wounds and closure Flashcards
outermost surface, squamous epithelial cells, devoid of blood vessels and nerve endings
Provides the cells for new epidermis during wound healing
epidermis
Thicker, connective tissue to include fibroblasts, macrophages, lymphocytes and mast cells.
Small number of blood vessels and nerve endings
dermis
hick, dense, fibrous tissue, above muscle, bone, and tendons
Must be repaired to re-establish supportive function
deep fascia
loose connective tissue, many blood vessels, and nerve endings
Subcutaneous fat is variable depending on the location
Anesthetic spreads easily in this layer
Superficial fascia/Subcutaneous tissue
Lines of cleavage – clefts in the skin that indicate the
direction of orientation of the underlying collagen fibers.
If the wound is disrupted parallel to the long axis of the fibers
re-approximation will occur.
If the wound is disrupted to where the fibers are
perpendicular the wound will gape. Thus greater tension is
required to re-approximate the wound edges.
tension lines (langer lines)
Classification of Wounds
Wounds are classified based on their degree of contamination with bacteria, or foreign
matter or both.
Timing of wound closure is imperative
The chance of wound infection increases with each day that wound closure is delayed.
Generally: wounds that are 6 to 8 hours old are considered clean and eligible for closure
with sutures.
Highly vascular areas such as the face and scalp can be considered for primary closure up
to 24 hours after the injury.
incisions made during
surgical procedures where aseptic
technique is followed.
Without GI, Resp, GU involvement
Likelihood of infection < than 2%
and warrants primary closure
- no inflammation
- no break in sterile technique
- wound primarily closed/not drained
- biliary tract not entered
- potential infection rate 1%-5%
- examples: thyroidectomy, mastectomy, lipoma excision
clean wounds
similar to
clean except GI, Resp, GU
tracts can be involved.
- no inflammation/infection present
- minor break in sterile technique
- aerodigestive or genitourinary tract entered without spillage
- potential infection rate 8%-10%
- examples: simple appendectomy, prostatectomy, cholecystectomy
clean contaminated wound
Similar to clean
and clean contaminated except
there is Gross spillage (blood, bile,
stool).
Traumatic wounds
- acute inflammation present
- major break in sterile technique
- gross spillage/contamination from respiratory, gastrointestinal, biliary, or genitourinary tracts
- potential infection rate 15%-20%
- example: traumatic wounds
contaminated wounds
Established infection before
wound is made or heavily contaminated
wounds
Gross spillage of stool
Incision and drainage of an abscess
- organisms present at surgical site prior to procedure/existing infection
- presence of pus
- perforation (gastrointestinal, biliary, respiratory, genitourinary tract
- potential infection rate 27%-40%
- example: appendiceal abcess, peritonitis
dirty/infected wound
All layers closed
Minimal scarring
Usually preformed in clean or clean contaminated wounds
primary intention wound closure
Deep layers closed, superficial layers left open to granulate on their own
Leaves a wide scar
Prolonged scar
secondary intention wound closure
deep layers primarily closed, superficial left open until reassessment on
the 4th or 5th day after closure at which time the wound is inspected for infection
If clean and granulation occurring the wound is irrigated and closed
If infected, then it is left open to heal by secondary intention
Initially contaminated wounds
third or delayed primary intention wound closure
Factors that affect healing
*Long term conditions such as diabetes or Chronic Obstructive Pulmonary Disease (COPD).
*Medication such as steroids or diuretics.
*Reduction in tissue oxygenation eg peripheral vascular disease, smoking.
*Poor nutritional state.
*Presence of infection.
*Older age.
*Socioeconomic issues affecting care - ability to pay for prescriptions, accessing transport for care
occurs when:
- the edges are clean and held together with ligatures
- there is little gap to bridge healing
healing properties
- occurs quickly
- rapid ingrowth of wound healing cells (macrophages, fibroblasts)
- restoration of the gap by a small amount of scar tissue
- united within 2 weeks
- dense scar tissue is laid down within 1 months
primary intention
occurs when:
- the edges are separated
- the gap can not be directly bridged
- extensive epithelial loss
- severe contamination
- significant sub epithelial tissue damage
healing properties
- occurs slowly
- granulation; healing from the bottom towards the surface
- reservation of the gap by a small amount of scar tissue
- scaring
- wound contracture
secondary intention
wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation
- inflammation –> reduced bacterial concentration (debribe) –> allow safe closure
indications:
- infected or unhealthy wounds with high bacterial content
- wounds with a long time lapse since injury, or
- wounds with a severe crush component with significant tissue devitalization
- wound edges are approximated within 3-4 days
- tensile strength develops as with primary closure
healing by third intention
Assess Drainage
To assess the amount of drainage is to look at the dressing and assess the amount of drainage on the
dressing.
