Wound Healing: Clinical Wound Management (via jillianmaul8)

Wound not progressing thru the Normal healing pathway

Chronic wound

Partial thickness goes through these two tissue layers

Epidermis + dermis

Full thickness goes through these three tissue layers

Epidermis + dermis + sub-Q

Partial thickness wound heals by ____ ONLY; no only phases of healing occur

Re-epithelialization

___ thickness wound heals through full wound healing process; includes inflammation, proliferation, re-epithelialization, and remodeling

Full

High ___ might indelicate infection or inflammation

WBC

low ___ may indelicate immunosuppression, chemotherapy, steroids, surgery, radiation, malnutrition

WBC

Normal WBC

4500 - 11000

This lab value determines risk of bleeding

INR

___ INR is normal, ok for sharp debridement

1.0

This level of INR is increased; selective or sharp deride with caution

1-2

This level of INR means they need anticoagulation therapy; consider automatic enzymatic debridement

2-3

This level of INR indicates risk of excessive bleeding

> 3

Blood glucose optimal control is < __ mg/dL

<150

Active infection (incr/decr) blood glucose

INCREASE

Normal Hyperglycemia // NO WOUND HEALING if over this amount

> 180 mg/dL // >200

A1C values

Normal: <5.7%

Pre-diabetes: 5.7-6.4%

Diabetes: 6.5% +

These two lab values are nutrition related

Albumin and pre-albumin

___ pre-albumin is needed for healing

> 29 mg/dL

During dermatology screening, we should determine baseline ___

SKIN TONE

Change in skin tone

Erythema

Due to aging, hyperpigmentation (incr/decr) over time

INCREASES

No FC on pitting edema scale and vascular assessment pulse exam (slide 42-46)

Non-viable tissue; byproduct of the immune system "wound debridement"

Slough

Granulation tissue is formed via what process?

Neoangiogenesis

Non-viable tissue; no breakdown by immune system; usually black and indicates no blood flow; "gangrene"

Eschar

T/F: we should do debridement on eschar on heel

FALSE!!!! Unless it is infected, we dont want calcaneous to get exposed

(Viable/nonviable) adipose tissue is golden, brown-yellow, dull

NON-VIABLE

(Viable/nonviable) adipose tissue is yellow, globular, shiny, and moist

VIABLE

Excess moisture on the skin

Maceration

Not enough blood flow; area is cooler and can turn blue/purple

Cyanosis

Bruising

ecchymosis

Occurs when fibrotic changes happen around the wound from chronic inflammation; wound is very FIRM compared to other parts of body; occasional temperature change

Induration

Fluid coming out of wound; normal process

Exudate

Exudate volume is (higher/lower) in inflammatory phase

HIGHER

This type of drainage is blood

Sanguineous

This type of drainage is typical; contains serum combined with RBC; clear pink-ish fluid

Serosanguinious

Clear yellow drainage from wound

Serous

Thick, opaque, potentially odorous and infectious drainage from wound

Purulent

T/F: odor always indicates inflection

FALSE!!! It's often due to dressing

This outcome measure includes 13 items related to the wound bed, periwound, and drainage

Bates-Jensen wound assessment tool (BWAT)

Finish outcome measures

This outcome measure is for all wound types; 45 items that encompasses 3 domains: physical sx/everyday life, social life, well-being

Cardiff wound impact schedule

Review POC paradigm chart

Is tap water safe to cleanse the wound?

YES — but NO WELL WATER

T/F: sterile saline can be used even if has been opened for 24 hours

FALSE!

This is a wound cleanser that is non-cytotoxic, has a pH neutral to skin, is a broad-spectrum antimicrobial, and can penetrate & disrupt biofilm; anti-inflammatory & reduces pain/itching

Hypochlorous acid (HOCl)

T/F: cytotoxic agents such as hydrogen peroxide, hypochlorite, and betadine are recommended wound cleansers

FALSE!!! AVOID CYTOTOXIC AGENTS

For a wound that is grossly infected, has thick exudate, necrotic tissue and slough, what method would we use to cleanse the wound?

Pulsed lavage w/suction

T/F: pulsed lavage with suction is indicated in a wound that has long tunneling and undermining

FALSE!! CONTRAINDICATION

what is a precaution for pulsed lavage?

INFECTION RISK — SPRAYS ALL OVER THE ROOM (WEAR PPE!!!!)

To unbridle or remove a restraint; this method improves assessment of wound, decreases infection risk, removes physical barriers, and activates healing pathways

Debridement

What to consider before debridement....

-blood flow

-patient tolerance (pain)

-PT tolerance and safety (takes a long time)

-what is under that tissue (+ emergency planning if you hit important structure)

How much do you debride?

Everything that is necrotic; can do multiple days in a row

This type of debridement is "nature's process"; selective but slow; follows moist wound healing properties

Autolytic debridement

T/F: with autolytic debridement, we want the wound to be as dry as possible to avoid infection

FALSE!!!! WE WANT MOIST SO CELLS ARE ALIVE

___ debridement is least costly

AUTOLYTIC (hydrogel)

This type of debridement involves applying topical enzymes to break down necrotic tissue; selective; faster and more expensive than autolytic

Enzymatic debridement

How often is enzymatic debridement performed?

