Week 1: Wounds Flashcards
3 phases of wound healing
Inflammation
Proliferation
Maturation/remodeling
Goal of inflammation
Process of inflammation
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.
Cardinal signs of inflammation
Edema, redness, warmth, pain, decreased function
Cellular response to inflammation
Increased leakiness of vessel walls > pushes PNMs to sides of vessel walls (margination)
Macrophages arrive > kill pathogens, direct repair process
Mast cells > produce histamine and secrete enzymes to accelerate riddance of damaged cells
Key cells: platelets, PMNs, macrophages, mast cells
PMNs
Polymorphonuclearneutrophils
1st to site of injury (12-24 hrs), kill bacteria, clean wound, secrete matrix metalloproteases, degrade debris
Steps of proliferation
- Angiogenesis— formation of new blood vessels
- Granulation tissue— fibroblasts lay down extra cellular matrix (eventually replaced by scar tissue)
- Wound contraction— myofibroblasts pull wound margins together
- Epithelialization— keratinocytes and epidermal appendages multiply and migrate across wound bed
Key cells: angiolasts, fibroblasts, myofibroblasts, keratinocytes
Maturation
Granulation tissue must be strengthened and reorganized
Rapid collagen synthesis
Up to 2 years following wound closure
80% of full tissue strength
Unable to sweat due to loss of sweat glands
Less sensitive to touch and temperature
General factors affecting wound healing
Mechanism of onset Time since onset Location— blood supply, bony prominences, typical skin thickness Wound dimensions—circular is slower than square or rectangle is slower than linear Temperature (37-38 degrees C is best) Wound hydration Necrotic tissue Infection
Local factors affecting wound healing
Circulation—micro and macro; sympathetic responses to cold, fear, pain.
Sensation— decreased knowledge of pain, additional trauma to area
Mechanical stress—friction, shear, weight bearing, pressure
Systemic factors affecting wound healing
Age
Nutrition—carbs, protein*most important *
Comorbidities—O2 perfusion, immunocompromised, activity limitations
Medications— steroids and chemo significantly slow healing
Behavioral risk taking— smoking, ETOH
Normal age-related physiological changes
Slowed immune response Decreased collagen synthesis Epidermal and dermal atrophy (thinner skin) Less sweat and oil glands (dryer skin) Decreased pain perception Decreased inflammatory response
More comorbidities
More susceptible to infection
More medications
Clinician induced factors affecting wound healing
Inappropriate wound care:
Prolonged or inappropriate use of antiseptics
Wrong dressing selection
Failure to detect/treat infection
Inappropriate irrigation, debridement, compression etc.
Poor wound exploration
Poor temperature management
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
Primary intention wound closure
Wound edges are approximated without/little formation of granulation tissue
Not typically seen by PT unless preparing for delayed primary closure
Secondary intention wound closure
Wound edges unable to be approximated
Granulation tissue fills in wound bed
PT more likely to be involved
Wound bed preparation
Assessment: healable, maintenance, non-healable/palliative
Healable— address underlying cause; move to local would care or DIME
maintenance & non-healable/palliative—conservative approach
DIME
Debridement
Inflammation/infection
Moisture balance
Edge effect
Patient history for wound exam
General demographics
Lifestyle and functional status—living environment, prior and currently LOF, employment, health habits
Past and current medical history—review of systems, medications, allergies
PST and current wound history—acute/chronic, labs/tests?, improving/getting worse, pain, previous wounds, dressing/when last changed
Systems review
Wound specific tests and measures for wound exam
Location—terminology, body chart/drawings, photos, assign #s for multiple wounds
Size— direct measurement, clock method, tracings, photos, volumetric, total body surface area
Wound bed— tissue identification (granulation, necrotic or non-viable, names tissues)
Wound bed—undermining, tract, tunnel
Wound edges— well defined/defuse, thick/thin, attached to base/raised/rolled (epibole), color, evidence of epithelialization
Drainage— type, color, consistency, amount
Odor— assess after irrigation (present or absent)
Periwound— area around the wound, palpation, maceration, skin, callus, local sxs of infection, circulation
Wound bed tissue description:
Granulation tissue
Slough
Eschar
Granulation tissue— temporary scaffolding of vascularized connective tissue; healthy granulation is bright beefy red; if pale or dusky, blood supply may be poor or may be infected
