Wound Management and Reconstruction Flashcards
what is a class 1 wound?
0-6 hours since occurrence?
minimal contamination and tissue trauma
what is a class 2 wound?
6-12 hours since occurrence
microbial burden has not reached critical level
what is a class 3 wound?
occurred more than 12 hours ago
wound infection
which wound class is not suitable for surgical closure?
class 3
what considerations would we have for a patient presenting with an open wound?
when it happened
exactly how it happened
overall stability of the patient
consider effects of shock
what should we consider in out initial assessment of a patient presenting with a wound?
general assessment and history
possibility of trauma
vital signs
analgesia required?
first aid required?
regular monitoring to stabilise patient if necessary
what are the main phases of wound healing?
inflammatory phase
debridement phase
repair/proliferative phase
remodelling
when is the inflammatory phase?
0-5 days
what occurs during the inflammatory phase?
haemorrhage
vasodilation
increased vascular permeability
when is the debridement phase?
day 0 onwards
what occurs in the debridement phase?
phagocytosis
migration of WBC
removal of cellular debris
when is the repair/proliferative phase?
day 3 to 4 weeks
what occurs in the proliferative phase?
fibroblasts proliferate
collagen synthesis
epithelialisation and contraction
when is the remodelling phase?
day 20-ongoing
what occurs in the remodelling phase?
wound contraction and remodelling of collagen fibres
what is the purpose of wound lavage?
reduction of bacterial load (50% for every hour earlier)
allows for visualisation of underlying tissues
what equipment should be used for wound lavage?
35/40ml syringe and 19G needle - pressures still widely unclear
approx how much fluid should be used for wound lavage?
50-100ml per square cm of wound
why is it important not to use too much pressure during wound lavage?
can encourage bacteria further into the wound
what solution should be used for wound lavage?
isotonic saline
can start with tap water if finishing with saline
why must we consider warmth of the lavage solution?
patient often sedated/under GA - warm fluid to avoid getting any colder
what are the different overall options for wound management?
primary wound closure (first intention healing)
delayed primary closure/secondary closure (third intention healing)
second intention healing (contraction and epithelialisation)
what considerations do we have when choosing second intention healing?
use of topical agents, dressings, types of bandage material
client compliance
cost
expertise
what are the 5 general principles of wound management?
non-introduction of anything harmful
tissue rest
wound drainage
avoidance of venous stasis
cleanliness
what are the advantages of negative pressure wound therapy?
reduced oedema and exudate accumulation
elimination of strikethrough - wound fluid collected into canister = reduction in dressing changes
increased central wound perfusion and vascularisation
rapid contraction and wound healing
why is honey used for wounds?
broad spectrum antimicrobial activity
anti-inflammatory properties
shown to be effective against MRSA and pseudomonas
which honey product has been found to be more beneficial for wounds?
table honeys generally possess lower antibacterial activity than medical grade honey, contain wide range of microbial species
medical grade honey is sterile
which types of wound is honey more beneficial for?
chronic, non-healing wounds
how does manuka honey promote wound
healing?
related to decreases in pH levels leading to a rise in oxygen release from haemoglobin in the capillaries
how can use of honey lead to a prolonged inflammatory phase?
lower pH levels cause a suppression of proteases in the wound bed - leads to breakdown of protein fibres and the fibrin matrix
means fibroblasts and epithelial cells struggle to migrate across the wound bed
what is the result of a prolonged inflammatory phase?
over-granulation of the wound
what are our considerations for using honey on wounds?
higher level of exudate - consider dressing
consider the cellular damage in healthy granulating wounds and epithelialisation
consider initial honey use to aid granulation then switch to hydrogel
what is the primary benefit of using silver in wound healing?
antimicrobial effects - indicated for use in the inflammatory phase
what formulations is silver available in?
creams
dressings
why are wet-to-dry bandages used less often in practice now?
overhydrate then dessicate wound bed, compromising function of cells involved in wound healing
bacteria can penetrate gauze
cause discomfort when worn and removed
fibres remain when removed, causing inflammation
what type of debridement does wet-to-dry do?
