wound care

WOUND CARE

2016. 3. 10 STAFF LECTURE Dep. of Emergency Medicine, Sung Wook, Song

WOUND CARE

REFERNCES

‣ Tintinalli’s Emergency Medicine, 7th, Section 6: Emergency Wound Management

‣ Rosen’s Emergency Medicine, 8th, Section 4: Soft tissue injuries

‣ Trott AT. Wounds and Lacerations. Elsevier Sciences 2012.

‣ Dealey C. The Care of Wounds. John Wiley & Sons 2012.

‣ Knoop K, Stack L, Storrow A, et al. The Atlas of Emergency Medicine, Third Edition. McGraw Hill Professional 2009.

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WOUND CARE

CONTENTS

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1. BACKGROUNDS 2. WOUNDS HEALING 3. WOUND TYPE & CHARACTERISTICS 4. EVALUATION & DOCUMENTATION 5. MANAGEMENT

WOUND CARE: 1. BACKGROUNDS

SKIN STRUCTURE & FUNCTION

▸ Epidermis = Protection

▸ Dermis = nourishment of epidermis

▸ Hypodermis(subcu. tissue) = adipose tissue insulation

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https://www.youtube.com/watch?feature=player_embedded&v=d-IJhAWrsm0

https://www.youtube.com/watch?feature=player_embedded&v=d-IJhAWrsm0


DEFINITION OF WOUND

Discontinuity of the skin, mucous membrane or tissue caused by physical, chemical

or biological insult ”“

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ETIOLOGY OF TRAUMATIC WOUNDS

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CLASSIFICATION OF WOUNDS

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ACUTE Recent wound which has yet to progress through the sequential stages of healing

CHRONIC Wound that has arrested in one of the wound healing stages usually inflammatory phase

Cuts, Abrasion, Lacerations,

Contusions, Pucnture, Skin flaps and Bites

BENBOW ( 2005)

Any wounds > 3 months considered


CLASSIFICATION OF WOUNDS: NEW TREND

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Acute vs Chronic Wounds

SIMPLE WOUND those wounds which are readily managed by local wound care /contraction, direct closure, skin grafting, local tissure rearrangment.

COMPLEX WOUND these are large wounds requiring tissue distant from wound site i.e. regional, distal transposition or microvascular composite tissue transfer

PROBLEM WOUND Those wounds which fails to achieve closure with the above methods or recurres due to local or systemic causes.

WOUND CARE: 2. WOUND HEALING

WOUND HEALING PROCESS

1. Hemostasis

2. Inflammation

3. Proliferation (Granulation)

4. Remodeling (Maturation)

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WOUND HEALING

1. Hemostasis

2. Inflammation

3. Proliferation (Granulation)

4. Remodeling (Maturation)

contraction

scarring

remodeling

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KELOID HYPERTROPHIC SCAR

HEMOSTASIS INFLAMMATORY PHASE 11

PROLIFERATIVE (GRANULATION) PHASE 12

REMODELING (MATURATION) PHASE 13


NORMAL HEALING PROCESS

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RELATED FACTORS: “DIDN’T HEAL”

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DIABETES

INFECTION

DRUGS

NUTRITION

TISSUE NECROSIS

HYPOXIA

EXCESSIVE TENSION ON WOUND EDGE

ANOTHER WOUND

LOW TEMPERATURE

WOUND CARE: 3. WOUND TYPE & CHARACTERISTICS

CLOSED

▸ Contusion: tissue injury w/o breaking of skin

▸ Hematoma: tissue injury that disrupts a blood vessels

CONTUSION

HEMATOMA

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OPENED

▸ Incision

▸ Laceration: traumatic seperation of tissues with clean, smooth edges

▸ Abrasion: traumatic scrapting away of surface layers of skin

▸ Puncture: sharp, pointed object through skin or mucous membrane

▸ Penetrating: variable-sized open wound through skin and underlying tissues

▸ Avulsion: Tearing away of a structure or a part

▸ Ulceration: excavation of skin/underlying tissue from injury or necrosis

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ACCORDING TO WOUNDS DEPTH

▸ Superficial: epidermis

▸ Partial Thickness

epidermis + dermis

▸ Full Thickness

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OHTERS: PRESSURE ULCER

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OHTERS: DIABETIC FOOT ULCER

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▸ 14~20% : amputation

GRADE 0 GRADE 1

GRADE 2 GRADE 3

GRADE 4 GRADE 5


OHTERS: ARTERIAL ULCER

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▸ Located in area of pressure, tip toe

