Wound Management

Wound Classification

superficial, partial thickness, full thickness

ex: abrasions, punctures, lacerations, blisters, avulsions, incisions

Superficial wounds

loss of epidermis only

Partial Thickness wound

disrupt epidermis and dermis

Full thickness wound

involve all layers skin to subcutaneous layer & beyond

4 stages of healing

1-hemostasis

2- inflammation

3- proliferation

4- remodeling

Hemostasis

occurs immediately, BV constict to stop bleeding, blood clots form

Inflammation

occur w/in 4 days, neutrophil & macrophage work to remove debris, infection prevention

*if get stuck in this phase→ worry about infection

Proliferation

occur w/in 2 week, wound rebuilds CT for protection, granulation of skin promoted, tissue rebuild (look worse before better)

Remodeling

occur anywhere 24 day-1yr, new epithelial tissue forms (new healthy skin)

Goals for wound closure

control bleeding

remove necrotic tissue & promote wound healing

prevent, eliminate, or control infection

absorb drainage (exudate)

maintain moist wound environment

protect from further injury

protect surrounding infection or trauma

“air out” allow O2 to help increase healing

Steps to manage acute skin trauma

Cleansing

Debridement

Dressing

Cleansing

apply non toxic solution to aid in removal of exudate, bacteria, foreign debris and dressing residue to create environment that is conducive to healing

Potable tape water or Saline= superficial to full thick

irrigate

Irrigation

4-15 psi

range 7-11 psi w/ syringe or cannula

Debridement

removal of necrotic or devitalized tissue, microorganisms, contaminate tissue, fobrin or forgein bodies and cellular debris

avoid pushing debris further into injury

type of debridement

Irrigation

hydrotherapy

wet to dry/wet to moist

scrubbing

conservative sharp

chemical

autolytic

enzymatic

hydrotherapy

soak/bath

*typically avoided b/c cross contamination

my be useful for fingers/toes

wet to dry

avoided b/c tissue removal, p! and nonselective

Wet to moist

typically used for scabs, to creat moist environment to promote heal

Scrubbing

only superfical/partial thickness/ contaminated w/ small debris

conservative sharp

surgical cutting out

nail, callus, blisters, avulsion

Chemical debride

avoid b/c damages surviving tissues

Autolytic debride

body disolve nectrotic tissue

enzymatic debride

topical enzymes break down debris

Dressing

wound covering aimed to support healing

Primary Dressing

makes contact w/ wound bed

secondary dressing

desinged to be used in combo w/ primary to provide additional absorption, portection or occulsion for wound bed

Non-Occlusive Dressing

allow air to pass through to wound surface

• woven, non woven, impregnated (has med/anticoagulant) sterile gauze (change dressing

• non-adherent pad

• adhesive strips & patches

• Wound closure strips (may need change every 5 days)

Occlusive Dressing

semi-permeable and Impermeable dressing designed to interact w/ wound to facilitate healing & lessen infection risk

• alginate (hemostatic/blood clotting agent)

• films/foams

• hydrogel- semi occulsive high water content to hydrate wound and aid autolytic debride

• hydrocolloids (2 layer, closer layer to pull exudate out)

• dermal adhesive (glue)

Common procedure for wound closure

adhesive skin tape: bandaid, butterfly/steri strip

topical liquid skin adhesive: Dermabond, histocycl, benzethonium choloride (new skin), expensive/expire quick

Sutures

asepsis

absence of infection organism

goal of aseptic technique is to prevent transfer of microorganism into wound

Sterille vs nonsteris

aseptic technique cna include both

once person dons sterile equipment- maintian sterility

nonsterile person must not contaminate

Sterile Field

imaginary box encompass space above area

only sterile packages, instruments, material may be placed

under no circumstance should sterile and nonsterile mix

nonsterile person must not contaminate

Adhesive Skin tape

used to close small superficial, low tension wounds or reinforce larger wounds closed by suture

used after remove suture to protect wound during proliferation & early remodel phases

temporarily close wound during comp before more definitive wound closure after

Topical Liquid Skin Adhesive

polymers formulated to be used in place of non-absorbable suture for primary closure of skin wound

approved for closing skin wound & form barrier against certain bacterial infection

products have shown a lower incidence wound infection

Sutures

used to approximate wound edges in good position to facilitate healing

should be in place long enough to allow healing (facial 3-5 days, trunk/extremities 5-7, scalp feet back hands over jt 10-14 days)

Absorbable sutures

degrade and eventually eliminated either by inflammatory reactions caused by enzymes in body or hyrolysis

non-absorbale sutures

weakens but are permanent and do not dissolve in body

natural sutures

biologic origin & typically cause more inflammatory reaction in tissue

cat gut= purified collagen fibers from sheep or cow intestine

Synthetic sutures

nylon, silk

Monofilament vs multifilament

1 strand vs braided w/ greater resistance

Suture sizes

according to diameter w/ 0 as reference size

number alone indicates progressively larger sutures (1,2,3)

number followed by 0 indicate progressively smaller (2-0, 4-0)

sutures needles

shape: curve vs straight

type of point: taper point, cutting needle, reverse cutting needle

degree of curve

basic suturing techniques

depend on type of wound, area to be sutur, preference/experience of suturer

common technique: simple, interrupted, continuous (running), vertical vs horizontal mattress, subcuticular (intradermal)

After suture care

keep area clean and dry 24-48hr & monitor for signs of infection

typically cover w/ bandage

Suture removal

use sterile suture removal kit & gloves

use forceps, lift the suture, snip suture close to skin (below knot), grasp knotted end w/ forceps & slowly pull suture through from other side

cover wound w/ dressing→ still healing

Risk factors Impaired wound healing

age, hormones, heredity, nutrition, infection, smoking, alcohol, chronic conditions (diabetes/clotting issues)