Wound Care

What is the largest organ of the body?

The skin

Where is the skin the thickest?

The hands and the soles of the feet

What are the three layers of the skin?

- Epidermis

- Dermis

- Subcutaneous

What is the function of the epidermis?

Protection and pigmentation (melanocytes)

What are dermal appendages?

Specialized structures derived from the epidermis that reside within or extend into the dermis

What are four examples of dermal appendages?

- Hair follicles

- Glands

- Sensory nerves

- Blood vessels

What is the function of the subcutaneous layer of the skin?

Insulation

What are six effects of aging on skin?

- 50% reduction in cell turnover rate

- 20% reduction in dermal thickness

- Reduction in dermal vasculature

- Redistribution of subcutaneous tissue

- Decreased adhesion between skin layers

- Decreased sensation

What does decreased adhesion between skin layers make older people more susceptible to?

Tearing

What are three ways of classifying wounds?

- The way it heals

- Phase of healing

- Type of wound

What are three wound classifications based on the way it heals?

- Primary intention

- Secondary intention

- Tertiary intention

What is primary intention?

- Edges are pulled tightly together and stitched/stapled closed to heal

- Surgical procedure or sutured/glued in the ED

- Involves re-epithelialization and results in minimal scarring

How long should primary intention take to heal?

4-14 days

Why would secondary intention be used over primary?

When the edges cannot be easily approximated

What are two drawbacks of secondary intention?

- Healing by wound repair which takes longer

- Some scar formation

How are wounds that require secondary intention classified?

- Partial thickness: wound extends through epidermis and into, but not through the dermis

- Full thickness: wound extends through epidermis and dermis and may involve subcutaneous tissue, muscle, and bone

What is tertiary intention?

Wound is deliberately left open to allow edema or infection to resolve

In tertiary intervention, what is done after edema or infection resolves?

Wound is surgically closed

What are the four phases of wound healing?

- Hemostasis

- Inflammation

- Proliferation

- Maturation/remodeling

What occurs during the hemostasis phase of wound healing?

Vascular contraction and platelet aggregation

What occurs during the inflammatory phase of wound healing?

Phagocytosis

How long does the inflammatory phase of wound healing last?

4-6 days

What occurs during the proliferation phase of wound healing?

Angiogenesis, collagen deposition, epithelialization

How long does the proliferation phase of wound healing last?

4-24 days

What occurs during the maturation/remodeling phase of wound healing?

Collagen realigns along tension lines

How long does the maturation/remodeling phase of wound healing last?

21 days to 2 years

What are nine factors that affect wound healing?

- Nutrition

- Oxygenation

- Infection

- Age

- Chronic health conditions

- Medications

- Smoking

- Access to healthcare

- Social support

What are three important nutritional factors for wound healing?

- Protein

- Albumin levels

- Fruits and vegetables

How does infection slow down wound healing?

Perpetuates inflammatory phase

What are three types of chronic health conditions that can affect wound healing?

- Autoimmune conditions

- Cancer

- Chronic kidney disease

What are two examples of medications that can affect wound healing?

- Steroids

- Blood thinners

How does smoking slow down wound healing?

Decreased oxygen and overall circulation to tissues

What are eight types of wounds?

- Surgical

- Traumatic

- Arterial/venous

- Pressure

- Neuropathic

- Burns

- Dermatologic

- Autoimmune

Which aspect of surgical wound care is the physical therapist most likely to be involved with?

Inspection

What are three situations where a patient might experience a traumatic wound?

- Car accident

- GSW

- Stabbing

What are two examples of traumatic wounds?

- Open fracture

- Road rash

Where are arterial and venous wounds usually located?

- Arterial: lateral

- Venous: medial (think of great saphenous vein)

What causes neuropathic wounds?

Lack of sensation

What should be performed frequently in patients with a condition such as diabetes that causes impaired sensation and puts them at an increased risk for neuropathic wounds?

Checks of their feet

What are two types of autoimmune wounds?

- Rashes

- Open sores

Who will be more involved than the physical therapist in care for autoimmune wounds?

Dermatologist

What are seven risk factors for pressure ulcers?

- Previous pressure ulcer

- Advanced age

- Decreased mobility

- Impaired sensation

- Impaired cognition

- Incontinence

- Poor nutrition

Where is skin breakdown most likely in a patient with incontinence?

Over sacrum

What are two settings that have a high prevalence and incidence of pressure ulcers?

- Acute care

- Long-term care

What are three populations that have the highest prevalence of pressure ulcers?

- Quadriplegia

- Femoral fractures

- Critical partner

What is the difference between shear and friction in pressure wounds?

- Friction relates to one surface moving over the other

- Shear is tangential force applied to a surface as two surfaces are moved in opposite directions (e.g. a patient slides down in bed as the HOB is raised)

Where are pressure ulcers seen?

Bony prominences

What are seven places pressure ulcers are commonly seen?

- Sacrum

- Ischial tuberosities

- Heels

- Elbows

- Occiput

- Greater trochanters (patients spending time in side-lying)

- Vertebrae in very thin patients

What are the four stages of pressure ulcers?

- I: redness over an area, non-blanchable

- II: epidermis is not intact, going into but not through the dermis

- III: complete loss of dermis, down to subcutaneous tissue but not through it

- IV: extends through subcutaneous tissue; exposed muscle, tendon, or bone in the wound bed

What makes a wound unstageable?

