Wound Management
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Wound Management
Wound Types
Traumatic
Non-Traumatic Pressure Sores Surgical
Skin Disorder Diabetic wounds Infection
Malignant Vascular lesion Burns
Wound Definition Wound is defined as disruption of anatomic or functional continuity of living tissues & is the product of integrated response
Wound Definition A wound is a physical trauma where the skin is torn, cut or punctured. a wound is considered as minor when it is: superficial; away from natural orifices; there is only a minor bleeding; it was not caused by a tool or an animal. Any other wound should be considered as severe.
Wound Development: Physiology of capillary Flow A. Forces moving the fluid outward from capillary bed*Mean Functional Capillary Pressure =17.0mm of Hg. *Negative Interstitial Pressure =7.0mm of =28.5mm of Hg. Hg. *Interstitial fluid colloid osmotic Pressure of Hg the Fluid Inward from capillary B.=4.5mm Forces Moving bed* Plasma colloid osmotic Pressure = 28.5mm of Hg.
= 0.5mm of Hg.
e above factors are responsible Net Outward Pressure=for A-Bflow of fluid in the capillar
Wound Development
By the process of diffusion nutrients and oxygen are delivered to the tissues from the capillaries; during which small amount of fluid enters in to the surrounding interstitial spaces. This is done by net outward pressure of 0.5mm of Hg.
Wound Development
Subsequently, lymphatic system returns this fluid back in to the venous system. Venous system is easily impeded by external pressure due to small differential pressure, which depends upon near total relief of pressure at frequent intervals to avert anoxia.
Pressure sore Development
When pressure over a given part of the body exceeds the capillary pressure at venous end, the blood flow to the tissue stops; the tissue becomes anoxic due to lack of oxygen supply; and if anoxia persists, necrosis sets-in. The whole process takes 1-6hrs based on combination of factors.
Pressure sore Development
Erythema
BlistersBlister Rupture Necrosis
Eschar Formation
Pressure sore Development Mechanism of Formation
Pressure Friction by rubbing against bed sheet, cast, brace, etc., or Prolonged exposure to cold. Any area of tissue that lies just over a bone is more likely to develop a decubitus ulcer. These areas include the spine, coccyx or tailbone, hips, heels, and elbows.
Pressure sore Development Person's body weight presses on the bone, the bone presses on the tissue and skin that cover it, and the tissue is trapped between the bone structure and bed or wheelchair surface. The tissue begins to decay due to lack of blood circulation & formation of decubitus ulcer sets in.
Stages of Wounds Wounds are categorized according to severity by the use of stages. The staging system applies to burn wounds, Decubitus ulcers and several other types of wounds.
Stage I This stage is characterized by • Skin is unbroken and wound is superficial • Would be a light sunburn or a first degree burn as well as a beginning Decubitus ulcer • Burn heals spontaneously or the Decubitus ulcer quickly fades when pressure is relieved on the area.
Key factors to consider in Stage I wound o Cause of wound and methods to alleviate pressure on wound area to prevent it from worsening. o Improve nutritional status of individual to prevent wound worsening. o Note: The presence of Stage I wound is an indication or early warning of a problem and a signal to take preventive action.
Stage-1: Treatment • Alleviating pressure and avoiding more exposure to the cause of the injury by covering, protecting, and cushioning the area. • An increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of prevention.
Stage II
This stage is characterized by • a blister either broken or unbroken. • partial layer of the skin is now injured. • Involvement is no longer superficial.
Stage II: Treatment o Goal of care is to cover, protect, and clean the area. o Coverings designed to insulate and absorb as well as protect are used. Additional padding and protective substances used to decrease the pressure on the area o Skin lotions or emollients used to hydrate surrounding tissues oClose attention to prevention, protection, nutrition, and hydration is important
Stage III Wound extends through all of the layers of the skin. Primary site for a serious infection to occur. The goals and treatments of alleviating pressure and covering and protecting the wound still apply as well as an increased emphasis on nutrition and hydration. Medical care is necessary to promote healing and to treat and prevent infection.
Stage IV Wound extends through the skin and involves underlying muscle, tendons and bone. Diameter of the wound is not as important as the depth. Very serious and can produce life threatening infection, if not aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure on the area still apply. Nutrition and hydration is now critical. Without adequate nutrition, this wound will not
Stage IV: Treatment Needs medical care by professional skilled in wound care. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. A skilled wound care physician, physical therapist or nurse can sometimes successfully treat a smaller diameter wound without the necessity of surgery. Surgery is the usual course of treatment.
Stage V Wound is extremely deep, having gone through the muscle layers and now involves underlying organs and bone. It is difficult to heal. Surgical removal of the necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some situations.
Note
It is possible for a wound to "go from a stage I wound to a stage III or IV" without the intermittent stage[s] being observed.
