wound management

epidermis layers superficial→deep

stratum corneum

stratum lucidum

stratum granulosum

stratum spinosum

stratum basale

specialized epidermal cells

melanocytes—pigmentation

langerhans cells—infection barrier

merkel cells—infection barrier

dermis layers superficial→deep

papillary—thin layer of collagen

reticular—collagen, elastic tissue, reticular fibers; provides skin elasticity, more scarring when injured

epidermis

very thin

avascular

thickest on palmar hand & plantar foot

specialized dermal cells

sweat glands, sebaceous glands

subcutaneous tissue

provides thermal regulation

basement membrane

junction btwn dermis and epidermis

cancer metastasizes when it crosses this

more corrugated when younger, makes it firmer

more smooth/parallel when older, makes skin easier to tear (shearing)

acid mantle

provides protective coating

pH 4-5.5

low pH better (low pH lotion helps!)

CT injury

interruption in continuity

each phase has distinct characteristics

inflammation: immediate-2 weeks

proliferation: 48 hrs to 2-4 weeks

maturation: 2-4 weeks to 1-2 years

time frames of CT injury repair depend on

shape of wound, type of wound (acute v chronic), depth of wound (partial vs. full thickness), type of closure (pry vs. sec)

shapes of wounds & what they result from

round/elliptical—pressure

jagged edges—shear/friction

irregular—venous

linear—trauma/friction

acute wounds

heal by themselves uneventfully

surgical, trauma/burn, skin tear

complex non healing/chronic wounds

pressure injury

neuropathic (diabetic)

vascular—venous ulcer, arterial/ischemic ulcer

mixed—diabetic/arterial, venous/arterial

two mechanism of CT repair determined by depth

regeneration & repair

regeneration

partial thickness: epidermis & superficial dermis

heal by epithelialization

repair

heal by granulation, contraction, epithelialization

start by filling wound in with granulated tissue, then epithelialize and contract from outside in

wounds surgically repaired

full thickness: all layers

deeper wound=

more involved repair process

primary intention

closure by direct approximation without tension due to little loss

clean or clean-contaminated wounds— ex. surgical incisions, lacerations

within 4-8 hrs of injury

palpable healing ridge under suture during proliferation phase

ex. sutures, steri strips, dermabond, stitches

linear shaped wound cleaning techniques

gently wipe from top to bottom in one motion from wound outward starting directly over wound and moving outward

open circular wound cleaning techniques

gently wipe in concentric circles, starting directly over wound and moving outward

secondary intention

contaminated or dirty wounds

enough tissue loss cannot close w/o tension

delay in clinical consultation

wound is left open to heal spontaneously

delayed primary/tertiary intention

delayed closure after several days to weeks of healing

combo btwn pry and sec intention

surgical closure after granulation tissue present in wound bed—skin graft, skin flap, skin substitute

hemostasis

blood flows into wound

immediate vasoconstriction

vasocongestion

blood coagulation, platelet aggregation

fibrin-rich clot

seals disrupted vessels and fills tissue

vascular spasm→platelet plug formation→blood clotting

inflammation phase

mast cells release histamines: incr vasodilation

migration of leukocytes: polymorphic neutrophils (PMNs), monocytes (macrophages) for phagocytosis, release of GFs, matrix for cell migration

stim nociceptive receptors

phagocytosis

remove foreign debris

release of growth factors

initiates repair process

classic signs of inflammation

erythema, swelling, incr tissue temp, pain, los sof function

proliferation (collagen phase)

deposition of collagen (cross linking): fibroplasia

vascular integrity restored: neoangiogenesis

fibroplasia

fibroblast proliferation

collagen synthesis (Type III)

neoangiogenesis

formation of capillary sprouts

new capillary and arteriole production

results in development of granulation tissue

wound healing contraction

during proliferation

wound edges contract

fibroblasts and myofibroblasts create closure

shrinks defect

limited by tension in surrounding tissues

wound healing epithelialization

proliferation of keratinocytes

differentiation

clinical considerations of healing phases

maintain proper moisture of wound surface

granulation tissue is fragile

monitor for infection

consider underlying pathology

type III collagen doesn’t provide tensile strength

maturation

lasts up to 1 yr in normal healthy adult, 2 in child, elderly or immunocompromised pts

tensile strength incr to 80% ish

matrix remodeling—collagen synthesis/degradation, bond conversion (type III to I or II)

scar tissue compaction/contraction

normal scar

white or pink, indented below skin surface

hypertrophic scar

white, pink, or red, slightly raised; firm; follow wound borders

keloid scar

deep red or purple; very raised; firm; extend beyond wound borders

keloid scar treatment

surgical excision

laser

anti-histamines/corticosteroid therapy

cryotherapy w/ liquid nitrogen

radiation

responds poorly to reconstructive surgery

vancouver scar scale: vascularity

0=normal

1=pink (incr in blood supply)