Covered in a layer of scabbing or tough, black eschar, and what is underneath cannot be seen

What are two places stage I pressure wounds are typically seen?

- Heels

- Sacrum

How should an unstageable wound be managed?

Wait for the layer of scabbing/black eschar to come off on its own because it is protecting the underlying tissue

What is a suspected deep-tissue injury?

Purple or maroon discoloration of intact skin; looks like a boggy bruise, skin is not open but can tell that inside of that there is a deeper injury

What are three pressure ulcer risk assessment tools?

- Norton

- Braden

- Gosnell

- Pressure Ulcer Scale for Healing (PUSH)

What are the five categories of the Norton Pressure Ulcer Scale?

- Physical condition

- Mental condition

- Activity

- Mobility

- Incontinence

Do lower or higher scores on the Norton Pressure Ulcer Scale indicate higher risk?

Lower scores

What are the six categories of the Braden Scale for Pressure Ulcers?

- Sensory perception

- Moisture

- Activity

- Mobility

- Nutrition

- Friction and shear

Do lower or higher scores on the Braden Scale for Pressure Ulcers indicate higher risk?

Lower scores

What are the five categories of the Gosnell Scale for Pressure Ulcers?

- Mental status

- Continence

- Mobility

- Activity

- Nutrition

Do lower or higher scores on the Gosnell Scale for Pressure Ulcers indicate higher risk?

Higher scores

What are the three categories of the PUSH that scores are based on?

- Surface area

- Drainage

- Tissue type

How are physical therapists involved in prevention of pressure wounds?

- Recognize risk and intervene

- PT consult for positioning, mobility, and education

- Utilize interdisciplinary team for nutrition and incontinence

What are five physical therapy interventions for pressure wounds?

- Wound care (better to prevent)/debridement, dressings, pulsed lavage, wound vac

- Recommend pressure reducing devices/wheelchair cusions, specialty bed (no donuts)

- Positioning schedules

- Exercise to strengthen patient to improve mobility/flexibility

- Functional traning/transfers, gait

What are four MOIs for burns?

- Thermal

- Chemical

- Electrical

- Radiation

What is the most common MOI for burns?

Thermal

What are four sources of thermal burns?

- Hot liquid

- Touching hot surface

- Radiator

- Fire

What causes chemical burns?

Typically something that is very acidic

What causes electrical burns?

Electrical current

What causes radiation burns?

Radiation therapy

What are five cardiovascular effects of burn injuries?

- Edema

- Hypovolemia

- Tachycardia

- Hypotension

- Dysrhythmias

What are six pulmonary effects of burn injuries?

- Smoke inhalation

- CO poisoning

- Pulmonary edema

- Hypoxia

- ARDS

- Pneumonia

What are five metabolic effects of burn injuries?

- Increased metabolic rate

- Heat loss

- Malnutrition

- Hyperglycemia

- Metabolic acidosis

How can major traumas or infections lead to metabolic acidosis?

- Hyperglycemia occurs as a stress response to trauma/infection

- Stress causes release of more glucose and becomes more insulin-resistant

- Can lead to metabolic acidosis

What are five psychological effects of burn injuries?

- Depression

- Confusion

- PTSD

- Disrupted sleep

- Agitation

What is the rule of 9s?

Used as a way to estimate the amount of body surface area that the burn covers

What are four classifications for burns based on severity?

- Superficial burn

- Superficial partial thickness burn

- Deep partial thickness burn

- Full thickness burn

What layer of the skin is affected by a superficial burn?

Involves only the epidermis

What does a superficial burn look like?

- Dry red or pink skin

- Blanches easily

- Minimal edema

- No blisters

How long do superficial burns take to heal?

3-5 days

What can cause a superficial partial thickness burn?

Results from severe sunburn, scalds

What layers of the skin are affected by a superficial partial thickness burn?

Epidermis and upper dermis (papillary dermis)

What does a superficial partial thickness burn look like?

- Moist, weeping

- Blisters

- Blanch easily

Are superficial partial thickness burns painful?

Yes, as all nerve endings are still intact

How long do superficial partial thickness burns take to heal?

10-14 days

What can cause a deep partial thickness burn?

Scalds or chemicals

What layers of the skin are affected by a deep partial thickness burn?

Epidermis and dermis (deep dermal layer)

What does a deep partial thickness burn look like?

- Mottled white and red

- May have blisters

- Sluggish capillary refill

Are deep partial thickness burns painful?

May be painful or insensate

How long do deep partial thickness burns take to heal?

Healing times vary

What can cause a full thickness burn?

Results from immersion scald, flame, chemicals, and electricity

What layers of the skin are affected by a full thickness burn?

Epidermis and dermis (down to subcutaneous tissue)

What does a full thickness burn look like?

White, grey, or black eschar (eschar is leathery and dry)

Are full thickness burns painful?

Minimal pain and decreased sensation (nerve endings are destroyed by the burn)

What occurs as a result of a full thickness burn?

Scarring

What is essentially the standard of care for burns?

Silvadene (topical agent) with a petroleum type of gauze placed on top of it

Why are skin grafts used?

- Burn covers a large surface area

- Scarring would decrease mobility

What is a skin graft?

Desired thickness of skin for grafting is shaved away and placed over a wound site

What types of burns that require a skin graft?

- Deep partial or full thickness

- Clean non-infected wounds

What might be done before a skin graft is performed?

Surgical debridement

Are autografts (self) or allografts (from donor) the preferred method for skin grafts?

Autografts