Test1 Flashcards
1
Q
Infection-
Rubor
A
Poorly defined border, disproportionate, possible red streaks
2
Q
Autolytic Debridement
A
Selective
Conservative
Least painful, easy
Cheaper- but takes time
Maintains favorable wound environment: Occlusive dressings, moist, warm - “cook” Hydrocolloid Transparent films Foams Hydrogels
Typically changed at “strike thru” or spiked
Combine w/ cross hatching if appropriate
3
Q
Compression garments
A
Farrow wrap
Foot pieces and series of Velcro bands (similar to short stretch)
Easier don on/off vs compression stockings
Circ-Aid
Custom, non-elastic, Velcro bands
For VI and lymphedema
4
Q
Modes of Delivery- NPWT
A
Continuous
Intermittent (on/off)
Variable (up/down but not off)
Combination (continuous then intermittent)
5
Q
Signs of healing-
Surgical-
Positive Days 1-4
A
Edges approximated
Normal inflammation
Minimum to moderate drainage (bloody progressing to serosanguineous)
Primary dressing: dry or non-adherent gauze
6
Q
Mechanical Debridement
“Mechanical force”
A
Nonselective: Soft abrasion Hydrotherapy (WP, PLWS) Wet to dry or wet to moist Low frequency contact ultrasound
Painful (?)
Can be effective if used correctly
Familiar to healthcare workers
Wet-to-Dry rarely used; must be 100% non-viable
7
Q
DM monofilament testing
A
5.07 monofilament (10 gram)
Test each site 3x
> 1 absent = LOPS
(LOPS = Loss of protective sensation)
8
Q
AI interventions-
Referrals
A
Dietician
Reduced caffeine, smoking, proper nutrition and hydration
Diabetic educator
Podiatry
Prosthetics (if having amputation)
9
Q
Pressure injury classification-
DTPI (deep tissue pressure injury)
A
Localized area of discolored intact or non-intact skin
Purple or maroon
Damage of underlying soft tissue
Difficult to detect in dark skin tones
10
Q
NPWT- parameters
A
Filler and protective barriers
Mode of delivery
Frequency of change
Pressure
11
Q
NERDS
A
If 3 or more present,
Treat topically
N- nonhealing wound
E- exudative wounds
R- red and bleeding wound surface granulation tissue
D- debris (yellow or black necrotic tissue) on the wound surface
S- smell or unpleasant odor from wound
12
Q
Surgical wound healing-
Tertiary or Delayed primary closure
A
Initially wound left open then after a short time edges are approximated
13
Q
Irrigation -
What and why
A
Use of fluid to remove loosely adherent cellular debris, surface bacteria, wound exudate, dressing residue, and residual topical agents
Facilitate debridement
Maintain moist wound environment
Enhance wound healing
14
Q
Enzymatic Debridement-
Adverse effects
A
Burning/Stinging, allergic reaction
Peri-Wound irritation: highly exudative wounds, contact w/ skin
15
Q
Tube-like (Tubigrip)
A
Least compression, inexpensive, easy to apply/remove/reapply, reusable, comfortable
Generally considered light compression (can double it), stretches out with repeated use
Conservative trial to determine compression tolerance
Utilized with UE and LE issues or with at risk mild edema- sprains, wounds
Typically 10-12 mmHg
Different sizes
16
Q
Pseudomonas
A
Blueish, green Drainage
Odor
17
Q
AI - Wound characteristics
Location
A
commonly below ankle
Foot, heel, metatarsal heads, tips of toes, “bunion” areas
Possible superior to lateral malleolus or anterior lower leg
18
Q
DIME-
E
A
Edge effect
Progressing, stalled/rolled, callus, clean
19
Q
AI wounds:
Prevention
A
Recognize risk factors and encourage lifestyle changes before it progresses
Takes less O2 to maintain intact skin than to heal skin loss
Smoking cessation Control DM (A1c < 7%), HTN (< 130/80) Take prescribed meds Healthy diet and hydration Exercise (30 min, 3x week), control stress Soft appropriate/protective shoes Avoid cold temps Offloading and positioning prn Bed sheets/blankets, soft “heel lift” boots for bed
20
Q
Pressure injury classification-
Stage II
A
Partial thickness skin loss with exposed dermis
Red or pink wound without slough or granulation tissue
Usually moist
Stage II is NOT skin tears, dermatitis, maceration
21
Q
Treatment of pressure injuries-
Cleanse
A
Cleanse the wound and periwound
Normal saline
Tap water
Antiseptics
22
Q
Whirlpool- positives
A
Cleanses Agitation Additives Temperature range Tx large areas Exercise
23
Q
Local factors
Wound healing
A
- Circulation
Macro and Micro
Sympathetic nervous system responses to: cold, fear and pain - Sensation
Decreased knowledge of pain
Additional trauma to area - Mechanical stress
Friction, shear, weight bearing, pressure
24
Q
Cellulitis
A
Spreading bacterial infection of skin and subcutaneous tissue
Localized or advancing:
Tenderness, induration, fever
Necrosis, blisters.
Streaks- spreading along lymphatic channel
25
Epithelialization
Proliferation
Keratinocytes and epidermal appendages multiply and migrate across wound bed
26
STONEES
If 3 or more present,
Treat systemically
```
S- size is bigger
T- temperature of 3* F or more vs mirror image
O- Os (probe to or exposed bone)
N- new or satellite areas of breakdown
E- exudate is increased
E- erythema and/or edema (cellulitis)
S- smell
```
27
AI interventions-
| Supervised exercise program
3x wk
Short bouts of treadmill walking 40-60 min each session
Improved oxygen metabolism, collateralization, improved blood viscosity, improved walking economy
28
Enzymatic Debridement-
| How does it work?
Denatured collagen filaments anchor debris to wound bed
Collagenase digests these collagen filaments
```
Do NOT use with dressings containing:
Silver
Iodine
Hydrogen peroxide
Acetic acid
```
29
Pressure injury interventions-
| Prevention: Positioning In-chair
Sitting in intervals
Change position in chair
Reposition frequently: WC pushups, weight shifts
Support surfaces
30
VI- Patient education
Compression
Chronic situations, understand etiology and intervention
Extended standing or sitting, crossing legs
Ankle pumps, kneee bends, etc when necessary
Elevation - true elevation above heart
Elevation alone not adequate, must have compression when dependent
Care and replacement of compression stockings
Healthy lifestyle- weight, smoking, diet, sleep, etc
31
Braden Risk Assessment Scale
15-16 mild risk
12-15 moderate risk
<12 high risk
15-18 mild risk for those >75 y/o
```
Sensory/Mental
Moisture
Activity
Mobility
Nutrition
Friction/Shear
```
Pressure ulcer risk predictor
32
Wet gangrene
```
Drainage
Odor
Fluctuance/Edema
Erythema
Less clear line of demarcation
```
Urgent referral
Vascular surgeon
33
Greatest risk for pressure injuries
SCI
Hospitalized patients
Long term care patients
34
In-Elastic (Unna boot)
```
Applied only with enough tension to hold in place
No specified technique
2-3 layers over entire LE (or UE)
Requires 2ndary wrap
Usually long stretch or Coban
Kerlix May be added for padding
Considered multi-layer
```
Longer wear time- up to 1 week
Telescopes as edema reduces
Can cause frequent changes during first week due to initial changes in limb size
Can rub- especially along bend at ant ankle
35
Wound- Drainage
| Serous
Protein rich fluid with WBC
| Clear-pale yellow, watery
36
Neuropathic ulcer characteristics
Round, punched out. May be deep/probe to bone. Tracts/Tunnels
Peri-Wound callus (surrounding skin dry/cracked)
Often on plantar aspect of foot (metatarsal heads, great toe)
Min-mod Drainage, eschar uncommon
Red-pale granulation
Typically pain free (abnormal sensation/burning)
Wound itself not painful
37
Irrigation solutions-
| Tap water
Caution with immunocompromised
38
Wound bed
| Tissue identification
Describe in percentages present
1. Granulation tissue- temp scaffolding of vascularized connective tissue
Healthy granulation is bright or beefy red
Pale or dusky: blood supply poor or may be infected
2. Necrotic or Non-viable
Slough: yellow or tan, stringy or mucinous
Eschar: black necrotic tissue, soft or hard, wet or dry, adherent or non-adherent
3. Fascia, adipose, muscle, tendon, joint capsule, bone, new epithelium
39
```
Systemic factors (wound healing)
Nutrition
```
Carbs for energy
| Protein for cellular repair/regeneration
40
Stocking - mmHg levels
15-20 mmHg
Support
Early s/s w/o ulcer, lite prophylaxis for high risk pt; “tired legs”
20-30 mmHg
Therapeutic- Mild VI,
30-40 mmHg
Therapeutic- moderate VI, lymphedema; varicose veins
40-50 mmHg
Therapeutic- severe VI, lymphedema
60+ mmHg
Therapeutic- severe lymphedema, elephantiasis, post thrombotic disease
41
```
Systemic factors (wound healing)
Medications
```
Steroids
Chemotherapy
NSAIDS (?)
