Module 6 - Vascular Disorders Flashcards
What is a non-healing wound
Any wound that takes longer than 3 weeks to heal and has not responded to conventional therapies. Examples include non healing surgical wounds; diabetic ulcers; arterial, venous, mixed ulcers; pressure ulcers.
Why are non healing wounds significant
Cost (direct & indirect) - resources required to manage such wounds
Lifestyle impact for those with NHW
Uncertainty, fear
Whats the difference between acute and chronic wounds
Acute wounds have a limited pro-inflammatory stimulus
Chronic wounds have a prolonged pro- inflammatory stimulus
Persistent pro-inflammatory stimuli include for chronic wounds:
Ischaemia ( or other underlying disease process)
Bacterial contamination / colonisation
Repeated trauma
What are matrix metaloproteinases (MMPs)
MMP’s are enzymes sub-classified in the metalloendopeptidase family. One of their roles is to degrade extracellular matrix components following trauma, which in turn assists in wound debridement and consequently facilitates cell migration.
What is the MMP activity in chronic wounds
Elevated pro-inflammatory response
Protease activity elevated
Growth factor activity decreased
TIMP activity increased
Importantly senescent cells do not have receptors and therefore will not bind with growth factors
What is the role of MMP in tissue repair?
Inflammatory phase: produced by macrophages, keratinocytes and fibroblasts to assist in removal of damaged & denatured extracellular matrix components
Remodelling phase: assist in remodelling
TIMP (tissue inhibitors of matrix metalloproteinases) increase while MMP’s decrease at the end of the inflammatory phase
Why is Removal of eschar & slough material
Debridement a good principle of wound care
Accelerates wound healing, decreases risk of infection, allows full assessment of the wound bed
What are the 4 mechanisms used for debridement
Sharp
autolytic
mechanical
enzymatic / chemical
What are the indications to use sharp debridement + how is it done
- Lge amounts of necrotic tissue
- When infection / sepsis present
Instruments used to remove nonviable tissue
E.g. sharp forceps / scalpels
What are the indications to use mechanical debridement + how is it done
Slough / minimal eschar
Large wounds
Removal of non viable tissue by physical forces e.g. wet to dry dressings (saline packs allowed to dry)
What are the indications to use autolytic debridement + how is it done
- Dry eschar
(vascular status needs confirming) - For those not requiring urgent debridement
Bodies own process – leukocytes & proteolytic enzymes digest
What are the indications to use chemical debridement + how is it done
- Smaller wounds
- When clients are not surgical candidates (at risk)
Application of prescriptive medicine to remove NV tissue
Why is moist wound healing a good principle of wound care?
- Wound fluid contains growth factors – stimulate connective tissue formation and epithelial migration
- Thought to accelerate healing by 40%
How is a moist wound achieved?
Achieved through wound exudate and product use
Be careful not to have too much moisture in base of wound can spill onto surrounding tissue (peri-wound skin) and cause maceration (water logging) which in turn affects the supply of nutrients and oxygen to the tissue (through micro circulation) and removal of waste products
Why is the maintenance of thermoregulation a principle of good wound care?
- Ideal wound temp is 370C
- Hypothermia / cold irrigating fluids causes vasoconstriction can lead to decreased oxygen to the tissues.
This can impair the production of growth factors, alter phagocytosis, and impair collagen deposits (all essential for healing) - Most contemporary wound dressings are designed to maintain ideal wound temp.
- If wound temp drops below 28 C then leucocyte activity may stop
Why is identifying and eliminating infection a principle of good wound care
- All open wounds are contaminated with bacteria, therefore they may be colonised, but not infected
- Chronic wounds can show much higher concentrations before becoming infective
What is erythema
is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries
Why is the management of exudate a principle of good wound care
Generally agreed that a decrease in the amount of exudate means that healing is taking place
Excessive exudate results in maceration of surrounding tissue further degrading the wound
Why is managing oedema a principle of good wound care?
Need to determine vascular status
ABI less than 0.8 determined to be arterial and should not have compression therapy
ABI greater than 0.8 determined to be venous or ‘mixed’ and may require compression therapy
Why is eliminating dead space a principle of good wound care
- To prevent:
premature closure of wounds abscess formation - Requires packing retrievable material into the ‘dead space
Why is Protection of wound and surrounding skin a good wound principle?
