Wound Care Flashcards
function of the skin
- protection: acts as barrier against pressure, friction, chemical, heat, cold, UV
- regulation: essential for maintaining the body’s fluid balance and providing thermoregulation
- sensation: provide communication of external stimuli to body via touch, pressure, temperature and pain receptor
what is a wound
any break in the skin or any process that leads to the disruption of normal architecture and function of the skin
wound classification
- acuity (acute/chronic)
- depth (epidermis, dermis, subcutaneous, bone)
- color (pink, yellow-green, black)
- level of exudate
acute wound
- occurs suddenly
- healing progresses in a timely predictable manner
- typically heals by primary intention
eg. falls, cuts, laceration, minor burns
chronic wound
- may develop over time
- healing has slowed or stopped
- typically heals by secondary intention
eg. pressure ulcers, diabetic neuropathic ulcers
depth classification of a wound
- superficial (epidermis)
- partial thickness (epidermis, dermis)
- full thickness (epidermis, dermis, subcutaneous, hair follicle)
- deep wound (including bones, open cavities, organs) * need to refer
color of wounds
pink: normal inflammation
red: granulating (formation of collagen fibre and blood vessels
yellow: slough dead skin, need to remove
green: pus (infection- need abx)
black: eschar (dry dead cells- necrotic)
types of exudates and characteristics
- serous: thin clear straw-color
- haemoserous: thin pink color
- sanguineous*: thin red color
- purulent*: thick yellow/green color
- refer
amount of exudate and wetness distribution
- none: dry wound tissues
- small: wound tissue wet, moisture evenly
- moderate: wound tissues saturated, drainage may or may not be evenly distributed
- large: wound tissue bath in fluid, drainage freely expressed
types of wounds
- surgical wounds: clean surgically induced (sutures)
- cuts and lacerations: caused by high shearing force, no skin loss, can stitch up
- friction and abrasion: by mechanical forces, scrape away part of the skin, not much tissue loss
- burns: thermal, chemical, electrical, sun
- foot ulcers: common in diabetics due to reduced sensation of skin on feet or narrowing arteries, increase risk for overweight, foot problems ppl
physiology of acute wound healing
- hemostasis: release chemical mediators to form platelet plug, clot, and stop bleeding
- inflammation: vasodilation and increase capillary permeability
- proliferation and migration: start from d3-w3, collagen synthesis
- maturation and remodelling: w3-y2, shrinking and strengthening scar
primary intention of wound healing
for clean wounds that usually dont involve tissue loss
- wound have well approximated edges that can be pulled together neatly eg. via suturing
- healing occurs from side to side
- minimal scarring
eg. suture wounds, superficial traumatic wounds
secondary intention of wound healing
wounds that involved some degree of tissue loss with edges that cannot be approximated
- healing occurs form bottom up where the wound is filled with granulation tissue
- wound close by epithelization and contraction
- takes longer to heal
- can result in scarring
eg. pressure ulcers, dehisced surgical wounds, traumatic injuries
tertiary intention of wound healing
contaminated or dirty wounds
- left open for 4-6d to allow edema/infection to resolve or exudate to drain
- wound is closed via suturing, skin grating or flap
- result in scarring
tertiary intention of wound healing
contaminated or dirty wounds
- left open for 4-6d to allow edema/infection to resolve or exudate to drain
- wound is closed via suturing, skin grating or flap
- result in scarring
factors affecting wound healing
- temperature: optimal 37 degree
- desiccation or maceration: moist wound environment enhance epidermal cell migration and epitherlialisation
- hypoxia: decrease collagen synthesis, impaired leukocyte activity
- infection: delays collagen synthesis, epithelisation and prolong inflammatory phases
- age and weight: ageing delays inflammation, obesity leads to poor tissue perfusion
- nutrition: malnutrition reduce healing
- coexisting medical condition: DM (decrease O2 and nutrients supply)
- medications: corticosteroids, NSAIDs, neoplastics (affect cell division)
disadvantages of traditional theory of wound care
- scab composed of dehydrated exudate and dying dermis is a physical barrier to healing
- epidermal cells cannot move easily under the scab resulting in poor cosmetic results and scarring
- exposure to air reduces surface temperature of the wound and dries the wound causing further delay in wound healing
