Wound Care Flashcards
3 Wound Categories
- Healable
- progresses through normal healing in oderly fashion
- adequate blood flow
- 30% smaller at week 4; healed at 12 weeks - Chronic: Non-Healable
- >6 months unable to heal
- inadequate blood supply
- can’t treat cause
- wound-exacerbating factors can’t be fixed - Chronic: Maitnence
- >6 months with no significant progression
- refuses treatment of cause
- health system error/barrier
DIME Categories
D: Debriedment
- problem: defective matrix/cell debris
- treatment: debried
- goal: restore wound base/ECM proteins
I: Infection/Inflam
- problem: high bacterial counts/prolonged inflam
- treatment: antimicrobials
- goal: low bacteria counts/control inflam
M: Moisture Imbalance
- problem: dessication or excess fluid
- treatment: dressings or compression
- goals: restore cell migration/avoid maceration
E: Edge of Wound [non-advancing/undermining]
- problem: non-migrating keratinocytes; non-responsive wound cells
- treatment: bio agents, adjunct therapies, debried
- goals: stimulate keratinocyte migration
5 Goals of Debriedment
AIBNS
- Enhance wound assesment
- Decrease infection potential
- necrotic tissue can mask signs/serve as medium for bacteria prolif - Remove biofilms with bacteria
- Remove necrotic tissue
- physical barrier to healing via excessive amounts of proteases
- supports bacterial growth - Remove senescent
- no cellular activity
Autolytic Debriedment
OCCLUSIVE dressing
-traps wound fluid; enzymes break down non-viable tissue
NOTT for infected wounds
-risk of maceration to periwound
Autolytic Contraindications
infected wounds exposed tendon/bone friable skin deep extensive wounds severe neutropenia immunocompromised
3 Mechanical Debriedment
- Wet-to-dry: non-selective
- painful, maceration, disperse bacteria - Whirlpool: non-selective
- NO! - PLWS: selective (
Biological Debriedment
Maggot larvae- consumes necrotic tissue/bacteria
-potential increase in pain in ischemic wound
-selective and rapi
-painless
FOR INFECTED WOUNDS!
Enzymatic Debriedment
Topical med- breaks down necrotic tissue in wound
-collegenase in petroleum base breaks down necrotic collagen (use with sharp debriedment)
FOR INFECTED!
Selective; cross0hatch for more surface area
Ultrasound Debriedment
low frequency US ~25kHz
.1-2Wcm2
Saline drip with US
Surgical & Sharp Debriedment
Surgical: Removes VIABLE and Non-viable
Sharps: removes only NON-viable
- can be painful, risk of bleeding
- costly, need patient consent
- no for anticoagulant therapy
Surgical & Sharp Contraindications
malignancy, clotting probs, ischemic tissue, fistula, immunocompromised
WOUND contras:!!!!!
- non-infected heel ulcers in dry eschar
- dry gangrene (arterial insufic)
- non-draining wounds w/ limited perfusion
- blood floww compromised
- Precaution with anticoag patients
Infection/Inflammation
Superficial Compartment= TOPICAL therapy
NERDS
Non-healing Exudate increase Red, friable Debris Smell
-critical collinization
Infection/Inflammation
Deep Compartment= SYSTEMIC therapy
STONEES
Size increasing temperature increasing Osteomyelitis New/satelite wounds Erythmeia Edema Smell
-infection
Moisture Imbalance
3 Types of Treatment Categories
- Passive: absorbs drainage; cover to prevent contam
- Interactive: antimicrob agents, growth factors, lysis of necrotic tissue
- Bioactive: migration/cell mitosis, live cells introduced, gives collagen
5 Types of Passive Dressings
[Moisture Imbalance]
- Transparent Films
- NOT for infected
- autolytic debriedment, secondary dressing, or to anchor catheters - Impregnated Gauze
- flat/dry partial thickness wounds, secondar dressing - Hydrocolloids
- NOT for infected
- thick sponge w/ little absorption
- shallow/flat wounds w/ minimal drainage - Hydrogels
- hydrates
- dry wounds for autolytic debriedment
- tendon, muscle, bone-> prevents dessication - Foams
- abosrbs A LOT
- heavy exudate wounds, flat wounds
- donor sites, skin tears, surgical incision
4 Types of Interactive Dressings
[Moisture Imbalance]
- Calcium Alginates
- salts from seaweed become gel once hit exudate; absorbs 5-15x wt
- draining cavity wounds - Cellulose/Hydrofiber
- absorbs exudate/becomes gel; absorbs 35x
- keeps moist environ; conforms well
- wounds w/ heavy exudate, flat or cavity - X-Cell
- cellulose layers, can have antimicrob
- flat w/ minimal exudate, painful, donor sites, venous wounds, burns - Honey
- antibacterial, can have CaAlginate for cavity/drainage
- partial thickness burn, wounds with odor or eschar
4 Types of Bioactive Dressings
[Moisture Imbalance]
- Collagen
- cells dissolve in bed and use as scapholding
- clean/granulating wounds; faciliates migration to bed - ORC-Collagen
- dissolve into wound, bind to excess matrix, release growth factor
- NOT for infection!