42
Pain pattern - Arterial Insufficiency (AI)
Increases with elevation and exertion (walking)
Numbness, tingling, cold, ache with exertion
Worse at night (Go to sleep, then up w/pain)
Can walk but require rest breaks (fatigue, pain)
Increasing pain is an indication for vascular consult
Pain can be masked by neuropathy in patients with DM
43
Pt education-
| Self-care (surgical wound)
Infection: s/s and action to take
Showering/Bathing
Nutrition/social habits
Wound cleansing, dressing changes, protection
Antibiotics
Pain meds
44
Inflammation-
| Dolor
Proportional pain
45
Tri-Neuropathy
| Sensory
Poor awareness of trauma to feet
Occurs gradually
Paresthesias:
Burning, tingling, aching
Painful and debilitating
False sense of protective sensation
46
Proliferation
Angiogenesis
Granulation tissue
Wound contraction
Epithelialization
47
Irrigation solutions-
| Wound cleansers
Shur-Clens : surfactant (oil, grease)
Vashe: hypochlorous acid- antimicrobial, R
Wound wash
48
Inflammation
| Vascular response
Goal: control bleeding, fight infectious agents
Transudate leaks out of vessel walls: local edema
Local blood vessels reflexively constrict
Platelets aggregate and are activated: forms a plug to wall off affected area and closes off lymphatic channels creating more edema, release chemical mediators necessary for wound healing
Within 30 min of vasoconstriction, vasodilation occurs: localized redness, warmth, edema
49
Potential risk factors-
| Arterial insufficiency
History:
Hyperlipidemia, hypertriglyceridemia (CAD, heart disease, etc)
Smoking (cessation: circulation improvements in 4 weeks, decrease CAD risk by 1/2 in 1 year)
DM (DM assoc neuropathy May prevent pain normally assoc with AI)
```
HTN
Trauma
Advanced age
PAD (occlusive, inflammatory, vasomotor)
Obesity
```
50
Surgical site assessment-
| Screening
Onset, fever, pain, last dressing change
| Complicating factors
51
Infection- function
Malaise, May feel sick
52
Stockings
Not just for VI, can be for support/vein health
Replace ~6 months, buy 2 pairs: hand wash, air dry
Custom vs OTC - different colors and materials, can double layer
Can be worn during wound closure after edema resolved
Not 100% effective at prevention/maintenance
Prescribe lowest effective level for maintenance
53
Pressure ulcers
| Treatment of cause
```
Redistribute pressure (relieve heel pressure)
Promote physical activity as tolerated
Manage incontinence and moisture
Reduce shear
Enhance and optimize nutrition
```
54
Dry gangrene
Mummification
No drainage, hard
Little/No odor
Clear demarcation
Protect, off-load
Monitor for conversion to wet gangrene
Auto-amp?
55
Irrigation-
Low pressure capsules
PSI?
PSI 4-8
| Max 10
56
Surgical wound healing-
| Primary intention
Edges approximated during surgery
| Sutures, staples, dermal glues
57
Wound- Drainage
| Amount
None, minimal, moderate, copious
Must consider dressing used and when last changed
58
Signs of wound deterioration (NPWT)
```
Increased peri-Wound erythema
Repeated need for sharp or surgical Debridement
Increased drainage, bleeding
Newly observed infection/necrosis
Increased pain
Increased wound size
Newly observed undermining or tracts
```
59
Cadexomer iodine
Broad spectrum antimicrobial
Slow release of iodine, non-cytotoxic
Absorptive- turns white w/ absorption
Various forms
Can be cheaper - depends on dressing frequency
Can stain skin
Cannot combine with collagenase
60
Exercise for patients with VI ulcers
Gastroc stretches to optimize ankle ROM (facilitate calf muscle)
Assess ankle ROM/flexibility- May also require ankle mobs, etc
Ankle pumps, circumduction, ABCs
Rocker board exercise
Heel-toe raises in sitting and standing
Step-overs - step 3-4 inch obstacle using heel strike in front, toe-pushoff in back
Exaggerated heel-toe sequence during walking
Walking
Biking
Aquatics (if no Wound)
61
Enzymatic Debridement-
Discontinue when?
Application?
“Clean”
Can promote cell migration
If not “clean” in 2 weeks, switch to another method
Application: thickness of nickel, must be kept moist
Cover w/ saline moist gauze, adaptic, hydrogel, etc
Frequently used for burns- except on face
May take longer if used alone (combo)
62
Debridement-
| Sharp- Indications
Presence of non-viable tissue/callus
Amount of non-viable tissue rendering other methods too slow (infection or risk)
Advancing cellulitis
63
S/S of sepsis
```
Shivering, fever or very cold
Extreme pain or discomfort
Clammy or sweaty skin
Confusion or disorientation
SOB
High HR
```
64
Signs of healing-
Surgical-
Negative Days 5-9
Drainage
Little to no new pink epithelium
Absent or partial healing ridge
S/S of Infection
Dehiscence
65
Tri-Neuropathy
| Autonomic
Altered sweating
Dry, less elastic, cracked skin
Callus formation (increased pressure)
Blood flow
AV shunting (less perfusion at skin)
Vasodilation (increase blood to bone, leaches calcium, predisposes bones of foot to fx 2ndary to osteopenia)
66
Biosurgical Debridement-
| Contraindications
Near eyes, upper GI or upper respiratory tract
Allergy: fly larvae, brewers yeast, soy
Exposed blood vessels connecting to deep vital organs
Decreased perfusion
Malignant wounds
67
Debridement and AI
Caution- lack of good blood flow = decreased healing
Sharp Debridement - typically contraindicated
Collaborative decision with MD
=<0.8 ABI - NO Debridement of “stable” eschar
Goal is maintenance
Same for heel pressure wounds
68
Margination
Cellular response- Inflammation
Increased leakiness of vessel walls: pushes PMNs to sides of vessel walls
69
Systemic factors
| Wound healing
```
Age
Nutrition
Comorbidities
Medications
Behavioral risk
```
70
Irrigation-
Gentle and rinsing
PSI?
Safe and effective PSI 4-15
71
AI- Interventions
| Ther Ex: Before a wound
Address modifiable risk factors
Positioning - avoid excessive hip/knee flexion (periodic dangle LE)
Gentle flexibility exercise- especially ankle
Aerobic exercise- graded walking program
Benefits: collateral vessel formation, weight loss, etc
Screening and monitoring- high % w/ CAD
Excessive exercise diverts blood flow to mms = pain
72
Cadexomer iodine-
| Cautions
Allergy to iodine/shellfish
Pregnancy/breast feeding
<6 mo old
Widespread prolonged use (hyperthyroidism/cytotoxicity)
73
Irrigation solutions-
| Sterile water
Must use with silver dressings
74
Infection-
| Status
Plateau or changes in granulation tissue
75
Wound- Drainage
| Type, color, consistency, amount
Serous
Sanguineous
Purulent
Amount: none, minimal, moderate, copious
76
Inflammation-
| Function
Temporary decrease
77
ABI and compression
Generally (a place to start)
ABI => 0.8 compression 35-40 mmHg
MD “ok” below 0.8 (follow facility guidelines)
May see claudication start when<0.8
ABI <0.8 but >0.6 cautious light compression 17-25 mmHg
ABI < 0.5 = NO compression; rest pain
Pain/sensation, contraindications for compression
Always better to be conservative, start low
78
Dressing surgical wound-
| When is moist dressing appropriate? What type?