A rule of thumb is: ¼ or less means small or scant, ½ to ¼ is medium and ½ or greater would be
large
is clear fluid
serous
is a combination of blood and serous drainage. The drainage would be thin watery, pale red or
pink in color.
Serosanguineous
bloody flow.
Sanguineous
drainage that is thin or thick and color sometimes yellow or brown. Could be related to type of dressing
being used. Wound is in the inflammatory stage of wound healing, or an indication of infection. If there is a concern
of infection, then silver could be used for a short period of time.
purulent
Chronic venous stasis changes the skin texture and elasticity that results in a brownish
discoloration of the lower legs. This staining occurs when the pressure in the veins causes the red blood cells to
break. When the red blood cells break, they leak out hemoglobin. Hemoglobin contains iron which leaks out into
the tissue and stains the skin. This eventually will lead to a venous stasis ulc
Hemosiderin staining
Warmth, increase in pain, and increase in drainage could be indication of infection. Erythema is also
present with the application and removal of 3 to 4 layer compression dressin
erythema
Indicates that the edges of wound have extra fluid around them. This could be related to fluid
collection or further breakdown of the edges. This is an indication that the wound has backtracked to phase 1, the
inflammatory phase. This could be related to a new trauma or the wound is critically colonized. A silver dressing for
14 days can help to move the wound back to healing. Then return to a regular dressing that will continue the
healing process. Silver dressings should not be the only type used throughout the healing proces
induration
venous blood pools in the extremities with the formation of edema
hemosiderin staining
May be slightly lighter to light pink surrounding, indicating past wounds that have healed recently or
quite some time ago. This would indicate a need for teaching and interventions to prevent future breakdown. Scar
tissue is only 85% as strong as the original tissue
scar tissue
irrigation of wounds
Decreases bacterial load and removing loose material, and should be a part of routine wound management.
Warm, isotonic (normal) saline is typically used; however, systematic reviews have found no significant
differences in rates of infection for tap water compared with saline for wound cleansing.
The addition of dilute iodine or other antiseptic solutions (eg, chlorhexidine and hydrogen peroxide) is generally unnecessary. These solutions have minimal action against bacteria and could potentially impede wound healing through toxic effects on normal tissue.
Low pressure irrigation (eg, <15 pounds per square inch [psi]) is usually adequate to remove material from the surface of most wounds
Strongly bactericidal against Gram – and Gram +
Can be toxic to wound tissues
Painful to open wounds
Hand cleanse
Povidone-iodine surgical scrub
Strongly bactericidal against Gram +
Less strong against Gram –
Can be toxic to wound
Hand cleanser
Alternative wound periphery cleanser
Chlorhexidine
Bacteriostatic action against Gram +
Much less effective against Gram - negative
organisms.
It is mainly used in soaps and creams and is
an ingredient of various preparations used for
skin disorders
Teratogenic with repeated use.
- photosensitivity problem
Hexachlorophene
Very weak antibacterial activity
Toxic to red cells
Wound cleanser adjunct
hydrogen peroxide
Cadexomer iodine (eg, Iodosorb) is an antimicrobial
that reduces bacterial load within the wound and stimulates healing by
providing a moist wound environment.
Cadexomer iodine is bacteriocidal to all gram-positive and gram-negative
bacteria.
For topical preparations, there is some evidence to suggest that Cadexomer
iodine generates higher healing rates than standard care.
iodine based
sterile antimicrobial dressing formulation of
Cadexomer Iodine. When applied to the wound, IODOSORB absorbs
fluids, removing exudate, slough and debris and forming a gel over the
wound surface. As the gel absorbs exudate, iodine is released, killing
bacteria and changing color as the iodine is used up
IODOSORB Gel
Although silver is toxic to bacteria, silver-containing dressings have not demonstrated
significant benefits.
A systematic review evaluating topical silver in infected wounds identified three trials that treated 847
participants with various silver-containing dressings. One trial compared silver-containing foam (Contreet)
with hydrocellular foam (Allevyn) in patients with leg ulcers. The second compared a silver-containing
alginate (Silvercel) with an alginate alone (Algosteril). The third trial compared a silver-containing foam
dressing (Contreet) with best local practice in patients with chronic wounds.
