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Physical Agents > Wound Healing and Treatment > Flashcards

Wound Healing and Treatment Flashcards

1
Q

Role of physical therapy in wound healing and treatment

A
  • debride and cleanse wounds
  • minimize drainage to healing tissues
  • promote healing of wounds
  • restore function to tissue and surrounding tissues (unique to PTs)
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2
Q

3 factors affecting wound healing

A
  • wound environment
  • local factors
  • systemic factors
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3
Q

4 components of wound environment

A
  • temperature
  • wound hydration
  • tissue necrosis and foreign bodies
  • infection
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4
Q

What is the ideal temperature for healing wounds?

A
  • all wounds desire a warm, moist, environment
  • ideal wound healing occurs above 30 degrees Celsius
  • maintaining a normothermic wound environment of 37-38 degrees Celsius improve wound healing
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5
Q

what do dry wounds inhibit?

A

progression of the inflammatory phase

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6
Q

what can help add or retain moisture of the wound?

A

covering wounds and adding moisture via dressings or topical preparation

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7
Q

what do wound fluids have?

A

growth factors and enzymes important to healing

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8
Q

what can wet wounds do?

A

prohibit wound healing and lead to periwound maceration

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9
Q

Wound environment - Tissue Necrosis and Foreign Bodies

A
  • epithelial migration can not occur over dry tissue
  • necrosis provides food for bacterial microbes
  • debris in the wound will also feed microbial colonies
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10
Q

Wound environment- Infection

A
  • presence of microbes or colonization is normal as skill normally has the presence of some bacteria
  • however, levels that raise too high will impair wound healing
  • infection prolongs the inflammatory stage of healing
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11
Q

3 local factors of wound healing

A
  • circulation
  • sensation
  • mechanical stress
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12
Q

Local Factors - Circulation

A
  • Inadequate circulation increases the risk of infection
  • blood needs to reach microcirculation
  • issues with SNS
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13
Q

Local Factors - Sensation

A
  • Impairs ability to identify signals of tissue damage
  • can lead to continued trauma to the area
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14
Q

Local Factors- Mechanical Stress

A

Sheer and friction forces are linked with initiating and perpetuation skin breakdown
- Have to great pressure off a wound
- Major issue to address to assure a good healing environment

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15
Q

What are the 5 systemic factors of wound healing?

A
  • Age
  • Inadequate nutrition
  • co-morbidities
  • medications
  • social behaviors
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16
Q

How can age affect wound healing?

A
  • slowed immune response
  • decreased cellular turnover
  • epidermal and dermal atrophy (thinner skin cant handle sheer forces
  • impaired pain perception
  • increased probability of co-morbidities
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17
Q

How can inadequate nutrition affect wound healing?

A
  • decreased cellular energy
  • protein required for cellular repair and will affect all phases of healing
  • changes in food intake will cause immediate changes in healing (ALL phases)
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18
Q

How do co-morbidities affect wound healing?

A
  • diseases affecting tissue perfusion
  • immunocompromised conditions
  • Mobility issues
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19
Q

How do medications affect wound healing

A
  • steroids can make the skin thinner
  • NSAIDs –> thinning blood –> not great circulation
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20
Q

What social behaviors can negatively affect wound healing?

A
  • alcohol use
  • smoking (AT LEAST cut down)
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21
Q

Main purpose of debridement

A
  • remove necrotic (non-viable) tissue
  • a warm, moist environment is needed for epithelialization to occur and epithelial cells will not migrate across necrotic tissue
  • debridement removes necrotic tissue, eschar, and slough
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22
Q

Other purposes of debridement

A
  • decrease bioburden
  • remove old cells
  • decrease stimulation of inflammatory cell production
  • remove callous and epiboly edges
  • facilitate angiogenesis
  • prepare wound bed skin equivalents/growth factors
  • prepare wound bed for flap/graft
  • determine depth of tissue destruction
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23
Q

4 Types of Debridement

A
  • Mechanical
  • Chemical/ Enzymatic
  • Autolytic
  • Sharps/ Surgical Debridement
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24
Q

Mechanical Debridement- Used for, advantages, disadvantags

A
  • Used for: very superficial and scant slough, small, visual foreign debris (gravel, dirt, etc)
  • Advantages: very easy to do and cheap
  • Disadvantages: not very selective (can harm good tissue)
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25
Q

Mechanical Debridement Definition

A
  • Removal of tissue with a rubbing force
  • Can occur when removing dressings
  • Non-selective
  • Can be harmful to healthy or granulating tissue (don’t use around granulating tissue)
  • Other conditions of the wound will tell you the aggressiveness to use
  • Can add saline in the wound to add a little pressure
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26
Q

