L7 Wound Care Flashcards
1
Q
Overlapping phases of healing in chronic wounds
A
Inflammatory (clean it up)
Proliferative (fill the void)
Maturation (remodel it)
2
Q
Inflammatory phase steps summary
A
Vasoconstriction
Fibrin blood clot
vasodilation
neutrophils
macrophages
removal of bacteria and debris
3
Q
Inflammatory phase
A
processes begin immediately upon tissue injury
simultaneously, several players work together to initiate and maintain this phase and the sequence of cells involved
includes coagulation cascade, AA pathways, creation/release GF, cytokines
4
Q
Purpose of inflammation
A
clean wound of debris and stimulate fibroblast cells to produce collagen
5
Q
Inflammation is clinically characterized by
A
redness, heat, swelling, pain, loss of function
6
Q
Proliferative phase summary of steps
A
Macrophages release cytokines that signal endothelial cells, growth factors, epithelial cells
Causes new blood vessel growth, re-epithelization, fibroblasts–> collagen–> granulation tissue
7
Q
Proliferative phase
A
- begins 2-3 days after wound, signaled by fibroblasts
- Fibroblasts migrate from wound margins using fibrin matrix (from inflammatory)
- Fibroblasts become dominant cell type, reaching peak at 7-14 days
- Collagen is a major component of acute wound connective tissue
- With cellular proliferation, angiogenesis in granulation occurs b/c of budding vessels
8
Q
Results of proliferative phase
A
granulation tissue
contraction, epithelialization of wound
9
Q
Granulation tissue
A
red, bumpy, doesn’t bleed easily
made of collagen, capillaries, ECM
10
Q
Maturation phase summary steps
A
Collagen
Deposition
Remodeling
Increase tensile strength
scar reduction
11
Q
Maturation phase
A
- Collagen production begins in 6 weeks
- Collagen is depostied randomly in acute wound granulation tissue, but remodeling into more organized structure occurs during maturation, increasing strength
- During scar formation, collagen 3 is replaced by type 1
- Wound eventually closes by migration of epithelial cells from wound edge. Once fibroblasts contact each other, causes myofibroblast formations
12
Q
2 year post injury, tensile strength is
A
80% of normal strength
wound strength will never exceed this
13
Q
Wound Exam
A
- Location
- Behavior of symptoms
- wound cultured
- wound type
- Size/depth
- signs of infection
- dry or draining
- swelling
- skin discoloration
- vascular exam
- skin nutrition
14
Q
Hypergranulation tissue
A
also called proud flesh
extends above the surface of surrounding epithelium
has to be removed
15
Q
Inflammatory exudates
A
- Hemorrhagic = surgery
- Seosanguinous = yellow, 2-3 days after injury
- Serous = watery, early stage of inflammations
- Purulent = cloudy pus, indicates infection
16
Q
Wound eval steps
A
- hx of current wound
- pertinent medical history
- subjective and objective exam
17
Q
Pertinent medical history
A
what impacts wound healing? what are the barriers to healing?
diabetes
PVD
hypertension
smoking
meds (glucoco, immunosupp)
last tetanus shot
allergies
nutritional status
activity level
wound culture
18
Q
Best glucose level for best healing
A
<180 mg/dl
19
Q
Methods to measure size/depth of wound
A
- plnimetry = wound tracing
- ruler method
no gold standard!