Viable tissue exposed
Impregnated gauze cut to fit over opening
Dry gauze over the rest
79
NPWT
Negative pressure wound therapy
Closed wound dressing system with suction
Controlled sub-atmospheric pressure across open wounds
0-125 mmHg
80
Clinician induced factors
| Inappropriate wound care
Prolonged or inappropriate use of antiseptics
Wrong dressing selection (macerates or dries out)
Failure to detect/treat infection
Inappropriate irrigation, debridement, compression etc
Poor wound exploration
Poor temperature management
81
Alginate - Contraindications
Not to be used over bone, tendon, etc
| Not to be used on neonates (<38 weeks gestation)
82
Impregnated gauze
Atraumatic removal- “contact layer”
Multiple sizes, cut to fit
Mild occlusiveness, promotes moist wound healing
Less permeable than “regular” gauze (fluid held underneath)
Can be combined with topicals
Can be primary or 2ndary
Some can be left in place several days
Typically used on wounds w/o a lot of depth (some used to protect deeper names structures)
Ex: adaptic, xeroform
Cautions: maceration, adherent if allowed to dry
83
Combo Debridement
Sharp- remove loosely adherent tissue: cross hatch thicker areas
Enzymatic- applied collagenase to all non-viable areas
Autolytic- warm, well insulated, thick dressing
Pt education: rest, nutrition, etc
84
Surgical Debridement-
| Indications
Complexity of wound
Gross infection or high risk of infection
When amount of non-viable tissue is too much within acceptable timeframe
Extensive undermining
Unknown depth or abscesses
Involves fistula
Named structures
Bleeding tendency, extreme pain, or trauma
85
If think patient has AI?
MD referral
Pt education:
disease, progression, self-care
Skin care and protection (shoe checks, warming, etc)
Hot water bottles, “gentle warming” - heat groin, low back..
Behavior modification (smoking, diet, exercise, meds...)
Sleep (bed position)
Wound mgmt (protection, off-loading, wound care, etc)
Safe graded exercise (if cleared) - careful monitoring
86
NPWT- reducing pain at dressing change
Soak wound filler 3-5 min w/ saline- infuse via tubing
Protective layer-prevents adherence
Xeroform strips around edges
Pull occlusive sheeting parallel to skin
Frequent dressing changes (24 vs 48 hrs)
Granulation ingrowth less likely w/ gauze
White foam may be less painful to remove vs black
Calcium alginate under foam
At dressing change, cover tissue w/ soak to prevent dehydration
87
Signs of healing-
Surgical-
Negative Days 1-4
No signs of inflammation
Tension along incision line
Primary dressing: dry or non-adherent gauze
88
Surgical wound healing-
| Secondary intention
Left open after surgery, healing with scar tissue
89
Wound edges
Well defined (demarcated) or Diffuse
Thick or thin
Attached to wound base or raised or rolled (epibole)
Color
Evidence of epithelialization
90
Most common visual with venous insufficiency
Hemosiderin staining
91
HAI
Healthcare-associated infections
Infections pt got while receiving treatment for medical or surgical conditions
```
Most common:
Central line-associated bloodstream infections
Catheter-associated UTI
Surgical site infections
Ventilator-associated pneumonia
```
Prevention key
92
Intermittent claudication
Arterial insufficiency
Activity specific discomfort
Discomfort goes away within 1-5 minutes of stopping activity
Repeatable and predictable
Differential diagnosis: spinal stenosis
S/S relief with change of position
93
15 common locations of pressure injuries
1. Posterior heel
2. Sacrum/Coccyx
3. Spinous process
4. Medial/Lateral humeral epicondyles
5. Scapula
6. Occiput
7. Anterior tibia
8. Anterior knee
9. Iliac crest
10. Malleolus
11. Medial/Lateral femoral condyles
12. Greater trochanter
13. Ear
14. Ischial tuberosity (WC)
15. Greater trochanter (WC)
94
Pathophysiology of pressure injuries
Pressure creates increase in intracapillary blood pressure
= decreased blood flow to soft tissue and obstructed lymphatic channels
Local tissue ischemia
Increased metabolic waste and acidosis
= increased cell death
Capillary permeability and local edema increases further limiting circulation and increased tissue necrosis
Decreased fibrinolysis leading to fibrin deposits leading to microthrombi further occluding vessels and increasing necrosis
95
Signs of healing-
Surgical-
Negative Days 15 up to 1-2 years
Keloid or hypertrophic scarring
96
Surgical site assessment
Screening
Observations
Measurement of incision
Palpation (incision and surrounding area)
97
Pressure injuries-
| Intrinsic factors
```
Muscle atrophy- impaired mobility
Medications
Malnutrition
Medical conditions- impaired sensation; previous pressure injury
Advanced age
```
98
PLWS- negatives
Expense
Aerosolization risk:
Confined space
Cover horizontal surfaces
99
Alcohol hand rub
When hands NOT visibly soiled
Enough to saturate all parts of hands
Rub hands together 15 seconds
Allow product to dry
100
Infection-
| Tumor
Disproportionate edema, possible induration
101
Prediabetes - exercise
Lose 5-10% body weight
At least 150 min moderate exercise per week
Focus on overall health and importance of regular exercise
Gait, balance, fall prevention
102
Common infectious disease needing droplet precautions
```
Ebola
Pertussis (whooping cough)
Influenza
Rhinovirus
Pneumonia: Adenovirus
Streptococcus Group A
Rubella
```
103
Wound bed preparation
After comprehensive exam/assessment
Determine ability of wound to heal (includes underlying cause, pt status, complicating factors, etc - broad picture)
Healable- address underlying cause
Maintenance- potential but barriers
Non-healable/palliative- irreversible causes/illnesses
Once status determined, appropriately dose care
104
Wound bed-
| Tunnel
Entrance and exit
Document location and length
105
Common infectious diseases requiring contact precautions
MDROs (multi-drug resistant organisms):
MRSA; VRE
```
CRE (carbapenem-resistant enterbacteriaceae)
Ebola
C.difficile
Norovirus
RSV
Rotavirus
Herpes Zoster (Shingles) -in some cases
Scabies
```
106
Debridement-
| Sharp
Fast
Aggressive (high level of skill- some states require special license)
Painful (can be bc non-viable is attached to viable tissue)
Often combined w/ other forms
Selective- forceps, scissors, scalpel, curette
MUST have order from MD to perform
107
Clinical exam-
| Neuropathic ulcer
Lab values (Fasting glucose, A1C, albumin, pre-albumin)
Inspection of skin and nails (Skin: Dry, scaly, callus; Nails: Hypertrophic, fungus)
Foot deformity (Joint subluxation, dislocation, etc)
Vascular: Noninvasive vascular screen including ABI
Motor/ROM: STR if ankle/foot mms; Flexibility (DF at least 10*; great toe, metatarsal mobility); General gait analysis and balance
Sensory testing: monofilament, vibration, etc
108
Signs of healing-
Surgical-
Positive Days 15- up to 1-2 years
Pale pink scar progressing to white/silver
Will be darker in darkly pigmented skin
Note: scar will always be weaker. Only up to 80% of full strength
109
Wound - Odor
Assessed after irrigation
Present or absent
```
Caused by:
Infection
Non-viable tissue
Old dressing
Hot weather
```
110
Pressure injury classification-
| Stage IV
Full thickness skin and tissue loss
Exposed bone, tendon or muscle
May have slough and eschar
Undermining and tracts common
111
Autolytic Debridement-
| Contraindications
Infection
Dry gangrene
Deep cavity wounds
Other methods more appropriate
112
Clinician induced factors
| Appropriate wound care
Initial use of antiseptics to kill everything
Maintenance care when wound healing is not priority
Use of iodine to encourage/maintain non-viable tissue desiccation
113
Droplet precautions
Prevent spread by close mucous or respiratory membrane contact.
Usually passed through a cough, sneeze, or talking
Private room preferred, but if not available spatial separation of >3 feet needed and curtain drawn between patients
PPE: mask on healthcare provider or on patient if transport outside of room necessary
Don upon entry; Doff before exit
114
Signs of healing-
Surgical-
Positive Days 10-14
Sutures/Staples removes
Pink incision site
Tiny openings post removal
115
PMNs
Polymorphonuclearneutrophils
1st to site of injury (12-24 hours)
Kill bacteria
Clean wound
Secrete MMPs (matrix metalloproteases) - degrade debris
(Inflammation- cellular response)
116
Visual inspection - vascular status
Skin:
Discoloration, hyperpigmentation (hemosiderin staining)
Dry/cracked, old scar, hair loss, thick yellow nails
Dermatitis, lipodermatosclerosis, atrophic blanche
Vein distention, varicose veins
Edema- compared to contralateral side, bilateral? Soft, hard, pitting, etc
117
Irrigation solutions-
| Antiseptics
Use cautiously
Acetic acid: pseudomonas
Chlorhexidine gluconate (Hibiclens): intact skin, surgical scrub
Dakin’s sol’n (sodium hypochlorite, bleach): inanimate objects
Chloramine-T (chlorazene) : heavily colonized or infected wounds
Hydrogen peroxide: cleanse around pin sites and sutures
Povidone-iodine (Betadine) : surgical scrub, very short term acute
118
Sepsis
Systemic inflammatory response to infection
Combination of virulent infection and body’s strong response
Bacteria in blood, may travel to other areas (UTI, pneumonia...)
