Exam 2-wound care Flashcards
1
Q
What’s special about the first month of wound healing?
A
Their immune system is suppressed, and they have an increased risk of infection
2
Q
What kinds of wounds do we stage?
A
Only pressure ulcers. The others are superficial, partial, deep, etc.
3
Q
repair vs. regeneration
A
- repair: new stuff; worse
- -heal by granulation, contraction, epithelialization; wounds surgically repaired; full thickness
- regeneration: fill in with old stuff; better
- -partial thickness; heal by epithelialization
4
Q
What considerations should be made for wounds and the acid mantle of the skin?
A
- pH should be 4-5.5
- use a low pH lotion
- urine is alkaline, so incontinence can change the acid mantle
5
Q
What are the phases of CT repair?
***
A
- inflammation: injury to 2 weeks
- proliferation: 48 hrs to 2-4 weeks
- maturation: 2-4 weeks to 1-2 years
6
Q
What does healing time depend on?
A
- type of wound
- size of wound: partial vs full
- type of closure
7
Q
What direction do wounds heal in?
A
outside-in
8
Q
What are local factors affecting wound healing?
A
- primary: blood supply, tissue oxygen tension
- secondary: tissue damage, mechanical stress (over a jt), pain, radiation, infection, surgical and suture techniques
9
Q
What are systemic factors affecting would healing?
A
- hemodynamic conditions
- age, smoking (vasoconstriction->decreased wound healing), meds, disease, nutrition anemia, alcoholism
10
Q
Phase of hemostasis
A
- process of clotting
- blood flows into wound
- immediate vasoconstriction, vasocongestion, blood coagulation and platelet aggregation
- fibrin-rich clot seals disrupted vessels and fills tissue
11
Q
What effects hemostatis?
A
- anticoagulant therapy
- coagulation dx
- long term corticosteroids
12
Q
Inflammatory phase
A
- mast cells release histamines-increase vasodilation
- migration of leukocytes: polymorphic neutrophils, monocytes
- -phagocytosis, release of growth factors to initiate repair process, matrix for cell migration
- stimulation of nociceptive receptors
13
Q
What are clinical considerations for inflammation?
A
- wound care (if present)-topical tx, occlusive dressings, debridement, RICE/positioning
- protection, rest
- NSAIDs, corticosteroids, aspirin
- pain inhibitory technique (Grade I/II)
- PAINFREE exercise for edema reduction
- nutritional concerns
14
Q
Proliferative phase
A
- collagen phase
- deposition of collagen (cross-linking): fibroblast proliferation, type 3 collagen synthesis
- vascular integrity restored: neoangiogenesis (new capillary and arterial production results in development of granulation tissue)
- -don’t use a gauze dressing-rips out sprouts!
15
Q
Proliferation
A
- granulation: primary closure (palpable healing ridge under suture; not a lot of inflammation on the sides), secondary closure (red, vascular, granulated wound bed)
- contraction: fibroblasts and myofibroblasts create closure, defect shrinks; limited by tension in surrounding tissues
- epithelialization: proliferation of keratinocytes (put smooth layer over wound), differentiation
16
Q
What parts of proliferation happen in repair? Regeneration?
A
- granulation, contraction, epithelialization
- epithelialization
17
Q
What kind of ROM should you do in the proliferation phase?
A
AROM or gentle isometrics; no PROM-type 3 collagen doesn’t provide tensile strength, granulation tissue is fragile
18
Q
How long does maturation take?
A
may take up to 1 year in a normal healthy adult, up to 2 years in a child, elderly, or immunocompromised patient
19
Q
Maturation
A
- tensile strength may increase up to 80%
- matrix remodeling: collagen synthesis/degradation, bond conversion (type 3 to type 1/2)
- scar tissue compaction/contraction
20
Q
What happens if collagen degradation is disrupted?
A
hypertrophic or keloid scars
21
Q
Properties of normal, hypertrophic, and keloid scars
A
- normal: white/pink, indented below skin surface
- hypertrophic: white, pink, red; slightly raised, firm, follow wound borders
- keloid: deep red or purple; very raised, firm, extend beyond wound borders
22
Q
Hypertrophic scars: when do they happen, do they go away, how can they be treated?
A
- most common with deep injuries involving delayed wound closure (infection)
- follow wound borders
- regress spontaneously
- reconstructive surgery and scar management can improve function and cosmesis
23
Q
Keloid scars: why do they happen, what do they look like, can they go away, how do they feel?