Need to protect wound from trauma as this can destroy fibroblasts and disrupt the formation of newly formed blood vessels
What are the major reasons for amputation
PVD – most frequent candidates for extremity amputation
Diabetes – major aetiology of arterial occlusion – also highly associated with lower extremity amputations
What dressing would you put with a wound assessment that is Superficial Partial thickness – low exudate
Adhesive film or soft hold foam (e.g. mepilex - skin tear protocol in Brisbane Hospitals)
What dressing would you put with a wound assessment that is Mild to mod exudate
Foams, hydrocolloid*, alginate #, hyrdofibre # (# require a secondary dressing)
What dressing would you put with a wound assessment that is Contaminated, mod to heavy exudate
Alginate, hydrofibre, antimicrobial (e.g. silver), Curasalt with secondary dressing (see below), also hydro- capillary dressings.
What dressing would you put with a wound assessment that is heavy
Primary dressings: Alginate, silver alginate / hydrofibre, AMD gauze.
Secondary dressings: Absorbent pad wicking laterally & vertically e.g. combine such as exudry, Zetuvit, Mesorb
What dressing would you put with a wound assessment that is dry, necrotic
Hydrogel, hydrocolloid, honey, SSD cream, Flaminal Hydro, Iodosorb. Combined with secondary dressing that is weekly absorptive
What are some non-adherent dressings?
Adaptic, Atrauman, Melolin, Cutilin
What are some wound type examples for non-adherent dressings
- Suture lines (primary closure) Melolin / Cutilin
- Blisters
- Graft sites- Adaptic or Atrauman appropriate (no stick required)
What are some wound type examples for transparent film dressing
Often used for more superficial types of wounds e.g. donor sites, abrasions, primary closures, IV sites
What are some wound type examples for Hydrocolloid dressings
Often used on pressure sores - for superficial skin protection
Protection of skin surrounding a heavily exudating wound
What are some wound type examples for Hydrogels & Gels
Dry necrotic wounds (not of arterial origin) such as highly sloughy venous ulcers, wounds with scab formation
What are some wound type examples for Alginates
Packing heavily exudating ulcers, cavities
What are some wound type examples for foam
Shallow wounds with predominantly granulation in bed, so venous ulcers, skin tears, de-roofed blisters
What are some wound type examples for Exudate absorbers / wicking dressings
Wounds requiring padding / secondary dressing which have moderate to large exudate such as venous ulcers, infected wounds
What are some wound type examples for Silvers (Antimicrobial effect)
Heavily contaminated / colonised / infected wounds
What are some examples of Topical treatment properties for antimicrobial effect.
- Curasalt
- Honey
- Burn aid/wound aid
What are some wound type examples for Topical treatment properties for antimicrobial effect.
Wounds where there is heavy colonisation / infection
What are some examples of Protease modulators
Iodosorb / Inadine
What are some wound type examples for Protease modulators
Chronic wounds and infected wounds as they sequester bacteria in the same way as proteases in the wound bed.
For venous ulcers, the key to healing is
the key to healing is compression therapy (with appropriate wound care), good debridement of dead tissue (mostly through autolytic &/or sharp mechanisms),
For arterial ulcers, the key to healing is
For arterial ulcers a more conservative approach is taken. Debridement is not usually indicated as the blood supply is not sufficient to support tissue growth. Usually the underlying disease process needs correction (e.g. bypass surgery etc) prior to the wound having a chance at healing.
If there is a large amount of maceration, what needs to happen
Then the dressing needs to be reviewed as it is not doing the ‘job’ in adequately wicking away wound fluid (exudate) from surrounding tissue. A wicking / absorptive dressing needs to be employed.
If the wound is dry / dark / necrotic what needs to happen
it needs hydrating, so a hydrating the wound be a appropriate course of action. In this case you need to think about the secondary dressing if you are hydrating then you do not want to draw the product into the dressing rather you need to keep at the wound face to let it do it’s job.
Topical corticosteroids actions / uses are anti-inflammatory in nature and are used in the treatment of inflammatory dermatoses. Corticosteroid creams should be applied:
- In a small amount and massaged in
- Thickly and left on the surface to absorb
- Thinly and is not to be rubbed in
- None of these
- Thinly and is not to be rubbed in
It is important that you do not put it on broken skin as it is anti-inflammatory, therefore will impede the healing process
Topical steroids should not be used on infected areas because as it may increase the infection through the immunosuppressive actions of the drug:
- True
- False
True
Barrier creams protect the peri-wound skin from:
- The wound care products within the base of the wound
- Excessive exudate and subsequent maceration
- Toxins produced from bacteria in the wound
- Irritation and dryness
