like a traumatic injury? Maybe they bump their leg and the most common thing We bump our legs on. Do you know what it is It's a dishwasher door. That's one of the most common things we bump our legs on. So let's say we bumped our legs on that. Well now we have a wound. So do I need less blood or more blood to heal that I need more. So maybe that patient was just on the threshold. You know, they just had enough blood to maintain good tissue. But now that they have a wound. and they just don't have enough to heal it. So maybe that traumatic wound evolves into an arterial wound because they just don't have enough. This text is not pop popping up. Let's see if there it goes. So arterial wounds are typically very painful wounds when I see them. Um the patients normally complain of pain. And then on that one out of 10 pain scale, it's not uncommon for me to hear them say it's an eight. You know, maybe even a nine. Like it's it's pretty painful out of the wounds that I've treated often. These are the most painful wounds. Um They normally have regular borders that often appear punched out almost like you took a tissue biopsy, you know, with those those little round punch biopsies. Sometimes the wounds look so much like that because they have these really regular borders. They are most common on the toes, feet, lower legs. Why, why would that be the case And it's the case because that's the furthest thing away from your heart, right, So it is most commonly found um on the distal extremities. But it can be found they can be found on other extremities. So fingers, fingertips, hands um genitals, you know the top of the head. It di as far away from the heart, The further the way away from the heart you get, the more common these become. one clue to arterial is insufficiency wounds is the wound bases are typically necrotic. So in contrast to a wound base that has that healthy um moist red bumpy granular tissue. Um These don't normally have that these normally are dry um Maybe they're covered with a dry sluff or maybe scar and that's more even more common like that black scar now? Why does that make sense to your head? it should make sense because we know that it takes blood to make granulation tissue. And what's wrong here, we don't have the blood. So the body can't make the good tissue that it needs. So instead it makes this pseudo covering um like that fluff and that scar that we see, right? And that's really important to recognize because sometimes we see that slap in scar and we've learned in wound care that um typically we want to get rid of that. But in an arterial wound, if you get rid of that right? If you if the doctor de breeds it. then what would you expect? is it gonna heal at that point? Well if the ideology is that they didn't have enough blood flow then they're still not gonna have enough blood flow unless some intervention has happened so often. What will happen is the wounds are debleed and the more necrotic tissue forms And then the wound is debrided and more necrotic tissue forms because we have not reversed the etiology. And that's why I'm saying that's really what you need to focus on first. And so normally a vascular clinic or a vascular doctor is the one that will really work these up and determine. What is the level of blood flow? Where is the occlusion? Where's the problem happening? Is this something that we can correct? And normally that means surgery, right. That just like somebody who might have a coronary artery bypass graft or cabbage, their lower extremity bypasses um can be done. And sometimes so that patient needs to be evaluated and worked up to see if that or a stent or something like that can happen so to provide more blood flow to the area. in the meantime. Often you'll see doctor's orders to keep these dry and stable and um I would just say I would follow the doctor's orders really closely on these because these are very precarious wounds. So here is a foot that has some arterial insufficiency going on. And you see many areas of loons and what color are they they're all black. Does that surprise you? No. From what we just talked about, Why do you think this patient has a whole bunch of of little dots like that I I don't know for 100%. But the times I have seen that as a podiatrist, have been when they've had a blood clot that got loose and then it hit like a bifurcation of of the arteries and kind of shattered and the little fragments of that blood clot got stuck when the vessels got small enough causing little dark spots. Now again, I can't tell you 100% I would have to have a patient have a vascular consult would be really be worked up. But um in my clinical history? That's that's what I've seen Ok, let's move on to cancerous wounds. Cancerous wounds may or may not be painful. I'm more concerned when I hear that they're not painful. Right? That sends up more red flags in my mind than when they say they do hurt. they can be located anywhere on the body, but we do know specific cancers are more common in certain areas, right? So like um melanoma is really common on the band area, right back arm, neck scalp, those type um of areas? So specific cancers can be located in specific areas, but cancer can be anywhere on the body. One clue for clinicians is that cancers grow despite appropriate treatment. So, you think you're providing the