A
- overabundant ECM deposition (collagen)
- abnormally raise, firm, deep red/purple, extend beyond wound borders
- don’t regress spontaneously
- painful and itchy; change with barometric pressure
24
Q
How can keloid scars be treated?
A
- surgical excision
- laser
- anti-histamines, corticosteroids
- cryotherapy with liquid nitrogen
- radiation
- respond poorly to reconstructive surgery
25
What are the 4 parts of the Vancouver scar scale?
- vascularity
- pliability
- pigmentation
- hieght
26
How do you score vascularity on the VSS?
0: normal
1: pink-increase in blood supply
2: red-greater increase in blood
3: purple-significant vascularity
27
How do you score pliability on the VSS?
0: normal
1: supple
2: yielding
3: firm
4: banding
5: contracture
28
How do you score pigmentation on the VSS?
0: normal
1: hypo
2: mixed pigmentation
3: hyper
29
How do you score height on the VSS?
0: flat
1: 5mm
30
What are two other scar scales?
- Visual Analog Scale: photo based, doesn't include pt; simpler and easier to conduct than VSS
- Patient and observer scar assessment scale: includes itching, stiffness, relief, etc; may not adequately express pt perceptions and concerns; focuses on scar severity from pt and clinician perspective
31
What is an adheremeter?
- measures adherence of post surgical scar; pull scar in different directions to measure adherence (mm)
- good validity when compared to VSS at initial exam, but less after rehab
- good to excellent interrater reliability, excellent intrarater reliability
32
What are effects of aging on wound healing?
- delayed wound contraction
- decreased tensile strength, epithelialization, inflammatory response, pain perception, mast cells, capillary growth
- increase in wound dehiscence
33
What can cause dehiscence?
- increase in tension
- infection
- obesity
- age
34
When do kids have integumentary maturity?
33 weeks
35
Why is epidermal stripping a concern for kids?
- decreased epidermal to dermal cohesion
- tape, splints can pull epidermis off
- infection risk
36
What should you think about with premies and wounds?
- don't have developed integumentary system: careful handling, swadling
- IV leak can cause edema that can completely damage skin
37
What is aplasia cutis?
- absence of epidermis and part of dermis in certain parts of body
- -partial or full thickness
38
What is epidermolysis bullosa?
- blisters all over body with minor friction (clothing, rubbing against someone)
- avoid tight clothes, tape; safe handling
- -gauze netting instead of tape
- systemic infection usually is mode of death
- do have it their whole lives
39
What do sickle cell wounds kind of remind you of?
venous wounds
40
How can lymphedema effect wounds?
- increased cellulitis risk
| - and you know the vascular stuff
41
How can chemo and HIV/AIDS effect wounds?
- increase infection risk
- -cellulitis
- -sepsis
42
How can obesity effect wounds?
- impaired skin barrier repair, higher pH, increase sweat gland activity
- impeded lymph flow
- insulin resistance syndrome
- decreased vascularity of adipose tissue
- excess tension on wound edges-dehiscence
43
When does dehiscence usually happen?
3-11 days after injury
44
How can you tx dehiscence?
- abdominal binder
| - Montgomery strap
45
What skin diseases can be aggravated by obesity?
- irritant dermatitis
- lymphedema
- chronic venous insufficiency
- plantar hyperkeratosis
- diabetic foot ulcers
- pressure ulcers
- psoriasis (impaired blood flow->immature skin)
- gout
46
What is plantar hyperkeratosis?
- keratotic scar tissue on feet
- brown, scaly
- increased risk of wounds on feet
47
What is necrotizing fasciitis?
- A strep or staph aureus-rapidly growing anaerobic bacterial infection
- appears red, swollen, hot, painful
- full thickness skin loss
- high mortality
- Fournier's gangrene affects perineum: dead tissue has to be removed, skin grafts-don't take welll on obese pts
- -blisters
- -fast growing
48
How does radiation effect wounds?
- can set up fibrotic tissue due to injury of fibroblasts
- decreased collagen production
- destruction of cells in mitosis
- vascular damage
- decreased tolerance to bacterial burned, increased infection risk
- decreased healing ability-stuck in proliferation phase
- may have to stop radiation to heal
49
What meds can effect wounds?
