WONDERFUL WORLD OF WOUNDS WOUND HEALING, ASSESSMENT, ETIOLOGY BASIC TREATMENT
WHY DO WE GET WOUNDS? • • • • • • •
CHRONIC COMORBIDITIES TRAUMA HABITS/BEHAVIORS BACTERIA/VIRUSES HYGEINE REACTIVE AGENTS EXPOSURES
–ETC…ETC….ETC……..ETC
IT’S A COMPLICATED WORLD…
Types of Wounds
• Chronic Wounds: – Don’t go through a systematic predictable cycle of healing. The natural process of healing is delayed. It is a sign of underlying pathology. • Acute Wounds: -Go through a predictable process of healing
ETIOLOGY PRESSURE VENOUS ARTERIAL DIABETIC NEUROPATHIC ATYPICAL SURGICAL SKIN TEARS
Wound Management Based on Wound Appearance Necrotic Debridement
Infected Draining Granular
Control Bioburden Absorption Provide Moisture
Wound Bed Characteristics Granular draining
No two wounds are alike Necrotic draining
Granular Non draining
Necrotic nondraining
Stages of Healing Inflammation
Proliferation
Remodeling (maturation)
Inflammation • • • •
When insult happens: OUCH!!!! Hemostasis: Bleeding stops Fibrin Clot Vasoconstriction
INFLAMMATION Stimulation of Nerve Endings • Release of prostaglandin and histamine • Vasoactive substances • Leukocytes • Proteolytic enzymes Artery Vein
INFLAMMATION • • • •
Erythema Warmth Edema Pain
INFECTED
ESCHAR
SLOUGH
Proliferation • Busy healing time in the wound bed • Cellular activity is high • Scar Tissue Forming: Grannulation
GRANULATION Fibroblast Macrophage Capillary Bud Collagen Fiber Artery Vein
CONTRACTION Fibroblast Contraction Artery Vein
GRANULATION
RE-EPITHELIALIZATION
GRANULAR
Remodeling/Maturation Remodeling: Job retraining of cells Connective tissue matures
Scar is formed
PHASE – MATURATION (REMODELING)
General Anatomy of the Skin
TYPES OF WOUND HEALING Primary
Secondary
Tertiary
PARTIAL-THICKNESS WOUNDS
• EPIDERMAL REPAIR
• DERMAL REPAIR
FULL-THICKNESS WOUNDS
• GRANULATION • CONTRACTION
Pressure Ulcers • Soft tissue is compressed, circulation becomes impaired results in tissue injury • A number of contributing factors are associated with pressure ulcers • Commonly over bony prominences – Ischial tuberosities – Greater trochanters – Sacrum – Coccyx – Elbows – Heels – Thoracic spine – Ears • Commonly caused by pressure, friction, shear, and moisture
Things to Consider When Staging An Ulcer • ONLY pressure ulcers can be staged • Ulcers cannot accurately be staged when covered by necrosis or eschar • Often mistakes are made by UNDERSTAGING • Once staged, an ulcer IS ALWAYS THAT SAME STAGE
Wound Staging • Definition approved by the National Pressure Ulcer Advisory Panel • -Stage I: Non-blanchable erythema • -Stage II: Loss of epidermis or dermis • -Stage III: Subcutaneous damage/necrosis:SLOUGH • -Stage IV: Through fascia, into muscle, bone tendon, joint capsule • Suspected Deep Tissue Injury • *OK TO REPORTS “PROBABLE..” AND “UNSTAGABLE”
STAGE I
Stage II
STAGE III
STAGE IV
SUSPECTED DEEP TISSUE INJURY • Definition: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and or shear. The area may be precede by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
DEEP TISSUE INJURY
Arterial • Due to a disease process caused by hardening of the arteries or by the occlusion of the artery by plaques or fats • Usually on the toes, interdigital spaces, dorsum of the foot, and lateral malleolus • Are usually circular or punched out in appearance, deep and often have tendon involvement • Usually with a pale base, lack granulation • Have pain with elevation, prefer dependent position
Arterial Wound
ARTERIAL
DIABETIC • Neuropathy: Damage to peripheral nerves causing decreased sensation which allows for undetected and inappropriate pressure to the plantar surface of the foot • Associated with a loss of sensation, deformity an limited joint mobility • Usually with a callus • Infection risk • Often round, deep, pale wound base
DIABETIC
SURGICAL • Multiple causes – Infection – Edema – Wound dehiscence – Foreign bodies – Cell death/necrosis – Tension at the surgical site – Poor vascular Left open due to contamination or infection , heal by secondary intention. Connective tissue must fill in the defect.
SURGICAL
SURGICAL
Venous Ulcers •Valves in veins don’t function properly and venous blood pools causing venous hypertension. Fluid leaks into tissue and causes edema. Usual above the medial malleolus (gaiter area) • Hyperpigmentation/hemosidran staining • Edema • Inverted champagne-bottle look • Shallow base, irregular edges with heavy drainage
Venous Ulcer
SKIN TEARS
DRAINING
HEMATOMA/TRAUMA
How To Dress The Wound • Protect the skin • Fill the wound • Cover the wound • Prevent the cause
Protect the skin around the wound • Use skin prep to areas where tape will be applied • Protects fragile areas with protective ointment such as: -perianal -elbows -heels APPLYING PADDING TO AN AREA DOESN’T REDUCE THE PRESSURE
Fill It Up: PRIMARY DRESSING • Fill the dead space with an appropriate filler -gauze, VAC, ointment, etc • This is the PRIMARY DRESSING -it is intact with the base of the wound -causes stimulation to the wound base
Cover The Wound: SECONDARY DRESSING • Protect the primary dressing with a secondary dressing which will – Protect the primary dressing – Hold the primary dressing in place – Absorb the drainage. – Prevent the wound from loosing heat and drying out.
TYPES OF DRESSINGS • Alginates • Transparent Films • Foam • Hydrocolloid • Hydrogel • Gauzes • Debriding agents • Skin Barriers • Compressions Wraps • VAC • Skin Substitutes
RULE OF THUMB IF IT IS WET, DRY IT OUT IF IT IS DRY, WET IT DOWN ALWAYS CONTROL SWELLING/EDEMA IF ITS IS BLACK DO NOT ASSUME IT IS A “SCAB”
PONDER!!!!!!! • Things to ponder – Dressings don’t HEAL patients, Patients HEAL patients – ALWAYS determine etiology of the wound: ITS YOUR DIAGNOSIS THAT DRIVES REIMBURSEMENT – Know when to refer – Know the dressings you have available: PRIMARY AND SECONDARY!!!!!!! – Know your patient situation
IT’S THE WHOLE PATIENT NOT THE HOLE IN THE PATIENT
????????????????????????????????????????? MARTA OSTLER PT, CWS, CLT
[email protected] 307-672-1161