20
Q
Negatives of planimetry
A
difficult to race wound edges
doesn’t measure wound depth
21
Q
Ruler method
A
dimensions with a ruler using clock method
12 to 6, 3 to 9
depth is done with q-tip
22
Q
Signs of infection
A
- Odor
- Colored Drainage
- Fever
- Cellulitis
in a nonhealing wound, you must consider infection
23
Q
Odor
A
pseudomonas smells sweet
proteus smells like urine
24
Q
Colored drainage
A
pseudomonas is greenish
proteus is yellowish
25
Cellulitis
diffuse infection of subcutaneous layer of skin, usually spreads rapidly
caused by bacteria
26
Types of chronic wounds
pressure injuries
venous stasis ulcers
arterial insufficiency ulcers
neuropathic ulcers
27
Purpose of wound care (no matter the type)
remove infection
remove devitalized tissue
promote healing
28
Pressure Injuries
localized areas of cellular necorsis resulting from prolonged, unrelieved pressure between any bony prominence and an external obkect, injury can present as intact skin or open ulcer
the unrelieved pressure results in ischemic hypoxia and damage to underlying tissue
29
Incidence of pressure injuries
1.5 million a year
in long term care, regulatory agencies use development of pressure injuries as an indicator of QOC to patients
30
Tip of the iceberg effect
Begins with ischemia first in
tendon, then subcutaenous, dermis, epidermis
31
Contributory factors to pressure injuries
prolonged pressure, shear forces, friction, maceration, repetitive stress and nutritional deficiencies
32
RF for pressure injuries
elderly, debilitated, immobilized
sitting for long periods
inability to reposition every 20 to 30 min
sitting in commode chair >20 min
exposure to unrelieved pressure during operation
decreased blood flow from hypotension
decrease sensation
cognitive impairment
loss of bowel/bladder control
33
Maceration
skin changes due to excessive moisture
34
For pressure injury prevention, do not raise HOB
> 30°
35
CP of Pressure Injuries
occurs over bony prominences
most common in sacrum, buttocks, hips, heels
color: red, brown, yellow
infection
painful if sensation is intact
inflammatory response with necrotic tissue
36
Stage 1 Pressure Injuries
nonblanchable erythema of intact skin whose indicators as compared to an ajacent or opposite area on the body
37
Stage 1 may include changes:
skin temp
tissue consistency-firm or boggy
sensation
persistent redness, NOT purple or maroon
38
Stage 2 Pressure Injuries
partial thickness skin loss with exposed dermis,
shallow open ulcer with red or pink wound bed without slough.
may also present as intact or open serum filled blister. no bruising
39
Stage 3 pressure injury
full thickness skin loss
adipose is visible
granulation tissue and rolled edges are present
can include undermining and tunneling
no fascia/muscle present
slough/eschar are present
40
Stage 4 pressure injury
full thickness skin and tissue loss
exposed muscle, bone, tendon
includes sinus tracts or tunneling
41
Epibole
rolled wound edges
42
Osteomyelitis
inflammation that occurs in the bone
43
Undermining
deeper wound than surface edge depth
44
Sinus tracts
most common in surgical or neuropathic wounds
present in stage 4
measured with q-tip
45
Unstageable pressure ulcer
obscured full-thickness skin and tissue loss
covered by slough and/or eschar
the true depth cannot be determined until slough is removed
46
Stable eschar on heel
serves as body's natural cover and should not be removed
47
Deep tissue pressure injury
persistent non-blanchable deep red, maroon, or purple localized area
intact or non intact skin or epidermal separation revealing dark wound bed or blood filled blister
damage of underlying soft tissue
often an evolution of stage 3/4 ulcer
must document color
educate about wound evolution
48
Vascular Ulcers Types
Venous
Arterial
Neuropathic
Mixed
not the same staging as pressure injuries
49
Venous ulcers
Associated with chornic venous insufficiency, valvular incompetence, venous HTN. Most common chronic wound
RF: HF, LE muscle weakness, prolonged standing, pregnancy, obesity, LE trauma, immobility, family hx, advancing age
50
Location of venous ulcers
can occur anywhere in leg, most common site is area over medial mallelous
usually bilateral
51
How does heart failure lead to venous ulcers?
the heart fails, right ventricle backs up into the body, leading to a lot of edema, and tehn venous stasis ulcers
52
Dynamic insufficiency
problems with:
capillary filtration
osmotic uptake of fluid
53
Mechanical insufficiency
problems with lymphatic drainage
54
CP of venous stasis ulcers
1. normal pulses b/c arterial system is intact
2. no pain to aching/throbbing, especially when body part is below heart
3. Color is normal or bluish
4. Temperature is normal
5. Edema is usually marked
6. Many skin changes like pigmentation from dying hemoglobin, drying skin, thickening of skin
7. Ulceration: especially over medial ankle, WET
8. Gangrene is absent
55
Common looks of venous ulcers
usually present as shallow, irregular, or oval in shape, with macerated borders. Wet/moist skin
color is red, brown, purple. Edema and scally
56
Treatment of venous insufficiency ulcers
1. CONTROL EDEMA with leg elevation and compression therapy
2. Topical therapy
57
Prevention of venous ulcers
no smoking, adequate nutrition, skin care, optimize venous return , compliance with meds like digitalis and diuretics
58
Topical therapy for venous ulcers
bandages, pressure garments, unna boot, mechanical pump
helps to promote favorable healing environment by removing exudate, infection, necrosis. also protects surrounding skin to avoid maceration
59
Whenis a Wound culture required?
