Wounds, wound healing and wound management (DONE)

Question 1

Normal skin

Answer 1

A complex multi-layered organ of continuous epithelium that:
Regulates water and temperature
Responds to UV
Limits ingress of chemicals
Prevents invasion by microorganisms

Question 2

What is a wound?

Answer 2

Discontinuity of epithelium barrier
Typically refers to the skin, can include contiguous tissues e.g. lips, anus
Can be caused by trauma, injury or infection
Usually deep enough to rupture microcirculation in skin
With or without loss of underlying tissues or organs

Question 3

Why is it important for a pharmacist to know about wounds?

Answer 3

Increasing encouragement for patients to consult pharmacist prior to booking a GP appointment, which can be up to 2 weeks
Must be able to spot potentially severe cases, in relation to:
Discuss professionally with GP or A+E
For less serious cases, must be able to recommend, from a wide variety of products, the most appropriate treatment, and provide advice on bandages/stockings

Question 4

Why is a wound bad?

Answer 4

Loss of blood and exudate
Pain
Shock
Ingress of microbes
Can lead to contamination or infection- systemic infection (septicaemia)

Question 5

Skin microbiota

Answer 5

The microorganisms (flora) which reside on the skin
Up to 1000 species on human skin from 19 phyla
Most are found in the superficial layers of the epidermis and the upper parts of hair follicles

Question 6

Types of skin flora

Answer 6

Skin flora is usually non-pathogenic and either commensal or mutualistic
Bacteria, fungi and viruses can cause skin diseases and enter the blood system, creating life-threatening diseases, particularly in immunosuppressed people
Wounds therefore provide convenient entry point for opportunistic microorganisms

Question 7

Wound classification

Answer 7

Clean wound- made under sterile condition, no organisms present, likely to heal without complications
Contaminated wound- result of accidental injury, pathogenic organisms and foreign bodies in wound
Infected wound- pathogenic organisms present and multiplying, showing clinical signs of infection, yellow, oozing pus, having pain, redness
Colonized wound- chronic, number of organisms present, very difficult to heal e.g. pressure sore

Question 8

Abrasion

Answer 8

Often referred to as a graze
Occurs after skin rubs against hard surface, often contains foreign particles
Usually superficial
Friction scrapes away the epithelium, exposing epidermal or dermal layers
Bleeding low to moderate

Question 9

Incision

Answer 9

Precise, regular wound caused by intended blunt trauma using a sharp edged object e.g. scalpel
Surgical incision is a cut made through the skin to facilitate an operation or procedure, in general made as small and unobtrusive as possible to facilitate safe and timely operating conditions

Question 10

Laceration

Answer 10

Imprecise tear-like wounds caused by blunt trauma and a sharp edge e.g. broken glass
Usually irregular edge
Most lacerations affect only the upper layers of the skin and subcutaneous tissues
permanent damage may occur if there is injury to internal structures such as muscles, tendons, blood vessels or nerves
Significant/profuse bleeding

Question 11

Avulsion

Answer 11

Skin is forcibly detached or torn from tis normal point of insertion by either trauma or surgery
Commonly refers to a surface trauma where all layers of the skin have been torn away, exposing the underlying structures
Involves partial or full detached from the body

Question 12

Puncture

Answer 12

Penetration of skin by sharp pointed object to create small hole e.g. nail, pin, needle
A puncture wound does not usually cause excessive bleeding
Often the wound seems to close almost instantly- hard to locate
Can still be a risk of infection
Surgical punctures- intentional, vary from superficial to deep, presumed sanitised

Question 13

Penetration/perforation

Answer 13

An object pierces the skin and enters subcutaneous tissue of the body, creating an open wound
Object may remain in the tissues, come back out the way it entered, or pass through the tissues and exit via another area
Perforation- where an object enters the body and passes all the way through

Question 14

Penetration with envenomation

Answer 14

Envenomation is the process by which venom is injected into an animal by the bite of a predator- a penetration wound
Necrosis or death may occur as a result of bites or stings
Most venoms are administered by biting the skin of the victim

Question 15

Symptoms of anaphylaxis

Answer 15

Loss of consciousness
Hives
Swelling of tongue, inability to swallow
Rapid swelling of throat tissues

Question 16

Haematoma

Answer 16

Haematomas (blood tumour) caused by damage to a blood vessel that in turn causes blood to collect under the skin
Haematomas that originate from internal blood vessel pathology are petechiae, purpura and ecchymosis

Question 17

Contusion

Answer 17

Blunt trauma causing damage to subsurface tissue without the skin being broken, more commonly referred to as a bruise
Eye contusion- black eye
Some claim to get relief from products containing arnica