nonselective mechanical debridement - much-needed cells and tissue (WBCs, granulation tissue, epithelium) and necrotic tissue are pulled off
how are hydrogel dressings (e.g. intrasite, granugel) used?
water-based, amorphous, cohesive application that is applied to the wound bed and covered with a secondary, non-absorbent dressing
how do hydrocolloid dressings work?
forms a non-adherent gel on contact with the wound (uncommonly used)
what are vapour-permeable films/membranes?
e.g. primapore, melolin
consist of a sheet of absorbent material between two thin layers of film that contain small pores for the movement of gas and fluid
what are foam dressings?
e.g. allevyn, kendall foam, activheal foam
hydrophilic dressings made of polyurethane foam, which can be adhesive or non-adhesive and with or without a breathable film backing
how do foam dressings work?
absorb exudate but doesn’t adhere to the wound - commonly used in open wound management
when might a tie-over dressing be used?
tie-over bandages are often the ideal choice for placement over wounds in areas that are mobile, difficult to cover, or lack sufficient local skin for tension-free primary closure
what is an abrasion?
superficial skin damage caused by friction parallel to the skin surface
what is an avulsion?
injury where tissue is separated from underlying tissues
what is a contusion?
injury where the capillaries have been damaged e.g. bruise
what is a crush injury?
an injury where the tissue has been compressed (and therefore may have vascular damage)
what is eschar?
a scab
what is excoriation?
erosion or ulcer caused by scratching, biting, or rubbing
what is exudate?
fluid full of inflammatory cells
what is a haematoma?
blood-filled swelling caused by blood vessel rupture
what is a hygroma?
soft fluidy mass found on bony prominences
what is a laceration?
deep cut/tear in the skin
what is maceration?
a breakdown of skin due to prolonged exposure to moisture (wrinkly bath fingers)
what does peracute mean?
extremely sudden onset
what is a seroma?
a fluid-filled swelling often associated with dead space after surgery
what is a shearing injury?
when tissue is damaged as layers move over the top of each other
what are the options for wound closure?
primary closure
delayed primary closure
secondary closure
second intention healing
what are the disadvantages of second intention healing?
can be painful and expensive
can lead to contractures which require revision
what are the options for surgical reconstruction techniques?
‘simple’ closure
subdermal (pedicle) plexus flap
axial pattern flap
free skin graft
what are the pros of ‘simple’ suturing of wounds?
simple, quick, easy
what are the cons of ‘simple’ suturing of wounds?
relies on accurate wound assessment - failure to assess correctly leads to breakdown
possible infection
non-viable tissue left behind
excess tension or inappropriate suturing can lead to breakdown
which wounds are most appropriate for simple suturing?
fresh wound, clean or clean/contaminated
wound not large, not much skin lost during injury
should wounds be debrided before simple suturing?
not usually required - increases skin loss
if done, should be minimal and unlikely to increase wound tension
what is required for simple suturing?
GA or sedation + LA
basic surgical kit
staples if very superficial
+/- bandage for post-op
what does a subdermal plexus flap utilise?
generous plex of small arteries and veins sitting in the subdermal tissue in a ‘plexus’ under the skin
how is the subdermal plexus flap achieved?
the skin is undermined and the vessels are preserved, with the skin elasticity allowing the skin to be moved to cover a larger defect
what does undermining mean?
where the skin is elevated and dissected away from the underlying musculature
what are the 2 named subdermal skin flaps?
flank fold flap for inguinal wounds
elbow fold flap for axillary wounds
what are the cons of a subdermal plexus flap?
relies on accurate wound assessment
has size limitations
damage to plexus possible
infected/non-viable tissue left behind
what are the pros of a subdermal plexus flap?
simple yet versatile
good for medium-sized wounds
reduces tension
which type of closure is a subdermal plexus flap most appropriate for?
primary
delayed primary
secondary
appropriate wound selection for a subdermal plexus flap
wound may be fresh or may have been bandaged for a while
anywhere on body, used for medium-sized defects
are wounds requiring a subdermal plexus flap likely to require debridement?
likely to require significant debridement - increases final skin deficit that requires closing
what is required for a subdermal plexus flap?
basic surgical kit
+/- bandage post-op (likely required)
what can make a subdermal plexus flap vulnerable to vascular necrosis?