advantage of moist wound healing
- decrease hydration and cell death
- increased angiogenesis
- enhanced autolytic debridement
- increase re-epithelialisation
- decrease pain
goals of wound healing
- facilitate hemostasis
- decrease tissue loss
- promote wound healing
- minimise scar formation
wound assessment for acute wounds
- wound history and cause
- location (depth and size of wound)
- color of wound bed
- level of exudate/moisture
- presence of pain
purpose of wound bed management
- identify barrier to wound healing
- implement a plan of care to remove these barriers
function of wound dressing
- provide protective barrier: prevent microbial bacterial contamination
- absorb exudate
- optimise moisture content of wound bed
ideal wound dressings
- remove exudate while maintaining moist environment
- allow gaseous exchange so that O2 , H2O and CO2 can pass in and out of dress
- provide insulation to keep wound at core body temp
- be impermeable to micro-organisms so as to minimise contamination of the wound
- minimise trauma and damage to granulating tissue on removal by not adhering to the wound surface
types of wound dressing
- inert (passive)
- interactive
- antimicrobial
examples of inert dressing
- gauze
- gauze replacement
- low adherent dressing pads
- paraffin gauze and tulle dressing
- plastic strip
- wound closure strips
what are gauze
- made from simple absorbent fibre such as woven cotton
- permeable
- eg. gauze pads, folded swaps of multiple layers of gauze
indication for gauze
- use for mod-heavy draining wounds
- secondary dressing
disadvantage of gauze
- difficult to maintain moist wound bed
- painful removal
- potential contamination
what are gauze replacement
- typically made from rayon polyester or a blend of the two
- eg. multisorb non woven swabs
indication of gauze replacement
- use for mod-heavy draining wounds
- secondary dressing
advantage of gauze replacement
- do not shed fibre
- more absorbent than gauze
- soft on the wound surface
what is a low adherent dressing pad
outer layer of polyethylene-lamination railing and inner layer of absorbent rayon-polypropylene blend or perforated polymeric film with an absorbent backing layers of non-woven material
eg. melonin, primapore (composite)
indication of low adherent dressing pads
simple, superificial wounds with low levels of exudates
eg. laceration, abrasion, minor burns, clean sutured wounds
what is a paraffin gauze dressing
woven cotton or viscose or a combination of the two impregnated with yellow or white soft paraffin
eg. Jelonet (non medicated); Bactigras (medicated)
indication of paraffin gauze
minor burns, scald and graze (and leg ulcers)
disadvantage of paraffin gauze
- permeable to microorganism
- adhere to wound
- can cause maceration (paraffin dont allow water to pass)
what is a newer tulle dressing
impregnante with polyethylene glycol or other substances
eg. Inadine (PEG impregnanted- medicated)
indications for inadine (tulle dressing)
ulcerative wounds, prevent infections in minor burns, minor wounds
what are plastic strips
commonly known bandaid
- have an absorbent pad attached to a piece of plastic adhesive tape
- impermeable or permeable
- eg. hansaplast
indication for plastic strips (bandaid)
simple superficial wounds
what are wound closure strips
specialised narrow tapes made of porous non-woven material
- act like sutures in first aid situation
- applied at right angles 3-5mm apart
- eg. steri-strip
indication for wound closure strips
- simple lacerations
- reinforce loosing sutured wounds
what are examples of interactive dressing
- film
- hydrocolloid
- foam
- alginate
- hydrofibre
- hydrogel
what are film dressings
- thin transparent adhesive polyurethane membranes coated with a layer of acrylic adhesive
- semi permeable membrane, waterproof
- impermeable to liquid and micro-organisms
-eg. TegaDerm, Opsite Flexifix, OpSite Flexigrid, Post Op (island film), TegarDerm with pad (island film)
indication for film dressing
- superficial wounds that are dry to low drainage such as lacerations, abrasions, minor burns and scalds
- use over sutures and for retention of primary dressing
what are hydrocolloid dressing
- flexible, waterproof, occlusive, self-adhesive wafer dressing
- contains a mixture of carboy methyl cellulose, gelatine and pectins bonded to a backing of polyurethane film
- forms a gel as it absorbs exudates
- avail in powder and paste
- eg. Duodenum Extra Thin or CGF, Comfeel Plus
indications for hydrocolloid dressing
