Wound Care - Study Guide Flashcards
Epidermis - Function
- Retain moisture
- Protect from bacteria
- Rapidly Regenerate
What structure stores cells to regenerate tissue?
a. Hair Follicles
b. Sweat Glands
c. Edges of the wound bed
d. Anywhere with keratinocytes
Difference between primary, secondary and tertiary intention
a. Primary: Incised – no tissue loss: epithelialization
b. Secondary: Incised – tissue loss: regeneration
c. Tertiary: Trauma – structural loss: replacement
Wound Care - What causes Vasoconstriciton?
- Platelets
- They release Serotonin
Wound Care - What causes Vasodialation?
- Mast Cells
- Release Histamine
Wound Care - Polymorphonuclear leukocytes response
-
Neutrophils release enzymes for Autolytic Debridement
– Phagocytosis, lysosome degredation, kill bacteria - Esonophils: phagocytosis, WBC
- Mast Cells: Release histamine, creates Vasodialtion. In addition, produce chemical chemokine for neutrophil migration to site of injury
Homeostasis (forming the platelet plug)
Hagemann Factor XII (12)
- Converts prothrombin into thrombin
- Converts fibrinogen into fibrin
Scab Formation
- Platelets come to injury site and release serotonin for VC
- Platelet release platelet derived growth factor that form fibrin clot (platelet plug)
Monocyte to Macrophage - Acute inflammatory to proliferative phase
Macrophage
i. 72 to 84 hours
ii. Function in low O2
iii. Phagocytosis (eat debris)
iv. Secrete cytokines, growth factors (helps create granulation) and Matrix Metalloproteinases
What cell types are produced by fibroblasts?
a. Synthesis Collagen and Glycosaminoglycans
What is a Positive Homan’s Sign
a. Dorsiflex foot and squeeze OR use BP cuff to pump up to 40 mmHg
b. Positive if they have pain
ABI levels and debridement
Normal: 1
Abnormal
- >1 Venous Insufficency
- <0.8 Mild Arterial Insufficency – Can debride
- Equal to or <0.5 – DO NOT OPEN – Long time to heal
What is the minimal protective sensation?
5.07 monofilament (10 g)
What are the three ways to stage a wound?
- Pressure Ulcer (1-4)
- Wagner (0-5); Diabetic Foot Patients
- Other wounds (Partial and Full thickness)
Pressure Ulcer Stages
Stage 1
- Non-blanchable erythema
- Slight redness
Stage 2
- Partial Thickness (epidermis and/or dermis, superficial ulcer)
- Abraision, blister or shallow crater
Stage 3
- Full thickness
- Damage or necrosis or subcutaneous tissue
- With or without undermining
Stage 4:
- Full thickness through fascia, bone, muscle
Unstageable
- Can’t see the base of the wound do to slough or eschar
Deep Tissue Injury
- Pressure-related injury to subcutaneous tissues under intact skin
- Appearance of a deep bruise (purple or blue)
Wagner Scale
Grade 0:
- Skin Intact. May be bony deformities or hyperkeratotic lesions
Grade 1:
- Superficial Ulcer, may be necrotic or early granulation
Grade 2:
- Lesion goes to bone, ligement, tendon, joint capsule or deep fascia. No abcess or osteomyelitis (NO infection).
Grade 3:
- Previous lesion and infection
Grade 4:
- Toes or forefoot have gangrene; moist or dry
Grade 5:
- No foot healing possible
Use for Diabetic Patients - Feet
All other wounds staging
- Partial thickness (seperation of the epidermis from the dermis)
- Full thickness (seperation of both epidermis and dermis from underlying structures)
- If you cannot see the bottom put full thickness/Unstageable and explain
Infection - Bacterial Counts
- > 10^5 colony forming units (CFU)
- > 10^3 for strep infections
Venous Insufficency Characteristics
- Increased drainage
- Painless
- Decreased pain with elevation
- Edema
- Increased redness (Hemosiderin Staining)
Causes 80% of ulcers
Arterial Insufficency Characteristics
- Minimal drainage
- Very painful and increased pain with elevation or exercise
- Rubor of dependency
- Pale Base
Mixed Insufficency Characteristics
- Have signs of both
- This will be determined with ABI and signs/Sx.