too big a flap raised –> blood supply inadequate
poor technique leading to plexus damage
what can occur if too big a flap is raised for a subdermal plexus flap?
vascular necrosis due to inadequate blood supply
how can good blood flow be ensured to an axial pattern flap?
incorporation of a direct cutaneous artery - less chance of vascular necrosis
what needs careful consideration when performing an axial pattern flap?
planning, assessment of skin tension, measurement and mapping
what are the pros of an axial pattern flap?
come with good blood supply
longer and wider flaps possible than with subdermal
can offer rapid healing of chronic wound
what are the cons of an axial pattern flap?
steep learning curve
flap necrosis can be catastrophic
good post-op care vital
+/- cosmetic result
which type of closure is most appropriate for an axial pattern flap?
secondary closure
what type of wounds might require an axial pattern flap?
usually a wound being bandaged for a while
wound must be ‘clean’ at time of surgery
only for specific sites on the body, used for large skin defects
what is required for an axial skin flap?
advanced procedure - more advanced surgical kit required
good post-op care vital to avoid major complications
what type of tissue is required for a skin graft?
a healthy bed of granulation tissue must already be present
what are the 2 common techniques for a free skin graft?
sheet graft
punch biopsy graft
where are free skin grafts useful?
distal limb defects where a subdermal flap/APF not an option
what are the pros of a free skin graft?
punch grafts are simple
sheet grafts often good for large extremity defects
offer rapid healing of chronic wound
what are the cons of a free skin graft?
sheet graft is an advanced technique
good post-op care vital
partial/complete failure not uncommon
what type of closure is a free skin graft used for?
only really used as part of secondary surgical repair - can be used if APF has failed
what is required for a free skin graft?
advanced procedure - more advanced surgical kit required
post-op care vital to avoid major complications
what types of burns are possible?
thermal (dry/wet)
chemical/radiation/electrical
what is degloving?
a type of severe avulsion affecting the legs, tails (extremities)
what types of degloving can occur?
mechanical - skin pulled from subdermal attachments
physiological - skin necroses and sloughs due to damage to blood supply
what cast/bandage complications might occur?
over-tight
inadequate padding
excess exercise
wet/dirty
what do we need to consider in terms of wound aetiology?
level of contamination - micro-organisms, debris
likelihood of infection, presenting signs of infection, depth of infection
determines whether flushing vs topical vs systemic abs
what patient factors go into our wound assessment?
signalment - young/old, species and breed, temperament
comorbidities - pre-exisitng or associated with injury, factors which could affect healing
which patient comorbidities might affect healing?
immunosuppressive conditions
poor nutrition
drugs therapy
stress
why do we need to think about wound position when during assessment?
how much spare skin at the site - depends on body position, breeds
how mobile is the area
whats ‘in the way’
what are the overall factors we should be investigating when assessing for methods of surgical reconstruction?
wound factors
aetiology factors
patient factors
when are we likely to take it to surgery
where is the wound
what are the 3 stages of skin healing?
inflammation
proliferation
maturation
what occurs in the inflammation phase of wound healing?
haemorrhage
vasocontriction –> haemostasis –? closes wound
vasodilation –> inflammatory cells (neutrophils and monocytes)
what occurs in the proliferation phase of wound healing?
fibroblasts
granulation
wound contraction
re-epithelialisation –> skin healing
what occurs in the maturation phase of skin healing?
collagen maturation
scar formation = increased strength
what should we consider in terms of patient assessment?
pre-existing co-morbidities
current status
injuries
primary vs delayed wound management
what action should be taken if the patient is unstable?
protect wound from further damage while stabilising patient
what action should be taken if the patient is stable?
fully assess wound and decide best course of action
what are the overall client factors influencing wound management?
cost
owner compliance
practicalities
why is cost a considerable client factor influencing wound management?
bandaging may not necessarily be cheaper than surgery
why does owner compliance influence wound management?
compliance with revisits, bandage management between visits, medications
how can we help consider client factors when making decisions about wound management?
make sure owners are aware from the beginning how costly and intensive the process could be
what does ‘TIME’ stand for?
