Wound Treatments Flashcards
methods of debridement
selective and non-selective
what are 4 types of selective debridement?
sharp, autolytic, enzymatic, and biologic
what are 2 types of non-selective debridement?
mechanical and surgical
what is sharps debridement?
removal of necrotic tissue by use of sharps instruments (forceps, scissors, scalpel, etc)
Sharps debridements is __________, _________, and ________.
selective, aggressive, and painful
What is a precaution for sharps debridement?
patient taking blood thinners
When is sharps debridement not appropriate?
insufficient vascular supply or nutrition
What is the role of debridement?
debridement allowed 54% wound reduction compared to wound that were not debrided
When should debriding start?
first 4 weeks
when do you terminate sharps debridement? (6)
- clinician fatigue, 2. pain is not adequately controlled for patient, 3. decline in patient status/tolerance to technique, 4. extensive bleeding, 5. new fascial plane identified, 6. nothing remaining to debride
what is autolytic debridement?
natural degradation of devitalized tissues with enzymes or moisture - dressing to occlude wound so moisture/exudate stay in the wound to help with healing
is autolytic debridement a slow or fast method?
slow
when is autolytic debridement not appropriate?
infection present or arterial insufficiency
autolytic debridement is _______ and _________.
conservation and little pain
what is enzymatic debridement?
use of enzymatic ointments to loosen and remove devitalized tissue and proteins; enzymes degrade substrate that is holding the slough to the wound
what enzymes are used for enzymatic debridement?
- papain-urea (tenderizes tissue from outside in) and
2. collagenase (natural enzyme in our body - works from inside out)
enzymatic debridement is ________, _________, and _______.
sometimes slow, nonselective (papain-urea), and may be painful
collagenase is selective
when do you terminate enzymatic debridement?
once satisfactory debridement has occurred OR if necrotic tissue fails to decrease in expected amount of time
what is the procedure for enzymatic debridement?
patient needs prescription, eschar to be crosshatched PRIOR to application, moist environment, observe for S/S of infection, and prophylactic topical antimicrobial therapy PRN
what is another term for biological debridement?
larva therapy
why does biological debridement have limited application?
squeamish factor
what do they use during biological debridement?
use sterile (don’t reproduce) maggots
what is maggot therapy?
larvae release enzymes that degrade necrotic tissue, and larvae digest necrotic tissue/bacteria
when is maggot therapy used?
pressure wounds, diabetic wounds, traumatic wounds, and chronic leg ulcers
what is mechanical debridement?
use of external forces to non-selectively remove necrotic tissue (gauze, wet-to-dry, whirlpool, pulsed lavage)
what can mechnical debridement cause?
bleeding and trauma to wound reducing new cells
is mechanical debridement painful?
yes
what is surgical debridement?
use of scalpels, scissors, or lasers in sterile environment (basically sharps debridement in sterile environment)
surgical debridement is performed by:
physician or podiatrist
what is an advantage of surgical debridement?
allows for extensive exploration of wounds bed and debridement of deeper tissues
what are indications for surgical debridement?
ascending cellulitis, osteomyelitis, extensive necrotic wounds, undermining, and necrotic tissue near vital organs
what are the contraindications for surgical debridement?
patients who are unlike to survive procedure; palliative care plans
What are the procedures for surgical debridement?
shaving of eschar, incision and drainage, tissue biopsy, and antimicrobial therapy
What are the goals of wound healing with debridement?
- promote cleansing to remove debris and necrosis
- reduce bacteria and risk of infection
- promote optimal environment
- promote inflammation to facilitate angiogensis
what are 4 general considerations for debridement?
- characteristics of wounds, 2. status of patient, 3. existing practice acts, and 4. clinical knowledge/skill level
what are contraindications for debridement?
- dry gangrene, 2. eschar that is intact (without drainage, erythema or fluctuance on a patient with poor circulation) and 3. unidentified structures in wound bed
what are the benefits of hydrotherapy (whirlpool)?
cleanse wound, promote circulation and debridement
what are the precautions of hydrotherapy (whirlpool)?
malignancy in area, increases edema, trauma to healthy tissue, promote maceration, and avoid diabetic wounds, also cautious with venous insufficiency wounds
what type of wounds should you avoid with hydrotherapy?
diabetic wounds - watch for maceration
what are some precautions/contraindications of hydrotherapy?
wounds that are:
- clean, macerating, actively bleeding
- tunneling, undermining wounds
- arterial insufficient wounds
- > 50% clean wound
- moderate-severe edema (venous insufficiency)
- incontinent and confused patients
what are hydrotherapy risks?
infection, superhydration (maceration of skin), and changing of skin pH
what are some hydrotherapy considerations?
water temperature, position of patient, duration of treatment, and additives/chemicals
what are the 3 water temperatures?
