wounds and closure Flashcards by Jasmin Maisuria

outermost surface, squamous epithelial cells, devoid of blood vessels and nerve endings
 Provides the cells for new epidermis during wound healing

epidermis

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Thicker, connective tissue to include fibroblasts, macrophages, lymphocytes and mast cells.
Small number of blood vessels and nerve endings

dermis

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hick, dense, fibrous tissue, above muscle, bone, and tendons
 Must be repaired to re-establish supportive function

deep fascia

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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

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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)

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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.

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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

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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

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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

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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

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All layers closed
 Minimal scarring
 Usually preformed in clean or clean contaminated wounds

primary intention wound closure

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 Deep layers closed, superficial layers left open to granulate on their own
 Leaves a wide scar
 Prolonged scar

secondary intention wound closure

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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

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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

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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

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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

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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

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 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

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is clear fluid

serous

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is a combination of blood and serous drainage. The drainage would be thin watery, pale red or
pink in color.

Serosanguineous

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bloody flow.

Sanguineous

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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

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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

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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

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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