Fever, tachycardia, tachypnea, inadequate blood flow to internal organs
Shock, organ failure
~50% mortality rate
119
Biosurgical Debridement-
| Precautions
Drown in heavy exudate, squished by pressure
| Patients with breathing disorders
120
Neuropathic wound =
Diabetic foot ulcers
121
Moist wound healing
Enhance wound healing and promote new tissue growth
Low moisture levels lead to necrosis and eschar formation, hindering wound re-epithelialization and closure
Moisture balance of the wound bed is critical for wound healing
122
Purposes of debridement
Decrease bioburden and risk of infection
Increase effectiveness of topicals
Improve bactericidal activity of leukocytes
Shorten inflammatory phase
Decrease energy required by body to heal
Eliminate physical barriers
Decrease wound odor
123
Treatment of pressure injuries-
| Dressing selection
Moisture balance
Amount of exudate
```
Bacterial bioburden
Tissue condition in wound bed
Peri-Wound skin
Size, depth, location
Tunneling, Undermining
Goals
```
124
Neuropathic-
| Physical agents
Careful with heat application
Faster insulin absorption from injection site ; Hypoglycemia
More likely to burn (blood flow; sensation)
Ex- abnormal cardiac responses, vitals, glucose levels, etc
Careful with cold application
Slower absorption from injection site; Hyperglycemia
Cold tissue injury (blood flow; sensation)
125
ABI interpretation
> 1.2 Unreliable (vessel calcification)
1. 0-1.2 Normal
0. 8-1.0 Mild PAD, compression for edema with caution/monitoring
0.5-0.8 Moderate PAD, intermittent claudication <0.8
0.6-0.8 cautious modified compression (contraindication <0.6), night pain
Refer to vascular specialist
<0.5 severe ischemia, rest pain (“critical limb ischemia”) - compression and Debridement absolutely contraindicated
<0.2 tissue death
126
Pressure injury interventions-
| Prevention: Mobility
Encourage
Lengthen lines and tubes as able
Avoid polypharmacy
Adequate pain control
127
NPWT- Contraindications (11)
1. >30% slough/necrotic tissue OR over dry wounds
2. Untreated osteomyelitis
3. Gross infection or sepsis
4. Malignancy (except in palliative care)
5. Lack of hemostasis
6. Blood dyscrasia (leukemia/hemophilia)
7. Directly over exposed vessels/by-pass grafts/organs/named structures
8. Ischemic wounds w/ significant proximal occlusion
9. No intermittent over grafts due to high potential for disruption
10. No suction devices/pumps in MRI, HBOT, or close to flammable anesthesics
11. Any wound showing negative response to initial tx
128
“Regular” gauze offers
Readily available, various sizes, inexpensive
Non-occlusive and absorptive (dry)
Mechanical Debridement
Padding, primary (w/ hydrogel) or 2ndary dressing (wet to dry)
Cut to size
Telfa- non-adherent, little absorption
Changed daily as primary dressing
Cautions: drying, can absorb topicals quickly, fibers, roll gauze applied at an angle
129
NPWT- AI
Precautions
NOT for moderate/severe AI
Compression at wound edges causes 1-2.5 cm area of hypoperfusion
Not good idea in AI where surrounding tissue is already compromised
Use lower pressures
Intermittent mode- if appropriate
130
Foam
Absorptive - can be used with most thicker topicals (ointments)
Flexible, variety of sizes, cut to size
Non-adherent, thick and thin
Primary or 2ndary dressing (padding, additional absorption; can be combined with other dressings)
Insulating (promote autolytic Debridement)
Can be left in place up to 7 days
Cautions: maceration, can roll with friction
131
Autolytic Debridement-
| Disadvantages
Odor upon removal
Time
Infrequent visualization
132
NPWT- equipment
Pump provides suction
Wound filler or cover transfer pressure across wound bed and allow fluid to move through and into canister
Tubing- delivers suction, transports fluid
Canister- hold evacuated fluids
Occlusive sheeting provides air-tight seal
Application- simple to complicated
133
Phases of wound healing
Inflammation
Proliferation
Maturation/Remodeling
134
Mast cells
Produce histamine and secrete enzymes to accelerate riddance of damaged cells
(Inflammation- cellular response)
135
Macrophages
Kill pathogens
Direct the repair process
(Inflammation- cellular response)
136
Dressing surgical wounds-
| Most common
Dry or non-adherent gauze
Bordered foam
May see beta-dine dabs along incision line as well
137
Common infectious diseases requiring airborne precautions
TB
Measles
Chickenpox
Smallpox
138
Irrigation solutions-
| Normal saline
0.9% sodium chloride
Can be made at home
Refrigerate but warm before use.
Wounds heal best when kept under warm conditions.
139
Inflammation
| Cellular response
Increased leakiness of vessel walls: pushes PMNs (polymorphonuclearneutrophils) to sides of vessel walls (Margination)
PMNs- 1st to site of injury (12-24 hours), kill bacteria, clean wound, secrete MMPs (matrix metalloproteases) degrade debris
Macrophages arrive: kill pathogens, direct repair process
Mast cells: produce histamine and secrete enzymes to accelerate riddance of damaged cells
140
Basic incision care
Keep dry (dry gauze, Telford; abx ointment and impregnated gauze if tissue exposed)
Protection (reduce tension -edema; steristrips)
Cleansing and Debridement (clean water; wipe toward incision line; remove loose debris/scab)
Monitor
141
Biosurgical debridement
Biologic
```
Maggot therapy (MT)
Larval Debridement therapy (LDT)
```
Used since 1500s
Selective, quick, painless
Invest non-viable tissue and decrease odor
Release enzymes that degrade non-viable tissue and biofilm
Antimicrobial- MRSA, strep, pseudomonas, biofilm
Change in pH
Killing (secreted enzymes) and ingestion of bacteria
Excretions and mvmt stimulate granulation tissue
142
Sharp Debridement-
| Technique
Forceps in non-dominant hand; scalpel/curette/scissors in dominant hand
Parallel to wound surface
Lift necrotic tissue with forceps
Avoid sawing
Cut parallel to plane of wound tissue
Remove in thin layers
Can sometimes use a “scrape” technique
Bleeding s/b minimal bc non-viable tissue doesn’t bleed
Good to take before and after pictures
Warn patient wound will be deeper/bigger
143
Tri-Neuropathy
| Motor
Paralysis of foot intrinsics
Increased plantar forces
Hallux VALGUS
Claw toe
144
Debridement- methods
1. Sharp (MDs, PTs, PTAs, Nursing)
2. Mechanical
3. Enzymatic
4. Autolytic
5. Biological
6. Surgical (MDs): named structures, large stage III and IV pressure injuries, significant undermining, tunneling, sinus tracts, epibole)
145
SSI: surgical site infection
Most common nosocomial infection
Majority related to incision
To avoid->
IV abx 1 hr prior to first cut: good infusion to tissue, continued throughout surgical procedure
Preoperative hair removal (clipped not shaved)
146
NPWT- patient education
```
Basic operation, alarms, how to patch
Benefits
Device “on” 24 hrs day
Keep tubing on, no kinks
24 hr troubleshooting assistance line
Keep battery charged
What to do: bleeding, increased pain, etc
```
147
Total contact cast
Gold standard
For forefoot ulceration and Charcot foot
Requires special training
Forced off loading
Changed 1-2 weeks
Decreases activity level, stride length, cadence
Hot, heavy, difficult self-care
148
Discontinue NPWT
1. Goals met
2. Good granular bed achieved, even w/ skin surface
3. No appreciable benefit post 48 hrs
4. S/S deterioration
5. Development of new infection post NPWT
6. Pt discomfort/intolerance
7. Other dressings better suited to current phase of healing
8. Progression too little/no drainage
9. Anticoagulants
10. Sanguineous Drainage, fills canister in 1 hr or >2 canisters in 24 hrs
149
Infection/
| Drainage
Disproportionate, thick consistency, purulent, May be copious,white, yellow, green or blue, May have odor
150
Surgical wound-
| When to contact MD
```
Early increased bloody drainage
Change to purulent drainage
Drainage after 5-6 days
Absence of healing ridge by day 9
Infection: local s/s post day 4; systemic s/s anytime
Dehiscence
Increased pain
Consider contributions of increased mobility
```
151
NPWT- intermittent pressure
125 mmHg: 5 min on/2 min off