- NSAIDs: decrease inflammation; longer than 72 hrs-can't move to proliferation
- immunosuppressives: prostaglandins decreased (epithelialization-wound can't close), WBC decreased (infection)
- steroids: inhibit collagen synthesis (proliferation), topical steroids effect epidermal resurfacing; keep sutures in longer, protect skin longer
50
A1C and wounds
under 6.5-bad healing
51
pre-albumin an wounds
risk for pressure, venous, arterial, and diabetic wounds
52
How is malnutrition diagnosed?
| ***
- serum albumin below 3.5 mg/dL
- total lymphocyte count is less than 1800 mm
- body weight decreases by 15%
53
diagnositc tests for arterial wounds
- capillary refill >5 seconds
- ABI
- tcPO2
- Doppler (should be triphasic, mono/bi means they don't have good blood flow)
54
diagnostic tests for venous wounds
Duplex US
55
What are 5 instruments to monitor wound healing?
- Sussman wound healing tool
- wound healing scale
- pressure sore status tool
- wound healing scale
- national pressure ulcer advisory panel pressure ulcer scale for healing
- -only for pressure ulcers, in case you didn't catch that
56
Wound assessment
- cause, location (tissue function/structure), shape
- pt concerns
- place pt in same position each time
- local wound characteristics (location, size, wound bed, exudate, wound edge, periwound, odor)
- clinical signs of critical colonization/local infection
57
What are examples of:
- clean wounds
- clean-contaminated wounds
- contaminated wounds
- dirty and infected wounds
- hernia repair
- appendectomy
- laceration, open fracture
- perforated viscera, abscess, devitalized tissue
58
Primary intention
- closure by direct approximation: sutures, steri strips, dermabond, stitches, staples
- ex-surgical incisions and lacerations
- within 6-8 hrs of injury
59
Suture removal
- anywhere from 4-14 days
- shortest: ear, face
- longer: back, fingertip
- can be delayed by age, mobility of part, steroids
60
pt education for wound sutures
- protection, elevation
- minimize direct sun, sunscreen for 1 year
- hand hygiene, showers preferable, maybe gentle soap and rinsing, pat dry
- keep covered with antibiotic ointment and dressing
- visual inspection
61
wound cleaning techniques
- linear: wipe top to bottom, start over wound and move out
| - circular: wipe in concentric circles, starting over wound and moving outward
62
Secondary intention
- wound left open to heal spontaneously
| - ex-contaminated wounds, partial-thickness wounds
63
Delayed primary intention
- delayed healing after several days: surgical closure after granulation tissue is present in the wound bed or spontaneous healing
- primary and secondary combo
64
Who's at risk for skin tears?
- elderly
- immunosuppressed
- premies
- renal insufficiency
65
How do you classify skin tears?
Payne-Martin
- 1: skin tears w/out tissue loss; flap covers dermis within 1mm of wound margin
- 2: skin tears with partial tissue loss
- 3: complete tissue loss; epidermal flap is absent
66
How do you treat skin tears?
- prevention: avoid sheering, proper transfers, remove leg rests from WCH, use paper tape, hold down skin as you remove tapes, slowly peel tapes
- dressing
67
How do you assess pressure ulcer risk?
Braden Scale
- sensory perception, moisture, activity, mobility, nutrition, friction and shear
- low score=higher risk
- but studies show Braden has insufficient predictive validity, poor accuracy in ICU; not effective for obese patients
68
Staging ulcers
- based on depth of soft tissue
- must have complete visualization for accurate staging
- long term care facilities are federally required to reverse stage
69
How to not confused secondary lesions with pressure ulcers
- excoriation: loss of epidermis, linear erosion, destruction by mechanical means-scratch, abrasion
- denuded: loss of epidermis; urine, feces body fluids, wound exudate or friction
70
Stage 1
- nonblanchable erythema
- epidermis and dermis intact
- no tissue loss
71
Stage 2
- partial thickness skin loss involving epidermis and partial loss of dermis
- superficial ulcer
- presents clinically as an abrasion, blister, shallow crater
72
Stage 3
- complete loss of epidermis and dermis down to but not through underlying fascia
- presents clinically as a deep crater with or without undermining of adjacent tissue
- superficial full-thickness wound
73
Stage 4
- deep full thickness wound
- extensive loss of epidermis, dermis, tissue necrosis, damage to muscle, bone or joint involvement
- undermining and sinus tracts may be present
- -between fascial plans
- slough
74
Deep tissue injury
- "pressure related DTI"
- skin usually intact
- outcomes; healing without ulceration, eschar formation, subcutaneous necrosis under intact skin, infection of necrotic tissue
75
Neuropathic ulcers: typical location, pain
- plantar aspect of foot; areas of trauma on the foot
| - painless-lack of protective sensation
76
What do neuropathic ulcers usually look like?