Question 18

Blister

Answer 18

A pocket of plasma or pus between epidermis and dermis

Typically caused by forceful rubbing, burning, freezing, chemical exposure or infection

Question 19

Hemidesmosomes

Answer 19

In skin as well as in other complex epithelia, multi-protein complexes called hemidesmosomes are involved in promoting the adhesion of epithelial cells to the underlying basement membrane
These are weak structures compared to desmosomes
Break down to allow ingress of fluid and create blister

Question 20

Burns

Answer 20

A burn is a thermal injury to the skin caused by heat, cold, electricity, friction, chemical or physical agents
Usually defined in terms of burn depth

Question 21

Pressure ulcer/pressure sore

Answer 21

Pressure ulcers are injuries that break down the skin and underlying tissue
They are caused when an area of skin is placed under pressure
They are sometimes known as bedsores or pressure sores
pressure ulcers range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle

Question 22

Decubitis

Answer 22

Degenerative change to microcirculation caused by the influence of compression and shear forces

Question 23

How do pressure ulcers develop?

Answer 23

Pressure ulcers can developwhen: large amount of pressure of applied to an area of skin over a short time; less pressure is applied over a longer period of time
The extra pressure disrupts the flow of blood through the skin
Without a blood supply, the affected skin becomes starved of oxygen and nutrients, and begins to break down, leading to ulcer formation

Question 24

Pressure points

Answer 24

About 500,000 people in the UK will develop at least one pressure ulcer in any given year. this is usually people with an underlying health condition.
People over 70 years old are particularly vulnerable to pressure ulcers, as they are more likely to have mobility problems and ageing skin

Question 25

Treatment for pressure ulcers

Answer 25

Includes alleviation of decubitus, the use of dressings, creams and gels designed to speed up the healing process and relieve pressure. Surgery is sometimes recommended for the most serious cases. For some people, pressure ulcers are an inconvenience that require minor nursing care. For others, they can be serious and lead to life threatening complications, such as infection, blood poisoning or gangrene

Question 26

Venous ulcers

Answer 26

Occur due to improper functioning of venous valves, usually of the legs, blood flow against gravity They are the major occurrence of chronic wounds, occurring in 70% to 90% of leg ulcer cases Develop mostly along the medial distal leg, and can be very painful

Question 27

Diabetic foot ulcer

Answer 27

Major complication of diabetes mellitus, and the major component of the diabetic foot Key feature of wound healing is stepwise repair of lost extracellular matrix that forms the largest component of the dermal skin layer Prolonged inflammatory phase which causes a delay in the formation of mature granulation tissue and a parallel reduction in wound tensile strength

Question 28

Why do wounds get infected?

Answer 28

An open wound is an open invitation for ingress of microorganisms, which proliferate in the nutrient-rich environment Open wounds become infected 24-72hours after the initial break in the skin

Question 29

Symptoms of infection

Answer 29

Pus or cloudy fluid draining from the wound Scab has got bigger Redness around the wound is worse More pain or selling 48 hours after the injury Fever Wound doesn't look like its healing

Question 30

Gangrene

Answer 30

Necrotic tissue can accumulate in chronic wounds Dead tissue which usually results from an inadequate local blood supply Contains dead cells and debris that are a consequence of the fragmentation of dying cells Characteristic black colour Potentially life-threatening condition may occur after an injury or infection, or in people suffering from any chronic health problem

Question 31

What is wound healing?

Answer 31

It is a dynamic process that starts immediately after trauma or injury Purpose to restore continuity between edges of wound and re-establish the function of the tissue after trauma Three major overlapping phases: inflammation, proliferation, maturation Not a linear process and reversal is possible, intrinsic and extrinsic factors influence rate of healing

Question 32

Inflammation

Answer 32

Coagulation is the first response to a new wound, lasting about 6-10 minutes: localised vasoconstriction, clot formation, control of blood loss Blood clot showing three components- platelets, fibrin and red blood cells via clotting cascade

Question 33

Prolonged bleeding

Answer 33

If patient presents with prolonged bleeding > 20 minutes: consider magnitude of wound, efforts to staunch the flow of blood, consider any drug therapy esp. anticoagulants Heparin and warfarin: DVT, PE, MI and angina

Question 34

Wound exudate

Answer 34

Exudate is the watery fluid that seeps out of a wound Early exudate: similar to ISF, able to leak to the surface when there is an injury involving the tissues of the dermis Composed mainly of water, with electrolytes, nutrients and waste products; also white blood cells, inflammatory mediators, growth factors and enzymes

Question 35

Cellular exudate

Answer 35

Contains matrix metalloproteases (MMPs), can contribute to breakdown of dead and devitalised tissue, other components contribute to building new tissue Predominant cells at work are phagocytic: leukocytes migrate to area, followed by monocytes ad macrophages

Question 36

Why is inflammation an essential part of the process?

