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Wound Care
456 Plays2 months ago
In this episode, Josh talks with new grad occupational therapist Tristany about the challenges of wound care. Tristany shares her experience of how intimidating it can be for new OTs, while they discuss tips to build confidence and improve skills in wound management.
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Transcript
Introduction to Hand Therapy Academy
00:00:06
mmateri
Hi, I'm Josh McDonald.
00:00:08
Tristany
And I'm Tristany Barry, and we are Hand Therapy Academy.
00:00:12
mmateri
All right, Tristan, he comes to us with another question. Tristan, what do you have for us today?
When Does a Wound Become Alarming?
00:00:17
Tristany
We recently had a patient that kind of sparked some concern for me, so I wanted to ask you, when does a wound kind of turn our head a little bit and become concerning?
00:00:31
mmateri
Yeah, you put that very delicately. I think maybe the better question is when should you be scared to death because that wound looks super, super sketchy? Yeah.
Misjudging Wounds: Importance of Professional Evaluation
00:00:42
mmateri
So we see all kinds of wounds that come in, right? And patients come in with like the distal radius fracture scar line and they're like, oh my gosh, it's so gross and disgusting. You know, like that's nothing. That's not that big a deal. We forget that patients aren't used to seeing what we see. And then you have patients come in and like, okay, I have a plan in mind. We're going to do some zero form. We're going to do some adaptive and we'll progress on.
00:01:01
mmateri
then there's the patient that comes in and you're like, oh my gosh, that is half a centimeter deep. There are structures I can see that I shouldn't be able to see. There's things inside there and they're like, oh, I don't know, it's squirting and it's kind of going everywhere. So yeah, I think there's there's like different levels of DEF CON awareness that we go through. And so I i don't really have like a category to say like, okay, this one I don't care about so much, this one is easy. and um But I would say when I feel like it is past the layer of the base of the dermis, and it's hard to identify, but when I can honestly, from a basic, basic perspective, when I feel like I can see other stuff, right? Like there's like, okay, I see other things inside there. We put a post up a while ago.
Case Study: Tendon Exposure and Treatment Shift
00:01:48
mmateri
Maybe this was a year ago. A patient texted me on a weekend. He texted our line and I just happened to get the alert. I'm working in the garage and he's kind of a nervous Nelly and he says, I think I see a tendon in here. Oh, you don't see a tendon, it's fine. And I watched the video and he's closing and opening his hand and he closes, closes, closes and then, oh my gosh, there's white structure. A white like three millimeter long, two millimeter wide, pops out clear as day. I'm like, oh my gosh, that's your flexor tendon. So I called him and we went a different direction. If I feel like that wound has a depth that is, depending on the structure, but like three millimeters or more, And it's hard to visualize. So I'll maybe even pull out my little ruler and visualize three millers. I'm not putting it in their wound, but I'm getting a visual on like, okay, this is a deeper wound or it's wider than it should be.
00:02:38
mmateri
You know, if it's a, if it's a, the zigzag stitch and you see something in this patient's case, we're like, okay, that is now de-hist or opened. It was closed. We know the doctor didn't send them out of here, out of the OR looking like that. That is opened back up again, or it's gone backwards in status.
00:02:56
mmateri
maybe the coloration. We talk about colors of wound. It's yellow. There's a significant amount of exudate or drainage coming out of it, and that is white or yellow. That raises my concern quite a bit more.
00:03:10
Tristany
And what are the signs of infection?
Identifying Infections: Key Signs and Symptoms
00:03:13
Tristany
Because that's kind of our biggest concern when a wound opens.
00:03:17
mmateri
Yeah. And so we talk about our color system and the the big color we're all looking for is yellow, right? Like if it's yellow. Well, I'm not great with colors. My wife is a has some design skill and she'll say, oh, that's got yellow in it. Well, that's not yellow yellow, right? Like i'm I'm expecting like yellow, right? Like banana yellow, canary yellow. I want something that's distinct. It may have like a grayishness to it that's like,
00:03:42
mmateri
just not normal wound we've all fallen or had kids scrape their knee or and like oh well that's just like it's it's not skin or red there's something in between and the whole wound may not be yellow you may have areas of the wound where you think like that distal aspect looks a little concerning. So I'm looking for color, I'm looking for a different kind of exudate that's thicker, um noticeably yellow, noticeably white, like a pus kind of drainage, or if there's something that is, if there's streaking, if there's like coloration that works proximal up the up the upper extremity from the wound, and you see that streaking redness and white streaking contrasting as they go up,
00:04:28
mmateri
If you see streaking, you're either sending them to the hospital or calling nine one one because that by definition means that is going septic and it's going to the bloodstream is about to go everywhere so if you see streaking that is like death con one that is our most important level of concern that's a big deal but otherwise i'm looking and saying like,
00:04:46
mmateri
Okay, is there structural integrity on that tendon? That patient with the tendon that popped out, he wasn't yellow. He didn't have drainage. He had really poor circulation and healing as a young guy. And so we didn't see yellow, but I'm like, there's a structural compromise here. Or if we keep doing range of motion, I can tell this is going to keep opening. So we have to change our plan of care so I don't make it worse and instead can take it the right direction.
Wound Care Products and Techniques
00:05:13
Tristany
Yeah, and can we talk about products to use too? it's For me, as a new therapist, it's really overwhelming. There's so much going on. So what is kind of your standard with a wound that just kind of popped open and more concerned?
