Small Animal Nursing I Final Review - Wound Care, Bandaging, Recumbent Patient Care, Nutrition, and Compassion Fatigue

Abrasions

Partial-thickness dermal wounds

Preservation of the dermis

What permits abrasions to heal well by re-epithelialization?

Accelerates epithelialization as opposed to a wound that scabs over

What is the benefit of a moist wound environment?

Lacerations (tissues sharply incised, trauma to the surrounding area is minimal)

Wounds that involve the tearing of skin and deeper tissues

Age of the lesion, size, and the extent of contamination

What does a wound's ability to close depend on?

Lavaged, debrided, and closed primarily

How are fresh lacerations with limited contamination treated?

Degloving injury (bone abrasion, joint exposure, heavy contamination with

foreign debris)

Type of injury that occurs as a large section of skin is torn off the underlying tissue

Aggressive wound lavage and wound debridement before granulation tissue

formation

How are degloving injuries initially treated?

A bandage that holds moisture

What is an occulsive bandage?

Penetrating wounds (bites, bullets, arrows, sticks, antlers, etc.)

Which wound is most commonly seen in veterinary patients?

Due to extensive injury to deeper tissues that may not be apparent on skin inspection

Why are penetrating wounds difficult to assess?

Sealed with sterile gauze and adhesive occlusive film (Ioban-3M)

How are penetrating wounds that involve the thorax and abdomen treated before surgery?

Contaminated

Bite wounds are always considered to be _____

• Surgical exploration, lavage, and debridement.=

• Closure depends on ability to remove contaminated and damaged tissue

• Drains used to move fluid out of dead space

How are penetrated wounds treated?

Severe inflammation and sepsis that can culminate in systemic inflammatory response syndrome (SIRS)

What an result if bites or underlying trauma caused by penetrating wounds are left untreated?

Classified on the base of the depth and the size of the affected area

How are burn injuries classified?

Animals with poor cutaneous blood flow due to hypothermia

Which patients are most at risk of heating pad related burns?

Confined to the outermost layer of skin (epidermis)

What constitutes a first-degree burn?

• Skin is red and painful but re-epithelializes within a few days without treatment

• Often heals by secondary intention

How is a first-degree burn treated?

Full-thickness epidermal and partial-thickness dermal injury

What constitutes a second-degree burn?

• Epidermis can appear yellow-white, black, charred, and may slough and leak

plasma

• Painful or non-painful to the touch

• Hair follicles can be spared or destroyed

How does a second-degree burn appear?

• Full extent of damage may not be known until several days after injury

• If not severe, will heal by epithelialization with minimal scarring in 10-21 days

• Severe burns may require surgical intervention

How is a second-degree burn treated?

Full-thickness injuries of the epidermis and deep-layer dermis, characterized by eschar that is insensitive to touch

What constitutes a third-degree burn?

Eschar

Leathery, black layer of dead tissue that sloughs off healthy skin after injury

• Extensive surgical intervention with eschar removal

• Wound debridement

• Application of skin grafts and flaps if second-intention healing is not possible

• Life-threatening and systemic effects are likely

How is a third-degree burn treated?

Involve tissue extending beyond the dermis, including muscle, tendon, and bone

What constitutes a fourth-degree burn?

• Surgical intervention required to prevent scarring that restricts movement

• Animals are critically ill and require intensive care to survive

• Fish skin grafts can be used when skin grafting is not an option

How is a fourth-degree burn treated?

Skin compression on hard surfaces during extended periods of recumbency

What causes decubitual ulcers over bony prominences?

Lateral or caudal surface of the olecranon

Identify the most common location for decubital ulcers

Pressure necrosis of the skin particularly over the olecranon, the calcaneus, and bony prominences of the feet

What can inappropriate or prolonged periods of bandaging lead to?

Prevention

What is the best treatment for decubital ulcers and bandage-associated pressure sores?

• Reddening of the skin with hair loss as early signs

• White, purple, or black color changes indicate severe damage to the dermis • Severe damage leads to sloughing and an open wound

Identify signs of pressure on the skin

Treated by second intention healing

How are most pressure sores treated?