Slough— yellow or tan, stringy or mucinous
Eschar— black necrotic tissue, soft or hard, wet or dry, adherent or non-adherent
Wound bed descriptions:
Undermining
Tract
Tunnel
Undermining— tissue under wound edge is gone, similar to a cave under the skin (“waggle room”)
Tract— narrow passageway, tube like extension of wound
Tunnel— entrance and exit
Drainage type descriptions:
Serous
Sanguineous
Purulent
Serous— protein rich fluid with white blood cells; clear-pale yellow, watery
Sanguineous— blood or drying blood; red-dark brown, consistency of blood or slightly thickened water
Purulent— indicator of infection; white-pale yellow, viscous or creamy consistency
Causes of wound odor
Wound infection
Non-viable tissue
Old dressing
Hot weather
Irrigation: What and Why
What: the use of fluid to remove loosely adherent cellular debris, surface bacteria, wound exudate, dressing residue, and residential topical agents
Why: facilitate debridement, maintain moist wound environment, enhance wound healing
indications for irrigation
all types of wounds with a few exceptions
perfect treatment for a healing granular wound
contraindications for irrigation
Do not immerse/soak– recent grafts, surgical incisions, or diabetic feet
active profuse bleeding wounds
dry gangrene
Solution options for irrigation
Normal saline: can be made at home; refrigerate but warm before use
sterile water: must use with silver dressings
tap water: caution with the immunocompromised
wound cleansers: Shur-Clens surfactant; Vashe hypochlorous acid- antimicrobial, Rx; wound wash
antiseptics and what to use them for
acetic acid- pseudomonas
chlorhexidine gluconate (hibiclens)- intact skin, surgical scrub
Dakin’s solution (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
types of irrigation
gentle irrigation and rinsing (safe and effective psi)
low pressure capsules (spi 4-8, max 10)
low pressure lavage
irrigation without suction
Jetox- 4-12 psi; uses wall O2 as pressure; jet strain
positives and negatives of whirlpool
+– cleanses, agitation, additives, temperature range, treats large areas, exercise
- – risk of infection, risk of tissue injury, additives, expense
whirlpool contraindications
clean & granulating edematous, draining, macerated active bleeding venous insufficiency multi-wounds in asme area uncontrolled seizures B&B issues
Pulsed lavage with suction (PLWS)
pulsed jets of irrigation with suction
creates a negative pressure
Positives and negatives of PLWS
+ – cleaning, known psi, sterile (no additives), temperature range, site specific, portable, disposable– easy cleanup, few contraindications
- – expense, aerosolization risk
PLWS contraindications
exposed named tissues body cavities facial wounds recent grafts or surgical procedures actively bleeding
purposes and goals of debridement
decrease bioburden & risk of infection
increase effectiveness of topicals
improve bactericidal activity of leukocytes
shorten inflammatory phase
decrease energy required by the body to heal
eliminate physical barriers (improves environment for closure, preps for graft or surgery)
tissue protection or exam
decrease wound odor
When are PT’s indicated to debride?
Red-yellow-black system
PT– non-viable tissue, callus, blister
MD– live tissue, large amount of non-viable, infection
contraindications for debridement
arterial compromise viable tissue granular tissue electrical burns deeper tissues
methods of debridement
sharp mechanical enzymatic autolytic biological surgical (MDs--names structures, large stage 3-4 pressure injuries, significant undermining, tunneling, or sinus tracts, epibole)
sharp debridement
fast aggressive painful often combined with other forms can use forceps, scissors, scalpel, curette
common scalpels for sharp debridement
#10-- thick/callus #11-- incision/drain #15-- precise/cross-hatching
precautions and contraindications for sharp debridement
precautions: anticoagulants/clotting issues, pain, immunosuppressants, unable to be still
contraindications: PT comfort/skill level, cannot see or identify tracts, consent (not consistent w/POC), ischemic ulcers (AI), hypergranulation (live tissue), pyoderma grangrenosum
Warning signs and when to stop debridement
Patient request, pain control issues wound is clean you get nervous, tired, unsure impending exposure of named structures holes you cannot see the bottom of unexpected infection/purulence extensive undermining excessive bleeding
how do we control bleeding during debridement
elevate
pressure for 10 minutes
silver nitrate (MD)
how do we control pain during debridement
meds 30 minutes prior, topicals, deep breathing, music, distraction, etc.