40-75 mmHg for mild arterial wounds (and lower pressures)
152
Trophic changes
Skin: dry, withered, shiny, thin, taut
Comparatively cool: recommend 5 min without socks/shoes before checking temp
Loss of hair
Limb/surrounding area pale/dusky
Pallor with elevation, Rubor with dependency
Decreased sensation
Muscle atrophy and weakness (MMT, girth)
Claw toes w/ mm atrophy of foot intrinsics
Nails: yellow, hard, brittle, thick (fungus)
Edema: not usually (dependent possible, CHF, VI)
153
Charcot foot
Fx and dislocation = foot deformity and abnormal pressure/shear forces
Suspect if:
Inflammation, edema, warm, bounding pulse, may have an open wound (or may come after)
Temp 4-15* higher w/o ulcer- May indicate Charcot foot
Dx: X-ray, MRI
Tx: casting 6-12 mo- TCC, boots (CROW)
154
Wound closure
| Secondary intention
Wound edges unable to be approximated
Granulation tissue fills in wound bed
PT more likely to be involved
155
Infection-
| Calor
Greater amount of increase, wider surface, may be febrile
156
```
Systemic factors (wound healing)
Comorbidities
```
Those affecting O2 perfusion
PVD, anemia, COPD, heart conditions
Immunocompromised
HIV/AIDS, diabetes
Activity limitations
157
Steri-Strips (3M)
PT placement
Post suture/staple removal
Sometimes placed over sutures/staples
Removal post closure:
When they fall off
Ok to shower
For ~2 weeks after suture/staple removal
158
Incision lines- scar management
Minimize inflammation
Encourage quick closure
Functional mobility during healing
Upright posture, ROM, etc
Moisturize lightly
STM
159
Diabetic foot ulcers-
| Exercise
Avoid if glucose >250 with ketosis or >300 without
No exercise if glucose <70
Stress = increased insulin requirements
Hydrate before: ~17 oz
Eat 2 hrs before exercise, or 1 hr after food intake
```
Snacks: quick vs slower absorption
Eat quick (fruit) every 30 min; Eat slow (bread) after exercise
```
Avoid heavy exercise late at night and do not exercise alone. (Delayed hypoglycemic event during sleep)
Don’t inject insulin over mm that will be heavily exercised that day
Type 2- no more than 2 days between bouts of exercise for best control
160
Dressings-
| Purpose
Provide optimal environment
Moisture, neutral warmth, protection/barrier, odor, delivery of topicals, reduce pain m
NOT static - applied in response to changing wound status/needs
Changes with drainage amount/type, healing phase, activity, temp, tissue, bioburden, etc
Re-evaluate dressing every visit
161
General factors
| Wound healing
```
Mechanism of onset
Time since onset (Acute vs Chronic)
Location- consider blood supply, bony prominences, typical skin thickness
Wound dimensions- circular is slower than square or rectangle is slower than linear
Temperature (37-38* C is best)
Wound hydration
Necrotic tissue
Infection
```
162
Inflammation-
| Tumor
Slight proportionate edema
163
Capillary refill - vascular status
Microvascular exam
Press end of toe/proximal to wound
Normal: <3 seconds
164
Inflammation-
| Calor
Local increase in temperature
165
ABI
Ankle brachial index
Ratio of ankle systolic to brachial systolic pressure
BP cuff proximal to ankle, inflated
Doppler: Dorsalis pedis and Posterior Tib pulses, use higher pressure
Obtain L and R brachial pressure, use higher pressure
Contraindications for test: ulcer near ankle
Considerations: calcified, noncompressible vessels will skew results (Diabetes, renal insufficiency, edema, obesity, poor cardiac output, etc)
166
Irrigation Solutions
Normal saline (0.9% sodium chloride)
Sterile water
Tap water
Wound cleaners
Other: antiseptics (use cautiously)
167
Pressure injury evaluation-
| Specific tools
BWAT: bates-Jensen assessment tool
15 items describing wound and peri-wound
Correlated with severity of wound
Higher number = more severe
PUSH : pressure ulcer scale for healing
Developed to monitor healing of ulcers
168
Debridement-
Sharp-
Contraindications
```
PT comfort/skill level
Cannot see (tracts etc) or identify tissue
Consent, or not consistent with POC
Ischemic ulcers (AI)
Hypergranulation - live tissue
Pyoderma gangrenosum
```
169
AI intervention- with a wound
| Plan?
Treat, wait for auto-amp, surgical intervention?
Conservative approach
Gangrene: monitor for conversion
Protection: dry, padded, NWB on affected limb
```
Moisturize surrounding skin
Monitor for infection
ROM for joint mobility and muscle flexibility
Exercise/walking program as appropriate
Foot care guidelines
```
170
Inflammation
| Cardinal signs
```
Edema
Redness
Warmth
Pain
Decreased function
```
171
AI- Wound characteristics
| Presentation
Start shallow then deepen
“Punched out” appearance
Usually round
172
Proliferation
| Key cells
Angioblasts
Fibroblasts
Myofibroblasts
Keratinocytes
173
Why not close via primary intention?
Risk on infection
Too much tissue removed- deep cavity
Closure would result in too much tension (edema)
174
Wound - size
Multi methods...
Direct measurement
Length (longest)
Width (perpendicular to length)
Depth (deepest)
```
Clock method
12 o-clock in area closest to head, but can be assigned differently by clinician
Length (12-6)
Width (9-3)
Depth (various: 2,4,8,10 or other)
```
Other methods: tracing, photos, volumetric, total body surface area
175
VI Wound characteristics
Uneven edges (can be diffuse or rolled)
Shallow
```
Highly exudative (especially at initiation of tx), primarily serous -
If little to no drainage-consider AI component
```
Pain- usually not too bad, if severe consider AI or vasculitis (or mixed)
176
Sharp Debridement-
| Controlling bleeding
Elevate, pressure x 10 min, silver nitrate (if have MD order for silver)
If structure pulsates- do not cut it!
Contact MD when:
Bleeding has a pulse, won’t stop, hear it
Fever/chills, downhill course, no improvement, impending exposure of named structures, unexpected abscesses or gross purulence
177
DIME-
| I
Inflammation/Infection
What stage of healing, immunocompromised, activity, s/s of infection, s/s out of proportion for phase of healing
178
MMPs
Matrix metalloproteases
Degrade debris
Secreted by PMNs
(Inflammation- cellular response)
179
Pressure injury classification-
| Unstageable
Obscured full thickness skin and tissue loss
Base covered by slough/eschar
True depth can’t be determined
(Eschar and slough have to be removed to stage the wound)
180
Enzymatic Debridement
Selective
Physician prescription
Pain free- some day it stings
Easy to apply - once daily
Can be used on infected wounds (combo): polymyxin b powder added
Do NOT use with silver or iodine products
Collagenase Santyl
181
PLWS- positives
```
Cleaning
Known PSI
Sterile, no additives
Temperature range
Site specific
Portable
Disposable (easy cleanup)
Few contraindications
```
182
Inflammation-
| Drainage
Proportionate, thin consistency, serous or serosanguinous
183
Wound bed-
| Undermining
Tissue under wound edge is gone, similar to cave under skin, “waggle room”
Documentation example:
Undermining of 4 cm from 10-12 o’clock
184
VI Peri-Wound
```
Maceration common
(Initially or with inadequate dressings or change schedule)
```
Diffuse edges
Irritation
185
DIME-
| M
Moisture balance
Tissue type/quality, maceration, activity, infection, dressing schedule, out of proportion, add or absorb moisture
186
Etiology and progression of arterial insufficiency
Decreased arterial blood flow ->
Intermittent claudication->
```
Ischemic rest pain
Burning pain with elevation or at night
Relieved by dependency
->
Ischemic ulcer or gangrene
```
187
Neuropathic wound exam
Thoroughly explore wound bed
Depth, tunnels, tracts, named structures
Callus
Classification: Wagner grading scale
188
What causes pressure injuries
Pressure (force/area)
Pathophysiology
Intrinsic factors
Extrinsic factors
189
Debridement-
Sharp-
Precautions
Anticoagulants/Clotting issues, pain
Immunosuppression
Unable to be still
190
Hyperglycemia impairs __ phases of healing
All phases of healing
Bacteria proliferate rapidly in high glucose environment
```
Impaired:
Production and migration of neutrophils
Chemotaxis, migration and mobility of macrophages
Function of fibroblasts