Chemical/ Enzymatic Definition

A
  • Enzymes used to selectively remove dead tissue
  • 3 types: Proteolytics, fibrinolytics, collagenases (only one used in US)
  • Apply to wound only and must be kept moist
  • Use scalpel to hatch open eschar and put collagenases in
  • the bigger it is, the less likely we will do that
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27
Q

Chemical/ Enzymatic - Used for, advantages, disadvantages

A
  • Used for: larger areas of necrosis, eschar
  • Advantages: more selective than mechanical
  • Disadvantages: very expensive, when it goes awry it can be very damaging, not a bunch to select from
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28
Q

Autolytic Definition

A
  • Uses body’s own enzymes
  • support by providing a moisture retentive dressing
  • takes time (the bigger it is, the longer it takes)
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29
Q

Autolytic: used for, advantages, disadvantages

A
  • Used for: most wounds at some point in healing
  • Advantages: natural
  • Disadvantages: slow, when we slow the process, microbiomes can get in and increase opportunity for infection
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30
Q

Sharps/Surgical Debridement Definition

A
  • Removal of dead tissue via cutting away
  • used when radial debridement is required
  • performed by MD or therapist (surgical sharps is typically MD)
  • Benefit by removing a large area at once and still be selective
  • Typically used when there is a lot of necrotic tissue in there
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31
Q

Surgical/Sharps Debridement: Used for, advantages, disadvantages

A
  • Used for: wounds with large amounts of necrotic tissue
  • Advantages: most selective, large areas at once
  • Disadvantages: surgical suite is expensive, can cause bleeding in the area (must be prepared)
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32
Q

Once debrided, how often are wounds cleansed?

A

as often as necessary

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33
Q

How can you promote healing?

A
  • through coverage of the dermal defect
  • prove a noise, clean environment
  • apply the appropriate form of dressing
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34
Q

Things important for PTs to remember

A
  • restore function to the tissue and surrounding structures
  • one needs to be mindful of the normal process of tissue repair including returning the tissue to its normal function
  • things such as tendon gliding and viscoelastic qualities need to be addressed
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35
Q

Types of Wound Management

A
  • Whirlpool
  • Pulsatile Levage
  • Negative Pressure Wound Therapy
  • Hyperbaric Oxygen
  • MIST (non-contact ultrasound)
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36
Q

Physical and mechanical effects of whirlpool

A
  • Softens eschar, loosens necrotic tissue
  • Deodorizes and cleanses wound
  • Soaking removes dressings
  • Stimulates granulation tissue due to agitation
  • Maceration of periwound area
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37
Q

Contraindications for Whirlpool

A

Venous insufficiency, DM, DVT, High fever, incontinence,
significant cardiac disease (including pts. with pacemakers and implanted defibrillators), dry gangrene, renal failure, severe phlebitis, compromised pulmonary status, unresponsiveness, lethargy, ostomies, severe contractures lending to poor positioning in whirlpools, casted extremities

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38
Q

Whirlpool precautions

A

Clean granulating wounds, epithelializing wounds, new skin grafts, venous wounds, and non-necrotic neuropathic ulcers

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39
Q

Whirlpool Additive: Providine-Iodine (betadine)

A
  • Powerful antimicrobial –effective at decreasing wound
    and water bacterial count
  • Only solutions especially prepared for whirlpools
    should be used
  • Non-specific agent = non-selectively cytotoxic
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40
Q

Whirlpool Additives: Sodium Hypochlorite (bleach)

A

 Results in the release of free chlorine which acts as an
effective antimicrobial agent
 Some dilutions can be painful to patients and may
irritate non-involved tissue

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41
Q

Whirlpool Additives: Chloramine-T (Chlorazene)

A

 Contains chlorine and a hydrogen nitrogen mix
 Effective at decreasing colony counts in wounds
 Less irritating and less cytotoxic than sodium
hypochlorite
 Added to water prior to submersion

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42
Q

Whirlpool Additives: Dakin’s Solutions

A

 Bactericidal agent used against streptococci and staph
 Non-specific –will damage clean wound bed
– Has to be real real real bad bc its real toxic

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43
Q

Whirlpool Additives: Acetic Acid

A
  • Removes Pathogens
  • Does not enhance wound healing
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44
Q

What is Pulse Levage?