right? treatment but this wound just gets bigger and bigger and bigger. Sometimes they do have irregular features like the one on the top and the one on the bottom. Um Both of these are cancerous wounds. The one on the top is a fungating breast mask or breast tumor. And these are are fairly common. Um And then the one on the photo on the bottom is on a thigh. and you know, you can tell that that looks odd. You see all these um odd looking growth. I almost wonder if that that communicates like if I could stick um a swab in there and if it would communicate with some of the other areas. I I wouldn't know unless I examined that, So they could have these irregular features or look odd to you. One thing I hope to spread the word about is that long standing non healing wounds can convert into malignancy, and typically that conversion rate is about 1 to 2%. So what I mean by that is that, let's say a patient has a different type of a wound, a skin tear or um a venous stasis ulcer or the most common one is a burn, right? And it doesn't heal and it doesn't heal and it doesn't heal. And maybe it doesn't heal because they aren't providing the right treatment and it would have healed. But but they didn't do uh good wound care. Right. but just because it's open for a certain length of time and there's different studies that give different amounts of advice, but often. Um They will say if you have a long standing wound that is not healing. Despite appropriate treatment, it might need a biopsy. And and that's one standard of care that's out there in the wound world right now. And I will tell you that I myself as a clinician have been fooled several times when I've seen a wound and it has certain characteristics and I've immediately jumped to what I thought was the right ideology. but when the wound did not respond to my care as it should, that's what triggered my mind that OK, I need to get a biopsy right, I need to have this patient get a biopsy. and most of the time it has shown that there, that wound had converted into malignancy, diabetic ceres, I don't really love the term diabetic ulcer. And the reason why I don't is it's not really the diabetes that causes the wound. What really is the factor is the neuropathy. And over 60% of diabetics typically have neuropathy at some point in their life, And this neuropathy, you know if if you think of neuropathy neuro means nerve. Pathy means disease of. So that's just a really generic term for a disease of the nerve. But the type of neuropathy, the peripheral neuropathy that these patients get. has a real classic progression. It will start in the longest nerves in the body and the longest nerves you have in your body start in your lower spine and end up in the end of your distal halluces or the end of your big toe right? And then your next longest nerve typically is yours nerve which starts in a similar location and ends up in the distal tip of your fifth toe and then it goes to the middle toes and then it works. Its what way up. Well that's the way that this neuropathy will present. Um they might get numb, they might have dyskinesias or odd sensations or they might have both. But when they lose that feeling. and they they lose what we call the protective threshold. Then they're really susceptible to having injury that they don't recognize, right? Now, the reason why I don't really like to call these diabetic ulcerations is that many of my patients that did not have diabetes also had neuropathy, This same kind of peripheral neuropathy. In fact, the next most common reason why people have neuropathy, secondary to diabetes is alcohol use alcohol um has a cumulative neurotoxic effect And so a lot of my patients were not diabetic but they were neuropathic. So you'll hear me use the terms interchangeably diabetic or neuropathic wounds. Um I think probably most accurate would be neuropathic But these wounds are often initiated by pressure or traumatic injuries but the patients don't feel them right? So maybe they have a rock in their shoe or maybe their shoes are too tight and they just don't feel it. Or maybe they have a callus and they don't feel that. And so eventually um that callus will break down and open up and now they have a diabetic or neuropathic ulceration. When they do have diabetes, diabetes complicates um wound healing it it affects their immune status? And those high blood sugars that are often seen in diabetes will slow down the migration of the cells that we need for wound healing. So diabetic um patients really have a lot of obstacles to overcome when they get a diabetic ulceration. So diabetic or neuropathic ulcers are usually not painful unless the infection goes deep. So once they've got that neuropathy, it's normally not the pain that's bringing them in to seek care. right? Um in fact, a lot of times, if you if you're a clinician and you've if you've been able to de breed these types of wounds, they don't flinch, you know, they don't they don't feel a lot of times what I'm doing is I'm trying to clean up the wound. Unless once they get osteomyelitis, that's typically when they would start to tell me, hey doctor Carr, this is this is hurting me now. They often are gonna be over a pressure point on the plant or surface of the foot or maybe the lateral side of the foot. But that's the most common location Often