Wounds/Burns

Question 1

Phases of Wound Healing

Answer 1

Hemostasis, Phase 1: inflammatory, phase 2: proliferative, phase 3: maturation; all overlap and should follow a standard timeline

Question 2

Hemostasis

Answer 2

Vasoconstriction following skin injury to stop bleeding, platelet aggregation, growth factors are stimulated to begin healing

Question 3

Inflammatory Phase

Answer 3

Occurs within 24hrs and continues for several days, fluid flows from capillaries, caused by enzymes and other cells, vasodilation caused by histamine and leukotrienes, phase involves neutrophils and macrophages

Question 4

Proliferation phase

Answer 4

Fibroblasts begin to move into area to regenerate tissue, neovascularization and granulation tissue formed, re-epithelialization occurs as the keratinocytes migrate to cover the wound

Question 5

Maturation

Answer 5

After wound is healed, protein degradation and collagen rearrangement, redness swelling ichy, lasts 6 mo to 2 years

Question 6

Acute Vs Chronic

Answer 6

Acute wounds are uncomplicated, orderly, and rapidly healing; chronic wounds have prolonged healing and deviate from expected sequence of repair

Question 7

Why arent they healing normal?

Answer 7

Look for infection, too much or too little moisture, deabris or necrotic tissue, too much heat or cold, another reason (comorbities)

Question 8

Comorbities

Answer 8

Age, mechanical stress (walking on wound), behavioral problems (smoking), circulation problems, sensation problems, lack of nutrition, medications impeding healing

Question 9

Aging

Answer 9

Cellular turnover decreased, decreased dermal vasculature thus thinner skin, impaired collagen and protein synthesis, decreased calories = decreased collagen, decreased sweat glands and oil glands causing dry skin, pain perception decreased, other comorbidities from old age

Question 10

Behavior

Answer 10

Alcohol abuse - usually malnutrition, less likely to seek medical attentionl; Smoking - vasoconstriction, increased clot, decreased O2; Noncompliance with meds or controlling blood sugar

Question 11

Circulatory Disease

Answer 11

Arterial insufficiency: decreased blood flow to area, ischemia, tissue death, usually distal; Venous sufficiency: decreased ability to pump blood out of extremities, edema resulting in wounds from leaking fluid, usually medial extremities bc less blood flow medial than lateral

Question 12

Decreased Sensation

Answer 12

Diabetes: elevated glucose leads to neuropathy, decreases all phases of wound healing, common on bottom of foot; Spinal cord injuries: nerve injury causing loss of sensation

Question 13

Big no no for weight bearing

Answer 13

Should not bear weight on a wound, should not perform non weight bearing on unaffcted foot of a diabetic this could lead to problems with skin breakdown and breakdown of foot biomechanics. May need to think of ways to safely off load the wounded foot but keep the patient mobile

Question 14

Burn injury

Answer 14

Healed skin is only 80% as strong as original, deeper the burn the more scarring, scarring is based on genetics and outside forcee, age when burned impacts healing (younger burn victims may require more surgery bc scars do not grow with skin)

Question 15

Burn Injury Types

Answer 15

Thermal, Chemical, Friction, Electrical, Radiation

Question 16

Pathophysiology of thermal burn injury

Answer 16

30% have systemic inflammatory response: results in dehydration and hypovolemia which affects oxygen transport and can arrest blood flow, decreased pulmonary function, decreased bacteiral killing function, BMR increases, burn shock can occur

Question 17

Metabolic Rate and Burns

Answer 17

Resting metabolic rate reaches astronomical levels depending on the size of the burn, burns exceeding 40% TBSA increases RMR 2 fold, negative effects at the cellular and systemic level, not just wound but the heart liver muscles and immune system negatively impacted

Question 18

what gets secreted

Answer 18

ceatecholamine, cortisol, glucagon, dopamine which trigger a series of events that lead to hypermetabolic response

