Wound Care Principles: Blood Flow, Nutrition, and Teamwork

What are the key pillars of wound care?

Moist Wound Healing

Know Blood Flow

Pressure Relief

Nutrition Matters

Debridement PRN

Match Interventions to Wound Needs

Why is blood flow important in wound care?

Blood flow is crucial as it affects healing; ABI and vascular studies are particularly important for upper extremity/hand wounds.

What conditions can lead to impaired blood flow in patients?

Conditions such as vasculopathy, coronary artery disease (CAD), and diabetes can lead to decreased blood flow.

Vasculopath

Person with impaired Vascular system

What is the significance of a very low ABI in wound care?

A very low ABI may indicate the need for revascularization surgery.

What role does teamwork play in wound care?

Teamwork enhances patient recovery, with the patient as the leader and various providers including physicians, nurses, case managers, therapists, pharmacists, and nutritionists.

What should be considered when treating a patient with a wound?

Treat the whole patient, considering their past experiences, educating them, and customizing treatment plans to meet their needs.

What are some indicators that a wound may need referral to a specialist?

Very low ABI

Failure to respond

Doesn't fit into a category of wounds

Suspect infection

Exposed bone/capsule

How does diabetes affect wound healing?

Diabetes can increase arteriosclerosis, which may impair blood flow and delay wound healing.

Stratum lucidum

a layer of the epidermis found only in the thick skin of the fingers, palms, and soles

fibroblasts produce

all 3 types of fibers (collagen, reticular, elastic fibers) through synthesis and secretion of protein subunits that combine or aggregate within the matrix

epidermis thickness

0.06-0.6mm

dermis thickness

2-4 mm

keratinocytes form in the

basal layer

stratum corneum

the most superficial layer of the epidermis consisting of dead cells

water resistant layer of skin

startum corneum

stratum granulosum

3rd layer of the epidermis where kertohyalin and kertin are made

startum spinosum

langerhans and melanocytes

langerhans cells

epidermal macrophages that help activate the immune system

stratum basale

the deepest layer of the epidermis consisting of stem cells capable of undergoing cell division to form new cells

merkel cells are located in

stratum basale

Where are keratinocytes produced?

stratum basale

startum basale attaches to

basal lamina

cells of the epidermis

keratinocytes, melanocytes, dendritic cells, tactile cells

merkel cells

touch receptors in the skin

dermis layers

papillary and reticular

epidermis vascular

avascular

dermis vascular

yes

dermis cell types

fibroblasts, macrophages, mast cells, white blood cells

fibroblasts provide skin

toughness and stretchability

mast cells

Cells that release chemicals (such as histamine) that promote inflammation.

superficial wounds

involve only the epidermal layer of the skin. DO NOT Bleeed

partial thickness wounds

Involve epidermis and part of dermis.

partial thickness examples

Superficial and deep partial thickness Blister

2nd degree burn

Stage 2 pressure injury

Wagner grade 1 ulcer

full thickness wounds

extend into the subcutaneous tissue and beyond

full thickness examples

Full stage thickness burn

Stage 3 pressure injury

Subdermal (4th degree burn)

Wagner grade 1-5 ulcers

signs of inflammation

redness, heat, swelling, pain, loss of function

angioblasts

cells that form new blood vessels

fibroblasts build

granulation tissue

myofibroblasts

wound contraction

keratinocytes

cause epithelialization

senescent cells

cells that are alive but not functioning

Reasons for chronic wounds

1. Presence of foreign bodies

2. Pathogenic invaders (bacteria, fungi, virus) → open longer = higher exposure

3. Underlying diseases (DM, circulatory disorders)

4. underactive cells (ex: macrophages, WBCs)

5. hyperactive MMPs (diggers) --> excessive tissue degeneration

6. excess inflammatory cytokines (thinking wound is still dirty)

7. bacterial contamination

deterrents to wound healing

-wound characteristics

-local factors

-systemic factors

-inappropriate wound management

local factors that affect wound healing

-circulation

-sensation

-mechanical stress

Oxygenation, stressors and pressure, sensation

circulation and healing

Lack of adequate circulation predisposes the individual to ischemia, infarction, and consequent infection of necrotic tissue, also known as gangrene.

systemic wound healing factors

Diabetes mellitus

Nutrition deficiency

Atherosclerosis

HIV, AIDS

Medications

Aging

Radiation Therapy

Nutrition and wound healing

Healing requires more protein, carbs, lipids, Vit A and C, minerals like iron, zinc and copper. Malnourished clients may need time to improve nutritional status before surgery if possible. Obese at increased risk of infection and slower healing because adipose tissue has minimal blood supply.