Minor wound First aid 1. Protection: remove the cause of wound so nobody else gets hurt, or at least to lead the casualty away and mark out the dangerous area; 2. Avoid further soiling: the bystander washes his hands, and makes the casualty wash his hands; 3. Avoid infection: the wound must be washed with water and soap or deinfected with an antiseptic (only one product should be used, as an antiseptic
Minor wound First aid 1. Prevention: Ask whether casualty was vaccinated against tetanus (the last injection must be less than ten years old); if not, the casualty should be vaccinated; 2. Give following advice: "if tomorrow or in the following days the wound becomes red or hurts, it is a sign of infection; go to clinician"; 3. If there is a risk of dirt (e.g. playing child or work in contact of any liquid or dusty product), the wound must be covered with a sticking plaster, otherwise it can be let in the air.
Major wound First aid 1. Avoid an aggravation of the wound and call for help 2. Remove the cause of wound so nobody else gets hurt, or lead the casualty away and mark out the dangerous area; when the casualty cannot walk, he should not be moved unless the danger is deadly and real; 3. Avoid aggravation: the casualty is let in the position he feels comfortable;when there is an important bleeding, control it (press on the wound when possible); 4. See general state of the casualty (alertness, breath) and the wound itself;
Factors Accelerating Wound Development
Anemic status: Compromises oxygen supply Malnutrition, fat loss, Vascular insufficiency, Fecal or urinary Incontinence: causes local skin irritation and maceration Elderly bed ridden patient: due to paucity of movements and impaired sensation have poor wound healing capacity Shearing forces due to sliding: causes injury to skin. Poor arterial circulation Muscular atrophy
Wound classification Wagner System
Grade 0 - intact skin, healed ulcers, bony deformity Grade 1 - superficial ulcer no subcutaneous involvement Grade 2 - through subcutaneous to bone, tendon. Ligament, capsule may be exposed Grade 3 - Osteitis, abscess, osteomyelitis Grade 4 - gangrene digit Grade 5 - gangrene foot
Gangrene Toe
Wound: Shea’s Classification Grade:1 Irregular ill-defined area of soft tissue and induration associated with heat and erythema overlying a bony prominence Reversible lesion
Wound: Shea’s Classification Grade:2 Continued intense local pressure intensifies acute inflammatory response causing fibroblastic response in all layers. Shallow full thickness skin ulceration involving dermis and subcutaneous fat with distinct edges of wound margins. Early fibrosis and pigmentation changes causing indistinct area of heat, erythema and induration.
Wound: Shea’s Classification Grade:3 Irregular full thickness skin defect extending in to subcutaneous fat exposing a draining, foul smelling, infected necrotic base and undermining the skin for a variable distance Skin edge is rolled with an altered dark and light pigmentation that sharply outlines the ulcer. Fever dehydration, anemia and leukocytosis are compounded by profound loss of fluid and protein from the opening
Wound: Shea’s Classification Grade:4 Resembles clinically like grade:3 except that bones can be identified at wound base with profuse drainage and necrosis
Pressure Ulcer Staging/Grading
Pressure Ulcer Staging/Grading
Wound Healing:3 Phases
Wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. Phase I: Inflammatory Phase A) Immediate to 2-5 days B) Hemostasis
Vasoconstriction Platelet aggregation Thromboplastin makes clot
C) Inflammation
Vasodilation
Wound Healing:3 Phases
Phase:II. Proliferative Phase
A) 2 days to 3 weeks B) Granulation Fibroblasts lay bed of collagen Fills defect and produces new capillaries C) Contraction Wound edges pull together to reduce defect D) Epithelialization Crosses moist surface
Wound Healing:3 Phases Phase:III. Remodeling Phase A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue
Wound Type: Pressure
Wound Type: Pressure
Combination of situations and factors. At cellular level, ischemia occurs when high pressure is applied to one area for a prolonged period of time. Ischemia produced leads to tissue necrosis. These pressure comes from bony prominence on one side and a hard surface on the other side. The soft tissue between these two surfaces is subjected to abnormal pressure. The tissue closest to the bone is typically the first tissue to undergo necrosis. Skin discoloration or redness
Wound Type: Pressure
It has been demonstrated that the capillary pressure on the arterial side is around 30-32 mmhg and around 12 mmhg on the venous side. Sustained pressures at values higher than these may result in circulatory compromise and tissue necrosis. Frictional and shearing forces also play roles in tissue necrosis. General health, skin texture and turgor, patient's mobility, nutritional status and body weight (too thin and too heavy) are
Wound Type: Arterial Ulcers
Wound Type: Arterial Ulcers
Complete or partial arterial blockage leads to tissue necrosis and / or ulceration. Signs are: Pulselessness of extremity Painful ulceration Small, punctate ulcers well circumscribed Cool or Cold skin Delayed capillary return time (briefly push on the end of the toe and release, normal color should return to the toe in 3 seconds or less) Atrophic skin (shiny, thin, dry) Loss of digital and pedal hair Can occur anywhere, but frequently seen on
Wound Type: Venous Ulcers
Wound Type: Venous Ulcers
