ࡱ> ^`]@ ,bjbjFF ^,,$44r%$$$$$$$$d&R(%%,%iii $i$ii:]","z $F " =#B%0r%"RX)DX)"X)"Xi S%%_ Wound Care Acute and Chronic Wound- a disruption of the integrity of the skin or tissues Wound healing is a normal body response to injury Can be a response to various disease states of typical aging There is a constant renewal of the skin surface An acute wound can be surgical or traumatic. The wound itself stimulates the series of events that are innately programmed to restore the newly injured skin Many factors influence wound healing The extent of the injury, the tissue involved, the type of injury, condition of the host (co-morbid condition) Acute Surgical Wound Surgical Incisional Excisional- characteristic of biopsy Traumatic Lacerations- traumatic injuries Abrasions- very superficial excoriation or circumscribed removal of superficial layers of skin, typically does not require stitches Skin tears- mostly involved with dry skin conditions Bites of the skin- causes microbial infection, typical do not require stitches Human Domestic animals- dog (pasturella multicida, bacteriodes, fusobacteria); cat (pasturella multicida 60% of cat bites- less complicated than dog) Spider (brown recluse)- small mosquito-like bite that ulcerates, pruritic Tick (bulls-eye pattern) Snake- 10% of snakes in US are poisonous Stages of Wound Healing Early wound healing Associated first with vasoconstriction and establishes hemostasis Coagulation cascade then begins after flow has been stopped This is followed by an inflammatory phase- days 1-4 (in closed wound), can be prolonged in open wound Leukocyte migration form intravascular space to extravascular space and bind to wound matrix PMN leukocyte is the most abundant first 24-48 hours this is the predominant cell Phagocytosis bacteria, works on damaged tissue, attacks any foreign material in the wound site, and releases cytokines Not essential for wound healing but it will prolong the inflammatory phase Monocytes- infiltration of these occur in the wound then differentiate into macrophages Macrophages are essential for wound healing Backup system for phagocytosis, removal or dead tissue, and release of cytokines At 48-72 hours these are the dominant cell in the wound Intermediate phase of wound healing Occurs at 2-4 days after occurrence of the wound Associated with angiogenesis (redeveloped circulation to the wound area) and epitheliazation (begins to restore the barrier) Sutured wounds (not infected)- can have intermediate phase happen earlier Epitheliazation at 24-72 hours Late wound healing Deposition of collagen into wound and wound contraction Typically occurs 4-5 days post-injury- can continue for 12-15 days Collagen is associated with increasing tensile strength Wound contraction decreases the size of the wound and wound edges move towards the center Final wound healing Begins 21 days post-injury Characterized by initial collagen being broken down and replaced by stronger collagen Strength returns to 80% tensile strength and finalizes at about 6 months Never get 100% strength back Treatment Options for Acute Surgical Wounds History of injury Time of injury- cannot suture after 6-8 hours Mechanism of injury- do not suture abrasions Medical, surgical and immunization and ALLERGY history Physical exam of the wound Foreign body assessment and/or removal Assessment of vascular and neurological injury- prior to the administration of anesthetic agents Anesthesia- local Lidocaine (xylocaine)- 0.5%-2% (action in 1-2 minutes) Lidocaine with epinephrine- cautionary use with nose, use on fingers, tip of penis, and toes Bupivacaine (marcaine)-longer acting (10 minutes to full onset) Wound cleansing Wound hemostasis and exploration Debridement of devitalized tissue- do not want to sew in wound edges that are crushed Wound closure Dry. Sterile dressing application Adjuvant therapeutics (tetanus prophylaxis, hepatitis B immunization, IV/PO antibiotic administration) Follow-up reassessment of wound Patient education regarding wound care Types of Skin Closures for Acute Surgical Wounds Skin adhesives- dermabond- skin glue used for shallow/superficial wounds for a good cosmetic result Steri-strips- skin tapes Sutures- can be made of silk, cotton, stainless steel, or Teflon Anytime you suture a wound it is considered primary repair; a wound that heals on its own is secondary intention; delayed closure of wound is tertiary intention (wound cleaned and debrided that is repaired after it begins granulated- AKA delayed primary closure) Chronic wound- acute wound or any wound that fails to heel Disruption in the normal acute wound healing process Will lead to poor anatomic and functional results as well as poor aesthetic results Staples Chronic