- non-thermal (80-92 F)
- neutral (92-96 F)
- thermal (96-104 F)
cross hatching
form of sharps debridement of the eschar that lets moist wound dressing or ointment get into the wound
What should you think about when making a decision to use hydrotherapy?
positioning, temperature, time, agitation, contamination, and clean up
what does pulsatile lavage promote?
LOCALIZED circulation
what does pulsatile lavage reduce?
bacteria load
what is pulsatile lavage?
debridement using high pressure jet system
For pulsatile lavage with suction, what are some benefits?
minimal risk of cross-contamination, eliminates edema issues, more focused cleansing, patient-specific supplies
what are some types of wound irrigation?
syringe/gauze, saline, wound cleansers, betadine, hydrogen peroxide, dakin’s solution, acetic acid
when would you use acetic acid?
psudomonas infections for about 2 weeks
what are adverse reactions of acetic acid?
cytotoxic to human cells
what is Dakin’s solution made from?
bleach
what are adverse reactions to Dakin’s solution?
cytotoxic to human cells
what is Dakin’s solution used for?
infection and odor
When do you use hydrogen peroxide?
first 48 hours after injury, infection, inflammatory phase only
What are adverse reactions to hydrogen peroxide?
cytotoxic to human cells
When do you use Betadine?
infection and exudate control - effective for large amounts of drainage
what is the method for using wound irrigation?
use saline/tap water, minimal force, recommended pressure of 4-15 psi
irritation after whirlpool removes ____ the bacteria when compared tot he whirlpool alone.
4x
what are the benefits of electrotherapy?
increase capillary perfusion, stimulates fibroblasts, increases wound tensile strength, antibacterial effect, debridement effects, and migration of inflammatory and repair cells
“current of injury”
electrical potential across the skin
Na+ ion pump: surface epidermis __________
negative
With injury, current flows between _____ and ____ layers; _________ flow of ions with polarity switching
outer and inner layers; unidirectional
First _____ mm of periwound skin has charge; there is no charge ___ mm from wound edge
1-2 mm; 3 mm
True or False: current does NOT disappear with regeneration of tissues
False; it does disappear
_____________ maintains higher electrical potential.
moisture
what does application of Electrical Stimulation do?
enhance movement of cells due to the bioelectrical potentials, leading to healing
Contraindications to electrical stimulation
ALOT - pg 8 of powerpoint
Precautions to electrical stimulation
osteomyelitis responding to antibiotics
What are the 3 methods of electrical stimulation?
- direct, 2. periwound, 3. immersion
What kind of impregnated gauze do you use with electrical stimulation
saline or hydrogel
where are the carbon electrodes located?
over wound and other is 15-20cm proximal or opposite side of extremity
what are the parameters for electrical stimulation? (time, frequency, voltage and pps)
- time: 45-60 minutes
- frequency: 3-7x per week
- pps: 50-120 pulses per second
- voltage: 80-150 volts
is electrical stimulation reimbursed?
yes - AFTER no changes in wound for 30 days
What does positive polarity do when associated with ES?
- coagulation of protein, 2. hardening of tissue, 3. coagulation of blood, 4. enhancing congealed scar formation
what does negative polarity do when associated with ES?
- liquefying proteins, 2. softening tissue, 3. bactericidal, 4. debridement
When is non-thermal US for wound healing indicated?
non-necrotic wounds after documented standard wound care has been used for at least 30 days with no measurable sign of healing
What is US NOT used over?
malignancy, gonads, eyes, RadRx area, and DVT
What are US benefits (3)
- stimulates release of chemotaxic agents by fibroblasts, mast cells and macrophages = reduce inflammatory phase
- stimulate fibroblasts proliferation for collagen deposition, improved granulation, tissue formation, angiogensis and wound contraction
- increases wound tensile strength
What are US contraindications?
osteomyelitis, active bleeding, severe arterial insufficiency, acute DVT, untreated wound infection
What are the 3 methods of US?
direct, periwound, and immersion
What do you use to fill the depth of the wound for US?
saline or hydrogel and cover wound with semipermeable filt or sheet hydrogel - then apply US gel
With low frequency US, what does cavitation cause?
destruction of bacteria, helps with selective dissection and fragmentation of necrosis, and irrigation for cleansing
What does VAC/ NPWT help with?
increase perfusion to wound (increase oxygen and nutrients) and helps with drainage control
when do you change dressings for NPWT?
every 48 hours (3 days a week)
With NPWT, what does the closed, localized negative pressure promote?