- round, punched out lesion
- callus rim-dead tissue
- granular bed
- if they have vascular disease it may not look so red and granular
- -amputation risk
77
Neuropathic ulcers: glucose, basement membrane, ischemia
- poor control; impaired immune response, poor tissue oxygenation; wounds love sugar; can't due ABIs with hardened arteries
- thickening-can't close wound efficiently, no epithelialization; need skin substitute; defects in leukocyte function
- regional; PVD
78
Neuropathic ulcers: motor and sensation, ANS, risks
- Charcot foot, claw toes, poor footwear can contribute; glycolization on tendons-not as flexible, elastic, lose mobility, risk for spontaneous rupture
- dysfunction: anhydrous skin
- osteomyelitis, fungal infections in nails, ulceration/amputation, potential for silent infection
- -don't see it, smell it or see blood/pus
79
Charcot foot
- painless, progressive, degenerative
- microtraumas cause microfractures in joints
- increased blood flow and bone reabsorption
- osteoporosis
- clinically appears painless, swollen, red
- usually heal by casting
- 10-15degree temp difference between feet (Charcot hot)
- -offload and cast until temp difference is gone
- risk for ulcers especially in mid and hind foot
80
Other foot deformities with neuropathy
- claw toe: stress on MT heads, dorsal aspect of PIP
- hammer and mallet toes: pressure on distal end of toe
- hallux limitus: decreased MTP extension causes great toe ulceration in neuropathic foot due to increased pressure during toe off
- equinus: limitation of DF; increased stress of forefoot during gait
- foot drop: peroneal nerve palsy; extended bed rest, adaptive shortening of Achille's
81
How do you classify neuropathic ulcers?
Wagner
-0-5
-based on depth from pre-ulcerative lesion to gangrene of foot requiring amputation
University of Texas-San Antonio: more detailed than Wagner, harder to work with? Stages A-D, Grades 0-3
82
What does a monofilament of 4.17 mean? 5.07?
- normal
| - lose of protective sensation if they can't feel 5.07 over 1 or 2 points
83
How do you use the tuning fork for diabetic sensation exam?
- 128 Hz fork
- perpendicular to dorsal side of distal phalanx of first toe
- do twice, but alternate with one mock application where the fork isn't vibrating
- at risk for ulceration with 2 out of 3 incorrect answers
- -loss of protective sensation
84
Describe arterial ulcers
- commonly with gangrene
- distal ends of toes; toes, feet, anterior tib
- well circumscribed shape
- no vascularization-pale granulation, little drainage
- absense of hair, cold, low ABIs, weak or absent pulses
- limited treatment options because they don't have good oxygenation and nutrients
- moderate to severe pain
- skin shiny, dry, pale
85
Describe venous ulcers
- can't pull drainage back up to heart-lots of exudate
- hemosiderin staining
- lipodermatosclerosis; edema
- brigth red granulation
- medial malleolus or above
- minimal pain
- irregular shape
- warm foot
86
What is hemosiderin staining?
brown staining on legs because of frequent ulcerations and injury; broken down RBCs that stain the skin
ONLY IN VENOUS ULCERS
87
What is lipodermatosclerosis?
- upside down champagne bottle
- small around ankle, big around calf
- edema that penetrates through skin that causes plaques of protein along skin
88
How do we classify venous ulcers?
CEAP Classification of Chronic Venous Disease
89
How do we score edema?
1+ barely perceptible depression
| 2+ easily identified depression, 30 secs
90
How do we score ischemic pain with ambulation?
-indicates degree of circulatory inadequacy; graded exercise test at 2 mph with grade increases
>150m=mild impairment
50-150m=moderate impairment
<50m=severe impairment
91
What are 2 methods to measure wounds?
- linear measurements
| - clock method
92
How do you linearly measure wounds?
- lenghtxwidthxdepth
- greatest length x greatest width
- wound edge to wound edge in a straight line in cm
- depth: visible surface to deepest area
- perpendicular lines, straight lines
93
How do you measure using the clock method?