required after 2-4 weeks of failing to respond to therapy or if it appears infected
60
Unna Boot
medication-impregnated dressing containing zinc oxide paste, calamine lotion, glycerin, gelatin
purpose is edema control, skin care, protection
less effective in non-ambulatory patients, espeically uncomfortable in hot weather
changed every 7-10 days
can help stop scratching and itching
61
Unna boot technique
Reduce local edema
apply unna boot with 4 layers w/overlapping spiral technique
last ace bandage layer applied firmly from foot to knee
62
Compression pump
goal to decrease edema, ideally would do this prior to unna boot
intermittent compression unit designed to reduce swelling in lower extremity
63
Arterial insufficiency ulcers
associated with chronic arterial insufficiency, arteriosclerosis obliterans, atheroembolism, hx of minor non healing trauma
most worrisome because of threat of limb loss
64
RF for Arterial ulcers
smoking, HTN, hyperlipidemia, diabetes, advanced age
65
Location of arterial ulcers
can occur anywhere in leg, most common in small toes, feet, on boney areas of trauma
66
CP of arterial ulcers
1. Poor/absent pulses
2. Severe pain; intermittent claudication that often progresses to pain at rest
3. Color is pale on elevation, dusky rubor on dependency
4. Cool temperature
5. Trophic skin changes, loss of hair in feet/toes, thickened toenails
6. Gangrene may be present adjacent to ulcer
67
Dusky rubor
redness below heart
due to increases in vasodilation
68
Arterial ulcers treatment
Patient ed
Control underlying medical problem of BP, A1c, diet, and weight
topical therapy
69
Prevention for Arterial ulcers
no smoking
diabetes control
compliance w/meds
proper fitting footwear
70
Patient ed for arterial
neutral or dependent position for legs
avoid sitting w/crossed legs, exposure to cold/friction/tight clothing, stop moisture between toes, don't walk barefoot
71
Topical therapy for arterial ulcer
promote favorable healing environment by removing excessive exudate, infection, necrosis
wound cleansing with saline
some debridement may be contraindicated for necrotic
non-necrotic require topical dressings
protect surrounding skin
72
When peripheral pulses are present (with alterial ulcers)
hydrogels, collagens, alginates, medicated creams
occlusive dressings should be used with caution
73
When should you get a vascular consult?
ABI <.5
pain is increasing
ulcer fails to respond to treatment in 2-4 weeks
74
Complications of arterial ulcer treatment
infection, gangrene, osteomyelitis, amputation
clinical manifestations of infection are likely to be subtle, due to reduced blood flow
75
Tests for vascular ulcers
PTs must use tests to detect and quantify peripheral arterial disease (PAD)
1. LE pulses: palpate or doppler
2. Dependent rubor
3. ABI
76
Dependent Rubor/redness
1. position patient supine with lower extremity elevate 45° for 1 min or until foot blanches
2. Observe color of foot
3. Instruct patient to sit up and dangle leg
4. Record time for color to return to foot
77
Capillary filling time
normal = 10-15 s
mod ischemia = 15-25 s
Severe ischemia = 25-40 s
Very severe ischemia = 40s+
78
ABI Method
1. position patient supine w/hips in slight ER, knees slightly flexed and lateral borders of foot in contact with table/bed
2. Record brachial SBP
3. Place BP cuff around leg just above malleoli and record SBP
4. Calculate ABI: Ankle SBP (higher value)/ Arm SBP (higher value). Choose the smaller ratio for the ABI
79
>1.4 ABI
vessel calcification/hardening
refer to vascular specialist/surgeon
80
1.0-1.4 ABI
normal
81
.9-1.0 ABI
acceptable
82
.8-.9 ABI
some arterial disease/occlusion
treat risk factors
83
.5-.8 ABI
moderate arterial disease/occlusion
refer to vascular specialist
84
<.8 ABI
No LE compression for wound healing
refer out
85
<.5 ABI
severe arterial disease/occlusion. usually pain at rest, wounds may need to be revascularized heal
refer out
86
Neuropathic ulcers
caused by diabetes, associated with arterial disease and peripheral neuropathy, caused by repetitive trauma on insensitive skin
87
Location of neuropathic ulcers
occurs where arterial ulcers usually appear, or where peripheral neuropahty appears (plantar aspect of foot)
88
CP of Neuropathic ulcers
