Module 13.4 - Wound Management Flashcards
What is an acute ulcer?
- Surgical wounds (either clean or contaminated after surgery) and traumatic wounds (clean or contaminated). These wounds are physiologically intact and healing is expected to progress as expected.
- Included in this category are simple lacerations, complicated lacerations needing debridement and closure, large tissue defects from large traumatic sounds, burns and postoperative surgical incisions (abdominal, orthopedic).
Describe a chronic ulcer
These occur when the normal structure and function of the skin is disrupted causing impairment in physiology. Wound healing will be compromised without intervention. Chronic wounds include the following:
- Arterial – caused by ischemia, associated with various types of arterial occlusive disease
- Venous – caused when there is impairment of the venous blood back to the central circulatory system
- Diabetic – occur when there is excessive and prolonged hyperglycemia and peripheral neuropathy in patients with diabetes
- Pressure – due to prolonged pressure or shearing. The tissues are damaged due to the decreased supply of oxygen
What factors cause a delay in wound healing?
- Excessive tissue load/pressure
- Decreased tissue perfusion
- Urinary or bowel incontinence
- Infection
- Systemic diseases
- Poor nutrition
- Necrosis
- Immunosuppress, decreased immune response
- Drugs (steroids)
- Vitamin, mineral, protein deficiencies
- Age
When is it appropriate to surgically close a wound/ use a skin graft on a wound?
Wounds that demonstrate progressive healing as evidenced by granulation tissue and epithelization can undergo closure surgically or coverage with a skin graft.
What are some subjective findings associated with ulcer development from all sources (venous, arterial, both)?
- Pain – claudication in arterial compromise, heaviness and soreness in venous compromise
- Neuropathy – seen in arterial blood flow compromise and diabetes. Patients complain of numbness and tingling
- Patients with arterial and venous flow compromise and diabetes will complain of poor wound healing
- Apply appropriate risk assessment tool such as Braden or Norton for those patients prone to pressure ulcer development
Describe how to use the Braden Scale to determine pressure ulcer risk
Describe the 8 steps to properly conduct a wound assessment
1. Review patient’s history for acute or chronic etiologies as possible cause- what diseases cause poor wound healing or circulatory compromise?
2. Look specifically at the location and document
3. Measure and record the wound in length and width in centimeters
4. Measure the depth of the wound – this findings will indicate the severity of tissue destruction and is classed in the following way
- Superficial
- Partial thickness – extends through the epidermis and partially into the dermis
- Full thickness –the wound extends through the epidermis, dermis and some subcutaneous layer involvement including muscle and bone. Note undermining and tunneling if present.
- Color- red-yellow-black classification system
- Red – wound bed is clean and healthy
- Yellow – exudate is present, debridement and cleaning is needed
- Black – eschar is present which indicates necrotic tissue. Cleaning and debridement are needed.
- Mixture of colors – wound needs to be closely examined to establish the prominent color to gear the treatment
5. Drainage – note color, amount and consistency
6. Odor- foul odor can indicate active infection
7. Appearance and temperature – is there erythema, maceration, induration or edema at the edges or surrounding tissues?
8. Pain present with inspection?
What are some characteristics of arterial and diabetic ulcers?
- Typical locations include toes and below the ankles for general arterial disease
- Decreased pulse volume/intensity
- Extremity appearance is shiny and feels cool
- There is an absence of hair, either complete or partial
- Ankle brachial index (ABI) is less than 0.5 (arterial). It may exceed 1.0 for diabetic patients although it can be unreliable in this patient group
- Deep ulcers are noted with smooth wound margins. A small amount of drainage is noted, possible necrotic tissue
What are some characteristics of venous ulcers?
- Typical locations include lower legs, above ankle
- Varicosities and edema are seen
- Extremities are warm with brawny discoloration
Where do pressure ulcers usually occur?
Typical locations include bony prominences including the sacrum, heels and occipitus
Describe the stages of pressure ulcer development
What lab/diagnostic tests are used to diagnose venous/arterial insufficiency?