- wound as a the face of a clock
- 12 is head, 6 towards feet, 3 and 9 on the sides
- on feet: heel is 12, toes are 6
94
What are other ways to measure wounds?
- trace shape on film
- photography
- computer digitalization of wound description
95
What is tunneling?
- channel/pathway extending in any direction from wound through subcutaneous tissue or muscles resulting in dead space with potential for abscess formation
- most often seen with pressure ulcers
- between fascial sheaths
- caused by shearing
96
What is undermining?
- tissue destruction underlying intact skin around the wound margins/edges
- caused by shearing
- shelves
- could be due to dressing in the wound
- have to fill in undermining before the wound heals
97
How do you measure tunneling/undermining?
- measure at 12, 3, 6, 9
- if there's no undermining at those positions you don't have to measure
- measure depth/length with a qtip
98
What's the rule for wound healing time?
You want to see 40% wound healing in 4 weeks.
99
What is a sinus tract?
- blind ended rarct from surface of skin to underlying area or abscess cavity
- caused by degradation of subcutaneous tissue in a linear manner
- pack a sinus; dressing
- -iodine string things
- can used pulsed lavage
100
What is a fistula?
- abnormal communication between 2 or more structures or spaces
- -rectum->skin
- -skin->bladder
- caused by dehisced wound or surgical incision; shearing forces
- -infection
- treat with surgery, negative pressure wound tx
- drain a fistula
101
What is periwound?
4cm of wound edge
102
How do you inspect periwound?
- color
- induration: hardness; infection, scar tissue
- warmth
- edema-venous
- hypo/hyper pigmentation
- palpation: moisture, temp, turgor (dehydration, edema), pulses, mobility
103
What does agranular tissue look like?
- shiny with red bumps
- infection cooking
- want bumps=new capillaries sprouting
104
Documenting periwound color
```
1 pink or normal for ethnic group
2 bright red or blanches to touch
3 white, grey pallor, or hypopigmented (maceration, callous-both have to be removed)
4 dark red, purple, and/o non-blanchable
5 black or hyperpigmented
```
105
Documenting induration
1 none present
2 50% around wound
5 >4cm in any area around wound
106
What is granulation tissue?
- growth of small blood vessels and CT into the wound cavity
- bright, beefy, red, shiny, granular
- may bleed easily
- agranular
107
What do you do for exposed structures?
- tendons and bones
| - keep tendon shiny and moist; grey, brittle, dry=dead tendon
108
How do you document granulation?
-divide by quarters
1 skin intact or partial thickness wound
2 bright, beefy red; 75% to 100% of wound filled &/or tissue overgrowth
3 bright, beefy red; 25% of wound filled
4 pink, &/or dull, dusky re &/or fills <25% of wound
5 no granulation tissue present
109
What is hypergranulation?
- over healing; granulation tissue pops out
- bad dressing, no health care
- won't heal-have to cross borders over so it can epithelialize
- silver nitrate, foam dressing, silver stick thing
110
How do you assess the base of the wound?
- look for necrosis, eschar, slough, etc
- adherance of tissue
- document % of tissue type and location
111
What do would base colors mean?
- red: clean, healing, granulation-good
- yellow: possible infection, needs cleaning, necrotic
- black: needs cleaning, necrotic
112
How do you assess wound edges?
- contraction (want)
- adherence (want)
- epibole (don't want): rolled edge, usually to undermining; due to bad dressing usually
113
How do you document epithelialization?
1 100% wound covered, surface intact
2 75-100% covered and/or epithelial tissue extends >0.5cm into wound bed
3 50-75% wound covered and/or epithelial tissue extends to <25% wound covered
114
Types of drainage
- serous: clear, shiny, can be yellow; healthy
- sanguineous: red, bloody; healthy
- serosanguineous: pinkish-red; healthy
- seropurulent: bright yellow, slight odor; infected
- purulent: thick cloudy or opaque exudate; odor; infected
115
Amount of drainage
- none
- scant
- small/minimal: 75% bandage
- ODOR: strong, foul, pungent, fecal, musty, sweet
116
wound assessment: infection
- classic s/s: induration, fever, edema, erythema
- can include foul odor, viscous drainage, pain
- interferes with collagen production (chronic inflammatory state)
- cultures performed to determine treatment
- quantity of bacteria/bioburden: quantitative culture (SOC), swab
- -10 to the 5th
- depends on number of organisms, virulence, host resistance
- lab values: increased WBC (>10000), increased ESR (>15, >20), elevated quatitative ounts
117
NERDS and STONES
- NERDS: superficial increased bacterial
- -nonhealing, exudating, red and bleeding, debris (yellow or black necrotic tissue), small
- -topic, antimicrobial
- STONES: deep compartment infection
- -size is bigger, temp increased, probe to exposed bone, new satellite areas for breakdown, exudate erythema edema, smell
- -topic, antimicrobial with systemic infection
118
most common pathogens
- staph: pt or health care providers skin
- escherichia coli: contamination from intestinal contents
- pseudomonas aeruginosa: anaerobes; contamination from whirlpool, hospital environment
119
What are biofilms?