there's a call surrounding the wound and let's just talk about that for a second. Why does Cali form Sometimes we call it Hypertosis. Ok. That's the other term for it. Why does somebody make Hypertosis or callus? Do you have under like where maybe a wedding ring is on your hand? that gives you a clue. So you make callus from chronic long term pressure it's the body's way to protect itself, right? If it's acute pressure a lot of times you'll get a blister, But if it's chronic pressure, you'll often get a callous and so when you and I get a call on the bottom of our feet. because I don't know, maybe it's our shoe gear or we have a long meal or a hammer toe or something that causes a a distribution of pressure that's different. If we get a pressure area and it's chronic and long term we will make a call. Well, if it's in the bottom of your foot, if you've ever had that before, it hurts right even before you consciously recognize that it's hurting you a lot of times people will start limping and then that's what triggers you. You'll be like, oh, uh I'm limping, what's up? You know, like this is hurting me and then you'll look at it. And often people will do what they're not supposed to do. They'll go to like the drug store and they'll buy the razor or the Um puma, Stone puma is ok but they'll try to take it off, they'll try to shave it down or take off the callus to relieve the pain. Well, if you're neuropathic guess what you're getting the pressure. You're getting the callus. But you're not getting the signal of pain. And so the pressure builds up builds up, builds up until at one point the body can't take it anymore and it will ulcerate smack dab in the middle of that callus. So when clinicians see a plant or foot wound with a callus around it on the bottom of the foot. then, that normally really points that this is a diabetic or neuropathic wound. because that tells you this area has been getting pressure. So this what you're looking at at this wound is this is under the first meal. Head planter surface of the first meta head on the right foot. And you see that hyper Caro rim. So that tells you exactly the path of physiology of what's happened here. They're often on the plant or foot. The wound is often a secondary finding. What I mean by that is it's not the pain that brought them in. It's that they said oh I saw a trail of blood on my linoleum floor. and that made me look at my foot or oh my wife said something was stunk something stinks and she looked at my foot. and that's when we saw the wound. So it's like the secondary finding all of those in a history would be a clue that you are dealing with a neuropathic or diabetic foot ulcer. Alright, moving on We're gonna talk about pressure injuries or pressure ulcers. We're gonna sit here for a while, we got a lot to unpack on this I just wanna get everybody kind of up to speed that the new terminology or current terminology for these types of wound is pressure injury. Or sometimes you'll hear pressure ulcer. Medicare still uses both terms. Um But the newest term probably is pressure injury We don't really use the term so much decubitus or bed sores or pressure sores. So you wanna kind of maybe push those a little bit out of your vocabulary and focus more on um pressure injury or pressure ulcer. Ok. Typically these are over a bony prominence or maybe a device or something that's putting external pressure on a body part and I focus on that because we saw this um happened so much more with Covid right when Covid now we prone patients. So we saw pressure injuries in places that weren't very common because it was on the anterior of the body and then those Covid patients in the IC. U. Often were on every tube and device and machine known to man. So we saw um some of these develop. in odd locations, breast clinicians um different than what we were used to And so pressure injuries typically form because they're localized tissue injury from not having enough blood or hypoxia and the tissue needs that oxygen to to be healthy or to heal. And so if you don't have it it will break down. in pressure injuries, we use stages the staging system, you're gonna learn that almost every type of wound has its own vocabulary. And so we use stages for pressure injuries. Sometimes I see people staging with these stages, other types of wounds, other ideologies, uh don't don't do that. These stages, as I'm gonna describe to you are specific for pressure injuries, And we do not reverse stage these. So, if something ends up as a stage four pressure injury as it closes, I'm not gonna say, oh now it's a stage three and now it's a stage two. No, I'm gonna say it's a closing Stage four or closed stage four. Ok, you don't reverse stage these. this is really important for documentation. This stands legally in the chart. And so it's very important that we stage pressure injuries as clinicians that they're staged correctly. Also note that with one of the recent updates uh from the National Pressure Injury Advisory Panel or Mp I. A. P. They switched using um from using roman numerals. to uh Arabic numerals Like you see here. So, um I'm just trying to give you the most up to date information so you can look really current with your documentation. So it goes stage one through four. And then there's also a deep tissue injury. There's unstageable, there's