Epithelial cell migration
```
Deficient blocking of “normal” enzymes that degrade tissue
Endothelial cell dysfunction
Further complicated by underlying decreased blood flow
191
Surgical site assessment-
| Observations
Epithelialization/Wound closure, exudate
Wound tissue, periwound, surrounding skin
S/S of infection (clinical and critical colonization)
192
Diabetic (neurotrophic) foot ulcers
Vascular: ensure adequate vascular supply
Infection: control superficial critical colonization/deep + surrounding infection
Redistribute plantar pressure
```
Callus= pressure
Blister = friction and shear
```
193
Wound- Drainage
| Purulent
Indicator of infection
| White-pale yellow, viscous or creamy consistency
194
LaPlace’s Law
Compression =
| Tension X number of layers X 4630
%
(Limb girth X bandage width)
195
Biosurgical Debridement -
| Patient population
Maggot therapy
Osteo, Inf around hardware, etc
Poor candidate for sx
Unable to tolerate other forms of Debridement
196
Tri-Neuropathy
Diabetic neuropathy
Sensory - Motor - Autonomic
Usually symmetrical
Affects distal nerves first - feet/hands
Severity increases with: age, disease duration (~10 years), glucose control
197
___ dressings are important for healable wounds, with ___ often more appropriate for non-healable or maintenance wounds
Moisture balance dressings for healable
Moisture reduction for non-healable and maintenance
198
Pressure injuries-
| Extrinsic factors
```
Amount of pressure
Duration of pressure
Friction
Shear
Moisture
Temperature
```
199
NPWT- Tissue protection
Can apply over any body tissue-w/protection
Cannot put over named structures directly- must be protected (so don’t dry out)
Adaptic
Sometimes3-4 layers
White foam
Less aggressive compared to black/green
200
Debriding blisters
```
Remove:
Larger than nickel
Area likely to rupture or tear
Worried about possible tissue injuries- burns
Great medium for bacterial growth
```
Secure with forceps
Release tension carefully
Skin/blister line
Clean away residue (can appear like jelly)
201
Dehiscence
```
Tension, edema
Smoking
Infection/osteomyelitis
Trauma (pressure)
HTN
Stress
Malnutrition
Decreased healing potential (DM, etc)
```
202
Wound bed preparation -
| Maintenance and Non-Healable/Palliative
Conservative approach-
| Limited debridement, bacterial reduction through antiseptics, moisture reduction
203
Autolytic Debridement-
| Indications
Pain
Palliative tx
Can’t be still
204
Whirlpool- negatives
Risk of infection (sterility; aerosolization)
Risk of tissue injury (PSI; maceration)
Additives
Expense (cleaning, space, water)
(They suck- not ideal- not recommended period- unless nothing else available)
205
Colonization
Microflora replicate and form colonies
No adverse affect
Does not cause host response
206
NPWT- continuous pressure
80-125 mmHg for most acute wounds and pressure injuries
100-125 over grafts first 3-5 days
80 mmHg = max effects on blood flow
50-75: if pain issue; most chronic wounds
40-50 M: wounds w/ decreased circulation
75 mmHg for abdominal wounds due to pressure receptors in abdomen
207
PLWS- Contraindications
```
Exposed named tissues
Body cavities
Facial wounds
Recent grafts or surgical procedures
Actively bleeding
```
208
Pressure injury interventions-
| Prevention: Positioning In-bed
Avoid side positioning- 30* lateral instead
Pillows or foam pads between bony prominences
HOB lowest degree of elevation (prevent shear)
Clean and wrinkle free bed linens
Pillows/Wedges to prop heels and head
Support surfaces
209
Opportunities for hand washing
Before and After...
Patient contact
Any patient procedure
Wearing gloves
Environmental or Equipment contact
210
Signs of healing-
Surgical-
Positive Days 5-9
No inflammation
No drainage
New epithelium along entire incision line
Healing ridge present
Firmness along incision line from collagen deposition - Feels like a pencil under incision line
211
Biosurgical Debridement- specifics, application
Sterile, non-reproducing
Medicinal maggots order from Irvine, CA (250-300 ~$98)
10 for 1 cm2 wound surface area
“Free range” or “contained”
Need air so don’t seal off- nylon mesh cover
Covered w/ dry gauze to absorb drainage and allow air flow
Change ~3 days
Don’t travel around body
212
Contact precautions
Also used when environmental contamination from excessive wound drainage, fecal incontinence, and other bodily discharges
Private room s/b utilized if available or at minimum >3 feet separation b/w beds to avoid sharing of equipment and touching of surfaces
Most common mode of transmission
PPE: gloves and gown
Wash hands before entry. Don after entry into room and Doff before exiting. Wash hands after exiting.
213
VI- Goals of PT
Prevention
Referrals
Tx- set stage for body to heal
Relieve pressure and congestion- resolve/manage edema
Care for open wounds- manage drainage, protection, etc
Compression- determine level/method
Help pt adjust to lifelong issue:
Educate- condition, expectation for other rounds w/o intervention
Longterm compression needs
214
Debridement-
Sharp-
When to stop and warning signs
```
Patient request, pain control issues
Wound is clean
You get nervous, tired, unsure
Impending exposure of named structures
Holes you cannot are bottom of
Unexpected infection/purulence
Extensive undermining
Excessive bleeding
```
(May have slight bleeding- connected to live tissue)
215
Signs of healing-
Surgical-
Negative Days 10-14
Signs of inflammation or infection
Drainage
Dehiscence
Absent or partial healing ridge
216
Ultrasound based Debridement
```
Low-frequency contact US (kilohertz)
Tissue vibration (unstable cavitation)
```
Sonoca 180 (spring medical technology)
Qoustic Wnd Therapy System (Arabella medical LLCArobella)
SonicOne (misonix inc)
Antimicrobial effects as well
217
Mechanisms of Action and Benefits of NPWT
```
Removal of exudate
Moist wound environment
Decrease bacterial burden
Reduce edema and excess interstitial fluid- increases blood flow
Increase in microvascular blood flow
Stimulation of granulation tissue- mechanical deformation
Promotes wound contraction
Reduced dressing change frequency
```
218
Inflammation
| Key cells in cellular response
Platelets
PMNs
Macrophages
Mast cells
219
Rubor of dependency- vascular status
Supine, LE elevated 30-60*
1 minute
Observe for pallor/blanching
Normal = little to no color change
Mild-Moderate insufficiency = 45-60 and 30 seconds respectively
Severe insufficiency = <=25 seconds
LE dependency - Observe color
Normal = < 15 seconds, return of pink
Reactive hyperemia = >=30 seconds and dark red/rubor (+ for severe ischemic disease)
Venous filling
220
VI - compression
| Considerations for decision making
Comfort, cosmetics, tolerance
Some compression is better than none
Frequency of dressing change
Ok to compress over most wound dressings
```
Change at home or only in clinic
Condition of skin
Vascular status- varying amts of compression
Ambulation- calf muscle pump working?
CHF?
Cost
What has/hasn’t worked before?
For wound healing or longterm maintenance/prevention?
```
221
Clinical vascular exam
Palpation
Skin temp, pulses (can use Doppler)
Capillary refill
Rubor of dependency (loss of vasomotor control)
Claudication time
ABI
Venous filling time
222
Long stretch
Stretches a long way (ACE wrap)
Wants to return to its resting state
Delivers constant compression-can feel tight at rest
Increased compression during calf contraction
Good for ambulatory and non-ambulatory
Apply with figure 8 or spiral technique- requires skill, difficult to self apply
Consistent tension and layering
Can telescope (injury/restricted blood flow)
Caution with use in AI
Reusable but stretches out quickly
Issues with inconsistent tension (self application at home)
223
Low pressure lavage
Irrigation without suction
Jetox :
4-12 PSI
Uses wall O2 as pressure
Jet stream tip
224
Bioburden
Number of organisms with which an object is contaminated
Possible high levels if:
Friable granulation
“Clean” wounds without improvement in 2 wks
MOI: laceration from trauma, war injury, torn wound...