when do we contact the MD during debridement
bleeding has a pulse, won’t stop, or can be heard
pt has fever/chills, downhill course, no improvement, impending exposure of named structures, unexpected abscesses or gross purulence
when to remove/debride blisters
larger than a nickel
area likely to rupture or tear
worried about possible tissue injury
great medium for bacterial growth
mechanical debridement
"mechanical force" nonselective-- soft abrasion, hydrotherapy, wet to dry or wet to moist, low frequency contact ultrasound painful? can be effective is used correctly familiar to health care workers
when is wet-to-dry mechanical debridement indicated?
only for 100% non-viable tissue
enzymatic debridement
selective debridement
physician prescription
pain free- may say it stings
easy to apply- once daily
can be used on infected wounds w/ polymyxin B powder added
do not use with silver or iodine products
collagenase Santyl– facilitates debridement
discontinue when “clean”
if not “clean” in 2 weeks, switch to other method
frequently used for burns, except on face
may take longer if used alone
how does enzymatic debridement work?
denatured collagen filaments anchor debris to the wound bed
Collagenase digests these collagen filaments
do NOT use with dressing containing: silver iodine hydrogen peroxide acetic acid
adverse effects and contraindications for enzymes
adverse effects:
burning/stinging, allergic reaction
peri-wound irritation
contra–
timeframe– takes too long
not for deeper wounds (tracts, body cavities, named tissues)
facial burns
autolytic debridement
natural debridement using moisture retentive dressings
selective
conservative
least painful, easy
cheaper–but takes time
maintains favorable wound environment using occlusive dressings to keep wound bed moist and warm to “cook”
can use hydrocolloids, transparent films, foams, or hydrogels
typically changed at “strike through” or soiled
combine w/ cross hatching if appropriate
indications
contraindications
disadvantages of autolytic debridement
indications: pain, palliative treatment, can’t be still
contra: infection, dry gangrene, deep cavity wounds, other methods being more appropriate
disadvantages: odor upon removal, time, infrequent visualization
combo debridements
Sharp + cross hatched areas
Enzymatic + collagenase to all nonviable areas
autolytic + warm, well insulated, thick dressings
pt education– rest, nutrition, etc.
Biosurgical debridement
Maggot therapy (larval debridement therapy LDT)
used since 1500’s
selective, quick, painless
ingest non-viable tissue & decrease odor
release enzymes that degrade non-viable tissue & biofilm
antimicrobial– MRSA, strep, Pseudomonas, biofilm
sterile, non-reproducing
cover with dry gauze to absorb drainage & allow air flow
patient population: osteo, infection around hardware, poor candidate for surgery, unable to tolerate other forms of debridement
contraindications and precautions for biosurgical debridement
contra–
near the eyes, upper GI or respiratory tracts
Allergy to fly larvae, brewer’s yeast, soy
exposed blood vessels connecting to deep vital organs
decreased perfusion
malignant wounds
precautions–
drown in heavy exudate, squished by pressure
pts with bleeding disorders
indications for surgical debridement
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 abscess
involves fistula
names structures
bleeding tendency, extreme pain or trauma
questions to determine what form of debridement to use`
what can they tolerate? will they need to do this at home? safety concerns cost risks? combo? is this something I can handle?
purpose of dressings
provide optimal environment– moisture, neutral width, protection/barrier, odor, delivery of typical, reduce.
