wounds! Flashcards
Skin has two main layers:
Epidermis
Superficial and thinner epithelial layer
Dermis
Deeper and thicker connective tissue layers
Combined, 2-3mm thick
Hypodermis
Storage site for fat, containing blood vessels that surround the skin
Skin anatomy: epidermis top and bottom layers
stratum corneum –> stratum basale
Majority of epidermal cells
Produce fibrous protein called keratin
Make our skin tough (strength and resilience)
Allow tissue to resist damage
Involved in wound healing and in the immune system
keratinocytes
Produce pigment granules called melanin: a brown to black pigment occurring in the skin
Found in the stratum basale
melanocytes
They are macrophages: Immune cells that play a role during the inflammatory phase of acute wound healing
Produced in the bone marrow and migrate to the epidermis
Found in the stratum spinosum and stratum granulosum
Langerhans cells
Function mainly as touch receptors
Found in the stratum basale
Merkel cells
dermis includes what 2 layers?
Papillary Dermis and Reticular Dermis
Dermal dendrocytes are involved in
Involved in wound healing, blood clotting and inflammation
Innervation of dermis
Supplied with sensory receptors for temperature, pain, and touch
Phases of Wound Healing
Hemostasis
Inflammation (1-3 days)
Proliferation (1-2 weeks)
Remodeling or maturation (1-2 years)
Process to prevent and stop bleeding (blood clots) in damaged blood vessel
Vasoconstriction (brief and intense)
Activation of keratinocytes and platelets
Hemostasis
Inflammation:
Contains
Neutralizes
Dilutes the injury-causing agent or lesion
Hemoattractant molecules released by platelets also increase
Inflammatory Phase: 1-3 days
Initial process of inflammation common to all tissue types
Neutrophils (WBCs immunity) and other inflammatory cells migrate into tissue
Overall tissue strength of a wound is minimal, since tissues do not regain their normal functional strength until inflammation transitions into repair
Scar tissue will be swollen, tender, and red
Inflammatory Phase: 1-3 days
Wound contracts:
Myofibroblasts help contract the wound, pulling edges together
Wound ‘rebuilt’ with new granulation tissue comprised of collagen and extracellular matrix and into which a new network of blood vessels develop (known as angiogenesis)
Proliferation: 1-2 Weeks
Healthy granulation tissue is granular and uneven in texture
does not bleed easily and is pink/red in color
Scar tissue is deposited
Scar is RED, RAISED and RIGID
Epithelial cells finally form on wound surface
a process known as ‘epithelialisation’
Proliferation: 1-2 Weeks
Final phase and occurs once the wound has closed
May take up to 2 years
Dermal tissues enhance their tensile strength
Remodeling or Maturation Phase
Scar tissue matures as collagen disappears
Presents as softened and flattened
Remodeling or Maturation Phase
Non-functional fibroblasts are replaced by functional ones
Remodeling or Maturation Phase
Cellular activity declines with time and the number of blood vessels in the affected area decreases and recede
Even after maturation, wound areas tend to remain up to 20 percent weaker than they initially were
Remodeling or Maturation Phase
Occur suddenly, rather than over time
Heal at a predictable and expected rate, according to the normal wound healing process
acute wounds
Can vary from superficial scratches to deep wounds damaging blood vessels, nerves, muscles, other tissue
Surgical wounds
Traumatic wounds
Abrasion, puncture, laceration, incision
acute wounds
TX: Cleaning with tap water, sterile saline solution, or antiseptic solution twice a day
Most clean open wounds do not require any antibiotics unless the wound is contaminated, or the bacterial cultures are positive
Once cleaned, wound should be covered with moist gauze
followed by application of dry gauze and then the wound covered with a bandage
Simple Laceration Wound Treatment
Wounds less than 12 hours old can be closed with sutures or staples
Wounds more than 24 hours old should be suspected to be contaminated and not closed completely
Simple Laceration Wound Treatment
Removing dead tissue from wounds
Wounds can heal faster
Dead tissue can trap bacteria leading to infections
Bacteria can cause odor
Infection can be life threatening or lead to an amputation
Wound Debridement
Types of Wound Debridement
Autolytic (body’s own healing process to remove tissue – moist dressing)
Enzymatic (chemical enzymes, such as an ointment, to help slough off dead tissue – ointment – can strip healthy tissue away)
Surgical (surgical removal of dead tissue)
Mechanical (wet to dry dressing regularly changed – can strip healthy tissue away)
Maggot (using larvae to remove dead tissue)
OT’s Role in Wound Healing
Wound care