Common type of ulcer affecting lower extremities. The normal vein has valves that prevent the backflow of blood. When these valves become incompetent, the backflow of venous blood causes venous congestion. Hemaglobin from red blood cells escapes and leaks into the extravascular space, causing the brownish discoloration. Transcutaneous oxygen pressure of skin surrounding venous ulcer is decreased, suggesting that there are forces obstructing the normal vascularity of the area. Lymphatic drainage and flow plays a role in these ulcers. The typical venous ulcer appears near the medial malleolus, is in combination with an edematous
Wound Type: Diabetic Ulcers
Wound Type: Diabetic Ulcers
Diabetics are prone to foot ulcerations due to neurologic and vascular complications. Peripheral neuropathy causes altered or complete loss of sensation in the foot and /or leg. Similar to the feeling of a "fat lip" after a dentist's anesthetic injection, the diabetic with advanced neuropathy looses all sharp-dull discrimination. Any cuts or trauma to the foot can go completely unnoticed for days or weeks in a patient with neuropathy. It's not uncommon to have a patient with neuropathy tell you that the ulcer "just appeared" when, in fact, the ulcer has been present for quite some time. There is no known cure for neuropathy, but strict glucose control has been shown to slow the
Wound Type: Diabetic Ulcers
Charcot foot deformity occurs due to decreased sensation. People with "normal" feeling in their feet automatically determine when too much pressure is being placed on an area of the foot. Once identified, our bodies instinctively shift position to relieve this stress. A patient with advanced neuropathy looses this important mechanism. As a result, tissue ischemia and necrosis may occur leading to plantar ulcerations. Microfractures in the bones of the foot go
Wound Type: Diabetic Ulcers
Micro vascular disease is a significant problem for diabetics and can lead to ulcerations. It is well known that diabetes is called a small vessel disease. Most of the problems caused by narrowing of the small arteries cannot be resolved surgically. It is critical that diabetics maintain close control on their glucose level, maintain a good body weight and avoid smoking in an attempt to reduce the onset of small vessel
Wound Type: Traumatic Ulcers
Wound Type: Traumatic Ulcers
Trauma to the body result in a Compromise to the arterial, venous or lymphatic systems. Changes to the bony architecture of the skeleton. Loss of tissue layers - epidermis, dermis, subcutaneous soft tissue, muscle or bone. Damage to body parts or organs. Loss of body parts or organs. All of the above situations present different problems, all of which could
Wound Type: Burns Ulcers
Sun Burn
Boiling water burn
Wound Type: Burns Ulcers
1st degree burn......is a superficial, reddened area of skin like a sunburn. 2nd degree burn.....is a blistered injury site which may heal spontaneously after the blister fluid has bee removed. 3rd degree burn......is a burn through the entire skin and will
Wound Type: Burns Ulcers
Scald..occur from scalding hot water, grease or radiator fluid. Thermal..occur from flames, usually deep burns. Chemical..from acid and alkali, usually deep burns. Electrical..Either low voltage around a house or high voltage at work Explosion Flash.. superficial injuries. Contact Burns..Usually deep and occur from muffler tail pipes, hot irons and
Wound Management: Wound Debridement Autolytic Debridement: Autolysis uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is liquefied. It is virtually painless for the patient. Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue. Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films.
Wound Management: Wound Debridement Autolytic Debridement: Advantages: Very selective, with no damage to surrounding skin. Process is safe, using the body's own defense mechanisms to clean the wound of necrotic debris. Effective, versatile and easy to perform Little to no pain for the patient Disadvantages: Not as rapid as surgical debridement Wound must be monitored closely for signs of infection
Wound Management: Wound Debridement
Enzymatic Debridement:
Chemical enzymes are fast acting products that produce slough of necrotic tissue. Some enzymatic debriders are selective, while some are not. Best Uses: On any wound with a large amount of necrotic debris & Eschar formation
Wound Management: Wound Debridement
Enzymatic Debridement:
Advantages:
Fast acting Minimal or no damage to healthy tissue with proper application. Disadvantages: Expensive Requires a prescription Application must be performed carefully only to the necrotic tissue. May require a specific secondary dressing Inflammation or discomfort may occur
Wound Management: Wound Debridement Mechanical Debridement: Used for decades in wound care. Allowing a dressing to proceed from moist to wet, then manually removing the dressing causes a form of non-selective debridement. Hydrotherapy is also a type of mechanical debridement. Best Uses: Wounds with moderate amounts of necrotic debris
Wound Management: Wound Debridement Mechanical Debridement: Advantages: Cost of the actual material (ie. gauze) is low Disadvantages: Non-selective and may traumatize healthy or healing tissue Time consuming Can be painful to patient Hydrotherapy can cause tissue maceration. Also, waterborne pathogens may cause contamination or infection. Disinfecting
Wound Management: Wound Debridement Surgical Debridement: Sharp surgical debridement and laser debridement under anesthesia are the fastest methods of debridement. Are very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind Surgical debridement can be performed in the operating room or at bedside, depending on the extent of the necrotic material. Best Uses: Wounds with a large amount of necrotic tissue.