- common cause of persistent infection
- slimy
- can't get off with debridement
- mist tx
120
Cellulitis
- lymphedema, vascular insufficiency, elderly at risk
- -but anyone can get it
- infection under dermis
- can become septic
- lymphanginitis: in lymphatic system; red streaking
- IV antibiotics
121
Osteomyelitis
- probing to bone has better sensitivity and specificity than an MRI
- can see infection on bone in radiographs
122
infection vs inflammation
- both are warm
- infection: pus, odor, trauma, immunosuppressed,diabetic, pain increases with spread, asymmetric, usually single site, pain, swelling, erythema, advancing margin; IV antibiotics
- inflammation: CV disease, RA, IBD origin; constant pain with onset of lesion; symmetric, multiple lesions, satellite breakdown, palpable purpura, local; should go through cycle in 3-4 days (infection takes longer)
123
VTE vs cellulitis vs CHF
- VTE: one leg bigger than other, recent surgery, throbbing/burning, sudden onset
- cellulitis: streaking, red, patchy, irregular borders
- CHF: pitting edema B, weight gain >10lbs , dyspnea
124
contamination/colonization
- in every wound
- no local pain, no fever, normal smell, healthy granulation, minimal exudate, normal wound margin, healing wound
- topical antimicrobial if risk of infection
- no healing in 2 weeks: consider adding topical antimicrobial-could be a biofilim
125
critical colonization/ocal infection
- new or increased pain, may have odor,abnormal/absent granulation, increased serous exudate, possible tunneling or pocketing, static wound
- no fever
- topical antimicrobial
126
infection
- severe, systemic
- severe or increased pain at wound and surrounding tissues; fever, systemic symptoms; foul or excessive odor; abnormal granulation or necrotic tissue; excessive or purulent exudate; tunneling, pocketing, warmth,maceration, edema, erythema; increased wound size
- systemic antibiotics, topical antimicrobial for added benefit
127
What is an antimicrobial?
-agent that kills or inhibits microorganisms
128
What are the kinds of antimicrobials?
- antibacterials
- antiseptics
- antifungals
129
antibacterials
- destroy or stop bacterial growth
- narrow spectrum
- bacitracin/neomyocin; gentamicin cream; sulfamyelon; silver sulfadiazine cream
130
antiseptics
prevent or arrest growth by preventing replication, inhibiting activity or killing bacteria
- broadly toxic, kills healthy cells
- only used for infected or critically colonized wounds; inflammatory phase
- reassess after 7 days
- povidine iodine, acetic acid, hdrogen peroxide, Dakin's solution
- cytotoxicity-very cytotoxic
- excessive use can result in allergies, superinfection
- recheck frequently
- can increase periwound if used on dressings
131
antifungals
- inhibits or kills fungi
- diabetic pts, obese pts
- nystatin, ketoconazole, miconazole nitrate
- fungicidal vs fungistatic
- limited absorption
- need physician referrals
- don't work well with hyperhydrosis: obese pts
132
bacitracin
- petroleum based ointment
- gram negative/positive cocci and bacilli; superficial and partial thickness wounds
- can cause hypersensitivity reactions
133
gentamicin cream
- gram negative bacteria, strep and staph, folliculitis, impetigo
- resistance is common
- can cause hypersensitivity, ototoxicity, nephrotoxicity
134
sulfamyelon
- broad spectrum
- partial and full thickness burns and wounds
- may develop fungal growth; may inhibit keratinocytes and fibroblasts; potential systemic reactions
- -use in inflammatory phase, not proliferation
- pain with removal and application
- not very successful
135
silver sulfadiazine cream
- broad spectrum, wounds of all types and sizes
- resistance is rare
- transient leukopenia, medication eschar, may be toxic to cells
- -leukopenia: increased healing times, infection risk
136
betadine
- aqueous solution of povidone-iodine
- -dilute it
- fast acting, broad spectrum; kills gram positive/negative, MRSA, fungi,viruses
- can effect fibroblasts, only use in inflammatory phase if critically colonized or infected
- dries out wound bed
- not usually recommended unless the pt is in hospice, or they have dry gangrene (autolytic debridement)
137
hypochlorite solution
- bleach; Dakin's solution
- 1/4 strength
- effective against gram positive and microorganisms known to infect burns
- whirlpools
- infected, systemic infection
138
Acetic acid
- vinegar
- bactericidal against gram positive and negative, esp pseudomonas
- diluted
- don't use more than 7 days
139
Hydrogen peroxide
- Kim does not like this one at all; don't use!