Silver-containing foam dressings were not found to significantly improve ulcer healing at four weeks
compared with non-silver-containing dressings for best local practices. Nevertheless, silver dressings are
used by many clinicians to decrease the heavy bacterial surface contamination [75]
silver based
fine mesh gauze impregnated with petroleum, paraffin wax, or other ointment, and have product names such as Xeroform, Adaptic,
Jelonet, and Sofra Tulle
This initial layer is covered by a secondary dressing of absorbent gauze and padding, then finally a third layer of tape or other method of
adhesive.
Benefits of semi-open dressings include their minimum expense and their ease of application. The main disadvantage of this type of
dressing is that it does not maintain a moisture-rich environment or provide good exudate control
semi open dressing
It is most useful to classify dressings by their
water-retaining abilities because the primary goal of a dressing is
the maintenance of moisture in the wound environment
primarily, gauze, which is typically moistened with saline before placing it into the wound
open dressing
include films, foams, alginates, hydrocolloids, and hydrogels
semi occlusive dressing
Wounds with large soft-tissue defects may have an area
of dead space between the surface of intact healthy skin
and the wound base.
These wounds are described as tunneled or undermined.
Undermining is defined as extension of the wound under
intact skin edges such that the wound measures larger at
its base than is appreciated at the skin surface.
Although, there have been no specific trials comparing
packed vs. non-packed wounds, wound packing is still
considered standard of care.
wound packing
Located right under the wound edges and is
an indication of shear, pulling at the wound bed. Measuring
and record the measurements at each time of the clock.
Example at 12:00-3cm, at 3:00 2cm, at 6:00-3cm, and finally
at 9:00-1cm
undermining
Located in the wound bed and going deeper
into the bed of the wound or to the side of the wound bed.
This indicates infection or unrelieved pressure. Record the
deepest and location on the clock. Example tunnel is 4cm at
6:00
tunneling
materials for wound packing
Many of the materials that are used as topical dressings
for wounds (foams, alginates, hydrogels) can be molded
into the shape of the wound and are useful for wound
packing
wound dressings
Wound dressing changes associated with large defects
can be managed without repeated applications of tape to
the skin by using Montgomery straps.
Anatomic Wound location
Note the exact location of the wound, not the general locations such as hip or buttock.
Include the following information for wound location:
Superior - above a wound or anatomic location
Inferior - below a wound or anatomic location,
Lateral - outside part of the body
Medial - toward the middle part of the body
Anterior -front part of the body
Posterior - back part of the body
The most common method of measurement is the Clock Method
In which the wound is considered as a face of clock. The position of the
wound is based on standard anatomical positioning of the patient (arms down
by the side, palms facing anteriorally, with thumbs facing away from the
body), the head being 12:00, the feet at 6:00. Note: on the foot, the heels are
at 12:00 and the toes are at 6:00.
When describing and documenting undermined wounds, it is important to accurately measure:
Depth of undermining in centimeters
Location of undermining using clock formation as a guide (12:00, 6:00, etc.).
The presence of necrotic tissue indicates the need for surgical debridement to decrease
bacterial burden and prevent sequelae of infection.
Side to side to include time on the clock if not at the exact 3:00 and
9:00 parts of the clock. Example: the wound width measured at 4:00 to 10:00 is 10cm
width
head to toe to include time on the clock. If not at the exact 12:00
and 6:00 parts of the clock. Example: The wound length is measured from
1:00 to 7:00 and is 5cm.
length
Distance from the skin’s surface to the bottom of the wound.
depth
Clostridium tetani
Preventable
Trismus, neck rigidity, dysphagia and severe uncontrolled reflex spasms.
At risk
Elderly – waning immunity
Immunocompromised
IV drug users
Reluctant to seek health care
tetanus
Greater than 6hrs old
>1cm deep
Stellate or have an avulsion configuration
Associated with devitalized tissue
Contaminated with feces, soil or saliva
Gunshot wound
Puncture or crush injury
Associated with a burn or frostbite
tetanus prone wounds
Tetanus Immunizations
DTaP vaccine is routinely recommended in children, with a single booster dose of a vaccine containing tetanus
toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) recommended for 11- to 12-year-olds.
Followed by tetanus toxoid and the reduced diphtheria toxoid in the form of Td recommended at 10-year intervals
throughout life.
