Lesson 2/Chapter 3 Flashcards
Deterrents to expedient wound healing
Wound characteristics
Local factors
Systemic factors
Inappropriate wound management
Wound Characteristics
Characteristics that affect rate of wound healing: Mechanism of onset Time since onset Wound location Wound dimensions Temperature Wound hydration Necrotic tissue or foreign bodies Infection
Mechanism of Onset
Surgical wounds
Traumatic wounds
Wounds with an insidious onset
Acute Wound
Wound induced by surgery or trauma in an otherwise healthy individual
Progresses through normal phases of wound healing in predictable time and manner
Chronic Wound
A wound whose progression through the phases of wound healing is prolonged or arrested due to underlying conditions
Time Since Onset
Can assist with predicting healing time in acute wounds
Assessment of limiting factors can also aid in prediction of healing in chronic wounds
Wound Location
Vascularity of area
Wounds over bony prominences
Presence of epidermal appendages
Skin thickness
Wound Hydration
Dry wound
Moist wound
Wet wound
Necrotic Tissue or Foreign Bodies
Necrotic tissue promotes infection
Foreign bodies prolong inflammation
Colonization
Presence of microbes
Normal skin microflora, up to 103 per g/tissue
Infection
Invasion and multiplication of microorganisms in body tissues
Culture with >105 microbes per g/tissue
Signs and symptoms similar to inflammation but disproportionate to wound
Local factors known to affect wound healing
Circulation
Sensation
Mechanical stress
Circulation
Inadequate macrocirculation
Inadequate microcirculation
Sympathetic response: vasoconstriction
Edema
Sensation
Warns of tissue damage
Prevents continued trauma going unnoticed
Mechanical Stress
Pressure Shear Friction Periwound edema Tension on wound edges
Systemic factors that affect wound healing
Age Inadequate nutrition Comorbidities Medication Behavioral risk taking
Age
Slowed immune response Decreased collagen synthesis and strength Epidermal/dermal atrophy Decreased number of sweat and oil glands Decreased pain perception Decreased inflammatory response Greater number of comorbidities Increased susceptibility of infection
Inadequate Nutrition
Increased incidence of wound complications
Delayed healing time
Comorbidities
Disease process affecting tissue perfusion/oxygenation
Immunocompromised patients
Activity limitations
Vascular occulsion:
venous insufficieny, atherosclerosis, sickle cell disease
Inflammation:
Pyoderma gangrenosum, Necrobiosis lipoidica diabeticorum, Panniculitis, Dysproteinemias, Idiopathic leukocytoclastic vasculitis, Periarteritis nodosa, Wegener’s granulomatosis, Lymphomatoid granulomatosis, Erythema elevatum diutinum
Pressure necrosis
Decubitus ulcers Neuropathic ulcers
Physical agents
Radiation, Heat, Frostbite, Chemicals, Trauma, Factitial
Infection
Bacterial, Fungal, Mycobacterial, Tertiary syphilis
Tumors
Lymphomas, Metastases, Primary skin tumors
Medication
Steroids at doses of >30–40 mg/day
Chemotherapy
NSAIDs
Behavioral Risk Taking
Alcohol abuse
Malnutrition
Greater risk for injury
Less likely to obtain medical assistance
Behavioral Risk Taking
Smoking
Decreases tissue perfusion Reduces tissue oxygenation Delays normal cellular response to wounding 3x increased graft/flap necrosis 3–5x increased infection rate
Patient-Related Issues
Home remedies Not following recommended treatment Lack of understanding of information provided Limited financial resources Insufficient caregiver support
Clinician-Related Issues
Failure to adequately asses wounds Failure to properly educate patient Inappropriate dressing Failure to manage wound with appropriate modalities Failure to adequately debride
Abnormal wound healing
absence of inflammation
chronic inflammation
Absence of Inflammation
Use of anti-inflammatory medications
Impaired immune system function
Chronic Inflammation
Presence of foreign body in wound bed
Repetitive mechanical trauma
Cytotoxic agents
Heightened inflammatory response
Prednisone/steroids
inhibit inflammatory response by stabilizing lysosomal enzyme membranes preventing release of acid hydrases
Inhibits granulation, contraction, collagen production, and decreased tensile strength
Impaired Proliferation
Hypo-granulation or Non-advancing Wound Edge
Hypogranular wound
Epibole
Chronic Proliferation
Hypergranulation
Chronic Remodeling
Hypertrophic Scarring
Keloids
Contractures
Dehiscence
Key differences from acute wound healing
Senescent cells
Increased number of inflammatory mediators (MMP’s)
Reduced number of tissue inhibitors of MMPs (TIMP’s)
Reduced or arrested epithelialization
Greater bioburden
Greater numbers of inflammatory cytokines
Arrested current of injury
Senescent cells
Cells that have become inactive and cease to divide
May be related to tumor growth and inhibition
Matrix Metalloproteases (MMP’s)
Family of protein degrading enzymes
Functions in neutral pH
Synthesized and secreted by neutrophils, macrophages, fibroblasts, endothelial cells, epithelial cells
Allows cells to migrate through tissues
Increased production in presence of bacterial endotoxins
Important for remodeling
In excess, degrades ECM and maintains inflammatory phase
Also play a role in tumor formation
TIMP’s
Tissue inhibitors of MMP’s
Necessary to mediate MMP’s
Inadequate levels in chronic wounds, allowing MMP’s to break down collagen faster than it can be produced.
Current of Injury
All cells process their own currents
Average skin surface charge is –23mV secondary to the sodium pump
Dry wounds eliminate the voltage gradient
Macrophages and neutrophils are attracted to the positive pole
What does positive current inhibit?
mast cells
What does a negative pole attract?
neutrophils during the inflammatory phase and fibroblasts, facilitates migration of epidermal cells and suppresses bacterial growth
How long is current positive?
Current becomes positive for 48 hours after injury, triggers repair process
Returns to negative 8-9 days after injury and fluctuates slightly until recovery
Tunneling
Use clock terms to identify position
Common in patients with neuropathic ulcerations and surgical wounds
Undermining
Use clock terms to identify position
Common in patients with pressure or neuropathic ulcerations
Wound color red:
pale pink to beefy red, granulation tissue
Goal for red wound
protect wound
maintain warm, moist environment
protect periwound
Wound yellow color:
moist, yellow slough
may vary in adherence
Goal for yellow color:
debride necrotic tissue
absorb drainage
protect periwound
Wound black color
thick, black, adherent eschar
Goal for black color:
debride necrotic tissue
Type of drainage
serous sanguinous serosanguinous purulent seropurulent
Serous
normal, transudate
Sanguinous
normal acutely or in resposne to traume
serosanguinous
normal
Purulent
possible infection
Seropurulent
possible infection