Tissue
Infection/inflammation
Moisture
Epithelialisation
what do the components of ‘TIME’ mean for wound management?
remove non-viable tissue
treat infection/factors pre-disposing to infection
ensure optimal moisture balance
identify delayed healing
what colour is epithelial tissue?
healthy pale pink
what colour is granulation tissue?
red and moist - bleeds easily
what colour is sloughing tissue?
yellowy/grey/brown
what colour is necrotic tissue?
black, hard and dry
how do we assess viability of tissue?
necrotic tissue promotes infection
difficult to know which tissue is viable and which isn’t
whether or not tissue has declared itself - can take several days
why is it difficult to tell whether tissue has declared itself?
can take several days
what should we consider in terms of timing of debridement of a wound?
patient stability often determines whether primary or delayed debridement
all at once vs gradually
removal of necrotic tissue promotes healthy granulation tissue
can also use debridement to remove grossly contaminated tissue
what do we need to consider in terms of debridement method?
surgical vs bandaging vs combo
care with debridement - only remove necessary tissue
why do we need to have caution during debridement (esp surgical)?
removed tissue can’t be put back - sometimes there is enough to sacrifice some tissue but other times you need all the spare tissue you can get
being cautious is prudent
what is how can we treat local infection of a wound?
topical antibiotics
how can we treat mild contamination of a wound?
clean wound
how can we treat colonisation of a wound?
debridement
how can we treat systemic infection due to a wound?
systemic antibiotics
how can we tell if there is likely a pre-existing infection in a wound?
age of wound
presence of discharge
smell
how can we determine risk of infection to a wound?
site of wound
wound aetiology
degree of contamination
wound lavage
what does unhealthy inflammation of a wound indicate?
infection
what does healthy inflammation of a wound indicate?
granulation and healing
how can we tell if a wound is too wet?
will be macerated and/or excoriated
how can we tell if a wound is too dry?
will be dessicated +/- eschar present
why might there be discharge from a wound?
wound maceration
pus
how can we assess epithelialisation progress of a wound?
assess wound edges and tissue surrounding wound
measurements - width, length, depth
photos
drawings
what do healing wound edges look like vs not healing?
healing = pink and smooth
not healing = darker red, uneven
what might we see in the tissue surrounding a non-healing wound?
cellulitis
oedema
what are the advantages of wound lavage?
rehydrates necrotic tissue
removes foreign material
reduces bacterial contamination
removes toxins and cytokines
which wounds are suitable for lavage?
any traumatic wound
how can we trap fur during lavage?
use of aqueous gels
how should wound lavage be carried out?
no sedation required
apply with even pressure, not too high
what equipment is ideal for wound lavage?
fluid bag (hartmanns?) with giving set
20ml syringe, 18g needle, 3 way tap
how can we identify if wound lavage is too high pressure?
areolar tissue will show it by having a bubble-wrap appearance
what is involved in surgical debridement?
sharp dissection to remove all contaminated, necrotic tissue
avoid damage to normal tissue!
what is involved in physical debridement (bandaging)?
using adherent dressings that remove tissue when the dressing is removed
what is involved in chemical debridement?
using chemical substances to remove dead tissue
how does bandaging protect wounds?
against self-trauma
against contamination/infection from environment
against dessication
what should a bandage provide for the patient?
pain relief
immobilisation of soft and any concurrent ortho injuries
pressure to reduce swelling/haemorrhage
deliver topical medications
how can bandaging help with debridement?
chemical - hydrogels, enzymatic agents
physical - wet-to-dry, dry-to-dry, larvae
how can bandages help with moisture of wounds?
keep moisture in e.g. hydrogels
take excess moisture away e.g. absorbent dressings
how do nurses help with continuity in wound management?
develop a team to care for a patient with long-term bandaging needs
ensures continuity of products, application technique and communications
how do nurses help advocate for clients in wound management?
discussions of cost and practicalities
emotional support - often difficult long journey
how do nurses advocate for patients during wound management?
physical and mental support, esp in relation to caging/reduced exercise/boredom
flagging if a change of direction might be worth considering
early recognition of complications
how can nurses advocate for the greater community through wound management?
antimicrobial stewardship - appropriate and targeted usage, appropriate course lengths, topicals wherever possible
