Module 1 - Wound Assessment Flashcards
What are 3 aspects that should be considered in a comprehensive wound assessment
Client
Wound
Enviroment
What does 1 square CM of skin contain?
- 15 sebaceous glands
- 1m blood vessels
- 100 sweat glands
- 3000 sensory cells
- 4m nerves
- 300,000 epidermal cells
- 25 pressure sensory cells
- 200 pain sensors
- 2 cold sensors
- 12 heat sensors
- 10 hairs
What are the 2 major processes of wound healing
- Haemostasis
2. Tissue Repair
What are the three phases of tissue repair?
- inflammation
- Reconstruction
- Maturation or remodelling
How long does the inflammation phase generally last?
0 - 4 days
Whats involved in the early phase of inflammation?
- Vasoconstriction
- Vasodilation
- Coagulation
Whats involved in the late phase of of inflammation?
-Recruitment and activity of inflammatory cells
How long does the reconstruction phase last?
2-24 days
What’s involved in the reconstruction phase?
- Angiogenesis
- Granulation
- Contraction
- Epithelialisation
How long does the maturation phase last?
24 days - 1 years >
Give some examples of some aberrant wound healing?
- hypergranulation
- contracture
- hypertrophic scar
- keloid
define an acute wound?
An acute wound is any surgical wound that heals by primary intention, or any traumatic or surgical wound which heals by secondary intention, and which proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical integrity.
Define Chronic wound
A chronic wound occurs when the reparative process does not proceed through an orderly and timely process as anticipated and where healing is complicated and delayed by intrinsic and extrinsic factors that impact on
THE PERSON
THE WOUND
THE ENVIRONMENT
Give a brief description of the epidermis?
- outer layer of the skin
- comprised of stratified, squamous epithelial cells or keritanocytes
- thinnest on the eyelids and thickest on the sole of the palms and feet.
- avascular and receives its nutrients from the under lying dermal layer
- continuously replacing outer cells which lasts 4 weeks
- there are 4 to 5 layers
What are the layers of the epidermis
- stratum germinativum
- stratum spinosum
- stratum granulosum
- stratum lucidum
- stratum corneum
What are the functions of the skin?
- protection
- sensation
- communication
- thermoregulation
- metabolic synthesis
- cosmesis
Explain Haemostasis?
rapid response to physical injury and is necessary to control bleeding.
What are the three components involved in haemostasis?
- Vasoconstriction
- Platelet response
- Biochemical response
Describe Vasoconstriction in haemostasis?
Vasoactive substance such as catecholamine’s and serotonin influence receptors on the endothelium to produce vasoconstriction of the arteries, arterioles and capillaries in or adjacent to the wound to stop the bleeding.
Describe the platelet response in haemostasis?
- the damaged endothelium of vessels exposes collagen fibres
- platelets stick to each other and the collagen fibres forming a plug
- the platelets release chemicals such as serotonin and prostaglandins to enhance the vascular spasm therefore reducing blood flow.
- phospholipids and adenisone diphosphate (ADP) are also released to attract more platelets therefore increasing the platelet plug.
- The platelet plug is compromised of fibrin, fibronectin, virtonectin, von willebrand factor, and thrombospondin forming the extracellular matrix
- the platlet also releases multiple cytokines, hormones and chemokines which attract inflammatory cells and fibroblasts therefore promotes wound healing
Describe the biochemical response in haemostasis?
it involves the formation and degradation of a blood clot which involves:
- intrinsic clotting factor
- extrinsic clotting factor
- clot retraction
- fibrinolysis
this cycle sees the development of a clot, the retraction and compaction of the clot and the breakdown of the clot by fibrinolysis
Explain the early phase of inflammation?
- starts from the moment of injury
- ischaemia in capillaries contract and thrombose to facilitate haemostasis
- ischaemia in the wound also causes a release of histamine and other vasoactive chemicals to vasodilate the surrounding tissue to facilitate the influx of leukocytes, erythrocytes and plasma proteins into the wound
Classic signs and symptoms of inflammation?
- excess blood flow into the wound and surrounding areas therefore demonstrates the classic signs and symptoms of inflammation
- redness,
- swelling
- erythema
- heat
- discomfort (throbbing sensation)
Define a wound?
