Wound Care Flashcards
Partial thickness wound healing
- steam burn, abrasion
- Re-epithelialization and regeneration
- nl skin function returns
- No scar
- Epithelial cells come from hair follicle or edge of wound
- 10-14 days
Full thickness wound healing
- heal by scar tissue formation
- lose nl tissue function
- four phases:
1. Inflammation
2. Granulation/proliferation
3. Epithelialization
4. Maturation/remodeling
Inflammation stage of full thickness wound healing
- First 7 days
- Provide hemostasis and clear bacteria, foreign material, dead tissue
- Can be confused with infection
Granulation/proliferation stage of full thickness wound healing
- Fibroblasts synthesize collagen
- Angiogenesis infiltrates collagen
- O2 and nutrition demands are high
Epithelialization stage of full thickness wound healing
- Overlaps with proliferative phase
- Continues from edges like partial thickness wounds
Maturation/remodeling stage of full thickness wound healing
- May last up to 2 years
- Overlaps proliferation and epithelialization
- Reorganizes matrix collagen along lines of stress
Intrinsic factors that affect healing
- General health
- Age
- Chronic disease
- Immunosuppression
- Sensory impairment (DM)
- Tissue perfusion (DM)
- Presence of necrotic tissue of foreign body (sutures)
Extrinsic factors that affect healing
- Medication
- Nutrition
- Chemo/radiation
- Stress
- Infection
Iatrogenic factors that affect healing
- Local ischemia
- Treatment choices (irrigation material)
- Trauma
- Extent of injury
Partial thickness burns
- describe
- epidermis is burned
- Red/pink, mildly swollen
- Skin feels raw and tender
- Sunburn is MC example
Deep partial thickness burns
- describe
- epidermis and dermis burned
- Blistered, swollen, moist
- Very painful
Full thickness burn
- describe
- completely through dermis
- Destroy fat cells, nerve tissue, muscle
- Dry, leathery, appear dark brown, black, or dry white
- May feel no pain if nerves are burned
Burn treatment
- overview
- Depends on depth and extent of damage
- Immediate care is important
- Improper care → infection, slower healing, shock
What topical agent is usually used to treat burns
- silver!
- Lots of silver products
- Good option for pts with sulfa allergy
- Newer options allow fewer dressing changes
How to treat blisters
- adults
- children
- Adults intact: protect, leave intact bc provide moist dressing for wound
- Adult broken: debride, easily infected with bacteria
- Peds: break intact blisters and debride, will pop anyways cause kids are crazy
Burn treatment
- cleansing
- dressing
- chemicals
- Cleansing options: Shower, pressurized saline, pulsed lavage
- Dressing: Non-adherent that allows drainage
- Chemicals: Only one chemical debridement treatment remains: Santyl. Hastens the removal of slough and eschar
How are facial burns treated differently
- do not use silvadene (silver): can permanently stain
- Bacitracin ointment is best
Circumferential wounds
- risk for compartment syndrome, ischemic limb
- check pulses often
Nutrition for burn care
- protein
- clear fluids
- multivitamin
Burn aftercare
- wil be itchy!!
- Benadryl
- Cold pack
- Protect at night from scratching
- Moisturize frequently
- Liberal sunscreen!
What is most common cause of leg ulcer
venous insufficiency
Location of ulcers due to
- venous insufficiency
- arterial
- venous: distal 1/3 of medial leg
- arterial: Lower leg, dorsal surface, foot, malleolus, toe joints, lateral border of foot
Venous insufficiency ulcer
- characteristics
- Irregular shape
- Shallow
- Mild pain (worse with standing, relieved with elevation)
- Pink/red base
- Edema
- Hemosiderin stain around edge of wound (dark)
Venous insufficiency ulcer
- RF
- Prev trauma in the area
- DVT hx
- Pregnant
- Obese
- Clotting disorder
- Fam hx
- Occupation – stand a lot
Venous insufficiency ulcer
- 4 steps to manage
- Clean
- Debride
- Absorb drainage
- Manage edema
Venous insufficiency ulcer
- clean
- Normal saline (warmed to body temp)
* If slough: wound cleanser with surfactant
Venous insufficiency ulcer
- Debride
- Chemical
- Sharps (forceps, scissors, scalpel, curette)
- Ultrasonic (new)
Venous insufficiency ulcer
- Absorb drainage
- 7 categories of dressing, gauze, alginates, hydrocolloids, carboxymethlycellulose, foams, ABD pads
- Drainage is caustic to surrounding, healthy tissue
Venous insufficiency ulcer
- Manage edema
• Must check ABI prior to applying compression: >1.0, verify with transcutaneous O2 before applying compression
- Vasopneumatic pump to move fluid caudally
- External bandages
- Multi-layer compression dressings
- Circumferential measurements before and after to assess effectiveness
Because healing a wound doesn’t treat venous insufficiency, what must occur to prevent recurrence of wound
maintain reduction of edema
How to reduce edema for venous insufficiency
- Forever wear support hose or circaids.
