Module 3 - Surgical wounds, trauma wounds and debridement Flashcards
Classification of wounds
CLEAN
Wounds made under aseptic surgical conditions.
Wounds that do not enter genitourinary, respiratory or alimentary tracts
or oropharyngeal cavity.
CLEAN/CONTAMINATED
Wounds are contaminated by the resident flora or the cavities
but there is no host reaction.
CONTAMINATED
Contaminated by bacteria with no host reaction.
INFECTED
Clinical signs of infection present, with increased leukocyte and macrophage levels.
Types of surgical wound healing?
-Primary Intention
Sutures, staples, surgical tape
tissue glue (Histacryl)
-Delayed Primary Intention
Suture after 3-10 days
- Skin grafts
- Tissue flaps
- Bioengineered Tissue
2 types of Natural Suture’s
-Absorbable
Catgut -Plain (lasts 7-10days) or chromic (lasts 10-14 days)
-Non-Absorbable
Silk
Linen
Stainless Steel Wire
types of synthetic sutures
- Absorbable
- Non-absorbable
- Vieryl
- Polydioxone
What are the different types of skin sutures?
Simple square interrupted Continuous subcuticular Vertical mattress Horizontal mattress Wound closure strips e.g. Steri-Strips Tension sutures –deep support
Principles for surgical wound healing?
- Protect the wound from
- physical or pathogenic assault
- Absorb exudate
- Maintain wound temperature
- Maintain body temperature
- Oxygenation
- Avoid stress –pain relief
- Observe the suture line for complications
Dressing the suture line
24-48 hours unless drains in situ Dry low-adherent dressings Island dressings Semi-permeable film Hydrocolloid Foam Other
Types of Drains?
Capillary-Penrose, corrugated, Portex
Attached negative pressure suction devices -Redivac -Jackson Pratt (similar to Redivac but larger bore) -Sump (double lumen) -Axiom (triple lumen)
Percutaneous –biliary, nephrostomy
Principles of drain management?
-Client/carer support & education
-Secure drain
-Maintain patency of drain
-Maintain skin integrity
-Contain exudate
-Observe type & amount of exudate
-Prevent infection
-Observe for complications
discomfort, infection, dislodgement, blockage,
if on negative pressure -loss of suction, loss of skin integrity
Surgical wound complications?
-Haemorrhage –primary or secondary
-Haematoma
-Seroma
-Oedema
I-nfection
-Occlusion blood supply -necrosis
-Dehiscence / evisceration
-Adhesions
Define Dehiscence?
Separation of a sutured wound resulting in an cavity that requires either a second attempt at primary closure or will be allowed to heal by secondary intention
Aetiology: Haematoma Seroma Infection Trauma
Define Sinus?
A track or opening into the tissues
Define Fistula?
A fistula is an abnormal track connecting one viscus to another viscus or to the skin surface
Aetiology of a fistula?
Leaking surgical anastomosis Spontaneous rupture due to obstruction, disease, trauma, radiotherapy damage Mesenteric ischaemia Sepsis –diverticulitis & appendicitis
Principles for management of a fistula?
Patient comfort & support Fluid & electrolyte replacement Nutritional assessment & supplementation Prevention & management of infection Maintenance of skin integrity Containment of effluent & odour Cost-effective care
Define abberant healing and the different types?
any deviation from the normal wound healing and remodeling process
Hypergranulation
Contracture
Hypertrophic scar
Keloid
Explain hyper-granulation?
Raised granulation tissue above the level of the surrounding skin commonly occurs as a result of:
Friction
Increased bacterial burden in the wound
Infection
Explain Contracture
Abnormal scar formation that can inhibit movement or function due to excessive myofibroblast activity
Explain Hypertrophic scar?
Excessive scar that remains within the perimeter of the original wound
Explain keloid
Excessive scar that extends outside the
perimeter of the original wound
Principles for packing wounds
- Determine goal of care
- Ascertain extent of sinus or dehiscence
- Do not pack fistulae
- Select appropriate packing dressing
- Avoid probes in favour of safer instruments
- Pack lightly & gently (unless haemorrhage)
- Protect the surrounding skin
- Select appropriate secondary dressing
- Support peri-wound tissue
- Ensure all packing is removed
When not to pack?
The 6 ‘Fs”... Fistula Fascial plane separation Facilitate exudate drainage Foreign bodies Formed track -lined with epithelium Fear of the unknown
Explain negative pressure therapy?
The use of controlled negative pressure wound therapy to assist and accelerate wound healing
Also known as vacuum assisted wound healing
Define a skin graft
A skin graft is a segment of dermis and epidermis which has been completely separated from its blood supply and donor site
attachment before being transplanted to another area of the body
What are the different types of skin grafts?