Surgical Wounds - Acute wound or any wound that does not heel - These wounds will require some type of treatment I. Infected Surgical Wounds EtiologyUsual OrganismPhysical FindingsTreatmentCellulitisBreak in skin barrierStreptococcus- Group ADiffuse nonblanching erythema, tendernessSystemic antibiotics and local wound cleansingFuruncle CarbuncleBacterial growth within skin glands and cryptsStaphylococcus- gram stain any pus or fluidLocalized induration, erythema, tenderness, selling, creamy pus formationI and D, systemic antibiotics for carbuncle/ Lesions are typically associated with scarringHidradenitis SupperativaBacterial growth within apocrine glandsStaphylococcus- can be polymicrobial or secondary infectionMultiple abscesses, very painful lesions, drainage, thick pus from axilla and groin regions; Associated with trauma to areasI and D of small lesions, wide debridement, excision and grafting of large areasLymphangitisInfection within lymphaticsStreptococcus- can have secondary infectionsSwelling/erythema of distal extremity, inflamed streaks along involved lymphatic channelsLocal wound cleansing, removal of any foreign body and systemic antibioticsGangreneDestruction of healthy tissue by virulent microbial enzymeSynergistic streptococcus/staph Mixed aerobic/anaer. ClostridiumNecrotic skin/fascia, extremity swelling, grayish liquid d/c, crepitation, gas formation within tissue planes (will need amputations)RADICAL DEBRIDEMENT of involved tissues parenteral antibiotics. Repeat debridement as necessary Lower Extremity Ulcers- Major Causative Factors Venous insufficiency (medial aspect of lower leg and ankle)- stasis ulcers; typically associated with chronic edema and swelling of the peripheral tissues Chronic edema Hyperpigmentation- nutritional deficits to the tissue Arterial insufficiency (distal, tips of toes)- characterized by nutritional deficit to tissues; thin, shiny extremities with decreased or absent peripheral pulses Intermittent claudication- typically calf pain but can include the entire lower extremity Rest pain- means that there is no demand for increased circulation but the pain is still present in the extremity Diabetes mellitus (thick, calloused ulcerations plantar aspect of foot and/or heels) Diabetic neuropathy- sensory deficits, constant microtrauma, unknown foreign body, ischemia Gait disturbances may precipitate callous formation Pressure Ulcers- result of prolonged applied to soft tissue over bony prominences Typically associated with recumbency, geriatric patients, and patients without the ability to ambulate Common anatomical locations of pressure ulcers Occiput Sacrum Greater trochanter Heels Ischial tuberosity National Pressure ulcer advisory Panel Classification Scheme StageDescriptionINon-blanchable erythema of intact skin: wounds generally reversible at this stage with interventionIIPartial thickness skin loss involving epidermis or dermis: may present as an abrasion, blister or shallow craterIIIFull thickness skin loss involving damage or necrosis of subcutaneous tissue but not extending through underlying structures or fasciaIVFull thickness skin loss with damage to underlying support structures (i.e. fascia, tendon, muscle or joint capsule) Burns (specialized evaluation and care burn unit- do not disturb blisters)- 3rd degree burns are usually not painful Electrical- can be much deeper than they appear on the surface; will require debridement; associated with deep tissue destruction and will require constant evaluation; neurological and functional deficits Oncologic radiation- must evaluate area and give surgical consult for wound development Treatment Open Wound Care Options Topical ointments- superficial lesions Impregnated gauze- maintains moisture, prevent excessive loss of fluid Plain- petrolatum Xeroform- mild deodorizing; most chronic wounds are associated with smells Gauze Packing- will remove and replace every 24 hours Prevents dead space Facilitates drainage of wound Useful in debridement of wound- removing devitalized tissue Dry-to-dry dressing- absorption to evaporation of drainage- without saline Wet-to-dry dressing (moist-to-dry)- decreases debridement Sterile normal saline Dakins solution (0.5% sodium hypochlorite) can be ordered in full, half or quarter strength- deodorizing function; weak solution of bleach Hydrogels (Intrsite)- typically dont put in the wound, put on the wound Gently rehydrates necrotic tissue Absorbs exudates Facilitates debridement Hydrocolloids Can be used under compression dressings Alginates (Kalostat), collagen-containing products, hydrofibers Growth Factors and Skin Substitutes %YZ( ) . / D L M W X | } * + 5 _ ` q D E [ > ? 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