Wound Management: Wound Debridement
Surgical Debridement:
Advantages: Fast and Selective Can be extremely effective Disadvantages: Painful to patient Costly, especially if an operating room is required Requires transport of patient if operating room is required.
Physical Therapy Modalities in Wound Care
Electrical Stimulation Ultrasound Whirlpool Hyperbaric Oxygen Laser Ultra violet Radiation
Electrical stimulation: Wound Healing
Electrical stimulation affects the biological phases of wound healing in the following ways: Inflammation phase Initiates the wound repair process by its effect on the current of injury,Increases blood flow,Promotes phagocytosis,Enhances tissue oxygenation,Reduces edema from reduced microvascular leakage,Attracts and stimulates fibroblasts and epithelial cells, Stimulates DNA synthesis,Controls infection,Solubilizes blood products including necrotic tissue
Electrical stimulation: Wound Healing Proliferation phase Stimulates fibroblasts and epithelial cells Stimulates DNA and protein synthesis Increases ATP generation Improves membrane transport Produces better collagen matrix organization, Stimulates wound contraction Epithelialization phase Stimulates epidermal cell reproduction and migration Produces a smoother, thinner scar
Electrical stimulation: Treatment Protocol Inflammation phase Wound progresses to the Proliferation phase Proliferation phase Polarity - negative Pulse rate - 100 - 128 pps Intensity - 100-150 volts Duration - 60 minutes Frequency 5-7 x per week, once
Electrical stimulation: Treatment Protocol Epithelialization phase Polarity - alternate every three days ie 3 days negative followed by 3 days positive Pulse rate - 64 PPS Intensity - 100-150 volts Duration - 60 minutes Frequency 5-7 x per week, once
Electrical stimulation: CONTRAINDICATIONS Placement of electrodes tangential to the heart Along regions of the phrenic nerve over the carotid sinus over the laryngeal musculature over topical substances containing metal ions over osteomyelitis Presence of a cardiac pacemaker or malignancy
Ultra Sound: Wound Healing Inflammatory Phase causes a degranulation of mast cells resulting in the release of histamine. Histamine and other chemical mediators released from the mast cell are felt to play a role in attracting neutrophils and monocytes to the injured site. These events accelerate acute inflammatory phase and promote healing. Proliferative Phase accelerates fibroblasts and stimulate them to secrete collagen. It leads to wound contraction and increase tensile strength of the healing tissue. Connective tissue will elongate better if both heat and stretch are combined. Continuous ultrasound at higher therapeutic intensities provides and effective means of heating deeper tissue prior to stretch.
Ultra Sound: Wound Healing Frequency As the frequency of ultrasound is increased, the penetration of the signal decreases. For most dermal wounds, it is preferable therefore, to utilize a frequency of 3 MHz. 1 MHz wound be more effective on deeper structures or peri-wound
Whirlpool: Wound Healing Objectives of whirlpool treatment: vasodilitation increased blood flow softening and loosening of necrotic tissue mechanical debridement wound cleansing: debris and topical agents exudate removal --- > reduced infection
Whirlpool: Wound Healing Theory behind whirlpool's effectiveness: effects the Inflammation Phase of healing Warm water increases vasodilitation of the superficial vessels; Increased blood flow brings oxygen and nutrients to the tissues and removes metabolites Increased blood flow brings antibodies, leukocytes and systemic antibiotics Fluid shifts into the interstitial spaces leading to edema Softening and loosening of necrotic tissue aides phagocytosis Cleansing and removal of wound exudate controls infection Mechanical effects of whirlpool stimulate granulation tissue formation Sedation and analgesia are induced by the warm water
Hyperbaric oxygen therapy:Wound Healing
In an hypoxic environment, wound healing is halted by decreased fibroblast proliferation collagen production, and capillary angiogenesis. Hypoxia also allows growth of anaerobic organisms, further complicating wound healing. Hyperbaric oxygen therapy provides a significant increase in tissue oxygenation in the hypoperfused, infected wound. It influences the rate of collagen deposition, angiogenesis, and bacterial clearance in wounds. The greatest benefits are achieved in tissues with compromised blood flow and oxygen supply.