A
  • occurs with concurrent suction (can also provide mechanical debridement)
  • Continuous fluid flow with a handheld device to regulate irrigation pressure
  • Suction creates a negative pressure at wound bed removing the irrigant (0.9% NS)
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45
Q

Objectives of Pulse Levage

A

 Facilitates removal of debris and pathogens
 Reduce bacteria and infection
 Promote granulation and epithelialization
 Negative pressure of suction stimulates granulation of clean wounds
 Cleansing with gentle pressure for irrigation and debridement

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46
Q

Does pulse leverage have systemic effects?

A

no
local effects only

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47
Q

Benefits of pulse levage

A

 Portable for PT
 Periwound maceration avoided
 Treatment of tunneling and undermining (at lower PSIs) (a go to but also a precaution)
 May be used in some situations where systemic effects makes whirlpool contraindicated
 Quick(efficient)
 Less risk of cross contamination

48
Q

Indications for pulse levage

A
  • necrotic wounds
  • tunneling and undermining in wounds
  • more appropriate for venous insufficiency ulcers
49
Q

Contraindications for pulse levage

A
  • actively bleeding wounds
  • clearly exposed arteries, nerves and deep connective tissue
50
Q

Pulse Levage Precautions

A

Facial wounds, near major vessels, near cavity linings
(pericardium, peritoneal), tunneling and undermining, Bypass/graft sites, anastomosis, exposed tendon/nerve/bone, use with anticoagulant meds., infection control issues

51
Q

Why do you have to be careful when using pulse levage on wounds with tunneling and undermining?

A

because you cant see what’s under there

52
Q

Method for applying pulse levage

A

 Irrigant is 1000-3000 mL of normal saline
 One sterile unit is used at each session
 Set up unit according to manufacturer’s instructions
 Choose PSI: varies between 4-15 PSI
 Apply to wound bed

53
Q

How often should pulse levage be applied?

A

BID for severly infected wounds, typically QD and
may be QOD based on wound condition

54
Q

What PSI should you use when applying pulse levage to wounds with tunneling and undermining?

A

4 ,5 ,6

55
Q

Benefits of NPWT

A

 Approximation of wound edges
 Removes interstitial fluid and infections debris
 Provides closed, moist environment for healing
 Increased local tissue perfusion
 Promotes granulation tissue formation
 Reduce bacterial load
 Decreased frequency of dressing changes
 Can be used where bone and tendon etc. may be exposed

56
Q

Indications for NPWT

A

 Pressure ulcers
 Chronic or acute wounds
 Dehisced abdominal wounds
 Neuropathic wounds
 Traumatic wounds and burns
*Wounds with < 30% necrotic tissue

57
Q

Contraindications for NPWT

A

 Wounds with > 30% necrotic tissue
 Malignancy in wound
 Untreated osteomyelitis
 Unexplored fistula
 Necrotic tissue with eschar present
 Directly over exposed vessels and organs
 Ischemic wounds

58
Q

Precautions for NPWT

A

Active bleeding, anticoagulants, exposed vessels and organs, bone fragments, fistulas, boney prominence, grafts
(20-30% necrotic tissue be very careful)

59
Q

Method for NPWT

A

 Cleans the wound
 Apply vac dressing of choice: GranuFoam (black
polyurethane) improves granulation, or VersFoam (white
polyvinyl alcohol PVA) less aggressive and more comfortable than some black foams: ? gray (new on market)
 Drape, Trac Pad, canisters to collect exudates
 Attach to machine
 Turn machine on and select parameters
——Pressure: 25-200 mmHG (typically 125 mm HG)
——Adjust pressure in 25 mm increments
——Mode: continuous vs. intermittent
 Achieve seal
 Frequency: Q48-72 hours, 24 hours if fear of irritation to new granular tissue
 VAC runs continuously 24 hours, may be turned off for a
maximum of 2 hours
 Wound must be off loaded to be affective

60
Q

What is hyperbaric oxygen

A

Application of oxygen in pressurized chamber; patient breaths 100% pure O2 for 90-120 minutes BIW to TIW

61
Q

Hyperbaric Oxygen Objectives

A

 Increased Oxygen concentration gradient
 May reduce bacterial load
 Enhances angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, wound contraction
 May reduce edema

62
Q

Hyperbaric Oxygen benefits

A

helps with treatment efficiency

63
Q

Hyperbaric oxygen indications

A

Chronic wounds or slow healing wounds that reverse with
oxygen test, TCOM (transcutaneous oxygen monitoring)
<40psi(could also read mmHg 760-2300 mmHg depending on sea level)