Answer 36

Localised erythema- increased blood flow to area (vasodilation) Increased heat- metabolic reactions (warm blood sent to area) Oedema- inflammatory exudate flows from dilated blood vessels into tissue spaces, swells if no exit Tenderness- caused by pressure as a result of increased fluid in tissue spaces, nerve damage or chemical reaction to wounding

Question 37

Proliferation

Answer 37

Rebuilding phase, characterised by formation of granulation tissue, wound contraction and epithelialisation Granulation tissue is a fragile mixture of proteins and polysaccharides linked together with collagens to form a highly vascular gel-like matrix with a characteristic re appearance Starts 3-4 days post injury, lasts up to 21 days Granulating wounds must be kept warm and moist- facilitates epithelial migration

Question 38

Healthy granulation tissue

Answer 38

Red and does not bleed unless trauma occurs Granulation tissue is laid down in wound bed and comprises collagen and extracellular matrix, into which new blood vessels grow (angiogenesis) Fibroblasts secrete collagen, healthy granulation depends on fibroblasts having sufficient oxygen and nutrients

Question 39

Maturation

Answer 39

Begins round day 21, after wound closure Cellular activity reduces, but macrophages continue to be key cells assisting in weaving collagen fibres into a tight pattern Wound contraction is an important part of secondary wound healing, begins around fifth day and overlaps proliferative and maturation stages

Question 40

Scab

Answer 40

Protective brown, dehydrated clot of platelets, white blood cells held in place with fibrin Scabs itch as a by-product of the regenerative process Picking must be discouraged- if a scab is prematurely removed, scar tissue may form there that wouldn't otherwise exist for such a shallow cut

Question 41

Scar

Answer 41

The end product of wound healing- areas of fibrous tissue With the exception of very minor lesions, every wound results in some degree of scarring Scar tissue is composed of collagen, which cross links and forms a pronounced alignment in a single direction

Question 42

Chronic wounds

Answer 42

Wounds that fail to progress through an orderly and timely sequence of repair, associated with delayed healing and re-occurrence Stuck in between inflammation and proliferation stages Faster healing, odour control and exudate management important in chronic wound care

Question 43

Matrix Metalloproteins

Answer 43

Chronic wounds contain increased levels of inflammatory cells and elevated levels of proteases MMPs are important in breaking down protein so that new tissue forms, but if the levels in the wound are too high, this can delay healing

Question 44

Wound bioburden

Answer 44

Sum of microorganisms present Some microflora are unavoidable in wounds, but a wound infection arises when one or more specie of microorganism successfully colonises the nutrient rich environment

Question 45

Biofilm

Answer 45

A group of microorganisms in which cells stick to each other, and often these cells adhere to a surface, embedded within a self-produced matrix of extra-cellular polymeric substance Thought to greatly enhance the tolerance of microbes embedded in the extracellular matrix

Question 46

Wound debridement

Answer 46

the process of removing non-living tissue from pressure ulcers, burns and other wounds Speeds the healing process Necrotic tissue may become colonized with biofilm, producing an unpleasant odour Though the wound is not necessarily infected, the bacteria can cause inflammation and strain the body's ability to fight infection

Question 47

Methods of debridement

Answer 47

Surgical- scalpel/scissors to cut dead tissue from wound, quick and efficient Mechanical- moist dressing dries to dead tissue, remove dressing and dead tissue, can be very painful Chemical- enzymes to dissolve necrotic tissue, selective Autolytic- body's own ability to dissolve dead tissue, slow Maggots- larvae of greenbottle fly, proteolytic enzymes in saliva digest necrotic tissue

Question 48

Antibiotic resistant infections

Answer 48

Until recently, wounds infected with pseudomonas responded well to antibiotics such as ciprofloxacin, increasing cases that don't respond Many patients now treated with potassium permanganate- strong oxidising agent

Question 49

Main considerations of wound management

Answer 49

Cleansing/disinfection- bioburden reduction | Dressing- protect impact, microbe ingress, retain moisture

Question 50

Antihaemorrhagics

Answer 50

Bleeding normally ceases within 6 minutes, send to A&E immediately if drug therapy is believed responsible A styptic is a special type of antihaemorrhagic that works by contracting tissue to seal injured blood vessels Systemic- these include antifibrinolytics, vitamin K, fibrinogen and blood coagulation factors

Question 51

Topical antihaemorrhagics

Answer 51

Microfibrillar collagen haemostat-attracts platelets and allows for the formation of a blood clot when it comes into contact with blood Chitosan haemostat- composed of chitosan and its salts which bonds with platelets and red blood cells to form a gel-like clot which seals a bleeding vessel Styptics pencils contain anhydrous aluminium sulphate, acts as a vasoconstrictor