2=red (greater incr in blood supply)

3=purple (significant vascularity)

vancouver scar scale: pliability

0=normal

1=supple

2=yielding

3=firm

4=banding

5=contracture

vancouver scar scale: pigmentation

0=normal

1=hypopigmentation

2=mixed pigmentation

3=hyperpigmentation

vancouver scar scale: height

0=flat

1=<2mm

2=2-5mm

3=>5mm

visual analog scale with scar ranking

scoring system: 0-100; excellent to poor

attributes: vascularity, pigmentation, acceptability, observer comfort + contour and summing individual scores

deficiencies: photo based, does not include patient

advantages: simpler than VSS; interrater and intrarater reliability easier to conduct

patient and observer scar assessment scale

scoring system: 5-50

attributes: VSS+surface area; pt assessments or pain, itching, color, stiffness, thickness, relief

deficiencies: may not adequately express pt perceptions and concerns

advantages: focuses on scar severity from clinician and pt perspective

adheremeter

measures adherence of post surgical scar (restriction or scar mobility)

good validity when compared to VSS at initial exam; less after rehab

good to excellent interrater reliability

excellent intrarater reliability

scar management: pain

extracorporeal shockwave therapy of 100 impulses per cm² on affected location (ESWT)

pulsed high-intensity laser therapy (HILT)

PT

massage 30 min at least 3x/week

scar management: pruritus

rehabilitation massage therapy, containing effleurage, friction, petrissage techniques

CO_2 laser

silicone gel sheets

scar management: pigmentation

silicone gel applied 2x/day on hypertrophic burn scars

silicone gel sheets

5 minute massage treatment

scar management: pliability

pulsed dye laser (PDL) therapy postsurgical scars (wavelength 585 nm w/ pulse duration of 450 ms)

massage

silicone gel and sheets (hypertrophic)

scar management: surface area

PDL (wavelength 585 nm, pulse duration 450 ms, mean fluence per pulse 7.0 J/cm²)—need more evidence on parameters

scar management: thickness

PDL (wavelength 585 nm, pulse duration 450 ms, mean fluence per pulse of 7.0 J/cm²)

joint mobilization and silicone and massage

takeaways of scar management

laser, silicone, massage

hx of wounds

how did the wound occur? (mechanism of injury)

when? (Timeline)—acute vs complex nonhealing/chronic

previous treatments

allergies—iodine, latex, bovine

last tetanus shot?

diagnostic tests

arterial: capillary refill (>5 seconds), ABI, tcPO2, doppler ultrasound (mono or biphasic waveforms)

venous: duplex ultrasonography

radiologic exams

lab values to consider

HbA1C

glucose

serum albumin

pre-albumin

CBC

total lymphocyte count

lipids and triglycerides

creatinine

HbA1C

long-term index of average blood glucose level

glucose

increased blood sugar levels associated with/ incr risk of ulceration and impaired wound healing

serum albumin

levels fall rapidly with protein deficiency and malnutrition

levels <3.5 mg/dL associated with longer length of stay and increased complications

there is a positive correlation btwn low serum albumin and pressure injury severity

pre-albumin

mortality risk increases as prealbumin levels drop; good indicator of effect of nutritional intervention

CBC

used to determine anemia, infection, oxygen-carrying capacity

SED rate will determine infection/inflammatory process

total lymphocyte count

indirect measure of nutritional status and immune function

decreased=associated w/ delayed wound healing, incr mortality

less than 1,500 cells/mm³ =immunocompromised

less than 1,200 cells/mm³=protein deficiency

lipids and triglycerides

level of risk for CV disease

creatinine

malnutrition decr creatinine levels

factors affecting wound healing

age >65

obesity

pressure/friction/shear

infection

nonadherence

lifestyle

health

medications

pain level

mobility

smoking

nutrition

comorbidities: stroke, HTN, PVD, diabetes, CV

effects of aging on wound healing

delayed wound contraction

decr tensile strength

decr epithelialization

decr inflammatory response

decr pain perception

decr mast cells

decr capillary growth

incr in wound dehiscence

pediatric considerations

poor wound care protocols

difficulty in rating pain

integumentary maturity at 33 weeks

decr dermal thickness

incr risk of medical device psi injury

epidermal stripping

epidermal injuries

decr epidermal to dermal cohesion

avoid adhesives, use silicone dressings

pediatric wounds

extravasation injuries

diaper dermatitis

congenital conditions—aplasia cutis, epidermolysis bullosa (NO tape, no gait belt, could cause sloughing)