Infection, dehiscence, or seroma formation

Identify complications that may occur at any time during the wound healing process

Dehiscence

The breakdown of a surgical wound

• Insufficient debridement causing wound edges start to become necrotic

• Poor local blood supply

• Suture reaction

• Movement of wound edges

What causes wound dehiscence?

• Redness and irritation

• Swelling

• Discharge

• Separation of the wound edges

Identify the signs of wound dehiscence

Seroma (usually don't require treatment as the fluid will be reabsorbed gradually over time)

The accumulation of serous fluid under the skin

• Where surgery has involved removal of SQ tissue

• Where skin is particularly loose or mobile creating dead space

Where do seromas typically form?

1 - Inflammatory phase

2 - Proliferative phase

3 - Maturation phase

Identify the phases of wound healing

Inflammatory phase (begins immediately and lasts for 3-5 days)

What is the first phase of wound healing, and how long does it last?

Platelets aggregate and form a fibrin clot within the wound to control bleeding and stabilize the wound edges

What is the role of platelets during the inflammatory phase of wound healing?

Macrophages and neutrophils

Identify two types of white blood cells present in the inflammatory stage that engulf pathogens to help the immune system heal injuries

• Modulate wound healing by releasing more growth factors

• Remove bacteria and cellular debris from the wound

What is the role of macrophages and neutrophils during the inflammatory phase of wound healing?

Formed of white blood cells and body fluid that leaks from blood vessels into nearby tissues

What is wound exudate?

The lag phase because wound strength is at its lowest during this phase

The inflammatory stage is also referred to as

Proliferative phase (Begins at 3-5 days after injury and continues for 2-4 weeks)

What is the second phase of wound healing, and how long does it last?

Proliferative phase

Identify the phase of wound healing marked by fibroblasts and endothelial cells migrating into the wound

A type of cell that contributes to the formation of connective tissue

What is a fibroblast?

Angiogenesis

The formation of new blood vessels

Granulation tissue

New capillaries that fill a wound 3-5 days after injury

Proliferative phase

In which phase does granulation tissue develop?

• Fill the wound 3-5 days after injury

• Produces a bacterium-inhibiting substance

• Produces scaffolding for re-epithelialization

What is the role of granulation tissue during wound healing?

Fibroblasts, myofibroblasts, endothelial cells, inflammatory cells, and new blood vessels, all connected by the extracellular matrix

What is granulation tissue made up of?

Fibroblasts decrease in number and are replaced by tissue rich in collagen

What occurs once the wound is covered by granulation tissue?

4-5 days after injury, starting at the wound edges then moving toward the center

When does epithelialization begin?

Enhances cell migration and cleanup as opposed to tissue that desiccates (dries up)

What is the benefit of a moist wound healing environment?

When myofibroblasts within the granulation tissue contract

When does wound contraction occur?

Reduces the size of the wound (Begins about 1 week after injury and can last for weeks)

What is the function of wound contraction?

• Maturation phase

• Begins after wound contraction, approximately 3 weeks after injury and continues for weeks to months

What is the final phase of wound healing, and when does it begin?

Maturation phase

Phase of wound healing characterized by remodeling and realignment of collagen fibers along tension lines

• Bleeding occurs after injury and platelets form clot to control bleeding

• Macrophages and neutrophils clean wound and modulate wound healing

• Release of growth factors

Briefly summarize the inflammatory phase of wound healing

• Fibroblasts and endothelial cells enter wound

• Formation of granulation tissue

• Epithelialization occurs under the scab until it falls off

• Wound strength increases considerably

Briefly summarize the proliferative phase of wound healing

• Remodeling and realignment of collagen fibers occurs

• Wound tissue gains the most strength

Briefly summarize the maturation phase of wound healing

• Cushing's disease

• Hypothyroidism

• Diabetes

• Hyperglycemia

• Chronic viral infections (FeLV, FIV)

• Orthopedic disease

• Neurological disease

• Poor nutritional status

• Obesity

Identify concurrent patient health issues that may delay healing

Alters tissue perfusion and O2 release

How can diabetes delay healing?