Question 19

Donald Jackson 3 zones

Answer 19

zone of coagulation: irreversible damage of tissues, zone of stasis: adjacent to above zone, moderate degree of damage with vascular leakage, zone of hyperemia: increased blood supply with healthy tissue

Question 20

Electrical burn

Answer 20

body converts electricity to heat, blood nerves and vessels have low resistance making electricity easier to travel inside the body causing major damage. Rhabdo form major muscle damage, electricity can cause defib and arrhythmias

Question 21

Chemical burns

Answer 21

PH immediately checked to determine if alkali or acid; Alcohol - causes least injury with de-epithelialization; acid - usually dcauses tissue coagulation and shrinking of collagen fibers, coagulation prevents acid from penetrating further; alkalis: cause changes in the fat (liqueficatoin necrosis) along with shrinking of collagen tissue fibers allowing further penetration and alkali into deeper tissues (worst because the damage is ongoing, more rapid and deeper advancement)

Question 22

Treatment (autograft, homograft, allograft)

Answer 22

Autografting: taking skin from your own body and putting it on the burned area, permanent (split skin thickness skin graft, sheet graft, cultured skin); Homografting: cadaver skin, temporary cover, for large burns, allows donor sites to heal for more harvesting; Allografting: fish skin, pig skin, temporary cover, for large burns, fish skin shown to enhance wound healing

Question 23

Hypertrophic Scarring

Answer 23

raised and rigid, hyper pigmented, can limit ROM, darker skin types more likely to scar

Question 24

Keloid Scarring

Answer 24

Excessive growth of scar tissue, hard benign growth, darker skins more likely to scar

Question 25

Standard of care for burn treatments

Answer 25

begin positioning in anatomical position as soon as possible, boots and splints, begin ROM quickly, immobilization due to grafting (typically 4-6 days after autografting, strength training quickly due to high metabolism and loss of muscle, know where tendons are and take care to minimize forces during ROM, older you are the lower life expectancy (closer to 140, higher likelihood of death), get patients to walk and up

Question 26

Contraindications to exercise or ambulation when you have a wound

Answer 26

Wound on foot, NWB should be tried; special shoes to off load area of wound; wound on achilles tendon and it is exposed, no forceful ROM as this could tear tendon; heterotrophic ossification: no passive motion, pain is the guid (mostly in burn patients)

Question 27

Goal and plan for wound care

Answer 27

Debridement: remove the obstacles; cleaning, modalities to improve circulation, topicals to prevent and treat infections, protection: various dressing to protect infection and facilitate healing

Question 28

Pulsed Lavage

Answer 28

Delivery of a liquid agent such as saline under about 5-15psi which breaks up bacteria to the wound bed. Applies a negative pressure during the suction aspect

Question 29

Electical Stimulation

Answer 29

Improves blood flow, transfers energy to the wound, treat infected wounds

Question 30

Mist Therapy

Answer 30

Uses sterile saline claims to disrupt and remove bacteria

Question 31

Oxygen therapy

Answer 31

increases O2. Studies show tha tmost non-healing of wounds is secondary to tissue hypoxia (increased edema, increased ischemia, increased infection)

Question 32

Negative pressure wound therapy

Answer 32

Suction that removes excess fluid allowing for enhanced circulation and disposal of cellualr waste

Question 33

Debridement

Answer 33

removal of dead tissue to decrease potential infection and allow healing (scalpel, forceps, scissors, curette, maggots)

Question 34

Maggot therapy

Answer 34

larvae ingect necrotic tissue, throught to be antimicrobial bc the larvae secrete ammonia which raises wound PH, larvae also ingest bacteria

Question 35

Arterial wounds

Answer 35

Decreased blood flow
ischemia and tissue death (necrosis)
Amputation

Question 36

Venous wounds

Answer 36

Edema resulting in wound from leaking fluid

Decreased ability to pump blood

usually medial extremities bc less blood flow medial than lateral

Question 37

Areas of risk for pressure injury

Answer 37

Elbow, back of head and ears, inner knee, greater trochanter, shoulder, lower back and glutes, hip, heel