-Autografts
Transfer of tissue from one site to another on the same person
-Allografts / Homografts
Transfer of tissue from one person to another
-Xenografts / Heterografts
Transfer of tissue from one species to another (e.g. pig skin)
-Tissue Culture
Epidermal cells cultured in the laboratory
-Bio-engineered Skin -Dermagraft, Apligraf
The difference between split thickness grafts?
Thin:
Contracts within the first few months
No hair
Higher survival rate as vascularisation occurs easily
Thick:
Less contraction
Usually contains some hair follicles.
Vascularisation of skin grafts?
Plasmatic imbibition: Almost immediately a skin graft comes in contact with the recipient bed, it begins to absorb a plasma like fluid from it (first 48 hours). A fibrin network is also being formed between the graft and the recipient bed to hold the graft in place.
Inosculation of blood vessels: In the first 48 hours, vascular buds grow into the fibrin network that binds the skin graft to the recipient site.
True Circulation: New capillary activity establishes in the graft within 4-7 days. The lymphatic system establishes concurrently with these stages.
Factors that inhibit graft take?
-Poorly vascularised recipient bed
-Shearing movement
Fluid collection beneath the graft (e.g. haematoma, seroma, pus,
debris)
-Infection
-Inadequate graft support when dependent
-Patient intrinsic or extrinsic factors
Define shearing movement?
Movement between the graft and the recipient bed causes
damage to the capillaries growing into the graft and prevents revascularisation
Whats involved in the care of a graft?
- Palpate for fluid collection
- Nick with fine point scissors and dab excess fluid
- protect with silicone or tulle gras dressing
- fill with fluffed gauze
Complication of grafts?
- shearing
- incomplete take due to fluid collection or infection
Flap Definition?
A flap is a surgical relocation of tissue from one part of the body to another part in order to reconstruct a primary defect. Flaps are described as skin or cutaneous flaps and composite flaps.
Types of flaps?
- skin or cutaneous
- composite tissue
- free flap
- pedicle flap
- rotational flap / z plasty
Skin Flap observations?
•Vital signs
•Fluid intake -IV and oral
•Monitor urinary output -0.5ml per Kg/ hr.
•Oxygen therapy and continuous saturations
•Drains for sudden increased drainage
•Type of exudate
•Pain management
•Warmth
•Change in tissue turgor
Prune-like or hollow if arterial occlusion
Tense, swollen and distended if venous occlusion
•Skin colour changes
•Bleeding
•Change in capillary refill time
•Doppler -arterial, venous, force, regularity
Goals of care burns?
Alleviate pain
Control microbial colonisation & prevent infection
Prevent wound conversion to a deeper burn
Achieve wound coverage as early as possible
Promote function of healing skin
Preserve function of the body part
Whats involved in the rehabilitation of burns?
-Bio-psychosocial adjustment
-Scar management
-Multidisciplinary input
Surgeon, GP, Nurse, OT, Physio, Dietician, Clinical Psychologist, Social Worker, Family
The effects of ageing skin?
- Thinning & flattening of the epidermis
- Decreased epidermal proliferation
- Cells in the horny layer lose elastin
- Atrophy of the dermis - contraction
- Changes to & loss of collagen
- Decreased vascularity of dermis
- Decreased number of oil & sweat glands
- Vascular response is compromised
- Altered or reduced sensation
- Fragility
Define skin tear?
A skin tear is a traumatic wound occurring
principally on the extremities of older adults, as a
result of friction alone or shearing and friction
forces which separate the epidermis from the
dermis (partial thickness wound) or which separates
both the epidermis and the dermis from underlying
structures (full thickness wound)
Explain Star 1A
A skin tear where the edges can be aligned to the normal anatomical position without undue stretching and the skin or flap is not pale, dusky or darkened
Explain star 1B
A skin tear where the edges can be aligned to the normal anatomical position without undue stretching and the skin or flap is pale, dusky or darkened
Explain Star 2A
A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened
Explain Star 2B
A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened
Explain Star 3
A skin tear where the skin flap is completely absent
What dressing would you use for a skin tear?
silicone dressing for fragile skin
-draw an arrow to indicate dressing removal direction.
Define debridement?
The removal of all foreign material and all contaminated and devitalised tissue from or adjacent to a traumatic or infected lesion until healthy tissue is exposed
Debridement methods?
Surgical Conservative sharp Mechanical Autolytic Enzymatic Chemical Biological or parasitic