Question 52

Common topical antiseptics

Answer 52

Germolene- thick antiseptic cream with distinctive pink colour and scented with oil of wintergreen Savlon is a smooth, white homogenous cream with an antiseptic odour Povidone iodine is a brown powder used as a broad spectrum antiseptic for external application, not for thyroid patients

Question 53

Hydrogen peroxide

Answer 53

Commonly used as a wound antiseptic solution At 3% it demonstrates broad spectrum efficacy Sometimes preferred as colourless so leaves no residue Greatest activity towards gram positive bacteria, but the presence of catalase in these bacteria makes dilutions below 3% less effective

Question 54

Dettol

Answer 54

Comprised of micellar chloroxylenol Can be used for gentle antiseptic wound cleansing and disinfection, antiseptic skin cleansing and as a disinfectant around the home Use diluted (1 in 20) for antiseptic wound cleansing for cuts, grazes, bites and stings

Question 55

Wound dressings

Answer 55

Facilitate the body's natural healing process and provide an optimal healing environment Considerations: wound aetiology, location, acute or chronic, method of closure, phase of healing, infective status, pain status, objectives etc.

Question 56

Primary closure dressings

Answer 56

Wound usually left covered until exudate or superficial bleeding has stopped Suitable dressing would be a non-adherent island dressing or a semi-permeable adhesive film used as a secondary dressing with a non adhesive or absorbent pad Where the objective is to observe and protect the wound without the need to manage bleeding or exudate, a semi-permeable film could be used alone

Question 57

Tapes and plasters

Answer 57

Used to cover simple wounds or to secure another dressing or bandage Be aware of allergies to adhesive A tape alone does not provide complete protection May not be waterproof, consider patient lifestyle

Question 58

Secondary intention healing

Answer 58

A superficial wound may be suitable for a semi-permeable adhesive film dressing applied as a primary or secondary dressing Depending on the wound assessment, size and depth, alternatives would be hydrogel, alginate, hydrocolloid or foam dressings Negative Pressure Wound Therapy should also be considered to promote faster healing or move chronic wounds from a static to an active healing phase In infected wounds, antimicrobial dressing should be considered such as honey, iodine or silver preparations

Question 59

Proliferation phase

Answer 59

Hydrogels: ideally fro dry wounds, able to re-hydrate, sheets or gel, needs secondary dressing, provides moist environment Foam dressings: not for dry wounds, last up to 7 days, sheets, island dressing and cavity fillers Protease modulators: prolongs inflammatory phase and delays granulation to promote healing, consider for chronic wounds

Question 60

Hydrocolloids

Answer 60

Provide a benchmark for modern dressings, suitable for clean granulating or sloughy/necrotic wounds with low to moderate exudate level Contain gel forming agents, combined with elastomers and adhesives to form absorbent waterproof barrier

Question 61

Alginate dressings

Answer 61

Exudate is needed to allow fibre to gel and produce a moist healing environment, suitable for wounds with moderate to high level of exudate, some have haemostatic properties

Question 62

Negative Pressure Wound Therapy

Answer 62

Increasingly used in the treatment of chronic wounds and to enhance healing of first and second degree burns Therapy involves the controlled application of vacuum to the local wound environment, using a sealed wound dressing connected to a vacuum pump

Question 63

Dressings: maturation phase

Answer 63

No dressings should be required at this stage of healing, unless very fragile and needs protection or management of scar tissue required In chronic venous leg ulcers, compression hosiery should continue to be used after the ulcer has healed

Question 64

Wound contact layers

Answer 64

Can be divided into simple low adherent dressing, and more advanced dressing which link into concept of moist wound healing Choice indicated by level of exudate, stage of healing, wound type, pain level, length of dressing life Simple contact layers effective for venous leg ulcers when used under compression bandages

Question 65

Bandage types

Answer 65

Retention- used to secure a dressing, medical device or splint Support- provides support and light compression Compression- used to assist venous return tot he heart Medicated- dual benefit of protecting the wound and providing activity against bioburden

Question 66

Silver dressings

Answer 66

Widely used to assist with management of infected wounds by controlling the bioburden Sustained release of positively charged ionic silver binds to negatively charged components in proteins and nucleic acids

Question 67

Honey dressings

Answer 67

Recognised for its antibacterial activity since ancient times- osmotic antimicrobial Manuka honey is a monofloral honey produced in Australia and New Zealand, contains high levels of methylgloxal

Question 68

Hosiery

Answer 68

A variety of compression hosiery is available- class 1 light, class 2 medium, class 3 strong Comes in standard fittings or made to meaure Cohesive- easier to apply than tubular Can be difficult to apply especially if patient is elderly or has medical conditions such as arthritis