Concepts in Wound Care Flashcards
What are the steps in wound healing?
1) Coagulation
2) Inflammatory process
3) Epithelialization occurs in epidermis
4) New blood vessel growth
5) Collagen formation
6) Wound contraction
Complete bridging of the wound occurs within how many hours after suturing?
48 hours
When does new blood vessel growth peak?
Four days after injury
What is necessary to restore tensile strength to a wound?
Collagen
When does collagen formation begin?
48 hours after injury
When does collagen formation peak?
Within the first week
When does wound contraction occur?
3-4 days after the injury
What are systemic disturbances that influence wound healing?
Renal insufficiency Diabetes mellitus Nutritional status Obesity Chemotherapy Corticosteroids Anticoagulants Disorders of collagen synthesis Patients of African/Asian ethnicity can be prone to hypertrophic scar formation of keloids
What are examples of acute wounds?
Lacerations
Avulsions
Skin tears
Abrasions
What are examples of chronic wounds?
Non-healing or infected surgical or traumatic wounds Venous ulcers Pressure ulcers Diabetic foot ulcers Ischemic ulcers
For acute wounds what does history and PE determine?
Timing of wound closure
Type of closure tape
Need for consultation
What are the goals of acute wound treatment?
Avoid infection
Assist in hemostasis
Prove an esthetically pleasing scar
What are important historical components for acute wounds?
Mechanism of injury Location of injury Time/age of injury Identification of risk factors that impact healing Tetanus immunization status Associated symptoms
What is the most important PE component for acute wounds?
Complete neurovascular exam distal to the injury
What are the three options for closure of acute traumatic wounds?
Primary closure
Delayed primary closure
Secondary intent
Most wounds are closed by what?
Primary closure
What is primary closure?
Closed in acute phase, on the initial presentation to the provider
When should delayed primary closure be used?
Wounds that present after 24 hours and have increased risk for infection
What happens with delayed primary closure?
Wound is irrigated, cleaned, debrided, and bandaged
Repair is scheduled for a later date (4-6 days)
What happens in healing by second intention?
Wound heals spontaneously from the inside out
What type of wounds are reserved for healing by secondary intention?
Dehisced surgical wounds
Grossly contaminated wounds
Wounds presenting very late after injury
Why shouldn’t you clean inside of an open wound with povidone/iodine or chlorhexidine?
They are cytotoxic
How should you clean a wound?
Start at wound margins and clean outward towards periphery
Should wounds be soaked in water or other solutions?
No
What is the benefit of irrigation?
Decreases the amount of bacterial contamination and removes debris
What solutions should be used for irrigation?
Sterile water
Saline
Tap water
What is the key factor in decreasing contamination when irrigating a wound?
Volume of irrigant
How much fluid should be used to irrigate the wound?
250cc
The more contaminated the wound the more or less solution should be used to irrigate it?
More
What should you document prior to anesthesia?
Complete neurologic exam
What are common local anesthetics?
Lidocaine
Lidocaine with epi
Bupivacaine
Where should you not use lidocaine with epi?
Fingers Nose Penis Toes Ears
What are options for wound approximation/closure?
Adhesive tapes/steri-strips
Tissue adhesives
Staples
Sutures
When should adhesive tapes/steri-strips be used?
Low tension
Linear
Superficial
Areas where sutures might not hold
When are adhesive tapes/steri-strips contraindicated?
High tension wounds
Wounds requiring layered closure
Wounds in high moisture areas
What are the indications for tissue adhesives/glues?
Low tension
Linear
Superficial
< 4cm length
What are the contraindications for adhesives/glues?
High tension wounds
Bite wounds
Contaminated wounds
Should you apply antibiotic ointment to a tissue adhesive?
No (it will dissolve the glue)
What are indications for staple use?
Scalp lacerations
Linear laceration on trunk or extremities where cosmesis is not a priority
What are contraindications for staple use?
Gaping wounds requiring layered closure
Wounds in areas where cosmesis is high priority
Which suture number is the biggest?
Zero
What are the nonabsorbable monofilamentous sutures?
Ethilon
Prolene
What are the non-absorbable multifilamentous sutures?
Silk
What are examples of the absorbable sutures?
Vicryl Polysorb Cat gut "Chromic" Monocril
What size suture should you use for face?
5-0
6-0
What size suture should you use for scalp?
4-0
5-0
What size suture should you use for trunk?
4-0
What size suture should you use for extremities?
3-0
4-0
What size suture should you use for oral?
4-0
5-0
When should you remove stitches from face?
5 days
When should you remove stitches from scalp?
5 days
When should you remove stitches from trunk?
7-10 days
When should you remove stitches from extremities?
7-10 days
How long should the dressing be kept on after suturing?
24 hours
What should wounds closed with nonabsorbable sutures but cleaned with?
Mild soap and water
Half-strength peroxide
How often should antibiotic ointment be used after suturing a wound?
2 times per day until suture removal
Do you prescribe prophylactic antibiotics for patients with low risk of infection?
No
For what patients should you prescribe prophylactic antibiotics?
Animal/human bites Intraoral lacerations Open fractures Wounds that extend into cartilage, joints, or tendons Patients with vascular insufficiency Patients with immunocompromised state
What are decubitus ulcers?
Pressure-induced skin and soft tissue injuries
Where do decubitus ulcers typically occur?
Over bony prominence
Where are decubitus ulcers found in people who are wheelchair bound?
Sacral
Ischial
Trochanter
Treatment of pressure ulcers depends on what?
Stage of the ulcer
What are the stages of decubitus ulcers?
1) Intact skin with localized area of nonblanchable erythema
2) Partial thickness loss of skin with exposed dermis
3) Full-thickness loss of skin, in which adipose is visible and granulation tissue often present
4) Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer
How are diabetic foot ulcers initially treated?
Broad spectrum antibiotics
What should be considered before surgery and in between surgical debridements in diabetic foot ulcers?
Negative pressure wound therapy
What causes ischemic ulcers and gangrene?
Lack of vascular supply (PAD, microvascular disease)
What is the treatment for ischemic ulcers and gangrene?
Optimization of blood supply and surgery
What causes venous stasis ulcers?
Venous hypertension secondary to chronic venous insufficiency, dysfunction of venous valves, and/or obstruction of venous outflow
What is the treatment for venous ulceration?
Local wound care and compression therapy
When is skin grafting indicated in venous stasis ulcers?
Inappropriate wound healing after 12 months of medical care
What are the goals for chronic wound treatment?
Reduce pain, itching, odor Minimize infection and bleeding from wound Deal with excessive exudate Address psychological issues Tissue coverage over wound
What is the treatment for chronic wounds?
1) Optimization of wound bed
2) Application of dressing to the wound
3) Topical agents such as antiseptics and antimicrobial agents
4) Sharp surgical debridement of devitalized tissue
5) Negative pressure therapy
6) Delayed closure or skin grafts
What are the wound bed requirements for optimal healing of chronic wounds?
Well vascularized
Free of devitalized tissue
Clear of infection
Moist
How do wound dressings facilitate chronic wound healing?
Eliminating dead space
Controlling exudate
Preventing bacterial overgrowth
Ensuring proper fluid balance
Only what chronic wound infections should be addressed with culture and antibiotic treatment?
“Clinically evident infections”