- promotes granulation in clean wound, secondary dressing needed, chronic wounds that are stalled - Allograft
- harvested cadavar skin, scaffold for dermal/epidermal
- burn therapy, clean full thickness wounds - Living Skin Equivalents
- neonatal fibroblasts in collagen/nylon mesh
- clean granulated wounds, promotes closure/protects before skin graft
Scar Dressing
[Moisture Imbalance]
Silicone
- reduces hypertrophic carring
- sheet/lining for casts in burn patients
- adherant layer for foam dressings
Antimicrobial Dressings
[Moisture Imbalance]
Restore balance between bioburden and local immune system
-tpoical: ionic silver, cadexomer iodine, PHMB, honey
Silver Dressings
[Moisture Imbalance]
Destroy spectrum of bacteria
- block cell respiration, destroy membrane, leaks cytoplasmt
- replication, respiration, and repair disabled
- decrease MMP- decrease zinc levels
- improve healing rates!!; decrease odor, pain, exudate
Cadexomer Iodine Dressings
[Moisture Imbalance]
- time released iodine
- partial thickness burns, drainage w/ bacteria
- NOT for allegic to iodine!
IF Healable wound-> Avoid these 4 dressings
Povidone iodine: skin disinfectant
Acetic Acid: okay for pseudomonas
Dakin’s solution: okay for necrotic/infected
Hydrogen peroxide: okay to dissolve clots
Biophysical tech
ELECTRO MODALS
-increase rate of healing
modulate pain
reduce swelling, inflam, or restriction
Biophysical tech
PHYSICAL AGENTS
increase rate of healing for open wounds/soft tissue
modulate pain
reduce swelling, inflam, or restriction
Biophysical technologies appropriate WHEN:
comorbities that delay healing: periph art disease, SCI, diabets, venous insuf, deep tissue injury/pressure ulcer
- wound not responding to other methods
- into subcutan tissue/deeper interfereing w/ function
Electrical Energy
E-STIM
Capacitative coupled electrial current trasfers energy to wound
- monopolar=direct: treatment electrode in wound
- bipolar=indirect: both on periwound saddling wound
E-STIM Contraindications
basal/squamous carcinoma/melanoma
osteomyelitis
placement of electrodes in heart muscle, phrenic nerve, ganglia, larynx, or by pacemaker
5 E-STIM Benefits to Wound Healing
bacteriostatic increases tissue perfusion improve venous flow increase granulation tissue formed faster reduction in wound area
2 E-STIM Electrical Current Properties
- Cell Migration
- “Skin battery”: exterior skin electronegativity
- “current of injury: movement of charged particles to uninjured dermis
- Elextrotaxis/Galanotaxis: direct migration of cells due to endogenous firleds or ES - Activation of Cutaneous Nerves
- increase circulation= increase nutrients and decrease waste
- sensory stim causes response regionally but NO stron stim causing pain (results in muscle contraction=decreased circulation)
Mechanical Energy
PLWS
Irrigation under pressure w/ suction to remove irrigant and drain debris
-4-15 psi removes bacteria from surface
PLWS COntraindications
No absolute-> clinical judgement based on fistulas, cavity lining, tunnels
Precautions: insensate areas, anticoags, tunnels, tracts, undermining
5 PLWS Benefits to Wound Healing
clean tunnels/undermining no maceration to periowound bedside/ less caregiver time facilitates sharp debried disposable supplies
Mechanical Energy
Negative Pressure Wound Therapy
Vacuum dressing to enhance healing- sealed to pump for controlled negative pressure