- wounds with light or moderate exudates such as burns, superficial leg ulcers and pressure wounds
- can be used over suture lines (thin wafer) and for small cavity wounds (power)
precautions of using hydrocolloid
- infected wound
- hypergranulation (overgrown scars)
- if dressing is saturated, need to change if not too much exudate which, can cause maceration
what are foam dressing
- porous, open cell sheet produced from hydrophobic polyurethane
- highly absorbent
- low adherent and insulating
- waterproof backing but permeable to water vapour
- eg. Allevyn, lyofoam
indications for foam dressing
minor and major wounds including moderate to heavily exuding wounds, leg ulcers, pressure ulcers, skin grafts and burn
what are alginates
- soft non-woven fibre composed of alginic acids derived from a variety of seaweed
- hemostatic (help stop bleeding)
- highly absorbent
- easily removed and do not adhere to wounds
- require secondary dressing
- avail as pads or ropes
eg. kaltostat, alginate M
indication for alginate dressing
medium to heavy exuding wounds such as leg ulcers, cavity wounds, pressure wounds
suitable for infected wounds but change daily
precaution for alginate dressing
should not be used for dry wounds
what are hydrofibre dressings
- non woven sodium carboxymethylcellulose
- absorb exudate to forms a gell
- do not have homeostatic properties
- highly absorbent
- require secondary dressing
- available as sheets or ribbons
eg. aquacel
indication for hydrofibre dressing
heavy exudating wounds such as leg ulcers, cavity wounds and minor burns
precaution for hydrofibre dressing
not compatible with oil based products (eg. petroleum jelly)
what are hydrogel dressing
- matrix of complex hydrophilic insoluble organic polymers
- contains 60-90% water content
- require secondary dressing
eg. IntraSite Gel, Duoderm hydroactive Gel, Purloin gel
indication for hydrogel
- used for wounds with no or minimal exudate
- used for burns due to its soothing and cooling property
precaution of using hydrogel
- propylene glycol allergy
- avoid in infect wound
examples of antimicrobial dressings
- iodosorb (cadexomer iodine dressing)
- silver dressing
what are iodosorb
Cadexomer iodine dressing
- 3D matrix of modified starch with 0.9% iodine immobilised in the matrix
- slowly release I2 from matrix to the wound in the presence of wound exudate
- reduces microbial burden
- no harmful effects on cells or angiogenesis
- available as dressing, ointment or powder
indication of iodosorb
treatment of chronic exudating wounds such as leg ulcers, pressure ulcers, diabetic ulcers
precaution when using iodosorb
may be absorbed systematically
- do not apply more than 50g in one application or 150g per week
- avoid in thyroid disorders
- CI: iodine sensitivity, Hashimoto’s thyroiditis, non-toxic nodular goiter, preg/lact, <12yo
what are silver dressings
- silver is a broad spectrum antimicrobial
- dependent on individual product (release silver into wound, partly release silver and hold some in dressing, keep silver within dressing)
- come silver dressing allow continued release of silver up to 7d
- eg. Acticoat, Allevyn Ag, Aquacel Ag
indication for wound care referral
- elderly
- comorbid conditions like DM, CVS, obesity
- steroids or immunosuppressants
- include face, mucous membrane, genitalia
- loss of movement/ sensation/ numbness
- deep cuts or edges that seperate deeply
- severe bleeding
- dirt/ foreign object (tetanus, esp w/o vax)
- 48h after injury, wound becomes red, swollen, warm, pain, pus-like exudate
steps for first aid for minor acute wound
- stop bleeding and irrigate
- apply antiseptic as required
- cover wound with suitable dressing
cleansing agents
- water for irrigation
- normal saline
- skin wash containing surfactants
antibacterial agents for wound cleaning
- disinfectant: kill or remove microbes (more of items, less for tissues of body where toxicity would impair healing)
- antiseptic: used on skin/wounds, to kill or prevent multiplication of potential pathogenic organisms
- antibiotic: chemical substance produced by microbes which has the capacity to selectively inhibit the growth or kill other microorganism
what does chlorhexidine gluconate do
antiseptic and disinfectant
- effective against Gram +/-, fungi
- low toxicity to granulation tissue
- deactivated by organic material and povidone iodine
- preferable to use individual satchets and discard any unused portion
what does povidone iodine do
iodine bound to carrier molecule (povidone)
- lower irritant potential
- wide spectrum (gram+/-, fungi, protozoan, virus)
- inactivated by body fluid