also um pressure injuries, of the of the mucous membranes and medical device related pressure injuries, so let's go through the different stages. Stage one is where the skin is intact but there's non blanch erma. I look at it as the body's warning sign, This is really easy to see on somebody that's got that, you know, light light light skin, but on your darker skinned patients, it can be really challenging to pick this up. If you don't get pressure off of this, the skin is probably gonna break down and let me just back up for a second. What I mean by non blanch er is its redness that when you push on it it doesn't go white. or lighter in color, it just stays dark. So again that's your body's warning sign, A stage two is a partial thickness wound. Now, you know what that means? What does that mean? It means it was just missing the skin right? Or the lid on the cup, right? So a partial thickness wound is just missing the skin. So a stage two is just missing the skin. That's a shallow And for clean ulcer. It also could be an open or closed serum filled blister, So a clear fluid blister, but that would um have to be a blister because of pressure right? There's lots of reasons why we form blisters. Sometimes it's like an allergic reaction, but if it's a blister from pressure, whether it's open or closed and it's a clear fluid, not a pasture, but a clear fluid. Then you would call that a stage two. Also to be a stage two, it has to be clean meaning there cannot be any sluff or scar on that. Um on that wound This is actually my heel. I had some new shoes and they rubbed right there and I was surprised at how painful that dumb little stage two was on my heel. Stage three pressure ulcers or pressure injuries, um have full thickness tissue loss. So now you're passed the skin into some deeper tissue, but you're not down to the tendon, muscle ligament cartilage or bone. They can have a little bit of fluffer esar, but it can't be so much that it obscures the view. meaning if it it covers the the wound, then it's gonna be unstageable. So you should be able to still still tell what depth it is. And it really depends on location. There's some parts of your body that the minute you're through the skin, you're to almost a stage three. I always have um my students when I'm teaching wound care, pinch the bridge of their nose. And if you're really like awake and listening on here, pinch the bridge of your nose, It really doesn't matter if you're fat or skinny, you probably don't have much there. And that's one of those areas that if you open that up, it's really common to be at a stage three, just through that skin. Ok, Stage four. Now you're to the deep stuff. Now, you have that full thickness tissue loss with exposed or palpable bone tendon ligament, cartilage or muscle. So once you're to one of those deep structures, you are to a stage four. And so if you can palpate it you know, you maybe you stick a probe, a sterile swab into that womb bed and you palpate bone or hardware or cartilage or muscle, then you're gonna say that's a Stage four. There could also be sluff present in these wounds. That's the highest um or the deepest stage noted in this scale. There's also something called deep tissue pressure injury. Now this is kind of interesting because in a deep tissue pressure injury The skin isn't normally intact. But under the skin you notice that there's damage and that's normal because it the damage happens typically at that bone muscle interface. And so what you're gonna see is some deep discoloration typically, or um if you see a blood blister, a blood blister is a deep tissue pressure injury, according to the National pressure injury advisory Panel. And they are really the gurus of this staging system. I would really encourage you to be very familiar with their website and the resources that they have available for staging these images came from them, So look at this deep tissue injury. I love love, love this picture. Because one thing you'll find out about deep tissue injuries is the majority of them devolve, meaning they open up And look at what's happening to this deep tissue injury as it heals from deep to superficial. Look at it, it the skin is now starting to slip so it is devolving and that is what I like. Um I used to like to tell my patients that when I would see this is don't be surprised if this opens up because that is how they typically heal. And when I should go back when they do open up, what are you gonna be left with? You're still gonna have a pressure injury. But once they they open up um you're gonna be left with the depth of a stage three or stage four typically right? There's also unstageable pressure injuries, those are pressure injuries where there's full thickness tissue loss. But now the base of the wound is covered by slapper scar so much that you can't tell really what stage it is. You know, if it was removed, it would be a three or a four because it's a full thickness, but you can't tell which it is because so much is covered. Or maybe there's a pressure injury that the doctor said there's a non removable dressing on here, I don't want you to take the dressing off. In that case, you're also gonna have to say it's unstageable. That was. pressure injuries. A lot of information to unpack. again? Very important to understand. And I would