DAILY

If patient has non-infected semi-large wounds with extensive necrotic tissue and is unable to tolerate selective debridement or has limited access to debridement services, we would use this method

Enzymatic debridement

autolytic and enzymatic debridement are contraindicated if...

THE WOUND IS INFECTED

Enzymatic debridement can NOT be used with __ or __ dressings

Silver or iodine

Autolytic and enzymatic debridement precautions include ___ maceration

Periwound

T/F: autolytic and enzymatic debridement are extremely effective in immunocompromised population and patients with poor perfusion

FALSE!!!! NO BLOOD FLOW, NO IMMUNE RESPONSE

This category of debridement is faster than autolytic and enzymatic debridement but is non-selective (pulls off some healthy tissue)

Mechanical debridement

Monofilament pads, whirlpool, contract ultrasound, wet-to-dry dressings (DONT DO), and pulsed lavage are all forms of ___ debridement

Mechanical

"Virtually painful" method of mechanical debridement; fibers trap bacteria and pull of necrotic tissue; excellent for the non-wound care clinician

Monofilament pads

T/F: Whirlpool is no longer standard of care due to extremely high infection risk, uncontrolled pressures, and dry skin

TRUE — alternative: shower

Use of sharp instrument to remove ONLY necrotic and non-viable tissue; selective & rapid but may be painful

Selective debridement

When doing selective debridement, we need to consider patient ___ ability

CLOTTING (determine INR — caution with liver failure pts)

When to stop selective debridement? (3)

-when all non-viable tissue exposed

-exposed a new structure (bone, tendon, nerves, organs)

-fatigue

For INR > ___ do NOT do selective debridement because patient is an uncontrolled bleeding risk

3.0

This type of debridement is known as larval therapy or maggot therapy; relatively rapid (3-5 days) and painless

Biologic debridement

What is the gold standard to determine infection/bioburden (bacteria in a wound)?

Tissue biopsy

This type of infection is also known as "critical colonization"; bacteria is kind of winning over WBCs, enough to irritate wound

Superficial

NERDS: clinical signs of critical colonization (superficial infection)

Nonhealing wound

Exudative wound

Red and bleeding granulation

Debris on wound surface

Smell/unpleasent odor

Management for a superficial infection?

Topical treatment

STONES: clinical signs of a deep infection

Size is bigger

Temperature increased

Oprobe to or exposed bone

New or satellite areas of breakdown

Exudate, erythema, edema

Smell

Do superficial infections need antibiotics?

NO, just topical tx

Management for deep infections?

Systemic tx or surgical intervention

T/F: topical dressing can fix a deep infection

FALSE!!!! Use topicals to control it, but will need systemic tx

This material has antimicrobial properties; products release it over 3-7 days (dont need new one everyday); concern for bacterial resistance

Silver

If you haven't cleared an infection using topical treatment in __ days, try systemic

14 days

This material has antimicrobial properties and is effective against biofilms; non-cytotoxic to human cells; do NOT combine with collagenase

Cadexomer iodine

This material has antimicrobial properties and is used in autolytic debridement due to high sugar content; stimulates stalled wounds and is available in multiple dressing cateogries

Manuka honey

Type of bacterial biofilm that is individual, free-floating; "typical" bacteria that causes ACUTE infection by triggering inflammatory response from immune system; metabolically active so antibiotics work on this

Planktonic bacteria

(Planktonic bacteria/biofilm) are able to be cultured in healthcare labs

Planktonic bacteria

This is a community of bacteria encased in extra polymeric substance (EPS); low antibiotic response since they are not metabolically active; induced chromic inflammatory response; an example is dental plaque

Biofilm

Biofilm can form in ___ hours; it is NOT VISIBLE, detectable, OR curable at bedside

6-12 hours

Biofilm (does/does not) respond to antibiotics

DOES NOT!!!!!

Can biofilm be rinsed or wiped away?

NO!!!!!! Must be physical removed by scraping

Bacterial biofilm as high prevalence in (acute/chronic wounds)

CHRONIC — prevent healing and release planktonic bacteria that cause more acute infections!

Biolfilm infections are prevalent in this population

Cystic fibrosis

When a wound dries....

-cells die

-nutrients dry up/evaporate

-no diffusion of O2

-dressing sticks to dry tissue = PAIN

-wounds cool off w dressing changes

Moist wound healing dressings need to be changed (more/less) often

LESS

When doing dressing selection, what do we want 1st layer, directly on the tissue?

"Active layer" — think abt moisture balance and if it's gonna hurt to remove

Dressing selection layers

1. Active layer (direct contact)

2. Fill space + manage drainage (consider cost - dont fill w silver!)

3. Secure (adhesive)

Hydrogel, collagenase ointment, and antibiotic ointments are used for moisture (donating/maintenance/absorption)

DONATING (+)

Impregnated gauze is used for moisture (donating/maintenance/absorption)

MAINTENCE + (donates a LITTLE)

Hydrocolloid dressing is used for moisture (donating/maintenance/absorption)

MAINTENANCE - (absorbs a LITTLE)