functions of the dermis

thermoregulation, sensory reception, supports epidermis, nourishes epidermis, infectiom protection

steroids and healing

High doses of 30-40mg per day interfere with wound healing

NSAIDS and healing

Long term use may possibly affect healing but not certain

alcoholism and wound healing

malnutrition and being drunk may cause more injuries due to impairment

Obesity and wound healing

Fatty tissue lacks adequate blood supply to resist bacterial infections and deliver nutrients and cellular elements for healing

smoking decrease tissue oxygenation by up to

30% for 1 hr

etiology of AI

-Trauma-Acute Embolism-Diabetes-RAThromboangitis-ARTERIOSCLEROSIS

ateriosclerosis

hardening of the arteries

Atherosclerosis

narrowing of the arteries

Normal A1C

less than 5.7%

Prediabetic A1C

5.7-6.4

DIABETIC a1c

6.5% or higher

Pain arterial wounds

intermittent claudication, resting, positional, nocturnal

Position of arterial ulcers

distal toes, dorsal foot, areas of trauma

presentation of arterial ulcers

-Round, regular

-May conform to precipitating trauma

-Pale granulation tissue if present

-Possible necrotic tissue/black eschar

-Minimal or no bleeding/drainage

periwound and extrinsic tissue of arterial ulcer

-o Thin, shiny, anhydrous skin

-Lack of hair growth

-Thcikened yellow nails

o Pale, dusky, or cyanotic skin

o Dependent Rubor

o Edema unusual, may indicate VI or CHF

Pulses in Arterial ulcers

diminished or absent

temperature and arterial ulcers

decreased

Physical Therapist Tests for Arterial Insufficiency

o Pulses

o Doppler Ultrasound

o Ankle-Brachial Indexo Rubor of Dependency

o Capillary Refill

o Venous Filling Time

ABI 1.1-1.3

vessel calcification

ABI 0.9-1.1

normal

ABI 07.-0.9

mild to moderate arterial insufficiency

ABI 0.5-0.7

moderate arterial insufficiency, intermittent claudication

ABI <0.5

Rest Pain (severe arterial disease)

ABI <0.3

rest pain and gangrene

Rubor of dependency test

-Assesses LE arterial circulation

-Patient begins with legs elevated to 35 to 45 degrees and assessed for color (pale vs. normal "pink")

-Then, placed in a dependent position

-Normal response: to see a rapid pink flush in the feet. Arterial insufficiency will demonstrate a deep, red color (rubor) after 30 seconds in this dependent position.

Rubor of dependency pallor after 45-60s of elevation

Mild arterial insufficiency

Rubor of dependency pallor after 30-45s of elevation

moderate AI

Rubor of dependency pallor within 25s

Severe AI

Normal capillary refill

less than 3 seconds

Venous Filling time >25 seconds

severe AI

Venous Filling time >5 S

VI

Normal venous filling time

5-15 seconds

AI venous filling time

>20 s

Normal TCOM

50 mmHg

TCOM >35

Supports wound healing

Tissue oxygen <30

unlikely to heal without surgical intervention

Toe pressure of 30 mmHg or less indicates:

POOR CHANCE OF HEALING FOR FOOT OR TOE ULCER***

A toe pressure is considered normal if it is:

50 mm Hg

Toe pressure of 30mmhg or more

good healing potential

Risk Factors for VI Ulcer Development

o Vein dysfunctiono Valve damage

o Calf Muscle Pump Failure

o Trauma

o Previous VI ulcer

o Advanced age

o Obesityo Diabetes

pain venous ulcer

Little pain, decreased with legs elevated

position of Venous ulcers

medial malleolusMedial leg

presentation of venous ulcers

irregular shape, red and ruddy wound bed

-yellow, fibrous slough, glossy coating

-hypergranulation

-moderate to heavy exudate, shallow wounds

Periwound and extrinsic tissue with venous ulcers

o Edemao Dermatitis and cellulitis are common

o Hemosiderin staining

Liodermatosclerosis

pulses in venous insufficiency

Normal but may be difficult to palate due to edema

Temperature and venous ulcers

Normal to mild warmth

C6

Current venous ulcer

no compression if ABI is

< or equal to 0.5

Trendelenburg with Tourniquet on

<20s = Deep or perforatr vein Incompetance

Tourniquet off

<10s= superficial vein incompetance

Contraindications to compression

ABI < 0.7Acute infection

Pulmonary edema

Uncontrolled or severe congestive heart failure

Active DVT

Claustrophobia (relative)