healing…. by 1. decreased edema, 2. increased blood flow, 3. decreased bacteria, 4. more granulation tissue, and 5. promotes epithelialization
What is NPWT indicated for?
arterial, venous, pressure, mixed vascular ulcers, dehisced surgical wounds, wounds with tunneling/undermining, flap graft
When is NPWT not indicated?
wounds with >20% non-viable tissue present
What does intermittent NPWT help with?
increase the amount and speed of granulation tissue formation
what does continuous NPWT help with?
the release of intracellular messengers that mediate growth factor production
Contraindications for NPWT
malignancy, osteomyelitis, unexplored fistulas, necrotic tissue with eschar, and exposed blood vessels
What are the precautions for NPWT
active bleeding, anticoagulants, enteric fistula, and close proximity to blood vessels/organs/bony fragments
what is monochromatic infrared energy - anodyne?
photo energy that produces nitric oxide in hemoglobin to reoxygenate blood and wound bed
what does monochromatic infrared energy do?
vasodilates blood in the area
HBOT administers ____ oxygen at a pressure greater than sea level
100%
What are the parameters for HBOT treatment?
1-2x a day; 90-120 minutes per treatment
what does HBOT promote?
angiogenesis and improved oxygen perfusion in blood and plasma hypoxic wounds
Benefits of HBOT in wound healing
hyperoxygenation, helps with oxygen transport, neovascularization, antibacterial effects
Hyperoxygenation increases: (3)
- alveolar pO2, 2. blood oxygen transport, 3. tissue pO2
how many HBOT treatments for angiogenesis to occur?
10
How does HBOT have antibacterial effects?
converts anaerobic wounds with low pH to aerobic wounds with a normal pH
HBOT provides >30 mmHg which helps with what biochemical reactions in the phases of wound healing? (5)
- fibroblasts function, 2. leukocyte function, 3. infection control, 4. new capillary growth, 5. epithelial coverage
What are some indications for HBOT (what kinds of ulcers can you use this on?)
diabetic LE ulcers, skin grafts/flaps, oseoradionecrosis, ST radionecrosis, arterial insufficiency, crush injuries, necrotizing faciitis, gas gangrene, chronic osteomyelitis
What do compression bandages do?
reduce and control edema
How should you wrap compression bandages?
distal to proximal; overlap 25-50%
what does the ABI have to be for compression bandages?
0.6-0.8
What is a precaution for compression bandages?
CHF
what patients should you not use an Ulna boot on?
non-ambulatory patients
OTC compression therapy is used primarily for?
maintenance of edema reduction and wound prevention
What is the pressure requirements for class 1 compression?
14-18 mmHg
What is the pressure requirements for class 2 compression?
18-24 mmHg
what is the pressure requirement for class 3 compression?
25-35 mmHg
what is the pressure requirement for class 4 compression?
40-45 mmHg
What is class 1 compression used for?
edema prevention, DVT prophylaxis, and nonambulatory patients
what is class 2 compression used for?
dependent edema, and failure with class 1
what is class 3 compression used for?
venous insufficiency, exercising patient, edema -/+ ulcer, >6 mon ulcer, and failed class 1-2
what is class 4 compression used for?
lymphedema
what are the 2 examples of bioengineered skin substitutes?
apligraf, and dermagraft
what is apligraf made from?
newborn foreskin tissue which replaces dermis and epidermis
what is dermagraft made from?
newborn foreskin tissue which replaces dermis ONLY (human fibroblast- derived dermal substitute)
what does apligraf contain?
viable dermal and epidermal layers with matrix proteins, active cytokines
what does apligraf not contain?
melanocytes, macrophages, lymphocytes, or blood vessels, hair follicles or sweat glands
when is apligraf indicated?
non-infected venous ulcers of >1 mon duration that have not responded to adequately to conventional therapy
what is a contraindication to apligraf?
bovine collagen allergies (sensitive to the shipping medium)
What is OASIS?
biosynthetics that are derived from porcine small intestinal submucosa (SIS)
Oasis is a temporary dressing for what?
partial and full-thickness loss wounds from pressure, vascular, diabetic, thermal, and surgical origins
What does Oasis consist of?
collagenous, ECM with cytokines and cell adhesion molecultes that support tissue repair
What is an example of a topical growth factor?
regranex
what type of ulcer is Regranex indicated for?
LE diabetic neuropathic ulcers
what is the regranex protocol?
wound bed preparation, apply thin layer of regranex to DFU daily, cover with moist gauze, and change dressing BID
Evaluation of Wound Treatment
last slide of the “wound treatment” lecture - long list that is a waste of time to memorize.