64
Q

hyperbaric oxygen contraindications

A
  • DVT
  • CHF
  • COPD
  • Pregnancy
  • Severe Arterial Insufficiency
  • Non-reversing hypoxia
65
Q

Hyperbaric oxygen precautions

A

claustrophobia

66
Q

What is MIST

A

saline mist delivered with an ultrasound applicator

67
Q

MIST objectives

A

 Soften necrotic tissue
 Reduce bioburden
 stimulate cell activity

68
Q

MIST benefits

A

 Painless application
 Stimulates growth factor production
 No cell death to viable tissue
 No cross contamination of wound bed

69
Q

indications of MIST

A

Chronic or slow healing wounds

70
Q

MIST contraindications/precautions

A

 Breast Implants
 Over thoracic area if pacemaker is present
 Over/near heart
 Over low back during pregnancy
 Over pregnant uterus
 Over areas of malignancy
 Epiphyseal plates
 Laminectomies (if central nervous tissue exposed)
 Joint cement
 Some plastics in prothesis
 Eyes

71
Q

MIST methods

A

 Frequency: 40kHz
 Intensity: < 0.50 W/cm2
 Rx frequency of visits: 3 X wk
 Duration: 3-20 minutes based on wound size; > 30cm2 saline
bottle to be refilled every 5 min.
 Transducer distance: 5-15 mm from wound bed

72
Q

Modalities for wound healing

A
  • electrical stimulation
  • ultrasound
  • UV light
  • Infrared
73
Q

Theory and rationale for electrical stimulation

A

 Skin surface is negatively charged
 Wound tissue is positively charged (sodium current)

74
Q

Galvanotaxic Effect of E Stim

A

(1) Anode – attracts neutrophils and macrophages
(2) Cathode – attracts neutrophils (when infected or inflamed) and fibroblasts

75
Q

What may inhibit Galvanotaxic Effect

A

dehydration, or non-conductive material in the wound

76
Q

What does E-Sim mimic

A

body’s bioelectrical signal to promote healing

77
Q

Does E Stimulation have an antibacterial effect?

A

Yes
Microamperage direct current vs. HVPC
Needs to be direct

78
Q

What is the electric potential of acute, non-infected wounds

A

during the first 3-4 days it is positive and then becomes negative

79
Q

electric potential of chronic wounds

A

Conflicting information – most current literature suggests initiating Rx with cathode and then switching to anode, or regularly switching polarity

80
Q

Parameters for HVPC

A

 Frequency = high
 Pulse duration = 60=100 microseconds (bigger pulse = more recruitment)
 Amplitude = sub-motor
 Electrode placement = monopolar with active wound bed (can be on wound or surrounding)

81
Q

When is ultrasound particularly effective?

A

during the inflammatory stage and early proliferation
stage if used at low intensities

82
Q

Ultrasound during inflammatory phase

A

 Evidence to suggest that ultrasound can increase the release of growth factors and stimulation of cells involved in early healing (mast cell, microphages…)
 Accelerate the inflammatory process, not an anti-inflammatory agent

83
Q

Ultrasound during proliferation phase

A

 Proliferation phase is also accelerated lending to early
remodeling
 Facilitates wound contraction by: increasing fibroblastic activity and indirectly increases macrophages through factors released

84
Q

Ultrasound during remodeling phase

A

 Mechanical properties of scar tissue are altered when exposed to US during the inflammatory and proliferation phases
 Provide better environment for patterning of scar tissue

85
Q

Effects of UV light

A
  • bactericidal effect
  • erythermal response
  • Vitamin D production
86
Q

bactericidal effect of UV light

A

may be due to interruption of DNA synthesis or RNA

87
Q

Erythermal Response

A

 Believed to stimulate wound healing by initiating the
inflammatory response
 Vasodilatation and increase capillary permeability

88
Q

Infrared

A

Superficial dry heating agent – effects of increased blood flow and capillary permeability major contributors to wound healing

89
Q

Functions of wound dressings

A
  1. provide moist environment
  2. provide thermal insulation
  3. provide barrier to microorganisms
  4. protect exposed nerve endings, thus decreasing pain
90
Q

Types of wound dressings

A
  1. Primary: direct contact with wound
  2. Secondary: provides protection, cushioning, & or absorption #1 can be used without #2, but #2 can’t be used without #1
    **cannot use secondary if you do not have primary
91
Q

Dressing categories

A
  1. gauze dressings
  2. impregnated gauze dressing
  3. film dressings
  4. foam dressings
  5. hydrocolloids
  6. alginates
  7. hydrogels
  8. composite dressing
  9. advanced wound managements products
  10. topical agents
92
Q