factors affecting healing

current/PMH: diabetes, vascular insufficiency, previous wounds, sickle cell anemia, chemo, lymphedema, HIV/AIDS

radiation: injury to fibroblasts, decr collagen production, destruction of cells in mitosis, vascular damage, decr tolerance to bacterial burden

factors affecting healing: meds

NSAIDs: decr inflammation

immunosuppressive therapy: prostaglandins and WBC decr

steroids: inhibit collagen synthesis; topical affect epidermal resurfacing

factors affecting healing: pain

pt centered concern: incorporate words pt uses; neonates to 6mo—CRIES; 2mo-7yr—FLACC; children >7–VAS

cause of pain: infection vs inflammation; tissue debridement and trauma

moisture balance (too little=adherent dressing, bleeding; too much=exudate, odor, periwound maceration)

pain meds, modalities, distraction

factors affecting healing: obesity

impaired skin barrier repair: higher skin surface pH, incr sweat glands activity

impeded lymph flow

insulin resistance syndrome

decr vascularity of adipose tissue

excess tension on wound edges, incr likelihood of dehiscence

dehiscence

complication of wound healing including separation of skin and tissue layers that commonly occurs 3-11 days after injury

skin disease aggravated by obesity

skin infections—candida, cellulitis, necrotizing fasciitis (group A streptococci, staphylococcus aureus, fournier’s gangrene affects perineum)

increase in hospitalizations

necrotizing fasciitis

rapidly progressing anaerobic bacterial infection

appears red, swollen, hot, painful

skin becomes blue-gray, fluid filled blisters

full thickness skin loss

extensive gangrene

high mortality

factors affecting healing: social hx

smoking, alcohol, dietary intake, weight loss

activity level

financial resources

family support

home environment

international travel

pt motivation

factors affecting healing: nutrition

nutrients to meet energy demands or cellular proliferation and repair

poor nutritional status can delay wound healing

malnutrition is diagnosed if:

• serum albumin levels below 3.5mg/dL

• total lymphocyte count <1,800 cells/mm³

• BW decr by 15%

systems review

CVP system

integumentary: shoes and orthotics, W/C fit

MSK: gross screen

NMSC:transfers, gait, use of ADs

communication ability, affect, cognition, language and learning style

instruments used to monitor healing

sussman wound healing tool (SWHT)

wound healing scale

pressure sore status tool

wound healing scale

national pressure ulcer advisory panel pressure ulcer scale for healing (PUSH)

identify wound etiology

acute: heal by themselves uneventfully—surgery, trauma/burn, skin tear

complex nonhealing (chronic) wounds

wound assessment: size

linear measurement: length x width x depth

• greatest length x greatest width method

• wound edge to wound edge in a straight line

• measure in cm

clock method, wound as face of the clock

• 12 is head, 6 toward feet, 3 to 9 side to side

• on feet, heel=12 toes=6

wound photography

need informed consent

confidential, accurate pt ID

control timing of photographs

criteria for validating competency

camera equipment/techniques

guidelines on cell phones

information on maintaining photographs safely

effective method of releasing copies to pt

wound planimetry/digital imaging

wound assessment: depth

staging: psi injuries only

partial thickness: involves epidermis and portion of dermis

full thickness: entire epidermis and dermis, extends in subq tissue, potentially beyond fascial plane; slough and/or eschar

tunneling

channel or pathway extends in any direction from the wound through subq tissue or muscle, resulting in dead space w/ potential for abscess formation

undermining

tissue destruction underlying intact skin along wound margins/edges

caused by shearing

measured at 12, 3, 6, 9 position

sinus tract

blind ended tract from surface of skin to underlying area or abscess cavity

caused by degradation of subq tissue in a linear manner

pack

fistula

abnormal communication btwn 2 or more structures or spaces

caused by a dehisced wound or surgical incision

tx by surgery, NPWT

drain