A wound is an injury to the integument or underlying structures that may or may not result in a loss of skin. physiological function of the tissue is impaired
Explain angiogenesis
angiogenesis occurs to establish a new vascular network
explain granulation stage of the reconstruction phase
granulation / scar tissue is formed
growth of blood vessels and connective tissue
Explain contraction
myofibrolasts draw the wound edges together in an attempt to reduce the surface area of the wound thus reduce the amount of tissue replacement required
define epithleliaisation
regeneration of epithelium over a wound
explain maturation phase?
collagen is slowly replaced in a more organised manner, resulting in increased tensile strength.
characteristics of matrix metaloproteinases (MMP)
Wound debridement and facilitating cell migration by Degrading extracellular matrix components following trauma -
Factors that inhibit wound healing
- Ageing process
- comorbidities
- nutritional status
- body mass index extremities
- medications
- allergies
- mobility and activities
- radiotherapy/chemotherapy
- psychosocial factors/lifestyle choices
- psychological state
Describe effects of the aging process of the skin?
-Thinning & flattening of the epidermis
-Decreased epidermal proliferation
-Cells in the horny layer lose elastin
-Atrophy of the dermis - decreased contraction
-Decreased vascularity of dermis
-Changes to & loss of collagen
-Decreased number of oil & sweat glands
-Vascular response is compromised
-Altered or reduced sensation
Fragility
Comorbidities that inhibit wound healing
- Diabetes Mellitus
- Anemia
- Malignancy
- Rheumatoid disorders
- Auto-immune disorders
- hepatic failure
- Ureamia
- Inflammatory bowel disease
- Reduced vascularity
- Respiratory disorders
- Neuropathy
- Radiation damage
- Disorders of sensation
Medications that impact wound healing?
Corticosteroids Cytotoxic agents Non-steroidal inflammatory agents Some antibiotics Nicotine
The effects of corticoid steroids on wound healing?
Decrease :
- Macrophages
- collagen production
- angiogensesis
- Wound Contradiction
- Epithelial migration
- Tensile strength of healed wound
- Immune responses
- chemotaxis
- proliferation of T lymphocytes
Increases -
Susceptibility to infection
The effects of cytotoxic agents on wound healing?
-Affects rapidly replicating cells (cancer cells, hair and epithelial cells)
-Haematological changes which impact on healing
Reduces tensile strength
The effects of NSAIDS on wound healing?
Suppress inflammatory phase of healing
by blocking prostaglandin synthesis
The negative effect of antibiotics on wound healing?
Penicillamine & penicillin -impairs cross linking of collagen
Increases risk of micro-organism resistance
Increased risk of topical sensitivity or systemic allergy
The positive effect of antibiotics on wound healing?
Controls infection
The effects of nicotine on wound healing?
Reduces vasoconstriction
Increases platelet aggregation
Impairs collagen synthesis
Impairs epithelialization
smoking for 10 minutes delays wound healing by 1 hour
Psycho-social implications of wound healing?
Fatigue impairs healing Anger impairs healing Self-esteem alterations Familial responsibilities challenged Social responsibilities challenged Employment issues Economic constraints
Local factors that inhibit healing?
- Reduced temperature
- Desiccation of wound
- Alteration in wound pH 4.2-5.6 normal, 7-9 deep wound
- Tissue hypoxia/poor vascularity
- Foreign bodies present/infection/malignancy
- Mechanical stress/Chemical stress
Wound Assessment Parameters?
Type of wound Aetiology Mode of healing Duration of wounding Location Dimensions (length, width, depth) Clinical appearance Wound edges Exudate Odour Surrounding skin Pain
What are the different types of wounds?
Incision Laceration Abscess Skin Tear Fistula/Sinus Dehiscence Penetrating/Perforating Leg/Foot Ulcer Graft/Flap Donor Site Abrasion Contusion Burn Tumour Bite/Sting Allergy
What are the 3 different types of wounds that you can stage?
Pressure Injury
Burns
Skin tears
mode of healing techniques?
Primary intention Secondary intention Delayed primary intention Skin grafts Flaps Bioengineered tissue
Clinical appearances of the wound?
