Integumentary Flashcards
What is the goal of inflammation? (vascular response)
Control bleeding, fight infectious agents
- transudate leaks out of vessels: local edema
- local blood vessesl contrict
- 30 minutes of vasocontriction, vasodilation occurs: localized redness, warmth, edema
Cardinal Signs of inflammation
Edema, redness, warmth, pain, decreased function
What are the key cells in inflammation?
- Polymorphonuclearnutrophils (PMNs) to sides of vessel walls
First to site of injury 12-24 hours, kill bacteria, clean wound, secrete matrix
- Macrophages: kill pathogens, direct repair process
- Mast cells: produce histamine and secrete enzymes to accelerate riddance of damage cells
(PPMM)
Key cells in proliferation
- Angiogenesis: formation of new blood cells (angioblasts)
- Granulation tissue - FIBROBLASTS lay down extracellular matrix (eventually replaced by scar tissue)
- Wound contraction - myofibroblasts pull wound margins together
- Epithelization - karatinocytes and epidermal appendages multiply and migrate across wound bed
Maturation Phase
- Granulation tissue strengthened and reorgainzed
- Rapid collagen synthesis
2 year following would closure 6-12 months greatest change
- 80% of full strength tissue
- Unable to sweat, less sensetive to touch and temp
What is an example of a systemic factor?
Age
- slowed immune response
- decreased collagen synthesis
Epidermal and dermal atrophy
less sweat
Decrease pain perception
Nutrition
Comorbidities
Affect O2 perfusion - PVD, anemia, COPD
Medications
Behavioral risks
Smoking
Primary (Primary intention) Would closure
Wound edges are approximated without/little formation of granulationtissue
Not seen by PT typically
Secondary (secondary intention) wound closure
- Wound edges unable to be approximated
Granulation tissue fills wound bed (scar tissue)
PT more likely to be involved
What can lead to eschar formation and necrosis?
Low moisture levels
D I M E
Debridement
Inflammation/infection - stage of healing, infection, phase of healing
Moisture Balance - tissue type, immunocompromised, activity infection, out of proportion for phase of healing
Edge effect - progressing/stage rolled, callus clean
Local wound care and assessment
HEALABLE - Address underlying cause
Granulation tissue
Temporary scaffolding of vascularized conenctive tissue, healthing granulation is bright beefy red; if pale or dusky, blood supply may be poor or may be infected
Necrotic/Non-Viable tissue
Slough - yellow or tan, stringy or mucinous
Eschar - black and nectroic tissue,
Fascia, adimpose, muscle, tendon, joint, bone, new epithelium
Undermining
Tissue under wound edge is gone, similar to cave under skin
Serous Drainage
Protien rich fluid WBC
Clear-Pale yellow, watery
Sanguinous
Blood/Drying blood
Red/dark brown
Purulent
Indicator of Infection
White pale yellow creamy
Odor in a wound
Assessed after irrigation or after cleanse
Caused by:
wound infection
non viable tissue
Old dressing
hot weather
Irrigation
Use of fluid to remove loosely adherent cellualr debris, surface bacteria, would exudate, dressing residue, and residual topical agents
- Facilitate debridement
- Maintain moist wound environment
- Enhave wound healing
Irrigation CONTRAINDICATIONS
- Do not immerse/soak
- RECENT skin grafts
- RECENT surgical insicion sites
- Diabetic Feet
- Active profuse bleeding wounds
- Dry Gangrene
Irrigation solutions and when to use them
Normal Saline (.9% Na Cl)
- need to be warm
Sterile water
- use with silver dressings
Tap
- caution for immunocompromised
Would cleaners
- Shur clens - sufactant oil
- Vashe - antimicrobial
- Wound wash
Low Pressure Lavage
Irrigation without suction
Jetox:
- 4-12 PSI
- Wall O2 as pressure
- Jet stream
Whirlpool Contraindications
- clean and granulating
Edematous, draining, macerated
Active bleedings
VI
Multi-wounds same area
Uncontrolled Seizures
B&B issues
Pulse Lavage W/ Suction (PLWS)
- Irrigation with suction
Pulse jets of irrigation with suction
creates NEGATIVE pressure
Positives:
-Cleaning disposable tips, site specific, sterile, no additives, temp range, portable, few contraindications
Negatives:
- Expense, aerosolization risk, confined space, cover horizontal surfaces
PLWS Contraindications
Exposed NAMED tissues (muscle, tendon, nerve, etc)
Body cavities (cannot visualize)
Facial wounds
Recent grafts or surgical procedures
Active bleeding
Goals of Debridement
- Decrease risk of infection
- Increase effectiveness of topicals
- Improve bacterial activity of leukocytes
- Shorten inflammatory phase or conver from chronic to acute
- Decrease energy required for body to heal
- Eliminate physical barriers for closure
- Tissue protection or Exam
- Decrease wound odor
What can PT’s debride?
Non-viable tissue, callus, blister
Debridement contraindications
- Arterial compromise
- Stable, dry, hard eschar
Sharp Debridement Precautions and contraindications
Precautions
- Anticoagulant/clotting issues, pain
- Immunosuppression
- Unable to be still (contra)
Contraindications
- PT comfort/skill level
- Cannot see or ID tissue
- Consent, not consistent with POC
- Ischemic ulcers (AI)
- Hypergranulation - live tissue
- Pyoderma gangrenosum
How to control bleeding from sharp debridement
Elevate, pressure x 10 min, silver nitrate
Pain control: meds 30 min prior, topicals, deep breathing
Contact MD: bleeding has pulse, wont stop heart it, fever/chills
Debriding Blisters
Remove:
- Larger than a nickel
- area likely to rupture or tear
- worried about possible tissue injury, burns
- great medium for bacterial growth
Enzymatic Debridement
- Pain free, easy to apply
Can be used on infected wounds - polymyxin B powder
- DO NOT USE WITH SILVER or IODINE products, HYDROGEN PEROXIDE, ACETIC ACID
- Discontinue when clean (2 wks then use something else)
Contraindications for Enzymes
Time frame - too long
- not for deeper wounds (tracts/body cavities)
- Named tissues)
- Facial burns
Autolytic Debridement
- Selective
- Conservative
- Least painful
- Maintains favorable wound environment (warm, moist) “cook”
Autolytic Debridement Contraindications
Infection, dry gangrene, deep cavity wounds, other methods more appropriate
Biosurgical Debridement
Maggot Therapy
Antimicrobial - MRSA, Strep, psudomonas, biofilm
Change in pH
- Killing and ingestion of bacteria
- Osteomylitis around hardare
- cannot tolerate any other form