- Primarily treated as Arterial insufficiency but also need to consider Venous Insufficiency playing into it.
What are the 3 methods of wound healing?
- Non selective (Remove some healthy tissue with necrotic tissue) Ex:
i. Mechanical (wet-to-dry dressings)
ii. Topical agents
iii. Surgical
iv. Sharp
v. Forceful irrigation (>8 psi); Spray surfactant - Selective (Remove only necrotic tissue) Ex:
a. Collagenase (collagen/fibrin specific); Enzymatic
b. Sharp Debridement
c. Spray surfactant (<8 psi) - Autolytic (Occurs in a sealed wound by Neutrophils)
What are the three phases of healing?
- Acute inflammatory (Stage 1; 1-4 days)
- Proliferative (Stage 2; 4 days - 11 months)
- Matrix Formation (Stage 3; 30 days -2 years); basement membrane that collagen sits on
- Other: Chronic inflammatory
Acute Inflammatory
1
- Platelet Plug
- Monocytes
– These are released in transition to Proliferative Phase and turn into Macrophages (Chemotaxis – Cytokines, GF (angiogenesis) and MMP)
Proliferative Phase
2
- Myofibroblasts – secrete collagen and glycosaminoglycans
- Revascularization
- Reepithelialization on top of collagen
Chronic Inflammatory
Other
- Monocytes do not turn into macrophages
- MMPs play a part, TIMP deficits. Leads to biofilm and degrading of proteins
Wound Vac
- Creates a negative pressure environment which pushes the granulation tissue up to the wound bed.
- Facilitates better healing
- Can put antibiotic through this
- Very good for skin grafts
Sharp Debridement
- Scalpel
- Selective or Non Selective
Whirlpool - Indications
- Arterial Insufficency
- Venous insufficiency
- Pressure Wound
- Trauma Wound
Whirlpool - Goals
- Rehydrate tissue
- Soften eschar
- Nonselective material debridement/remove foreign material
- Increase circulation 2-3 hours post Rx
Whirlpool - Contraindications
- Medical condition where increased body temperature is contraindicated
- Painful lesions
- Fragile, dry, irritated surrounding tissue
Whirlpool - Protocol
Warm; 98-101 degrees for 15-20 minutes
When should you use collagenase?
- Someone has AI and they won’t let you debride the hard eschar off
How to treat Arterial Insufficent Wound?
i. Deeper
- First: Premoistened Calcium Alginate
- Second: Vaseline Impregnated Gauze
- Third: Foam + Tegaderm (OR gauze/compression stockinette depends on intactness of surrounding skin) on top OR Hydrocolloid Thin (O2)
OR if patient is too sensitive and need to get rid of eschar
- First: Collagenase
- Second: Calcium Alginate
- Third: Foam + Tegaderm (OR gauze/compression stockinette depends on intactness of surrounding skin) on top OR Hydrocolloid Thin (O2)
ii. More Superficial
- First: Vaseline Impregnated Gauze
- Second: Foam + Tegaderm on top OR Hydrocolloid Thin
iii. Superficial
- Hydrocolloid Thin
How to treat Venous Insufficency wound?
i. Deep:
1. First: MeSalt
2. Second: Abdominal Pad OR Hydrocolloid thin (O2) OR Hydrocolloid thick (IF NOT INFECTED; absorbs more)
ii. Less weeping
1. First: MeSalt
2. Second: Hydrocolloid Thin (O2) OR Hydrocolloid thick (IF NOT INFECTED)
iii. Little weeping
1. Hydrocolloid thin (O2) OR Hydrocolloid thick (IF NOT INFECTED; absorbs more)
How to treat Mixed Insuffiency Wound?
- Similar to Arterial insufficency but also need to consider VI. Look at all considerations we look at for wounds.
How to treat a Chronic Inflammatory Wound?
- Use Collagenase Early
- Eventually switch to silver impregnated guaze
- Growth Factor - Prescription required
When is hydrogel good to use?
- Skin Flaps
- Place Steristrips then hydrogel on top. Cover with gauze and stockinette
____ pad can be used on infected wounds
- Abdominal Pad
When should growth factor be placed in a wound?
Diabetic patients with chronic inflammatory!