1. typically not painful due to sensory loss
2. pulses may be present or dimished
3. absent ankle jerks common
4. sepsis common, gangrene may develop
5. surrounding calluses are typical
89
Prevention of neuropathic ulcers
no smoking
control A1C ,7%
diabetic foot screen
routine professional foot care
compliance with meds
proper-fitting footwear
control underlying medical problem
90
Patient ed for neuropathic ulcers
exposure to cold, friction, moisture between toes, walking barefoot, external use of heat
91
Topical therapy for neuropathic ulcers
1. promote favorable healing
2. WOund cleansing with saline
3. Necrotic tissue--surgical consul, autolysis, mechanical
4. Non-necrotic ulcers--absorptive dressings
5. Shallow ulcers--hydrocolloid, moist gauze
6. Protect surrounding skin to avoid maceration
92
Complications of neuropathic ulcers
infection, gangrene, osteomyelitis
93
Infection control
ABX tx is prescribed if indicated
oral meds: antimicrobials, anti-inflammatories, analegesics
Topic meds: NSAIDs, lidocaine, silver nitrate (anti-inflamm, anesthetics, antimicrobials)
VAC
94
Vacuum assisted closure
open-cell foam dressing placed into wound
also called negative pressure wound therapy
provides controlled subatmospheric pressure
helps control edema, increase local blood flow, remove infectious material
you can mobilize with the patient
95
Surgical intervention for chronic wound care
indicated for excising an ulcer, enhancing vascularity and for resurfacing wounds, preventing sepsis and osteomyelitis
may be indicated for Stage 3 and stage 4 pressure ulcers
revascularization procedures may be done for neuropathic and arterial ulcers
96
Hyperbaric Oxygen Therapy
patient breathes 100% O2 in seated, full body chamber with elevated atmospheric pressure
helps reverse tissue hypoxia and facilitates wound healing due to enhacned solubility of O2 in blood
Used for nonhealing wounds that do not have adequate oxygenation
should NOT be used for untreated pneumothorax, some antineoplastic medications
97
Is HBOT effective for chronic wounds?
-Ulcer healing and rate of minor amputation were not affected HBOT
-significant reduction in risk of major amputation with HBOT
-HBOT improved healing rate short term in diabetic foot ulcers
-helps with mixed ulcers
-possible decrease in venous ulcers
98
Wound cleansing
removal of loose cellular debris, metabolic wastes, bacteria and topical agents that may slow healing
goal = obtain clean wound without trauma to new granulation tissue
wound should be cleaned initially and at each dressing change
99
Do not use the following on chronic wounds
some common topical cleansing agents are cytotoxic to healing tissues
1.iodine
2. hydrogen peroxide
3. weak bleach solution
4. dakin's
5. acetic acid
100
You should NOT use ____ for wound cleaning
harsh soaps
alcohol based products
harsh antiseptics
101
Use ____ for most ulcers
saline
102
Even if a wound does not look dirty, it needs regular cleaning because
bacteria can form a biofilm
biofilm = layer of bacteria bound together by compounds they secrete that protect the colony and help it grow
bacteria are more resistant to antibiotics when living in a biofilm
103
Methods of wound cleansing
1. minimal mechanical force
2. irrigation
3. Hydrotherapy
104
Minimal mechanical force
cleanse with gauze, cloth, or sponge
clean wound enough to enhance healing w/out causing trauma
105
Irrigation
can use a syringe, squeezable bottle with tip or battery powered irrigation device (pulsatile lavage)
Pulsatile lavage is usually with suction; Safe and effective pressures are 4-15 psi. goal is to loosen wound debris and remove it by suction
106
Hydrotherapy
not gold standard
indications: wounds/ulcers with large amounts of exudate, slough, and necrotic tissue
increases circulation, assists in wound debridement, and/or removal dressings
must be discontinued when ulcer is clean
107
Wound Debridement
removal of necrotic or infected tissue that interferes with wound healing
allows exam of ulcer and determination of wound extent. Decreases bacterial contamination in wound. Decreases spread of infection
5 methods
108
Autolytic
selective method of natural debridement that occurs under occlusive or semiocclusive moisture retentive dressings