Doppler pressure studies, reduced PVR waveforms
- Normal: pressure gradients less than 30 mmHg between cuffs
- Ankle brachial index is the ratio between pressure readings at the ankle and brachium
Digital plethysmography – measures systolic toe pressure
- Normal toe pressure is 80-90% of brachial systolic pressure
Transcutaneous oxygen measurements (TcpO2) – measures O2 delivery to skin tissue
- TcpO2 values higher than 30 mmHg indicate a wound area that will heal
- Lower than 20 mmHg indicate poor wound healing outcome
Venous Doppler ultrasonography
- Conclusive findings may indicate clots or incompetent valves
Guidelines for referral to vascular specialist (surgeon or vascular lab)
- Urgent referral reasons: presence of gangrene, visible tendon or bone at ulcer base, cellulitis or severe infection or ABI < 0.5
- Semi urgent referral reasons: TcpO2 > 30 mmHg and ABI > 1.0. Weak or absent pulses with ABI > 1.0. ABI between 0.5 and 0.8. Any evidence of poor wound healing despite aggressive wound care.
- Routine referral: ABI > 0.8
What is required for a wound to heal properly?
In order for a wound to heal properly, the wound bed needs to be well vascularized, free of necrotic tissue, clear of infection and moist. Studies have shown that contrary to prior beliefs, a moist wound will heal quicker than a wound that is left to air dry.
How do you manage a patient with an arterial ulcer?
The presence of ischemia determines the timing of revascularization, debridement and long-term management of IV antibiotics +/- closure of the wound.
If wet gangrene or abscess is present, the wound should be debrided immediately regardless of the plan for revascularization. Patients with dry gangrene without evidence of cellulitis, revascularization is done first. The following are components of ischemic ulcer treatment:
- Wet to moist dressing 3-4 times daily with normal saline are not recommended for infected wounds initially. Can be used after debridement for infection or for wounds that are at risk for infection
- Enzymatic agents collagenase (Santyl) daily, direct application to wound-may promote endothelial cell and keratinocyte migration prompting epithelialization-may also be a good choice for patients that are not surgical candidates
- Calcium alginates – particularly in infected wounds with large amounts of drainage
- Nonocclusive/Nonadherent dressing-dressings should be chosen on their ability to cover and control exudate
- Evaluation and treatment of underlying condition
- Pain management – assess pain threshold closely in diabetics with known neuropathy
How do you manage a patient with a venous ulcer?
- Evaluation of underlying condition for potential treatment
- Elevate limb
- Nonadherent dressing under compression
- Sharp (surgical) debridement if infection is seen
- Debride with Collagenase (Santyl) daily
- Hydrotherapy is contraindicated in venous ulcer management
- Empiric antibiotic treatment. Base your decision on severity of infection and available of information from the patient’s history. Were cultures obtained previously? Is there a recurrent organism? Antibiotics may need to be adjusted or de-escalated when culture results are available. Some antibiotic therapies include:
- Oral: cephalexin 500 mg PO Q6H or Dicloxacillin 250-500 mg PO QID. For penicillin sensitive patients: Erythromycin 250 mg PO QID or Clindamycin 300 mg QID.
- IV: Cefazolin 1 GM IV every 8 hours or Clindamycin 500 mg IV Q8H
- MRSA suspicion: Oral: Linezolid 600 mg PO BID, clindamycin 300-450 mg PO QID or Trimethoprim/sulfamethoxazole 1-2 tabletsPO BID.
- IV coverage: Vancomycin to achieve trough level of 10-15 ug/ml. Clindamycin 600 mg Q8H or Linezolid 600 mg Q12H
How do you manage a patient with a chronic ulcer?
How is maggot therapy used in wound treatment?
- It is a form of biological treatment of wounds, can be used as a bridge between debridement procedures, where surgical debridement is not available or the patient is not a candidate
- It has been used in the treatment of pressure ulcers, chronic venous ulcers and diabetic ulcers
- Randomized trials have not found consistent reductions in time to healing when compared to standard wound therapy