encourage all of you if you're not really familiar with that, to go back to Mp I. A. P. S. Resources, they have a lot of free resources on their website. Um and they are the gurus, Ok, let's go to surgical wounds. Surgical wounds are not gonna heal by that secondary intention. Typically they're gonna normally heal by primary intention, which is fast surgical incisions, seal They don't really granulate up, they seal and normally. Well, according to Medicare, they say that can happen even within 24 hours. And one of the ways you know that they're sealed or closed is when the drainage stops. If you see prolonged redness or drainage or warmth, that could be something that is um concerning and that can indicate those are signs of infection. And so normally clinicians are watching for deficient, they're watching to see is there any gapping? Are there any areas where that incision is pulling apart? Because those are things that we would watch out for. So in the case of a surgical wound, the goals are typically to keep those dressing, keep the dressing clean dry and intact. until the doctor wants. Things changed up traumatic wounds. traumatic wounds happen for a variety of reasons that I've listed here. Abrasions, abortions, contusions, there's all sorts of definitions that go with each of these descriptions of um traumatic wounds. What do you think has happened to the shin in the pitch that is a shin or a leg? An anterior lower leg, That is a contusion like a um Something hit this patient's leg and she presented like this. And so what are you looking at? What is that Some of you might say that looks like cancer, actually, that's a hematoma. That's a big um coagulated ball of blood and that um is gonna be a problem. Right. And so a doctor will need to evacuate that to help that that patient move along skin tears are also traumatic wounds. And I'm sure if you're a clinician, you've seen these skin tears are traumatic wounds that often result from external friction or shearing. And if you look at the risk factors for skin tears, I would imagine that you have patients that um have multiple of these right multiple medications, maybe impaired mobility, dry skin. I mean, this is typically our patient population, so just like N. P. Ip was good for pressure injuries. The International Skin care advisory Panel, it has some great resources for skin tears and they categorize skin tears into three types Type 12 or three. I'm gonna quickly tell you what they are a type one skin tear is where you have a flap and you can reposition the flap and it covers up the wound. A Type two skin tear is where you have a flap and when you try to pull it back, it doesn't cover the whole wound base, it just covers some part of it, And a type three skin care is you had so much trauma on that skin care that it removed the flap. You don't have a flap, so all covered for one part covered for a two. No coverage for a three. That's pretty easy, isn't it? That is such good information to have in your documentation because oftentimes type two and type three s are coded a little bit differently and warrant skilled nursing. Whereas a lot of times the type one doesn't. So this is great information to for clinicians to understand which types of skin care is it? And is it in your documentation venus ulcers love these venous stasis wounds. Um Remember this is from the veinous blood. So veinous blood is supposed to go back towards your heart and when the veinous blood doesn't it pools and it can cause problems. Normally these wounds are treated with compression but you can't um what also needs to be assessed is patients vascular status. Normally these are very very wet wounds, meaning they are highly exo so um just expect that, expect that these are the wounds that are gonna have a high amount of ex Remember the path of physiology of venus disease. Is that the valves are not working correctly in the veins. That means the blood gets pulled where gravity is gonna pull it. Which is the distal legs and feet which causes increased tissue pressure and eventually like an overfilled water balloon. You're gonna have leakage and that will leak into the tissues and then the tissues will eventually open up. So that's why there's such wet wet looms. there's many options for treatment. But remember at for venous stasis wounds, these are some of the most recalcitrant ulcerations. Statistically about 40% of them tend to open up within the 1st 42 weeks. after treatment. If you don't keep them into some kind of stocking or wrap. So they need some long term compression solutions. So it can't just be that you you treat them and you get it healed and off they go. This is something that they require long term um care with compression typically Ok. So I just threw tons of information at you. What do you think on this wound? I will orient you. This is on the lateral aspect of a patient's foot So what clues do you have? You have a location? So it's a distal. So you might be thinking hm arterial maybe or if we said venous stasis was a lot on the lower leg. but what do you see in that one? Do you see something that looks kind of yellow? And if you touch that it would be hard. That is a call, and under that callus you also see some dark discoloration. so if you work this patient up you would also realize that they're numb So guess what, they