- Leg elevation 2 hr a day, 20-30 min at a time, leg higher than heart, NOT bed rest
- Exercise that activates calf muscles (use compression)
- NO smoking
- Don’t’ cross legs
- Feet and leg hygiene
- Avoid trauma
- Nutrition, low sodium
- Inspect legs/feet daily
Arterial ulcers
- characteristics
- Pain, esp at rest
- Foot is cold or cool
- Weak, absent pulses
- Absence of hair growth
- Skin is shiny, dry, pale
- Thickened toenails
- Necrotic ulcers with min drainage
- ABI <0.5
- Pallor with leg elevation
- Rubor of dependency (white when elevated, red when down)
- Hx: HTN, smoking, claudication
Arterial ulcers
- risk factors
- Card hx
- HTN
- High cholesterol
- Smoking
- DM
- Fam Hx
Arterial ulcers
- eval of arterial flow
- Pulses: dorsalis pedis, posterior tibial, popliteal, femoral
- ABI: <0.8 → arterial compromise
- Transcutaneous O2 <30 mmhg → no healing potential
- Refer to vascular surgeon or cardiologist
What should NEVER be done to an arterial ulcer
debridement, will lead to further necrosis
Arterial ulcer
- treatment
- PT to increase circulation • Hot pack to femoral triangle • Rooke boots, bed cradles, and other protective gear and positioning • Antimicrobials: • Electric stimulation - STOP smoking!! - If gangrene keep dry - Wound on leg, encourage exercise to increase blood flow
Negative pressure therapy
- Wound vac
- Can be used on all kinds of wounds
- Wound must be fairly clean
- Cut foam slightly smaller than wound, do not overpack
Biological wound treatment
- Oasis
- Porcine small intestinal submucosa. Provides matrix for collagen to use as a framework.
- Do not remove, keep adding to it if it works
- Might produce inflammatory response but that is ok (it’s not infected)
Cultures for wound management
- Punch biopsy is best but swab is adequate
- Used to base topical treatment options
Hyperbaric oxygen
is another type of wound treatment
Topical commonly used
- Clobetasol
- Cyclosporin or dexamethasone
- Gentamycin
Why are pressure injuries important (business aspect)
- Stage III and IV are hospital acquired, won’t be paid to treat
- Inspect FULL body of patient when admitted to ensure none present. If present, document size and location
What can be confused with pressure injuries
- DM foot ulcers
- Skin tears and lacerations
- Maceration dt diarrhea or infection
- Arterial or venous leg ulcers
Pressure injuries
- risk factors
- Pressure
- Moisture
- Friction
- Shear
- Hypotension (poor perfusion)
- Lengthy immobilization
- Poor nutrition
Pressure injuries
- Common locations
bony prominences: • Occiput • Sacrum • Ischium • Heels • Trochanter • Knee • Ankle
Describe stage 1 pressure injury
Non-blanchable erythema of intact skin
Describe stage 2 pressure injury
- Partial-thickness loss of skin with exposed dermis
- Wound bed is viable, moist, pink/red
- May be intact or ruptured serum-filled blister
Describe stage 3 pressure injury
- Full-thickness loss of skin
- Adipose is visible, granulation and rolled wound edges are often present
- Slough or eschar may be visible
- Depth depends on location
- No exposure of fascia, muscle, tendon, ligament, cartilage, bone
Describe stage 4 pressure injury
- Full-thickness skin and tissue loss
- Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, bone
- Slough and eschar may be visible
Describe unstageable pressure injury
- Can’t evaluate dt presence of eschar or slough
* If can’t see base of wound, is unstageable
Describe deep tissue pressure injury
Often seen in patients who have “been down” for a long time, injury is still evolving, not sure how bad it will be
Describe pressure injury d/t medical device
- New category
* Tubes, drains, cannula, etc.
Describe facility acquired pressure injury
- Usually sacrum (also heels and occiput)
- Can occur in children
- Many pts have scI, spinal orthotics
- Perineal dermatitis or excoriation dt diarrhea is NOT a pressure injury but does place pt at increased risk for one