225
Standard precautions
Primary strategy for prevention of HAI
Combo of universal precautions and body substance
All blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes contain transmissible infectious agents
Hand hygiene, gloves, gowns, face shield/masks, eye protection
226
MRSA
Methicillin-Resistant Staphylococcus Aureus
May result in abscess, osteomyelitis, cellulitis
Can result in death (young and healthy)
Rise in CA-MRSA
Can live on surfaces for a long time:
Polyester 40 days, 3-9 months on dental chairs in high humidity
Grocery cart handles, skin-to-skin contact
Personal items- plinths
227
VI
| Methods of compression
```
Tubigrip
Long stretch
Short stretch
In-Elastic
Multilayer
Stockings
Garments
```
228
Transmission precautions
Used when route of transmission is not covered by standard precautions alone
Used in addition to standard precautions
229
Bite wounds
Can lead to serious infections (can develop rapidly)
Inoculation of oral (and skin) flora into body
Local infection, abscess, pain, loss of function
Use antiseptics and antimicrobial topicals
Check lymph nodes adjacent to injury
Follow up 24-48 hrs post injury
230
Offloading
Reduce pressure, promote slow ambulation, facilitate “normal” gait as possible
```
TCC: total contact cast
CROW: Charcot restraint orthotic walker
Boots
Half shoes and AFOs
AD: FWW, SPC, crutches ok for some; WC as last resort
```
231
Prerequisites for NPWT with Infection
1. Pt. free of most systemic s/s of gross infection
2. Necrotic tissue debrided
3. Abscesses drained
4. Adequate perfusion
5. Can be combined with silver (Ag)
6. Instillation (VAC) - Wound wash w/o removal of dressing (antibiotics, saline...)
232
Wound fillers - NPWT
Black, white, green foam
Gauze and JP “Type” drain
Flat, simple, disposable “stick on” dressings
233
VI wounds-
| Surrounding skin
Hyperpigmentation
Hemosiderin staining
Lipodermatosclerosis
Scarring of skin/fat (fibrin deposition)
Results in hard, thickened, immobile skin
Can cause “champagne-bottle leg” : scarring can restrict fluid flow
Hypertrophic changes- thick/scaly epidermis
Breaks in skin = openings for bacteria = risk of cellulitis
Irritation from chronic : exposure to large amounts of drainage; dressings and constant compression
Varicose veins- common due to overloaded, backed-up system
234
Contamination-Infection Continuum
Contamination->
Colonized ->
Critically colonized->
LocalSystemic (Infection)
235
AI:
| Wound care precautions and contraindications
1. Moist dressings-
NEVER on dry gangrene/eschar, careful at other times, depends on surgical candidacy
Unhealable AI Ulcers: tx all AI wounds this way until proven healable
Healable AI Ulcers: must have objective evidence of vascular status (ABI > 0.5)- consult with vascular MD
Expect slower progression
2. Avoid adhesives - no tape to injure fragile skin
3. PT role: identify, refer, protect, monitor, educate
Wound care, exercise
Treatment after re-vascularization/amp, team effort
236
Common interventions for Diabetic Foot Ulcers (DFUs)
Aggressive Debridement and callus saucerization
Depends on vascular status
No debridement for stable heel ulcers
Moist wound environment
Offloading is key
Monitor closely for infection
Patient education is key
Glucose control is key
Silver (antimicrobial) dressings common
Growth factors
237
Risk factors for abdominal dehiscence
```
Advanced age
Anemia
Chronic pulmonary disease
Infection
Increased intra-abdominal pressure (obesity, ascites, coughing, etc)
```
Drains
Continuous draining of fluids to reduce edema/tension
Can be located anywhere
Different types- negative pressure bulb, tubing
238
Whirlpool-
| Contraindications
```
Clean and granulating
Edematous, draining, macerated
Active bleeding
VI
Multi-wounds same area
Uncontrolled seizures
B and B issues
```
239
Debridement- goals
```
Conversion from chronic to acute
Reduction in bacteria
Improved environment for closure
Prep for grafting or sx closure
Tissue protection or exam (callus, blisters)
```
Check state practice act for debridement guidelines
240
Wound - Location
Correct terminology to describe location
Be specific and consistent
Medial/Lateral, Left/Right, Proximal/Distal...
Body chart or drawings
Photos
Multiple wounds : assign numbers
241
Infection
Microorganisms multiply and invade viable body tissues
242
Alginate- cautions
Maceration if placed outside wound margins
For highly draining wounds
Wounds desiccation
Look “bad” when wet
243
Wound bed preparation -
| Healable
Address underlying cause
Move to “local wound care” or DIME
(Debridement, Inflammation/Infection, Moisture balance, Edge effect)
244
Neuropathic ulcers :
| Risk factors
```
DM
Impaired healing
Vascular disease
Tri-neuropathy (sensory, motor, autonomic)
Mechanical stress
Impaired ROM
Foot deformities
Previous ulcer or amputation
```
245
Wound contraction
Proliferation
Myofibroblasts pull wound margins together
246
Wound closure
| Primary intention
Wound edges are approximated without/little formation of granulation tissue
Not typically seen by PT unless preparing for delayed primary closure
247
Multi-layer
2-4 layers
More layers = higher levels of compression 30-40 mmHg
“On” during work or rest
If long stretch layer- can feel tight at rest
Specific layering technique and sequence
Allows for some adjustment
Profore, Profore Lite, 3M, etc
More expensive, more time for application
Adds padding/bulk for fragile skin, bony prominences, shoes, heat...
Long wear time- up to 1 week
Requires skilled application
Disposable single use
248
Pressure injury interventions-
| Prevention: Education
Patients, caregivers and healthcare workers
```
Daily skin checks (mirrors)
Transfer techniques
Position changes
Incontinence mgmt :
Mild soap, pat dry, moisture barriers
No diapers, talc based powders
```
249
Inflammation-
| Rubor
Well defined border, proportionate to size of wound
250
VI wounds -
| Location
Above malleoli in the Distal 1/3 of the lower leg (medial and lateral)
If outside this area, may not have VI etiology (unless mixed etiology)
251
Critical colonization
Increasing number of bacteria becomes a bioburden
Adverse affects
252
DIME-
| D
Debridement
What tissues are present, safe to debride, type, frequency
253
Inflammation-
| Status
Normal phases of wound healing
254
Debridement- indications
Red-Yellow-Black system
Red: typically granular wound - NO debridement bc want to protect it
Yellow: indicates non-viable tissue- MAY want to debride
Black: eschar- USUALLY want to debride
PT: non-viable tissue, callus, blister
(MD only: live tissue; large amounts of non-viable; infected tissue)
255
AI - Wound characteristics
| Tissue
Black/Brown eschar
Pale granulation tissue
Mixed
256
Hydrocolloids
Highly occlusive
Promote autolytic Debridement
Highly adhesive
Sheets: various sizes, cut to fit, thick and thin
Paste: can be used for deeper wounds
Primary or 2ndary- usually primary
Cautions: maceration, skin damage w/ removal, edges can roll with friction,
Linked with hypergranulation
257
7 tests for examining vascular status
1. Visual inspection
2. Palpation
3. Capillary refill
4. Rubor of dependency
5. Venous filling time
6. ABI (ankle brachial index)
7. Claudication onset time
258
Critically colonized wounds (___ criteria) require ___ dressings.
With deep and surrounding infections (___ criteria) most appropriately treated with ___.