Wound Types
Traumatic
Non-Traumatic Pressure Sores Surgical
Skin Disorder Diabetic wounds Infection
Malignant Vascular lesion Burns
Wound Definition Wound is defined as disruption of anatomic or functional continuity of living tissues & is the product of integrated response
Wound Definition A wound is a physical trauma where the skin is torn, cut or punctured. a wound is considered as minor when it is: superficial; away from natural orifices; there is only a minor bleeding; it was not caused by a tool or an animal. Any other wound should be considered as severe.
Wound Development: Physiology of capillary Flow A. Forces moving the fluid outward from capillary bed*Mean Functional Capillary Pressure =17.0mm of Hg. *Negative Interstitial Pressure =7.0mm of =28.5mm of Hg. Hg. *Interstitial fluid colloid osmotic Pressure of Hg the Fluid Inward from capillary B.=4.5mm Forces Moving bed* Plasma colloid osmotic Pressure = 28.5mm of Hg.
= 0.5mm of Hg.
e above factors are responsible Net Outward Pressure=for A-Bflow of fluid in the capillar
Wound Development
By the process of diffusion nutrients and oxygen are delivered to the tissues from the capillaries; during which small amount of fluid enters in to the surrounding interstitial spaces. This is done by net outward pressure of 0.5mm of Hg.
Wound Development
Subsequently, lymphatic system returns this fluid back in to the venous system. Venous system is easily impeded by external pressure due to small differential pressure, which depends upon near total relief of pressure at frequent intervals to avert anoxia.
Pressure sore Development
When pressure over a given part of the body exceeds the capillary pressure at venous end, the blood flow to the tissue stops; the tissue becomes anoxic due to lack of oxygen supply; and if anoxia persists, necrosis sets-in. The whole process takes 1-6hrs based on combination of factors.
Pressure sore Development
Erythema
BlistersBlister Rupture Necrosis
Eschar Formation
Pressure sore Development Mechanism of Formation
Pressure Friction by rubbing against bed sheet, cast, brace, etc., or Prolonged exposure to cold. Any area of tissue that lies just over a bone is more likely to develop a decubitus ulcer. These areas include the spine, coccyx or tailbone, hips, heels, and elbows.
Pressure sore Development Person's body weight presses on the bone, the bone presses on the tissue and skin that cover it, and the tissue is trapped between the bone structure and bed or wheelchair surface. The tissue begins to decay due to lack of blood circulation & formation of decubitus ulcer sets in.
Stages of Wounds Wounds are categorized according to severity by the use of stages. The staging system applies to burn wounds, Decubitus ulcers and several other types of wounds.
Stage I This stage is characterized by • Skin is unbroken and wound is superficial • Would be a light sunburn or a first degree burn as well as a beginning Decubitus ulcer • Burn heals spontaneously or the Decubitus ulcer quickly fades when pressure is relieved on the area.
Key factors to consider in Stage I wound o Cause of wound and methods to alleviate pressure on wound area to prevent it from worsening. o Improve nutritional status of individual to prevent wound worsening. o Note: The presence of Stage I wound is an indication or early warning of a problem and a signal to take preventive action.
Stage-1: Treatment • Alleviating pressure and avoiding more exposure to the cause of the injury by covering, protecting, and cushioning the area. • An increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of prevention.
Stage II
This stage is characterized by • a blister either broken or unbroken. • partial layer of the skin is now injured. • Involvement is no longer superficial.
Stage II: Treatment o Goal of care is to cover, protect, and clean the area. o Coverings designed to insulate and absorb as well as protect are used. Additional padding and protective substances used to decrease the pressure on the area o Skin lotions or emollients used to hydrate surrounding tissues oClose attention to prevention, protection, nutrition, and hydration is important
Stage III Wound extends through all of the layers of the skin. Primary site for a serious infection to occur. The goals and treatments of alleviating pressure and covering and protecting the wound still apply as well as an increased emphasis on nutrition and hydration. Medical care is necessary to promote healing and to treat and prevent infection.
Stage IV Wound extends through the skin and involves underlying muscle, tendons and bone. Diameter of the wound is not as important as the depth. Very serious and can produce life threatening infection, if not aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure on the area still apply. Nutrition and hydration is now critical. Without adequate nutrition, this wound will not
Stage IV: Treatment Needs medical care by professional skilled in wound care. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. A skilled wound care physician, physical therapist or nurse can sometimes successfully treat a smaller diameter wound without the necessity of surgery. Surgery is the usual course of treatment.
Stage V Wound is extremely deep, having gone through the muscle layers and now involves underlying organs and bone. It is difficult to heal. Surgical removal of the necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some situations.
Note
It is possible for a wound to "go from a stage I wound to a stage III or IV" without the intermittent stage[s] being observed.