Dressing changes
Removal of stitches
Observation skills to detect possible infection
Manual therapy
Scar management
Scar massage
Develop when any acute wound fails to heal in the expected time frame for that type of wound
Important aspect in caring for wounds is to remove the causing agent
Chronic Wounds
Can be due to lack of one or more of the main requirements for healing
good supply of blood, oxygen and nutrients
clean and infection-free environment
Chronic Wounds
Whether bacterial, fungal or viral, cause of the infection must be treated with the proper medication
Typically have bad odor, pus drainage, debris (dead tissue), and ongoing symptoms of inflammation (fever, pain, redness, hotness and swelling)
Infected wounds
delays healing process or even prevents it
wound area will be pale and cold
may also have decreased hair growth and a weak pulse sensation in the area
Ischemic wounds
excessive exposure to ionizing radiating materials
can weaken the immune system cause damage to exposed tissue
delay the healing time of all wounds
radiation poisioning wounds
surgical incisions made during surgery can progress to chronic wounds
if the blood supply to the surgery area was accidentally damaged
or if wound care was inadequate
Possibly causing infection
surgical wounds
Typically occur at the site of a surgical incision
instead of a clean appearance, the tissue around the incision appears red, hot, and swollen
which can indicate infection or inflammation
surgical wounds
most common type of chronic wound
ulcers
can occur from
Poor delivery of nutrient-rich blood to the lower extremities
Hypertension, atherosclerosis (plugging) and thrombosis (clotting)
Where reduced blood supply leads to an ischemic state
arterial ulcers
Usually involve full thickness skin having a punched-out appearance with smooth edges
Occasionally pain subsides when the legs are lowered below the heart level
In some cases, ischemia (poor circulation to area) is present
arterial ulcers
Account for more than half of ulcer cases, especially in the lower limbs
as associated with deep vein thrombosis, varicose veins and venous hypertension
Venous ulcers can lead to stasis
stoppage or slowdown in the
Venous Ulcers
Skin is usually shiny and smooth with minimal to no hair
superficial, shallow, and irregularly shaped with pain and edema
Sometimes associated with infection or inflammation
Venous Ulcers
Common complication in uncontrolled diabetes mellitus
resulting in impaired immune function, ischemia, neuropathy, which can eventually lead to ulceration
Diabetic Ulcers
Origin can be neuropathic (secondary to nerve damage)
Where the lack of sweat makes the skin dry forming callus (accumulation of dead skin layers).
callused area, mostly on foot, can eventually break down and form an ulcer
Diabetic ulcers can also occur from neuropathy with ischemic origin; where the ulcer area is cool with no pulse
Diabetic Ulcers
Constant pressure and friction resulting from body weight over a localized area for prolonged duration
can lead to breakage of skin and ulceration (also known as bed sores)
Especially on the back and on the ankles and feet
Present with redness that doesn’t go away when pressed upon
Includes itching, blistering, hotness, swelling and discoloration of the area
Pressure Ulcers (also Decubitus Ulcers)
OT’s Role in Preventing Decubitus Ulcers
Frequent position changes – key
Repositioning shifts pressure stress on skin
Shift weight frequently
Lift body weight up
Use specialty reclining wheelchair or seat
Protect bony areas w proper positioning and cushioning
Preventing Decubitus Ulcers – Skin Care
Clean the skin with mild soap and warm water. Gently pat dry.
Use talcum powder to protect skin vulnerable to excess moisture
Apply lotion to dry skin
Change bedding and clothing frequently
Check for buttons on the clothing and wrinkles in the bedding that irritate the skin
Thoroughly inspect skin daily to identify vulnerable areas or early signs of pressure sores
If incontinent, take steps to prevent exposing the skin to moisture and bacteria
If no wound healing, consider factors that effect wound healing:
Wound moisture level Nutrition and hydration status Mobility Pressure, friction and shear Other etiologies that effect wound healing not yet identified
Systemic support
Nutrition and hydration support
Limit medications that impair wound healing: immunosuppressives, chemo
Control systemic conditions affecting wound healing: perfusion, oxygenation and metabolism
Maintain a physiologic local wound environment
Maintain a moist wound bed Eliminate dead space Protect surrounding skin Remove necrotic tissue Manage bioburden (number of bacteria living on a surface) Manage pain Control odor