>=3 NERDS : antimicrobial dressings
>= 3 STONEES criteria : systemic antimicrobial agents
259
Enzymatic Debridement-
| Contraindications
Timeframe- take too long
Not for deeper wounds:
Tracts, body cavities
Named tissues (organs, nn, vessels, tendons, bone, ligs)
Facial burns
260
Airborne precautions
Prevent spread of disease that remain infectious over long distances
If possible patient s/b in airborne infection isolation room (aiir)
If not possible- private room, door closed until patient can be transferred to an aiir
N95 Respirator
261
Bites: treatment
Short term use of antiseptics- if at risk for infection
Thorough irrigation- PLWS, syringe, catheter etc
Aggressive Debridement
Test sensation, monitor for s/s of infection- educate . 24 hr follow up
Medical mgmt - systemic complications: antibiotics, steroids, anti-inflammatories, anti-histamines
262
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Systemic factors (wound healing)
Behavioral risk
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Smoking
| ETOH
263
Treatment of pressure injuries-
| Debridement
If needed, appropriate and consistent with goals
For LE, ensure adequate vascular supply for healing prior to Debridement
Do NOT debride dry stable eschar in ischemic limbs
264
PLWS
Pulsed lavage with suction
Irrigation and suction
Creates negative pressure
265
Cadexomer iodine-
| Contraindications
Thyroid disease
| Deep cavity wounds
266
Pressure injury interventions-
| Prevention: Incontinence
```
Moisture barriers
Speedy gentle hygiene
Incontinence pads
Voiding/defacating schedule
NM re-re-education
Call light in reach
```
267
4 factors affecting wound healing
General
Local
Systematic
Clinician
268
AI interventions-
| Prescriptive exercise
Walking or biking until onset of pain-rest-repeat. (Monitor vitals)
Better utilization of oxygen
Increased ability for work
Can encourage collateralization
Ischemia triggers collateralization
Progressive conditioning program
Walk until pain - rest - walk again
Progress to max tolerable pain before rest
Progress to 30-45 min w/o pain in 6-8 wks
(Patients typically won’t do on own bc pain)
269
Cat bites
Tiny sharp teeth
Deep puncture wounds difficult to irrigate- higher rate of infection with puncture wounds
Consider opening with scalpel for easier cleaning- surgical consult
270
Granulation tissue
Proliferation -> Maturation
Fibroblasts lay down extracellular matrix (eventually replaced by scar tissue)
->
Strengthened and reorganized (maturation)
271
Pressure injury classification-
| Stage III
Full thickness skin loss
Adipose is visible
Slough May be present
Undermining, tracts, and epibole possible
272
Wagner grading scale
0 - No open lesions, May have deformity or cellulitis
1- superficial ulcer
2- deep ulcer to tendon, capsule or bone
3- deep ulcer with abscess, osteomyelitis or joint sepsis
4- localized gangrene
5- gangrene of entire foot
273
Pressure injury classification-
| Stage 1
Non-Blanchable erythema
Localized
Typically over bony prominence
Difficult to detect with dark pigmented skin
274
Semipermeable film
Thin, flexible, multiple sizes, cut to size
Transparent, occlusive (promotes autolytic Debridement)
Barrier to outside world, can stay in place up to 7 days
Little absorption of used alone, can be combined with other dressings
Primary or 2ndary dressing
Usually for more superficial wounds- requires primary dressing for cavity/deep wounds
Highly conformable, adherent to periwound/surrounding skin
Cautions: limit wrinkles, applied w/o tension, difficult to apply, not waterproof, specific removal technique, damage skin w/ removal
275
Infection-
| Dolor
New onset or increased
276
Must wash hands with soap and water when:
Hands visibly dirty
After using restroom
Leaving a pt/environment with C.diff infection
Rub soapy hands using friction at least 15 sec
277
Spiral and figure 8
50% overlap
50% tension
Base of toes to just over gastroc (2 fingers at posterior knee)
Smooth, Minimize wrinkles
Graded/graduated compression
Ex: ankle ~30-40 mmHg, proximal calf ~18 mmHg
278
Hydrogels
Donate moisture
Can absorb small amts of drainage
Decrease pain
Promote autolytic Debridement
Gel and sheet forms
Can be combined with other dressings
Silver power + hydrogel = silver gel
Regular gauze + saline + hydrogel = moist dressing
Mush into nu-gauze for easy wound filling- but adds moisture
Cautions: maceration, sheets not used on infected wounds
279
Maturation
Granulation tissue must be strengthened and reorganized
Rapid collagen synthesis
Up to 2 years following wound closure (greatest in first 6-12 months)
80% full tissue strength
Unable to sweat- loss of sweat glands
Less sensitive to touch and temperature
280
Venous ulcers
| Treatment of cause
Bandages for healing
Stockings to prevent reoccurrence
281
Periwound
Palpation: induration, fluctuance, general edema, increased temp...
Maceration (macerated), healthy, intact, Dey/peeling...
Skin: color, texture, dryness, hair, etc
Callus
Local s/s of Infection
Sensation
Circulation
282
AI:
| After Re-Vascularization/Amp
Ensure vascular status and monitor
Go after it- moist wound environment, Debridement
Amp: stump wrapping/shaping/prosthetics
ROM, positioning, STR, mobility, balance, offloading
Work with podiatrist for shoes etc
Edema control
283
NPWT Indications
Acute and chronic
VI, pressure injuries, traumatic, surgical, burns
Mass casualty and high energy injuries (military)
Bone or tendon exposure - w/. Protection
Over grafts- w/ protection
Removes fluid, compresses, stabilizes/splints
Intermittent mode contraindicated
Over sutures- w/ protection; intermittent mode contraindicated
284
Wound specific
| Tests/Measures
```
Location
Size
Wound bed (tissues)
Wound edges
Drainage
Odor
Periwound
```
285
Palpation- vascular status
Temperature
Pulses- macrovascular exam:
BUE and BLE
Compare intensity (spot to spot)
Warm room, in supine (Posterior tib; Dorsalis Pedis absent up to 15%)
Edema- soft, pitting, fibrous, etc
286
Wound bed-
| Tract
Narrow passageway, tube like extension of wound
Documentation example:
Tract at 5 o’clock 7 cm
287
Osteomyelitis
Infection of bone
Possible causes:
Should suspect when bone is “open to air”
DM- have it until proven otherwise
Sepsis- bacteria introduced into bone
Traumatic injury- increased bacteria
Chronic wound/infection- bacteria extends to bone
X-rat, bone scan....
Tx: removal, OV/oral antibiotics for weeks
288
Irrigation-
| Indications and contraindications
Indications: All types of wounds (unless contraindicated)
Perfect treatment for healing granular wound
```
Contraindications:
1. Do NOT immerse soak:
recent skin grafts,
recent surgical incision sites,
diabetic feet
```
2. Active profuse bleeding wounds
3. Dry gangrene
289
Typical suture removal times
```
Face 3-5
Scalp 7
Chest, abdomen, extremities 7-10
Ear 10-14
Back, foot 12-14
```
7-10 days is typical
290
3 initial local wound care components that should be addressed in healable wounds
Debridement
Inflammation/Infection
Moisture balance
291
Debridement- contraindications
Arterial comprise: stable, dry, hard eschar (remember “the heel is hard to heal”)
Viable tissue
Granular tissue
Electrical burns
Deeper tissues
292
All chronic wounds should be classified as?
Healable
Non-healable
Or
Maintenance
293
Adjustments to overall amount of graduated or graded compression:
Increase/Decrease tension
Change number of layers
Will change automatically based on girth
Ankle typically smaller than calf- so normally achieve graded compression with simple change in leg circumference
(Pad oddly shaped lower legs for “normal” conical shape)
Bandage width:
Smaller = Higher compression
Figure 8 wrap = 2x compression of spiral wrap
294
Wound- Drainage
| Sanguineous
Blood or drying blood
| Red-dark brown, consistency of blood or slightly thickened water
295
Short stretch
Stretches a short distance
Applied with consistent tension/spiral layering- sometimes >50% overlap
Can telescope- frequently rewarded 1-2x day
Can be used for most pt with AI unless compression contraindicated
Utilize ABI to determine safe levels
Good for mixed VI/AI ulcers
Delivers high compression during muscle contraction
Low compression during rest
296
Proper shoe fit - without ulceration
Shape of shoe conforms to shape of foot
3/8 - 1/2 inch space between longest toe and end of shoe
Deep toe box allows toes to spread and toe clearance
Adjustable laces or straps for snug fit over instep
Fit snuggly around heel- ALWAYS wear socks
Closed toe.
297
Venous filling time- vascular status
Supine, LE elevated 30-60*
Observe the veins drain out on top of foot (60 seconds)
Return to dependent position
Normal = 5-15 seconds
>=20 seconds indicates arterial disease
298
Human bite wounds
3rd most common bite
(Dog, Cat are 1,2)
Can be worse than animal bites
Antibiotics and tetanus typical
High risk of infection: 10-20%
S/P 72 hrs and no s/s : hold antibiotics
Determine health of other person:
Hepatitis (higher transmission rate than HIV) 75% have detectable antigen in saliva
HIV (1 in 250 in US; 1 in 5 unaware) - not saliva alone
299
Dog bites
Lacerations, punctures and crush
Rabies status, behavior, known dog, etc
Very low infection rate with tx 6-13%
Need to involve local health authorities
300
NPWT- precautions (9)
1. Anticoagulants, low platelet count
2. Non-enteric and unexplored fistulas
3. Over named structures- requires several layers of barrier dressing or white foam
4. Monitor for bleeding
5. Avoid circumferential occlusive sheeting application due to increased risk of ischemia
6. Monitor skin condition when placed over bony prominences or hardware due to compression
7. Sharp edges of bone s/b debrided prior to application to protect soft tissue
8. MD notified of drainage in canister is sanguineous, fills w/in 1 hour, or if >2 canisters w/in 24 hrs
9. AI (NOT for moderate/severe AI)
301
Claudication onset time
Walk on treadmill, 1 mph, level grade
Record time to onset
Used for:
Developing a supervised progressive walking program
Tracking improved ambulatory endurance
302
Angiogenesis
Proliferation
Formation of new blood vessels
303
```
Systemic factors (wound healing)
Age
```
```
Slowed immune response
Decreased collagen synthesis
Epidermal and dermal atrophy (thinner skin)
Less sweat and oil glands (drier skin)
Decreased pain perception
Decreased inflammatory response
```
More comorbidities, susceptibility to infection, and more medications
304
AI- Wound characteristics
| Drainage
Minimal to none
| Usually dry and hard