- 3% solution provides effervescent cleansing through release oxygen; cytotoxic at 3%
- doesn't decrease bacteria levels
140
What are iatrogenic factors?
- the way the wound is physically managed
- ex-poor wound management, removal of dressings, wound cleansing
- poor use of topical antiseptics
141
Types of debridement
- mechanical
- enzymatic
- sharp
- autolytic
- bio-surgical
142
Things you should never debride ever.
- dry, stable eschar with no signs of infection
- pyoderma gangrenosum: rare chronic inflammatory disease; if you debride it it keeps getting bigger and bigger (reintroducing inflammatory process)
- -irregular jagged wound margins, halo erythema; most common on legs, dorsal hands, extensor forearm or face
- -see with other illnesses: 75% w/ malignancy; RA, Crohn's, ulcerative colitis, IBD; pts between 40-60
143
ABI and debridement
- assess before doing sharps debridement
| - 1 calcified vessels if diabetic
144
transcutaneous oxygen
- tcPO2
- pressure reflects amount of o2 coming out through skin, which in turn reflects amount of o2 delivered o skin by blood
- 50-60 normal; 30 good healing
145
Mechanical debridement
```
NONSELECTIVE
-wet to dry dressings
-whirlpool
-pulsed lavage
-wound irrigation: after whirlpool, after some dressings, granulation tissue
SELECTIVE: blunt/sharp
```
146
hydrotherapy indications: whirlpool
- burns, traumatic, removal of adherent dressings, psoriasis, greater than 50% necrotic tissue, stage 3 or 4 ulcers with heavy amounts of necrotic tissue
- not our favorite
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hydrotherapy indications: pulsed lavage
- preferred
- pressure ulcers, diabetic foot ulcers, venous insufficiency ulcers, deep or tunneling wound, infected surgical sites, heavily contaminated wounds, burns, multiple wounds
- suction will stimulate wound healing
- shown to be very effective
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pulsed lavage: what does it do?
- cleanses and reduces bacteria and infection
- promotes granulation-negative pressure suction
- safe, effective ranges from 4-15 PSI (above that pushes bacteria back into dermis)
- used for tunnels and undermining (special tips)
- can put hot backs, but use even heating or you'll burn the pt
- change tips every time
- no family, wipe everything down; gloves, gown, the works
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enzymatic debridement
- enzymtic ointments to remove dead tissue (collagenase)
- santyl
- requires physician's order
- wound surface must be kept moist
- burning sensation or erythema with application
- selective
- NOT antibacterial or antimicrobial
- less painful than sharps debridement
- make sure it's not infected
- cross-hatching
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Autolytic debridement
- can use with enzymatic; decreased ABIs, decrease PCO2
- in combo with sharps to speed up
- breakdown of necrotic tissue by body's own WBCs
- moisture retentive dressings: hydrocolloids, hydrogels, nonadherent/contact layer, transparent films, hydrophillic/hydrofiber/speciality absorptives
- ex-ripping off a bandaid
- can have increased odors, exudate; lowers cost
- very slow; selective, less painful
151
Biologic/maggot debridement
- processed maggot dressing
- very selective
- diabetic neuropathy does best
152
Dry vs moist wound healing
- dry: forms scab, eschar; inhibits epithelial cell migration; food for pathogens, increased infection risk; affects blood flow, cools off wound; increased pt discomfort
- moist: facilitates autolytic debridement (WBCs); promotes angiogenesis; bathes cells in protein, enzyme rich environment; enhances epidermal cell migration; optimizes immune function; increases pt comfort, decreases dressing changes
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How to select the ideal wound dressing:
- moisture balance
- semi occlusive vs occlusive (minimize contamination from outside wound-barrier, pretend skin)
- thermally insulate (takes 20-30 mins to heat up again)-stops angiogenesis if cold
- nontraumatic
- compatible with wound characteristics: infected wound, debridement
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What should you consider for the pt?