Minor wound First aid 1. Protection: remove the cause of wound so nobody else gets hurt, or at least to lead the casualty away and mark out the dangerous area; 2. Avoid further soiling: the bystander washes his hands, and makes the casualty wash his hands; 3. Avoid infection: the wound must be washed with water and soap or deinfected with an antiseptic (only one product should be used, as an antiseptic
Minor wound First aid 1. Prevention: Ask whether casualty was vaccinated against tetanus (the last injection must be less than ten years old); if not, the casualty should be vaccinated; 2. Give following advice: "if tomorrow or in the following days the wound becomes red or hurts, it is a sign of infection; go to clinician"; 3. If there is a risk of dirt (e.g. playing child or work in contact of any liquid or dusty product), the wound must be covered with a sticking plaster, otherwise it can be let in the air.
Major wound First aid 1. Avoid an aggravation of the wound and call for help 2. Remove the cause of wound so nobody else gets hurt, or lead the casualty away and mark out the dangerous area; when the casualty cannot walk, he should not be moved unless the danger is deadly and real; 3. Avoid aggravation: the casualty is let in the position he feels comfortable;when there is an important bleeding, control it (press on the wound when possible); 4. See general state of the casualty (alertness, breath) and the wound itself;
Factors Accelerating Wound Development
Anemic status: Compromises oxygen supply Malnutrition, fat loss, Vascular insufficiency, Fecal or urinary Incontinence: causes local skin irritation and maceration Elderly bed ridden patient: due to paucity of movements and impaired sensation have poor wound healing capacity Shearing forces due to sliding: causes injury to skin. Poor arterial circulation Muscular atrophy
Wound classification Wagner System
Grade 0 - intact skin, healed ulcers, bony deformity Grade 1 - superficial ulcer no subcutaneous involvement Grade 2 - through subcutaneous to bone, tendon. Ligament, capsule may be exposed Grade 3 - Osteitis, abscess, osteomyelitis Grade 4 - gangrene digit Grade 5 - gangrene foot
Gangrene Toe
Wound: Shea’s Classification Grade:1 Irregular ill-defined area of soft tissue and induration associated with heat and erythema overlying a bony prominence Reversible lesion
Wound: Shea’s Classification Grade:2 Continued intense local pressure intensifies acute inflammatory response causing fibroblastic response in all layers. Shallow full thickness skin ulceration involving dermis and subcutaneous fat with distinct edges of wound margins. Early fibrosis and pigmentation changes causing indistinct area of heat, erythema and induration.
Wound: Shea’s Classification Grade:3 Irregular full thickness skin defect extending in to subcutaneous fat exposing a draining, foul smelling, infected necrotic base and undermining the skin for a variable distance Skin edge is rolled with an altered dark and light pigmentation that sharply outlines the ulcer. Fever dehydration, anemia and leukocytosis are compounded by profound loss of fluid and protein from the opening
Wound: Shea’s Classification Grade:4 Resembles clinically like grade:3 except that bones can be identified at wound base with profuse drainage and necrosis
Pressure Ulcer Staging/Grading
Pressure Ulcer Staging/Grading
Wound Healing:3 Phases
Wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. Phase I: Inflammatory Phase A) Immediate to 2-5 days B) Hemostasis
Vasoconstriction Platelet aggregation Thromboplastin makes clot
C) Inflammation
Vasodilation
Wound Healing:3 Phases
Phase:II. Proliferative Phase
A) 2 days to 3 weeks B) Granulation Fibroblasts lay bed of collagen Fills defect and produces new capillaries C) Contraction Wound edges pull together to reduce defect D) Epithelialization Crosses moist surface
Wound Healing:3 Phases Phase:III. Remodeling Phase A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue
Wound Type: Pressure
Wound Type: Pressure
Combination of situations and factors. At cellular level, ischemia occurs when high pressure is applied to one area for a prolonged period of time. Ischemia produced leads to tissue necrosis. These pressure comes from bony prominence on one side and a hard surface on the other side. The soft tissue between these two surfaces is subjected to abnormal pressure. The tissue closest to the bone is typically the first tissue to undergo necrosis. Skin discoloration or redness
Wound Type: Pressure
It has been demonstrated that the capillary pressure on the arterial side is around 30-32 mmhg and around 12 mmhg on the venous side. Sustained pressures at values higher than these may result in circulatory compromise and tissue necrosis. Frictional and shearing forces also play roles in tissue necrosis. General health, skin texture and turgor, patient's mobility, nutritional status and body weight (too thin and too heavy) are
Wound Type: Arterial Ulcers
Wound Type: Arterial Ulcers
Complete or partial arterial blockage leads to tissue necrosis and / or ulceration. Signs are: Pulselessness of extremity Painful ulceration Small, punctate ulcers well circumscribed Cool or Cold skin Delayed capillary return time (briefly push on the end of the toe and release, normal color should return to the toe in 3 seconds or less) Atrophic skin (shiny, thin, dry) Loss of digital and pedal hair Can occur anywhere, but frequently seen on
Wound Type: Venous Ulcers
Wound Type: Venous Ulcers
