Week 1: Wounds

Question 1

3 phases of wound healing

Answer 1

Inflammation
Proliferation
Maturation/remodeling

Question 2

Goal of inflammation

Process of inflammation

Answer 2

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.

Question 3

Cardinal signs of inflammation

Answer 3

Edema, redness, warmth, pain, decreased function

Question 4

Cellular response to inflammation

Answer 4

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

Question 5

PMNs

Answer 5

Polymorphonuclearneutrophils

1st to site of injury (12-24 hrs), kill bacteria, clean wound, secrete matrix metalloproteases, degrade debris

Question 6

Steps of proliferation

Answer 6

1. Angiogenesis— formation of new blood vessels
2. Granulation tissue— fibroblasts lay down extra cellular matrix (eventually replaced by scar tissue)
3. Wound contraction— myofibroblasts pull wound margins together
4. Epithelialization— keratinocytes and epidermal appendages multiply and migrate across wound bed

Key cells: angiolasts, fibroblasts, myofibroblasts, keratinocytes

Question 7

Maturation

Answer 7

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

Question 8

General factors affecting wound healing

Answer 8

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

Question 9

Local factors affecting wound healing

Answer 9

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

Question 10

Systemic factors affecting wound healing

Answer 10

Age
Nutrition—carbs, protein*most important *
Comorbidities—O2 perfusion, immunocompromised, activity limitations
Medications— steroids and chemo significantly slow healing
Behavioral risk taking— smoking, ETOH

Question 11

Normal age-related physiological changes

Answer 11

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

Question 12

Clinician induced factors affecting wound healing

Answer 12

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

Question 13

Primary intention wound closure

Answer 13

Wound edges are approximated without/little formation of granulation tissue
Not typically seen by PT unless preparing for delayed primary closure

Question 14

Secondary intention wound closure

Answer 14

Wound edges unable to be approximated
Granulation tissue fills in wound bed
PT more likely to be involved

Question 15

Wound bed preparation

Answer 15

Assessment: healable, maintenance, non-healable/palliative
Healable— address underlying cause; move to local would care or DIME
maintenance & non-healable/palliative—conservative approach

Question 16

DIME

Answer 16

Debridement
Inflammation/infection
Moisture balance
Edge effect

Question 17

Patient history for wound exam

Answer 17

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

Question 18

Wound specific tests and measures for wound exam

Answer 18

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

Question 19

Wound bed tissue description:
Granulation tissue
Slough
Eschar

Answer 19

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

Question 20

Wound bed descriptions:
Undermining
Tract
Tunnel

Answer 20

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

Question 21

Drainage type descriptions:
Serous
Sanguineous
Purulent

Answer 21

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

Question 22

Causes of wound odor

Answer 22

Wound infection
Non-viable tissue
Old dressing
Hot weather

Question 23

Irrigation: What and Why

Answer 23

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

Question 24

indications for irrigation

Answer 24

all types of wounds with a few exceptions

perfect treatment for a healing granular wound

Question 25

contraindications for irrigation

Answer 25

Do not immerse/soak-- recent grafts, surgical incisions, or diabetic feet active profuse bleeding wounds dry gangrene

Question 26

Solution options for irrigation

Answer 26

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

Question 27

antiseptics and what to use them for

Answer 27

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

Question 28

types of irrigation

Answer 28

gentle irrigation and rinsing (safe and effective psi) | low pressure capsules (spi 4-8, max 10)

Question 29

low pressure lavage

Answer 29

irrigation without suction | Jetox- 4-12 psi; uses wall O2 as pressure; jet strain

Question 30

positives and negatives of whirlpool

Answer 30

+-- cleanses, agitation, additives, temperature range, treats large areas, exercise - -- risk of infection, risk of tissue injury, additives, expense

Question 31

whirlpool contraindications

Answer 31

``` clean & granulating edematous, draining, macerated active bleeding venous insufficiency multi-wounds in asme area uncontrolled seizures B&B issues ```

Question 32

Pulsed lavage with suction (PLWS)

Answer 32

pulsed jets of irrigation with suction | creates a negative pressure

Question 33

Positives and negatives of PLWS

Answer 33

+ -- cleaning, known psi, sterile (no additives), temperature range, site specific, portable, disposable-- easy cleanup, few contraindications - -- expense, aerosolization risk

Question 34

PLWS contraindications

Answer 34

``` exposed named tissues body cavities facial wounds recent grafts or surgical procedures actively bleeding ```

Question 35

purposes and goals of debridement

Answer 35

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

Question 36

When are PT's indicated to debride?