- user friendly; family
- minimal dressing changes
- cost
- minimal need for secondary dressing
- remain in place for their lifestyle
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What are composite dressing?
- combo of 2 or more distinct dressings
- autolytic debridement
- primary or secondary dressing, minimal to heavy exudate, granulation tissue, necrotic tissue
- molds well, easy to apply and remove, but requires border of intact skin
- ex- bandaid: had adherent part and non-adherent part
- -foam dressing with silver
- combines adhesive, wicking, antimicrobials
- -easier for pt to use
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What do active dressings do?
- stimulate and accelerate wound repair: brings in cytokines and growth factors to bring in collagen, etc to move into proliferative phase
- -platelet derived growth factors
- -epidermal growth factors: dermal substitute (delivers growth factor to wound via scaffold), recombinant growth factor via gel, freeze dried collagen to improve functionality of growth factors
- not for infected or critically colonized wounds
- can help biofilm
- donor sites
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What are active dressings and what wounds are they used for?
- promogran: pressure and venous ulcers
- oasis: venous ulcer, recalcitrant sinus tracts
- apligraf: diabetic foot, venous ulcers
- dermagraft: diabetic foot ulcers
* all made in a lab, MD applies
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What are absorbent antimicrobials?
- Ag
- Cadexomer iodine: slowly releases over 3-5 days; shown to be effective
- Iodosorb, Acticoat
- wound exudate reacts w/ gel or properties in dressing; provide moist healing environemtn; highly absorbent
- concern with overuse of antibiotics
- only with infected or critically colonized
- vertical wicking>lateral wicking
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Caclium alginate
- seaweed
- highly exudating wounds; controls exudate-hemostasis
- gel mixture formed when exudate reacts with dressing; provides moist healing environment
- requires secondary dressing
- be sure to wash out wound during dressing changes
- -sheet better than fibers
160
Foam dressings
- absorb exudate; don't use for dry wounds; moderate to heavy exudate
- cushioning (stage 1 ulcers), insulation, semiocclussive (allows oxygen in), autolytic debridement
- with or without adhesive border
- curafoam, flexzan, allevyn
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Hydrocolloids
- adhesive, occlusive, conformable
- low to moderate exudate
- moist healing environment; autolytic debridement; can increase reisk of maceration, more debridement->more exudate
- don't use if infected
- angiogenesis
- duoderm, tegasorb, curaderma
- 3-5 days; remove when edges roll
- rub to warm up first; not much cushion, doesn't absorb much, odorous, can't see wound bed
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Hydrogel
- hydrate a dry wound bed-gives moisture back to wound
- autolytic debridement for wounds with slough/eschar
- minimal absorptive capabilities
- cooling effec
- requires secondary dressing
163
Hydrophilic fiber dressing
- synthetic
- highly absorbent; provide moist environment
- decreased maceration risk because it absorbs a lot
- -lateral wicking; depends, diapers
- not indicated for dry wounds
164
nonadherent/contact layers
- thin, nonadherent sheet, porous
- protects wound base from trauma; protect tendon
- primary dressing for partial and full thickness wounds, exudative wounds, donor sites, skin grafts
- not recommended for dehydrated or eschar covered wounds
- impregnated gauze: reduces adherence to wound bed, vaseline; adds moisture to wound
- only greater than 50% necrotic, frequent dressing changes
- in wound bed
165
transparent films
- maintain moist environment
- can see wound
- semiocclussive: oxygen in
- waterproof
- not absorbent, minimal exudate
- IVs, secondary dressings-bioclusive, blister film, polyskin
166
Medihoney
- used in all stages, hard to heal wounds/burns
- 100% active leptospermum honey
- dry to light exudate, hard to dress areas
- honeycolloid: light to moderate exudate
- impregnated alginate pad: moderate to heavy exudate
- -w/ calcium alginate
- Cochrane report says no