Hydrocolloid: Thin vs Thick
- Thin (Allows O2, absorbs some moisture)
- Thick (No O2/infection, lots of absorbing)
When is Semiperbiable film good to use?
Superficial intact skin. Reduces friction and is clear.
When should you clean a wound?
- EVERY TIME
How to knoe when do use selective vs non selective to clean a wound?
- > 50% = Nonselective (Whirlpool and Spray Surfactant >8 psi)
- <50% = Selective (Spray Surfactant <8 psi)
If you see a yeast infection you should…
have glucose levels checked
Semipermeable Thin vs Hydrocollpid Thin
- SMT is clear and cheaper
- Hydrocolloid can absorb; waterproof
MeSalt vs Calcium Alginate
CA:
o More expensive
o Better at remaining premoistened
o Better for superficial wounds
o Can stop bleeding and help renal insufficiency people clot
o 20x absorption
Me:
o Good for all infected wounds
o Packs in dead spaces
o 30x absorption
____ don’t stick to wounds and hydrates the area
Vaseline impregnated gauze
Nutritional Requirements and Why?
Acetic Acid:
- Lactic acid creates chemokines, signal for neutrophils to come to injury
Zinc:
- Required for MMPs
- Lack will result in only MMPs getting resources and not TIMPs resulting in chronic wounds
Magnesium:
- Smooths out nerve conduction velocity
- Building block of collagen
Protein
- Building blocks for cells and repairment
Vitamin C
Oxygen
You should never have people ____ when wound healing
lose weight
Red Flags - Contact ED
- Positive Homan’s sign/cuff test – DVT
- Tetanus NOT up to date (> 10 years since last)
- Systemic Infection (Temperature equal or > 101, night sweats); They are moving into sepsis
Non-life threatening: major delays in wound healing
- Infected wound (> 10^5 CFUs)
- High Blood Sugar (Glucose >100, A1c >6.0)
- Venous Insufficiency, LE edema
- Smoking
- Sedentary Lifestyle
Underlying conditions that delay/complicate wound healing
Conditions
- Diabetes
- Autoimmune diseases, RA, HIV-Aids-Lupus-RA
Circulation Impairments
- Arterial insufficiency
- Venous insufficiency
- Diabetic wounds (DM > 15 years)
Pressure ulcer risk needs to be assessed ____ for all hospitalized patients.
at least daily
____ wounds need daily dressing changes
Infected
When you have a dirt infected wound you should use ____
- Antimicrobial dressings (+Ag)
And - Silver impregnated gauze
NEVER SEAL AN ____ WOUND
INFECTED
What can you not use with silver impregnated dressings?
Collagenase
Elevation and Compression Guidelines for AI and VI
AI
* Leg at heart level
* Compression BELOW 32 mm Hg
VI
* Leg above the heart
* Compression at 40 mm Hg
8 psi
>10^5 CFUs (10^3 CFUs)
<0.8 ABI
10gm (5.07)
50%
40 mm Hg
32 mm Hg
175 mm Hg (125 mm Hg)
- 8 psi – maximum amount of pressure that does not disrupt granulation tissue.
- >10^5 CFUs – clinical evidence for infected. 10^3 = contamined, strep
- <.8 ABI – Arterial Insuffiency that you can still use an occlusive dressing and debride and compress
- 10gm (5.07) – monofilament testing, protective sensation in extremity
- 50% - Selective vs Non Selective; 50% or more Non selective; <50% Selective
- 40 mmHg – Venous Insufficency Stasis compression; amount of pressure in a cuff that indicates a DVT of pain in calf – Homan Test
- 32 mmHg – pressure to occlude capillaries (If AI must be below this)
- 175mmHg – Average VAC compression for most wounds; 125mmHg for AI or skin graft site.
Pulsed Lavage Indications
- Deep tunneling wounds or >70% necrotic tissue
- Immobilized or patients with multiple wounds (prevents cross contamination)
- Patients with wounds in isolation
- Forceful irrigation with adjustable psi
What is the main advantage of using enzymatic debridement with a wound?
Removed ONLY necrotic tissue from the wound
What is an advantage of an occlusive dressing?
Autolytic debridement
Skin charge
-
Tissue charge
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