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Management of Complex Patients > Week 1: Wounds > Flashcards

Week 1: Wounds Flashcards

1
Q

3 phases of wound healing

A

Inflammation
Proliferation
Maturation/remodeling

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2
Q

Goal of inflammation

Process of inflammation

A

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.

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3
Q

Cardinal signs of inflammation

A

Edema, redness, warmth, pain, decreased function

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4
Q

Cellular response to inflammation

A

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

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5
Q

PMNs

A

Polymorphonuclearneutrophils

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

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6
Q

Steps of proliferation

A
  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

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7
Q

Maturation

A

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

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8
Q

General factors affecting wound healing

A 
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
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9
Q

Local factors affecting wound healing

A

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

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10
Q

Systemic factors affecting wound healing

A

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

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11
Q

Normal age-related physiological changes

A 
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

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12
Q

Clinician induced factors affecting wound healing

A

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

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13
Q

Primary intention wound closure

A

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

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14
Q

Secondary intention wound closure

A

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

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15
Q

Wound bed preparation

A

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

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16
Q

DIME

A

Debridement
Inflammation/infection
Moisture balance
Edge effect

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17
Q

Patient history for wound exam

A

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

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18
Q

Wound specific tests and measures for wound exam

A

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

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19
Q

Wound bed tissue description:
Granulation tissue
Slough
Eschar

A

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

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20
Q

Wound bed descriptions:
Undermining
Tract
Tunnel

A

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

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21
Q

Drainage type descriptions:
Serous
Sanguineous
Purulent

A

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

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22
Q

Causes of wound odor

A

Wound infection
Non-viable tissue
Old dressing
Hot weather

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23
Q

Irrigation: What and Why

A

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

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24
Q

indications for irrigation

A

all types of wounds with a few exceptions

perfect treatment for a healing granular wound

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25
Q

contraindications for irrigation

A

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

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26
Q

Solution options for irrigation

A

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

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27
Q

antiseptics and what to use them for

A

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

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28
Q

types of irrigation

A

gentle irrigation and rinsing (safe and effective psi)

low pressure capsules (spi 4-8, max 10)

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29
Q

low pressure lavage

A

irrigation without suction

Jetox- 4-12 psi; uses wall O2 as pressure; jet strain

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30
Q

positives and negatives of whirlpool

A

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

31
Q

whirlpool contraindications

A 
clean & granulating
edematous, draining, macerated
active bleeding
venous insufficiency 
multi-wounds in asme area
uncontrolled seizures
B&B issues
32
Q

Pulsed lavage with suction (PLWS)

A

pulsed jets of irrigation with suction

creates a negative pressure

33
Q

Positives and negatives of PLWS

A

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

34
Q

PLWS contraindications

A 
exposed named tissues
body cavities
facial wounds
recent grafts or surgical procedures
actively bleeding
35
Q

purposes and goals of debridement

A

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

36
Q

When are PT’s indicated to debride?

A

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

37
Q

contraindications for debridement

A 
arterial compromise
viable tissue
granular tissue
electrical burns
deeper tissues
38
Q

methods of debridement

A 
sharp
mechanical
enzymatic
autolytic
biological
surgical (MDs--names structures, large stage 3-4 pressure injuries, significant undermining, tunneling, or sinus tracts, epibole)
39
Q

sharp debridement

A 
fast
aggressive
painful
often combined with other forms
can use forceps, scissors, scalpel, curette
40
Q

common scalpels for sharp debridement

A 
#10-- thick/callus
#11-- incision/drain
#15-- precise/cross-hatching
41
Q

precautions and contraindications for sharp debridement

A

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

42
Q

Warning signs and when to stop debridement

A 
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
43
Q

how do we control bleeding during debridement

A

elevate
pressure for 10 minutes
silver nitrate (MD)

44
Q

how do we control pain during debridement

A

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

45
Q

when do we contact the MD during debridement

A

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

46
Q

when to remove/debride blisters

A

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

47
Q

mechanical debridement

A 
"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
48
Q

when is wet-to-dry mechanical debridement indicated?

A

only for 100% non-viable tissue

49
Q

enzymatic debridement

A

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

50
Q

how does enzymatic debridement work?

A

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
51
Q

adverse effects and contraindications for enzymes

A

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

52
Q

autolytic debridement

A

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

53
Q

indications
contraindications
disadvantages of autolytic debridement

A

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

54
Q

combo debridements

A

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

55
Q

Biosurgical debridement

A

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

56
Q

contraindications and precautions for biosurgical debridement

A

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

57
Q

indications for surgical debridement

A

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

58
Q

questions to determine what form of debridement to use`

A 
what can they tolerate?
will they need to do this at home?
safety concerns 
cost
risks?
combo?
is this something I can handle?
59
Q

purpose of dressings

A

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

60
Q

considerations for wound dressing choice

A

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

61
Q

when do you change dressings

A 
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.
62
Q

“regular” gauze benefits & cautions

A

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

63
Q

impregnated gauze

cautions

A

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

64
Q

semipermeable film

cautions

A

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

65
Q

hydrogels

cautions

A

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

66
Q

foam

cautions

A

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

67
Q

Hydrocolloids

cautions

A 
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

68
Q

alginate

cautions & contraindications

A

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

69
Q

hydrofiber

A

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

70
Q

antimicrobial

A 
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

71
Q

Cadexomer Iodine

caustions & contraindications

A

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

72
Q

silver

cautions

A 
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

73
Q

Honey

cautions
contraindications

A

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

Management of Complex Patients (1 decks)

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