are have diabetes. They have neuropathy. and this is a diabetic ulceration. again. I know I threw a lot at you but um I wanna shift just for one slide and talk about the goals. Remember some wounds are heal, And that hopefully most of your wounds you treat are heal but sometimes they're not Let's take, for example, that first type of wound we talked about like the arterial wound, maybe they're not a surgical candidate. Maybe they need a low extremity bypass but they can't they they can't have the surgery. so in that case heal healing would be out of the off the table. Right? And maybe then we would focus to maintenance Or what about a cancer patient? Maybe it's a a patient on hospice. Um That that might mean that maybe maybe they're not heal. And so then maybe in that case instead of even maintaining, we know that cancer is gonna get worse. So maybe we have to shift to palliative care which is maybe more um comfort measures right? Maybe then we're gonna manage the date and the pain. and realize that it's not going to heal. So it's important to use your ideology to help you determine appropriate patient centered goals for that wound care Ok. going back to what we first started with what was our first goal of wound care to determine the ideology and reverse it. So I know a lot of you are probably listening and you really wanna dive into treatments. But that really is the first focus. If you do not do that, then it's like trying to fill a bucket with a hole right? You're never going to get behind what's causing that wound. And please forgive my primitive graphics that I created for that. Um so what you wanna look at is if the wound isn't healing after 2-3 weeks, you're providing the treatment. You you think you got the right ideology, you've got the right treatment and you don't see any improvement after about 2-3 weeks. Then guess what? You need to go back and reassess that ideology. You maybe you missed something, right? Or maybe there's a complicating factor that you've missed. Because normally you're going to see some kind of change, some kind of improvement and maybe it could be minor, but you should be seeing something after about 2-3 weeks of appropriate treatment. It's really important to get this right wow, that was a lot of information. that I threw at you but I want you to know that is here to help. Um We do have a clinical support number and this is that number And there are a team of us um that that support that number. So if you have questions and and need help with us pointing you towards some of those resources um just reach out and let us know if you have questions about products. Let us know. We are not your patient's doctor, we will not give you that kind of advice but we are are here to support you So I would love to open this up for some questions. Um Let's see if you have questions. Please put them in the question box and I will answer those while I'm looking at those. Um Please see this slide about saving your seat for future webinars if you like these educational webinars. Um This is the information about how to save your seat. Ok, So I have a some questions. Let's go down and start Let me open this up a little bigger here, I have a question about nurses in nursing homes. Um getting the correct staging of a wound when a doctor doesn't come to the facility. You know um You will need to check with your state association and your facilities S. O. P. S. Some of facilities have certain nurses that they allow to stage. pressure injuries. But I can tell you that in most states um an R. N. Staging a pressure injury stands legally in the chart So again check your own state ask at your facility for that um S. O. P. What is their policy for having you? Stage and normally an LP N. Does not stage. a pressure injury. But what you can do is you can describe in your own documentation what you're seeing. So if if it's been staged um as a stage two But now you're seeing the base of it. It's deeper. It's covered in sluff things you just learned are not indicative of the stage two Don't change the stage but go ahead and put your assessment. You can put the clinical things that you see in your documentation if that's ok in your facilities? S. O. P. All right. So there's a couple places you need to check before going. Um going ahead with that. Thank you for that question. Other questions. a question about the difference between unstageable and deep tissue injuries. how much necrotic tissue has to be there before you uh determine that it's unstageable. There's different advice from different uh sources. One the W. O. C. N. Recommends that if it's 25% or more of the wound base covered with uh necrotic tissue, then you say it's unstageable. And I think that's pretty good advice. I like, I like that rule to stand behind. Um The one of the ways you can tell the difference is remember on an unstageable. Um Typically the skin is not there. Whereas in a deep tissue injury. Like that image you saw that one in uh evolution the skin was intact. It you see the the damage under the skin. typically Great questions. Well thank you my friends, I appreciate uh your attention today. I appreciate what you do to help your fellow man in whatever clinical role you you uh fill. And again if we can ever help you at Uh We are happy to do so I appreciate it. Have a wonderful day.