Necrotic slough granulation epitheliating hypergranulation eschar
Clinical signs of a localized infection
Pain Heat Oedema Erythema Exudate - purulent or increased
Clinical signs and symptoms of a systemic infection
Elevated temperature Tachycardia Rigor Malaise Elevated leukocyte levels
Bacterial reaction to threats?
adaption - develop resistance
self-protection - form biofilms
Mechanisms of resistance
INTRINSIC OR INHERENT RESISTANCE
bacterium is naturally resistant to the antimicrobial agent
-ACQUIRED RESISTANCE
development of resistance in previously susceptible
Vertical evolution: a mutation in the organism
Horizontal evolution: genetic transfer of resistant genes from
one bacterium to another, even to different species of bacteria
What is biofilm
The bacteria secrete glycocalyx which forms a biofilm
(an extracellular polysaccharide) that protects the
organisms from immune responses by phagocytes and
from antibiotics
What is the Bio Film Process?
Bacteria form strongly attached micro-colonies in 2-4 hours Develop extracellular polymeric substance in 6-12 hours Form a mature resistant biofilm in 2-4 days Following disruption can reform in 24 hours
Wound Exudate assessment?
Amount of exudate
Type/colour of exudate? Serous -clear fluid, no blood or pus Haemoserous -slight blood stained serous fluid Sanguineous-bright red,frank blood Purulent -thick, cloudy, yellow, green
List possible causes of malodour in the wound?
- Fistula
- Autolysis
- Infection
What’s involved in assessing the wound edges?
Colour, thickness, raised, rolled edges, undermining
Clinical appearance of the surrounding skin
Erythema Oedema Macerated Dry / fragile Dermatitis / eczema Pigmentation Induration Neuropathy Perfusion / pallor
Wound healing - Protein
Amino acids required for:
- Fibroblastic growth
- Collagen synthesis
- Lymphatic function
- Remodeling
- Immune responses, phagocytosis & antibodies
Wound healing - Lipids (fats)
Essential unsaturated fatty acids: - Linolenic - Linoleic - Arachidonic Required for: - Cell energy - Cell proliferation - Phagocytic activity - Metabolism - Circulation - Inflammation
Wound healing - carbohydrates
Carbohydrates required for:
- Cellular energy for leukocytes & fibroblasts
- Synthesis of DNA & RNA
- Nerve tissue
- Red cells
- Regulation of blood glucose
- Modulation of nutrient absorption
- Fibre -gut function
Wound healing - Vitamin C
Required for: - collagen synthesis, - fibroblast production, - capillary formation Sources: Kiwi fruit, citrus, strawberry, parsley, rockmelon, b/currants
Wound healing - Vitamin A
Required for: - Epithelialisation, - collagen synthesis Sources: Liver, eggs, yellow & dark green vegetables, cod liver oil
Wound healing - Vitamin B complex
Required for: - antibodies, - lymphocyte function Sources: Legumes, grains, meats, poultry, fish
Wound healing - Vitamin D
Required for: - Metabolism of calcium Sources Sun, salmon, sardines, egg yolk
Wound healing - Vitamin E
Required for: - Corpuscles (an unattached cell, especially of a kind that floats freely, as a blood or lymph cell) Sources: Wheat germ, polyunsaturated vegetable oils, nuts, oysters,
Wound healing - Vitamin K
Required for: - Synthesis prothrombin - Clotting factors Sources: Green leafy vegetables, egg yolks, cauliflower
MAJOR TRACE ELEMENTS - Calcium
Required for:
- Bone growth
Sources:
Sardines, salmon, milk, cottage cheese
MAJOR TRACE ELEMENTS - Iron
Required for: - Hemoglobin & tissue oxygenation - Collagen synthesis Sources: Liver, beef, oysters, spinach
MAJOR TRACE ELEMENTS - Magnesium
Required for:
- Collagen synthesis
Sources:
Seafood, nuts
MAJOR TRACE ELEMENTS - Phosphorus
Required for:
- Bone and tissue growth
Sources:
Whole milk, chicken, pork, tuna, cheese
MAJOR TRACE ELEMENTS - Iodine
Required for:
- Thyroid function
Sources:
Iodised salt
MINOR TRACE ELEMENTS - Zinc
Required for: - cell mitosis & proliferation - cell membranes Sources: Seafood, organ meats, mushrooms, sunflower & pumpkin seeds
MINOR TRACE ELEMENTS - Copper
Required for:
- Collagen cross links
Sources:
Seafood, nuts, raisins
MINOR TRACE ELEMENTS - Folic acid
Required for: - red blood cells - metabolism of proteins - cellular growth & division Sources: Dark leafy & root vegetables, milk, salmon