Common type of ulcer affecting lower extremities. The normal vein has valves that prevent the backflow of blood. When these valves become incompetent, the backflow of venous blood causes venous congestion. Hemaglobin from red blood cells escapes and leaks into the extravascular space, causing the brownish discoloration. Transcutaneous oxygen pressure of skin surrounding venous ulcer is decreased, suggesting that there are forces obstructing the normal vascularity of the area. Lymphatic drainage and flow plays a role in these ulcers. The typical venous ulcer appears near the medial malleolus, is in combination with an edematous
Wound Type: Diabetic Ulcers
Wound Type: Diabetic Ulcers
Diabetics are prone to foot ulcerations due to neurologic and vascular complications. Peripheral neuropathy causes altered or complete loss of sensation in the foot and /or leg. Similar to the feeling of a "fat lip" after a dentist's anesthetic injection, the diabetic with advanced neuropathy looses all sharp-dull discrimination. Any cuts or trauma to the foot can go completely unnoticed for days or weeks in a patient with neuropathy. It's not uncommon to have a patient with neuropathy tell you that the ulcer "just appeared" when, in fact, the ulcer has been present for quite some time. There is no known cure for neuropathy, but strict glucose control has been shown to slow the
Wound Type: Diabetic Ulcers
Charcot foot deformity occurs due to decreased sensation. People with "normal" feeling in their feet automatically determine when too much pressure is being placed on an area of the foot. Once identified, our bodies instinctively shift position to relieve this stress. A patient with advanced neuropathy looses this important mechanism. As a result, tissue ischemia and necrosis may occur leading to plantar ulcerations. Microfractures in the bones of the foot go
Wound Type: Diabetic Ulcers
Micro vascular disease is a significant problem for diabetics and can lead to ulcerations. It is well known that diabetes is called a small vessel disease. Most of the problems caused by narrowing of the small arteries cannot be resolved surgically. It is critical that diabetics maintain close control on their glucose level, maintain a good body weight and avoid smoking in an attempt to reduce the onset of small vessel
Wound Type: Traumatic Ulcers
Wound Type: Traumatic Ulcers
Trauma to the body result in a Compromise to the arterial, venous or lymphatic systems. Changes to the bony architecture of the skeleton. Loss of tissue layers - epidermis, dermis, subcutaneous soft tissue, muscle or bone. Damage to body parts or organs. Loss of body parts or organs. All of the above situations present different problems, all of which could
Wound Type: Burns Ulcers
Sun Burn
Boiling water burn
Wound Type: Burns Ulcers
1st degree burn......is a superficial, reddened area of skin like a sunburn. 2nd degree burn.....is a blistered injury site which may heal spontaneously after the blister fluid has bee removed. 3rd degree burn......is a burn through the entire skin and will
Wound Type: Burns Ulcers
Scald..occur from scalding hot water, grease or radiator fluid. Thermal..occur from flames, usually deep burns. Chemical..from acid and alkali, usually deep burns. Electrical..Either low voltage around a house or high voltage at work Explosion Flash.. superficial injuries. Contact Burns..Usually deep and occur from muffler tail pipes, hot irons and
Wound Management: Wound Debridement Autolytic Debridement: Autolysis uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is liquefied. It is virtually painless for the patient. Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue. Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films.
Wound Management: Wound Debridement Autolytic Debridement: Advantages: Very selective, with no damage to surrounding skin. Process is safe, using the body's own defense mechanisms to clean the wound of necrotic debris. Effective, versatile and easy to perform Little to no pain for the patient Disadvantages: Not as rapid as surgical debridement Wound must be monitored closely for signs of infection
Wound Management: Wound Debridement
Enzymatic Debridement:
Chemical enzymes are fast acting products that produce slough of necrotic tissue. Some enzymatic debriders are selective, while some are not. Best Uses: On any wound with a large amount of necrotic debris & Eschar formation
Wound Management: Wound Debridement
Enzymatic Debridement:
Advantages:
Fast acting Minimal or no damage to healthy tissue with proper application. Disadvantages: Expensive Requires a prescription Application must be performed carefully only to the necrotic tissue. May require a specific secondary dressing Inflammation or discomfort may occur
Wound Management: Wound Debridement Mechanical Debridement: Used for decades in wound care. Allowing a dressing to proceed from moist to wet, then manually removing the dressing causes a form of non-selective debridement. Hydrotherapy is also a type of mechanical debridement. Best Uses: Wounds with moderate amounts of necrotic debris
Wound Management: Wound Debridement Mechanical Debridement: Advantages: Cost of the actual material (ie. gauze) is low Disadvantages: Non-selective and may traumatize healthy or healing tissue Time consuming Can be painful to patient Hydrotherapy can cause tissue maceration. Also, waterborne pathogens may cause contamination or infection. Disinfecting
Wound Management: Wound Debridement Surgical Debridement: Sharp surgical debridement and laser debridement under anesthesia are the fastest methods of debridement. Are very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind Surgical debridement can be performed in the operating room or at bedside, depending on the extent of the necrotic material. Best Uses: Wounds with a large amount of necrotic tissue.