Indications = all necrotic wounds in medically stable people
Contraindications: infected wounds
109
Enzymatic debridement
selective method of chemical debridement that promotes liquefication of necrotic tissue by applying topical preparations of proteolytic/collagenolytic enzymes to tissues
Indications: all moist necrotic wounds, eschar after cross-hatching
Contraindications = ischemic wounds
110
Eschar scoring
diagonal lines
111
Eschar cross-hatching
creating squares with opposite lines from the scoring
enzymatic debrider is placed on top
112
Mechanical Debridement
nonselective method that removes foreign material and dead or contaminated tissue by physical means. May also remove healthy tissue
includes wet to dry gauze dressings, wound vac, whirlpool
indications: moist necrotic tissue
contraindications = clean, granulated wounds
113
Conservative sharp wound debridement
selective method using sterile instruments that sequentially removes only necrotic tissue without anesthesia, resulting in little/no bleeding induced in viable tissue
includes: scalpel, scissors, forceps, silver nitrate stick
indications: scoring, cross-hatching, excision of eschar
contraindications: clean wounds, patients with clotting disorder, sepsis
114
Silver nitrate uses
regenerative effect (growth of good cells)
cauterization (stop growth of bad cells)
115
Surgical/sharp wound debridement
more efficient method, nonselective and performed by surgeon using sterile instruments in operative procedure in which pt is usually under anesthesia, removes most/all of necrotic tissue, and some healthy
indications = advancing cellulitis with sepsis, immunocompromised, infection
Contraindications = when OWL cannot be improved, underlying systemic disorders
116
Wound Dressings
topical products that protect wound from trauma and contamination, absorb drainage, may debride necrotic tissue and enhance healing
GOAL is to provide warm, moist healing environment
117
Simple Principles for wound dressings
if wound is dry = apply a moistening dressing
if wound is too wet = apply an absorptive dressing
118
Transparent films
Tegaderm, opsite
minimal exudate
skin donor sites, IV sites
non absorptive
secondary dressings are not required
119
Hydrocolloid Dressings
Duoderm, Curaderm
-not transparent, can't see wound
-there's characteristic odor w/yellow exudate that looks similar to pus when removing bandage
-causes smell when removed
-maintains moist environment
-comfortable, reduces pain, easy to apply, conformable
-for partial thickness, pressure injuries
-for mild exudate
120
Hydrogel dressings
minimal to moderate exudate
partial and full thickness wounds
most require a secondary dressing
121
Foam dressings
moderate exudate
provides padding, protection, insulation
-stops maceration of wound
-sometimes has antimicrobial
-non transparent
122
Alginate dressings
absorbs 20x its weight in exudate
expensive
mod to large amounts of exudate
easy to apply
requires secondary dressing
123
Black wound
Clean = minimal mechanical force or irrigation
Debride = yes, cross hatching and forceps, enzymatic solution, or biological, mechanical methods
Dress = hydrocolloid or hydrogel. Wet to dry gauze after enzymatic solution
124
Yellow wound
Clean = pulsed lavage w/suction or minimal mechanical
Debride = yes, conservative sharp, mecahnical
Dress = calcium alginate, gauze, wt to dry
125
Red Wound
Clean = very light mechanical, low pulsed lavage
Debride = no
Dress = hydrocolloid/hydrogel, foam
126
Edema management
leg elevation and exercise
compression therapy w/wraps, bandages, stockings, pump therapy
127
Nutrition
malnutrition and dehydration impede wound healing
nutritional assessment should be performed every 3 months to ensure adequate protein and caloric intake
patients need aggressive nutritional support
some vitamin deficiencies impede wound healing (C, A, zinc)
128
Patients at high risk for poor wound healing
weight loss >15-25% of body weight
protein depletion = based on albumin
129
Injury/wound prevention and reduction
1. Daily skin inspection
2. Positioning to relieve pressure and allow tissue reperfusion
3. skin protection techniques
4. pressure-relieving devices
5. avoid maceration damage
6. patient/caregiver educaiton