Not static– can be adjusted according to changing wound needs
Re-evaluate dressing every visit
considerations for wound dressing choice
exudate: type & amount
bioburden
tissues: granular, tendon, nonviable, etc.
location, size, depth
peri-wound & surrounding skin
etiology & treatment history
allergies
pt comfort, age, pt/caregiver ability
supplies, cost & coverage, schedule, goals
secondary dressing, retention, compression
common sense
when do you change dressings
when saturated "strike through" maintain moist environment timeline for topicals or combo dressings becomes soiled, contaminated, wet disrupted-- loose/falls off, MD visit Bathing odor when concerned: try new treatment, longer schedule, etc.
“regular” gauze benefits & cautions
readily available, various sizes, inexpensive
non-occlusive & absorptive
mechanical debridement
padding, primary (w/ hydrogel) or secondary 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
impregnated gauze
cautions
atraumatic removal “contact layer”
multiple sizes; cut to fit
mild occlusiveness, promotes moist healing
less permeable than “regular” gauze
can be combined with topicals
can be secondary or primary
some can be left in place several days
typically used on wounds w/o a lot of depth
cautions: maceration, adherent if allowed to dry
semipermeable film
cautions
thin, flexible, multiple sizes, cut to size
transparent, occlusive
barrier to outside world, can stay in place up to 7 days
little absorption if used alone, can be combined with other dressings
primary or secondary dressing
usually for more superficial wounds
highly comfortable, adherent to peri-wound/surrounding skin
cautions: limit wrinkles, applied w/o tension, difficult to apply, not water proof, specific removal technique, damage skin w/ removal
hydrogels
cautions
donate moisture–can absorb small amounts of drainage, decrease pain, promote autolytic debridement
gel & sheet forms
can be combined w/ other dressings–
silver powder + hydrogel = silver gel
regular gauze + saline + hydrogel = moist dressing
mush into nu-guaze for easy wound filling - but adds
moisture
requires secondary dressing
cautions: maceration, sheets not used on infected wounds
foam
cautions
absorptive (can be used with most thicker topicals)
flexible, variety of sizes, cut to size
non-adherent, thick & thin
primary or secondary dressing
insulating (promoting autolytic debridement)
can be left in place up to 7 days
expensive (leave on for 3-7 days to get money’s worth)
cautions: maceration, can roll w/ friction
Hydrocolloids
cautions
highly occlusive highly adhesive sheets: various sizes, cut to fit, thick & thin paste: can be used for deeper wounds primary or secondary dressing
Cautions: maceration, skin damage w/ removal, sheet forms not for deep wounds, past/particles expand in deeper wounds, edges can roll w/ friction, linked w/ hypergranulation
alginate
cautions & contraindications
highly absorptive
some assist w/ clotting
sheet & rope, various sizes, cut/tear to fit
frequently combined in or w/ other dressings
can be left in place for up to 7 days
non-occlusive
contour easily to wound surfaces, can be layered into deeper wounds
cautions: maceration if placed outside of wound margins, for highly draining wounds, wound desiccation, look “bad when wet
contraindications: not to be used over named tissues or on neonates
hydrofiber
highly absorptive (more than alginate)
absorb vertically (less risk of maceration than alginate)
different sizes, cut to size
Aquacel (ConvaTec)
antimicrobial
when to use it: critical colonization active infection high risk of infection When should it be discontinued? clean wound, epithelialization/granulating risk is removed short term dressings
Examples– Cadexomer Iodine, silver, honey
Cadexomer Iodine
caustions & contraindications
broad spectrum antimicrobial
absorptive (turns white)
various forms
can be cheaper than others depending on dressing frequency
can stain skin, cannot combo w/ collagenase
cautions: allergy to iodine/shellfish, preganancy/breastfeeding, <6mo old, widespread prolonged use
contraindications: thyroid disease, deep cavity wounds
silver
cautions
broad spectrum various forms (powder, gel, alginate, hydrocolloid, foam, sheets, cream, etc. various wear times (daily- 7 days) some require pre-moistening canot combine w/ collagenase
cautions: toxicity risk w/ prolonged use, allergy, irrigate w/ sterile water, use on newborns/infants/young children
Honey
cautions
contraindications
broad-spectrum antimicrobial
various forms and combos (some can absorb exudate)
can reduce odor and pain
promotes autolytic debridement (assists w/ breakdown of nonviable tissue)
cautions: initial stinging
contraindications: allergy to bees or honey