Interferes with defense against infection

How can hyperglycemia delay healing?

May lead to prolonged recumbency and associated decubital ulcers and poor wound healing

How can orthopedic or neurologic disease delay healing?

Low protein and albumin levels delay wound healing and strength

How can poor nutritional status delay wound healing?

Increased risk of wound infection and dehiscence due to decreased vascularization of fatty tissues impairing healing ability

How can obesity delay healing?

Degree of contamination and the length of time the wound has been open

What is wound classification based on?

Clean wound

Wound that is atraumatic and surgically created under aseptic conditions

Clean-contaminated wound (GI tract, respiratory tract, urogenital tract)

Wound created by controlled, surgical entry into contaminated areas

Clean wound is surgically created under aseptic conditions

Clean-contaminated wound is created by controlled, surgical entry into contaminated areas such as the GI or urogenital tract

What is the difference between a clean wound and clean-contaminated wound?

Contaminated wounds

Recent traumatic wounds with bacterial contamination from the pavement, soil, or saliva from a bite

Dirty wounds ( > 100,000 bacterial organisms/gram of tissue)

Older wounds with obvious infection often caused by an abscess, bite, contaminated puncture wound, or necrotic tissue

• Oncological radiation therapy

• Chemotherapy

• Corticosteroids

Identify concurrent factors that may delay wound healing

Can lead to tissue fibrosis and vascular scarring

How can oncologic radiation therapy delay wound healing?

Can suppress bone marrow function and decrease resistance to infection

How can chemotherapy delay wound healing?

Decrease the body's inflammatory response thereby increasing the risk for infection

How can corticosteroids delay wound healing?

Patient stabilization

What takes priority over wound care?

Wound lavage (LRS or 0.9% sodium chloride)

The washing out of a wound with a warm isotonic crystalloid fluid

To remove foreign or necrotic debris

Why is lavage used for wound management?

8 - 12 lbs per square inch using a pressure bag inflated to 300 mmHg

What is the appropriate lavage pressure strong enough to aid debris removal without damaging viable tissue?

Cytotoxic potential towards wound cells

What must be kept in mind when using antiseptic scrubs for wound care?

0.05% dilution (1:40 dilution of 2% chlorhexidine with water)

What is the proper dilution for a chlorhexidine solution?

0.1% dilution (1:100 dilution of 10% povidone-iodine with sterile saline)

What is the proper dilution for a povidone-iodine solution?

Remove contaminated, devitalized, or necrotic tissue and eliminate foreign debris from the wound

What is the goal of wound debridement?

Excision

The surgical removal of tissue from the body

Staged debridement

Used to remove necrotic tissue in wounds that may improve if given time to heal or may be removed if viability is lost

A mechanical (wet-to-dry) adherent primary bandage

Technique used during the inflammatory stage to non-selectively debride heavily contaminated wounds

Maggots

A biologic technique used for selective debridement of chronic wounds with poor tissue health

En bloc excision

Debridement technique that allows small wounds to be excised with primary closure

• Time since the injury

• Extent of foreign body contamination

• Degree of bacterial contamination

• Viability of the tissues

• Damage to neurovascular supply

• Location of the wound

• Availability of skin for closure

• Tension on the wound

Identify factors that can affect wound closure

Primary intention wound healing

Healing of a wound across a surgically closed incision using sutures, staples, or skin glue

• Direct apposition (wound edges close together)

• Primary intention wound healing

Surgical wounds are closed with _____ and will heal by _____

• Usually surgically created wounds

• Clean atraumatic lesions after wound lavage

• Small wounds with contamination can be excised en bloc and closed primarily

Which type of wounds typically undergo primary intention wound healing?

Delayed primary closure (closed before granulation tissue forms)

A wound older than 6-8 hours can be left open for 2-3 days to allow drainage and eliminate infection and then surgically closed

Secondary closure (third intention healing)

Wounds older than 6-8 hours are allowed to form healthy granulation tissue and then surgically closed

• Wounds older than 6-8 hours

• Infected or necrotic tissue

• Failed primary closure

Secondary closure is appropriate for which type of wound?