Answer 36

Red-yellow-black system PT-- non-viable tissue, callus, blister MD-- live tissue, large amount of non-viable, infection

Question 37

contraindications for debridement

Answer 37

``` arterial compromise viable tissue granular tissue electrical burns deeper tissues ```

Question 38

methods of debridement

Answer 38

``` sharp mechanical enzymatic autolytic biological surgical (MDs--names structures, large stage 3-4 pressure injuries, significant undermining, tunneling, or sinus tracts, epibole) ```

Question 39

sharp debridement

Answer 39

``` fast aggressive painful often combined with other forms can use forceps, scissors, scalpel, curette ```

Question 40

common scalpels for sharp debridement

Answer 40

``` #10-- thick/callus #11-- incision/drain #15-- precise/cross-hatching ```

Question 41

precautions and contraindications for sharp debridement

Answer 41

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

Question 42

Warning signs and when to stop debridement

Answer 42

``` 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 ```

Question 43

how do we control bleeding during debridement

Answer 43

elevate pressure for 10 minutes silver nitrate (MD)

Question 44

how do we control pain during debridement

Answer 44

meds 30 minutes prior, topicals, deep breathing, music, distraction, etc.

Question 45

when do we contact the MD during debridement

Answer 45

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

Question 46

when to remove/debride blisters

Answer 46

larger than a nickel area likely to rupture or tear worried about possible tissue injury great medium for bacterial growth

Question 47

mechanical debridement

Answer 47

``` "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 ```

Question 48

when is wet-to-dry mechanical debridement indicated?

Answer 48

only for 100% non-viable tissue

Question 49

enzymatic debridement

Answer 49

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

Question 50

how does enzymatic debridement work?

Answer 50

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 ```

Question 51

adverse effects and contraindications for enzymes

Answer 51

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

Question 52

autolytic debridement

Answer 52

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

Question 53

indications contraindications disadvantages of autolytic debridement

Answer 53

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

Question 54

combo debridements

Answer 54

Sharp + cross hatched areas Enzymatic + collagenase to all nonviable areas autolytic + warm, well insulated, thick dressings pt education-- rest, nutrition, etc.

Question 55

Biosurgical debridement

Answer 55

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

Question 56

contraindications and precautions for biosurgical debridement

Answer 56

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

Question 57

indications for surgical debridement

Answer 57

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

Question 58

questions to determine what form of debridement to use`

Answer 58

``` what can they tolerate? will they need to do this at home? safety concerns cost risks? combo? is this something I can handle? ```

Question 59

purpose of dressings

Answer 59

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

Question 60

considerations for wound dressing choice

Answer 60

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

Question 61

when do you change dressings

Answer 61

``` 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. ```

Question 62

"regular" gauze benefits & cautions

Answer 62

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

Question 63

impregnated gauze cautions

Answer 63

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

Question 64

semipermeable film cautions

Answer 64

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

Question 65

hydrogels cautions

Answer 65

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

Question 66

foam cautions

Answer 66

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

Question 67

Hydrocolloids cautions

Answer 67

``` 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

Question 68

alginate cautions & contraindications

Answer 68

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

Question 69

hydrofiber

Answer 69

highly absorptive (more than alginate) absorb vertically (less risk of maceration than alginate) different sizes, cut to size Aquacel (ConvaTec)

Question 70

antimicrobial

Answer 70

``` 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

Question 71

Cadexomer Iodine caustions & contraindications

Answer 71

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

Question 72

silver cautions

Answer 72

``` 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

Question 73

Honey cautions contraindications

Answer 73

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