00:05:28
mmateri
Yeah. So let's assume that there's no major infection. Let's assume it's just like open, right? Like, okay, this is, it's either dehistin reopened or it was never really closed all the way. Um, I will, we we rely on zero form, adaptive and Telfer. That's almost exclusively what we use. Most of our patients that need more than that have wound care nurses following them. And so that doesn't usually become our concern. They don't put that on us as therapists. Some clinic have to deal with that. And so that's a different, different issue.
00:05:58
mmateri
um I'm gonna rely on xeriform, possibly like a basitracin, if it's very deep. if it's the The purpose of xeriform is to act as a secondary synthetic skin to protect it from drying out and um and intrusion of outside bacteria, and to keep dressings from sticking to any exudate drainage. So I'll use that to keep that wound bed that has some depth to it,
00:06:27
mmateri
moist and humid ah ah sufficiently without using a big piece that covers the skin around it to macerate and weaken the neighboring superficial epithelial scale um cells. I'll use, if it's too deep, if it's like three millimeters or deeper, I'll take a sterile um ah tongue compressor or toothpick and I'll put a little Basset Tracy on it, maybe triple antibiotic, not meosporin, and put like a,
00:06:53
mmateri
like a pea-sized blob on there. And I'll spackle that into the wound. And I say spackle because I want that basitration flush with the surface epithelial cells and filling that void. And then I'll put a little bit of zero form over top of that to keep the basitration from absorbing into gauze or whatever I'm putting on. um And that keeps it moist.
00:07:14
mmateri
And those epithelial cells around the border of the wound need to migrate over, and if there's a step off down into that granular wound bed, those epithelial cells will catch at that cliff theoretically and not be able to migrate over and close the perimeter of that wound. That basitracin helps those epithelial cells migrate into that space.
00:07:37
Tristany
Sure.
00:07:38
mmateri
yeah um all that All that to say, if they still have exudate, I would throw TELFA on top of that so they're not oozing everywhere, making family members gross.
00:07:48
Tristany
Yeah, can we touch a little bit more on the size of the zero form you're using? I've learned from you that this the piece we need is so small, and I think that I would have never known that before. I think it's important to know.
00:08:02
mmateri
Yeah, yeah. A lot of times when they leave um the doctor's clinic follow-up visit, it's an MA that's dressing them. Or if they're leaving the wound the the surgery site, it's ah just a post-op nurse who's dressing them, and they have orders for xeriform. They'll open a pack, slap it on, wrap it up, and send them out the door. That xeriform, because it increases the humidity and the moisture of the area, will add mass saturation to any area that is at the right level of humidity, it increases it everywhere. So we have lots of patients who come in with these big old patches on a little one centimeter circumference wound and everything around is mass rated and weakening and stitches are pulling out. And so I'll take the size of the wound and cut the zero form to match that.
00:08:48
mmateri
Sometimes I can, I don't have to trim it exactly. I'll just kind of squoosh the edges of the rectangle in so it's not overlaying healthy, moist epithelial cells. um But yeah, very, very small is all that's needed. I may use, ah ah like if I take my one by eight and stretch it out,
00:09:04
mmateri
I may double it over once and add that in there. If it's a big space, like a big forearm wound um that's that's open and drying out, I may take two or three layers because there's more bulk to absorb ah moisture.
00:09:20
mmateri
But I'll see patients come in with like five, six, eight layers, and that's just adding too much humidity to the area. Yeah.
00:09:27
Tristany
Sure.
Subdural Signs of Infection in Closed Wounds
00:09:28
mmateri
We did have a patient come in that's interesting to touch on that was not wound based, but he had had a digit widget that failed because the pins wouldn't stay stable in his P2 bone. And so he came in just kind of off the street for us and said, after the digit widget had been removed, deciding what to do, he comes in and says,
00:09:47
mmateri
I can't sleep. I'm in so much pain. And he puts his hands up there for us to see and his affected side with this PIP flexion contracture, no more digit widget that was taken out. And he's probably a week, week and a half removed from that coming out. And his hand is 50% the size of the other one. So inflammation, he has temperature difference. It's warmer to the touch.
00:10:10
mmateri
He had coloration change, and he had loss of motion. He did not have streaking, but everything about this wound screamed, he's got an infection. he had been to his provider was out of town His surgeon was out of town, so he went to a different provider, a different hand surgeon in across town, and he gave him oral antibiotics. He had not been able to get those within 36 hours, so he comes to me saying, what do I do?
00:10:33
mmateri
we were able to figure out with his provider who was out of town, talked to her on the phone, start oral antibiotics. But if that doesn't make a difference, then we're going to send them to the yeah ER for blood work because she's out of town and can't do blood work till Monday. So sometimes it's not a wound issue that's an external infection obvious, but we can see signs subdural. We can see signs in a neighboring area or the the whole hand to say like redness, temperature, color, pain, loss of range of motion, maybe streaking. All those things are major signs that we need to like escalate our our level of awareness.
00:11:10
Tristany
Sure.
00:11:13
mmateri
Yeah. So hopefully some of those things are helpful for you when you get wounds that are a little scary.
Consulting Professionals for Wound Management
00:11:18
mmateri
um If there's infection, definitely go back and talk to the doctor about that. If you have concern about that, it's always better to talk to the doctor and him ah him or her say not that big a deal than to have missed that opportunity. So always go back and ask the surgeon if you're not sure, but then there's some ways to manage those wounds that maybe aren't infected, but we need to keep that that granular tissue populating well. Yeah.
00:11:39
mmateri
If you have any questions or need to reach out to us, um do so with our email, info at handtherapyacademy.com or via our social media accounts at Hand Therapy Academy.