Clean minor wounds: who have received three or more doses of a tetanus toxoid-containing vaccine, another dose
should be given only
if the last dose was given 10 or more years ago
The vaccine series should be continued through completion as necessary. If there is any doubt about whether or not
an adult received the primary serie
three doses of Td should be administered; the first dose and second dose
should be separated by four weeks and the third dose should be given 6 to 12 months lat
Wounds that are more severe than a clean and minor wound (such as, but not limited to, wounds contaminated with
dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite )
who have received three or more doses of a tetanus toxoid-containing vaccine, another dose should be given
only if
the last dose was given five or more years ago
A “localized damage to the skin and/or underlying soft tissue
usually over a bony prominence or related to a medical or other device.
The injury can present as intact skin or an open ulcer and may be painful. The
injury occurs as a result of intense and/or prolonged pressure or pressure in
combination with shear.
The tolerance of soft tissue for pressure and shear may also be affected by
microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue
pressure injury
the best way to assess the patient and the potential risks of
developing a pressure ulcer.
It is a summary rating scale made up of six subscales.
the Braden scale
Non-blanchable erythema of intact skin - Intact
skin with a localized area of “non-blanchable
erythema, which may appear differently in
darkly pigmented skin.
Color changes do not include purple or
maroon discoloration; these may indicate deep
tissue pressure injury”.
The area may be painful, firm, soft, warmer or
cooler as compared to adjacent tissues
Pressure Injury Stage 1
Partial thickness
skin loss with exposed dermis –
The wound bed is “viable, pink or red, moist,
and may also present as an intact or ruptured
serum-filled blister.
Adipose (fat) is not visible and deeper tissues
are not visible. Granulation tissue, slough
and eschar are not present.
These injuries commonly result from adverse
microclimate and shear in the skin over the
pelvis and shear in the heel
pressure injury stage 2
Full thickness skin loss - Full-
thickness loss of skin, in which “adipose (fat) is
visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often
present.
Slough and/or eschar may be visible. The
depth of tissue damage varies by anatomical
location; areas of significant adiposity can
develop deep wounds. Undermining and
tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage
and/or bone are not exposed.
stage 3 pressure injury
Full thickness skin and tissue
loss - Full-thickness skin and
tissue loss with “exposed or
directly palpable fascia, muscle,
tendon, ligament, cartilage or
bone in the ulcer. Slough and/or
eschar may be visible.
Epibole (rolled edges),
undermining and/or tunneling
often occur.
Depth varies by anatomical
location
stage 4
Incision and Drainage - I&D
Indications
localized collection of infection that is tender and no resolving
spontaneously.
Cardinal signs include infection, pain, fever, redness, swelling and loss of
function
I & D Contraindications
Facial furuncles within the triangle of the nose or corners of the mouth
Abscesses in or near the rectum or genitalia
Pt’s w/diabetes, debilitating disease, immunocompromised
I & D Complications
Cellulitis
Chronic fistula
Deep infection
causative agents of I&D
Staph ****
Strep
focal circumscribed accumulation of purulent materials
abccess
one that resolves without rupture
dry abscess
Sweat gland or hair follicle
furuncle or boil
When a furuncle extends into the sub tissue
carbuncle
abscess of the nail
parenychia
Perifollicular abscesses are commonly found on the
the extremities, buttocks, breasts
or in hair follicles
therapy for I&D
Warm compresses
Antibiotics
Drainage
I&D Patient Prep
Risk, Benefit, Consent
Materials Needed for I&D
Alcohol or iodine prep
1% or 2% lidocaine w/o epi
19-22 gauge needle
No 11 or 15 scalpel blade
Scalpel handle
Kelly clamp
Adson’s forcep
Curved hemostat
Gauze
Sterile Gloves
Normal saline
¼ to ½ inch packing Nu-Gauze
Scissors
Dressings
I&D procedure
Field Block anesthetic – 1cm away from abscess
Drape – isolate the area and gives yourself a sterile field
Make the incision along the Langers lines to reduce scarring
Open the abscess widely
Obtain a specimen – as soon as the purulent material is exposed (from the cavity not the surrounding tissue)
Explore the abscess cavity with a sterile tipped cotton applicator
Thoroughly irrigate the cavity
Insert iodoform gauze into the abscess cavity with 1cm of gauze exiting the cavity.
Apply a sterile dressings over the site
Wound is packed twice a day until healthy closure occurs
2 purposes
Prevents the incision from sealing over
Provides for adequate drainage
Removed and inserted every 12-24hrs
Healing will progress from the inside out. This reduces the chance of recurrence
Iodoform Gauze