Wound Management: Wound Debridement
Surgical Debridement:
Advantages: Fast and Selective Can be extremely effective Disadvantages: Painful to patient Costly, especially if an operating room is required Requires transport of patient if operating room is required.
Physical Therapy Modalities in Wound Care
Electrical Stimulation Ultrasound Whirlpool Hyperbaric Oxygen Laser Ultra violet Radiation
Electrical stimulation: Wound Healing
Electrical stimulation affects the biological phases of wound healing in the following ways: Inflammation phase Initiates the wound repair process by its effect on the current of injury,Increases blood flow,Promotes phagocytosis,Enhances tissue oxygenation,Reduces edema from reduced microvascular leakage,Attracts and stimulates fibroblasts and epithelial cells, Stimulates DNA synthesis,Controls infection,Solubilizes blood products including necrotic tissue
Electrical stimulation: Wound Healing Proliferation phase Stimulates fibroblasts and epithelial cells Stimulates DNA and protein synthesis Increases ATP generation Improves membrane transport Produces better collagen matrix organization, Stimulates wound contraction Epithelialization phase Stimulates epidermal cell reproduction and migration Produces a smoother, thinner scar
Electrical stimulation: Treatment Protocol Inflammation phase Wound progresses to the Proliferation phase Proliferation phase Polarity - negative Pulse rate - 100 - 128 pps Intensity - 100-150 volts Duration - 60 minutes Frequency 5-7 x per week, once
Electrical stimulation: Treatment Protocol Epithelialization phase Polarity - alternate every three days ie 3 days negative followed by 3 days positive Pulse rate - 64 PPS Intensity - 100-150 volts Duration - 60 minutes Frequency 5-7 x per week, once
Electrical stimulation: CONTRAINDICATIONS Placement of electrodes tangential to the heart Along regions of the phrenic nerve over the carotid sinus over the laryngeal musculature over topical substances containing metal ions over osteomyelitis Presence of a cardiac pacemaker or malignancy
Ultra Sound: Wound Healing Inflammatory Phase causes a degranulation of mast cells resulting in the release of histamine. Histamine and other chemical mediators released from the mast cell are felt to play a role in attracting neutrophils and monocytes to the injured site. These events accelerate acute inflammatory phase and promote healing. Proliferative Phase accelerates fibroblasts and stimulate them to secrete collagen. It leads to wound contraction and increase tensile strength of the healing tissue. Connective tissue will elongate better if both heat and stretch are combined. Continuous ultrasound at higher therapeutic intensities provides and effective means of heating deeper tissue prior to stretch.
Ultra Sound: Wound Healing Frequency As the frequency of ultrasound is increased, the penetration of the signal decreases. For most dermal wounds, it is preferable therefore, to utilize a frequency of 3 MHz. 1 MHz wound be more effective on deeper structures or peri-wound
Whirlpool: Wound Healing Objectives of whirlpool treatment: vasodilitation increased blood flow softening and loosening of necrotic tissue mechanical debridement wound cleansing: debris and topical agents exudate removal --- > reduced infection
Whirlpool: Wound Healing Theory behind whirlpool's effectiveness: effects the Inflammation Phase of healing Warm water increases vasodilitation of the superficial vessels; Increased blood flow brings oxygen and nutrients to the tissues and removes metabolites Increased blood flow brings antibodies, leukocytes and systemic antibiotics Fluid shifts into the interstitial spaces leading to edema Softening and loosening of necrotic tissue aides phagocytosis Cleansing and removal of wound exudate controls infection Mechanical effects of whirlpool stimulate granulation tissue formation Sedation and analgesia are induced by the warm water
Hyperbaric oxygen therapy:Wound Healing
In an hypoxic environment, wound healing is halted by decreased fibroblast proliferation collagen production, and capillary angiogenesis. Hypoxia also allows growth of anaerobic organisms, further complicating wound healing. Hyperbaric oxygen therapy provides a significant increase in tissue oxygenation in the hypoperfused, infected wound. It influences the rate of collagen deposition, angiogenesis, and bacterial clearance in wounds. The greatest benefits are achieved in tissues with compromised blood flow and oxygen supply.
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