Gauze Dressing description

A

Mesh cotton or synthetic fabric woven into various forms both in a sterile and non sterile format ; woven and non woven; available in sheets, packing strips

93
Q

Gauze dressings function

A

cushions wound, maintains moist environment, most common, mechanical debridement, may leave lint
behind, may traumatize granulation, may macerate periwound, absorbs exudate

94
Q

What is the go to dressing for infection and mild exudate

A

gauze

95
Q

impregnated gauze description

A

mesh gauze dressings that have been impregnated with petrolatum, bismuth, zinc

96
Q

impregnated gauze function

A

decreases trauma to wound bed, decreases pain

97
Q

What patient population does dr conroy like to use impregnated gauze on?

A

diabetic population

98
Q

Film dressing description

A

An acrylic hypoallergenic coated thin transparent polyurethane & polyethylene sheet that is semi-permeable to gas & impermeable to fluids & bacteria

99
Q

film dressing function

A

conforms, maintains moist warm environment,
allows for wound inspection, protects from shearing and
friction, waterproof, semipermeable to vapor, moisture &
gas exchange, promotes autolysis, never use on heavily
exudative wounds; not recommended for infection,
tunneling or deep cavities (lets you see inside)

100
Q

foam dressing description

A

polyurethane foam with hydrophilic wound side and hydrophobic outside; permeable to gas not bacteria
* Big bandaids

101
Q

Function of foam dressings

A

Cushions wound, maintains moist warm
environment, moderate absorbency, high rate of vapor
exchange & moisture, good for hypergranulation tissue,
heavy exudate, never use on dry wounds, eschar, heavy
infection (a little more absorptive than gauze)

102
Q

Hydrocolloids description

A

SINKORAMA
Combination of gel forming polymers
(hydrophilic colloidal particles) with adhesive compound
lamented onto flexible water-resistant outer layer; may be
occlusive or semi-occlusive with varying composition;
combines with the polymers to form a soft gel mass in the
wound

103
Q

Function of Hydrocolloids

A

Maintains temperature, encourages autolysis,
No air exchange, Impermeable to urine, stool, bacteria,
moisture retentive, min-moderate absorbency, never use on primary surgical sites, heavy infection, heavy draining
wounds, periwound maceration, not recommended for
eschar and fragile skin; may cause odor

104
Q

what is the go to for heavily draining wounds?

A

Alginates

105
Q

Alginate descriptions

A

Calcium or potassium based; works by
reaction of product with the sodium in the wound; a
chemical ion exchange occurs creating a gel-like substance; derived from brown seaweed spun into various form, -the gel formed by the exudate and dressing coats and conforms to the wound evenly distributing the fluid providing a warm moist environment for healing; multiple forms in sheets, ropes, wafers

106
Q

Alginates function

A

Supports cell migration, encourages autolysis,
Can absorb 20 times its weight in fluid, can be used with
infection, high absorbency, non adherent, never use on dry
eschar

107
Q

Hydrogels description

A

Group of complex organic polymers with high water or glycerin content from 30-90%; Available in sheet or gel form

108
Q

Hydrogels function

A

Encourages autolysis, reduces pain, Provides
moist environment, Softens eschar, minimal absorbency,
use with secondary dressing, never use on wet wounds,
periwound maceration; not recommended for infection

109
Q

composite dressings description

A

combination of 2 or more physically distinct
products; multi-layer dressings consisting of inner non
adherent contact layer, absorptive middle layer, outer
semipermeable film layer. Usually collagen based

110
Q

types of composite dressings

A

bovine- cow collagen
porcine - pig
equine - horse
ovine - sheep

111
Q

multilayer compressive dressing (composite)

A
  • two layers of absorptive
  • two layers of compression (little bit of elasticity)
  • go to for venous insufficient wounds
112
Q

Advanced Wound Management - Growth Factors

A

growth promoting substances that enhance cell activity
Examples: Regranex

113
Q

Advanced Wound Management - Biosynthetic Dressings

A

derived from natural tissues
Examples: Promogran, Oasis

114
Q

Advanced Wound Management - Skin Substitutes

A

tissue engineered consisting of bilayered systems that mimic epidermis & dermis
Examples: Apligraf, Integra

115
Q

Topical Agents

A
  • Gentamicin
  • Neosporin
  • Silver Sulfate (good antimicrobial)
116
Q

Review clinical decision making

A

Physical Agents (11 decks)

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