- Addresses I, M, and E but no debriedment
- Clean wound BEFORE NPWT
NPWT Precautions
active bleeding/clotting probs exposed blood vessels can't maintain seal uncontrolled pain non-adherance to POC
NPWT Contrindications
malignancy necrotic tissue/eschar osteomelitis exposed artery/vein/organ untreated coagulopathy allergy to dressing
4 NPWT Wound Healing Benefits
non-invasive
active therapy-> removes fluid from wound bed
moist wound healing environ
stimulates angiogenesis via mechanical stress
2 Mechanical Stresses of NPWT
- Macrostrain
- stretch of edges when vacuum turned on
- pulls together; drains/gets rid of infectious material - Microstrain
- microdeformation at cellular level (cell stretch)
- reduces edema
- promotes perfusion, granulation tissue formation by facilitating cell migration/prolif
NPWT Indications
acute wounds once hemostasis traumatic sub-acute dehiscised surgical incision chronic diabetic ulcer skin graft stage III/IV pressure ulver enteric fistula
NPWT Goals of Treatment
DECREASE WOUND VOLUME! gran tissue growth/contraction of edges drainage reduce bioburden wound bed prep decrease LOS, morbid, mortal decrease dressing change frequency prevent deterioration minimize contam/odor
NPWT Expected vs. Abnormal outcomes
Expected
- beefy red
- increased gran tissue
- decrease size
- decrease drainage
Abnormal
- bruised dark gray
- more slough
- more odor
- -rule out osteomyelitis/infection; evaluate change frequency; evaluate pressure setting
Sound Energy
Low Frequency Ultrasound
20-60kHz; deeper peneatration than MHz US
- contact better for adherant slough
- Saline as coupling medium
LFUS Precautions/Contraindications
Precautions:
acute inflam- do non-thermal
fractures
lowest intensity to produce desired effect!
Contrindications: cancer pregnant CNS tissue joint cement/plastic pacemaker near thrombophlebitis reprod organs eyes
2 Non-Thermal Effects of LFUS
- Cativation
- vibrational effect of microsized gas bubbles
- stable: enhances acoustic microstreaming
- Unstable/Transient: increase in size/explode
- - good: tiny shock waves cause PREFERENTIAL debiredment of necrotic/slough/bacteria
- -bad: tissue damage/free rad formation - Acoustic Microstreaming
- fluid movement along membrane/stable cat bubbles
- -good: increase permeability of wall/membrane, increase protein synthesis, degran mast cells, increase growth factor by macrophages
NC NT LFUS
Mist Therapy
40 kHz non-contact
- time varies on wound, single use, no aerosolization
- continuous method
Thermal and Bacteriocidal Effects of LFUS
Thermal:
- contact continuous method
- NOT for ischemic tissue or impaired circ
Bacteriocidal:
-bacterial death: acinetobacter, e coli, staph, strep
Fibrinolytic Effects of LFUS
Debriedment Effects
- 50-60 kHz removes debris/bacteria from surface
- removes necrotic NOT healthy
- 25kHz for tissues with adherent fibrins in chronic wounds
- selective removal!; no macroscopic changes of gran
3 types of LFUS for Debriedment
SONOC
SONICONE
QOUSTIC
SONOCA
- 25kHz; continuous contact
- probe autoclaved, aerosolization possible
- debrieds immediately; diff probes for agressiveness
SONICONE
- 22.2kHz contact continuous or pulsed
- probe autoclaved, erosolization possible
- debrieds immediately; diff probe colors
QOUSTIC
- 35kHz; contact
- 3 treatments per week/ 2 weeks
- autoclaved, potential aerolization
- debrieds immediately
- lease painful!