▸ Very painful

▸ Deep, may involve joint

▸ Usually circular

▸ Wound base: pale to black

▸ Little edema


OHTERS: VENOUS ULCER

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▸ Irregular wound edges

▸ Skin scaling

▸ Moderate to heavy exudate

▸ Partial to full thickness

▸ Malleolous region


OHTERS: SURGICAL WOUND CX.

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WOUND INFECTION DEHISCENCE

WOUND CARE: 4. EVALUATION & DOCUMENTATION

WOUND DESCRIPTION

▸ Location

▸ Measurements (cm): width x length x depth

▸ Tunneling / undermining

▸ Color of wound bed

▸ Color of exudate (drainage), odors

▸ Condition of surrounding tissue/skin (wound edge)

▸ Sign of infection

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MEASURING WOUNDS: LENGTH & WIDTH

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MEASURING WOUNDS: 3RD DIMENSION

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MEASURING WOUNDS

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3:009:00

12:00

6:00

▸ Undermining: tissue destruction to underlying intact skin along wound edge

▸ Tunneling/Tracts: a measurable tract from the wound bed

▸ Non-symmetrical: Across longest and widest areas


VISITRAK GRID

VISITRAK GRID

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STANDARDIZED SERIAL DIGITAL PHOTOGRAPHY

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PORTABLE DIGITIZING FOR WOUND MONITORING

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COLOR OF WOUND BEDWOUND HEALING CONTINUUM


COLOR OF WOUND BED


COLOR OF WOUND BED“CHICKEN FAT”

LOOSE, STRINGY, NONVIABLE TISSUE


COLOR OF WOUND BED


WOUND EXUDATE (DRAINAGE)

▸ Serous: clean, watery

▸ Sanguineous: bright red

▸ Serosanguineous: pale, red, watery mixture of serous and sanguineous

▸ Purulent: thick, yellow, green, tan or brown


CONDITION OF SURROUNDING TISSUE/SKIN

▸ Redness

▸ Induration: abnormal firmness of tissue with a definite margin

▸ Callous: firm, thickened area of tissue (DM foot)

▸ Maceration: softening of tissues by soaking in fluids

▸ Denuded: loss of superficial epidermis


SING OF INFECTION

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▸ Increased pain

▸ Copious amounts of exudate

▸ Malodour

▸ Cellulitis

▸ Pyrexia

▸ Inc. size of wound

▸ Pocketing/Abscess formation


WOUND INFECTION CONTINUUM


WOUND INFECTION CONTINUUM

Grey et al, 2005

HAND HYGIENE

FECAL & URINARY MX. SYSTEM


DOCUMENTATION

WOUND CARE: 5. MANAGEMENT

WOUND CARE PLAN (WCP) DEPENDS ON

▸ Type of wound

▸ Necrotic wound

▸ Sloughy wound

▸ Granulating wound

▸ Epithelialized wound

▸ Infected wound

▸ Mixed wound

▸ Amount & type of Exudate

▸ Critical colonization or infection

WoundCarePlan(WCP)

Pa#entCantered–dealingwithpersonwitha

chronicwound

Holis#c–Totalcare-Notonlywounditself-needtoaddressptsotherneeds,diseases,andpsychosocialwellbeing

Inter-disiplinaryNeedsPar>cipa>onofmul>tudeofdisciplines

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WOUND CARE PLAN (WCP) INCLUDE :

▸ 1’ Ass. & Documentation

▸ Identifying the risk factors

▸ Optimize Local wound care

▸ Systemic Tx. & Nutritional support

▸ F/U & Ongoing ass. periodically

▸ Change the plan if not improving

▸ Re-assessment

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WoundCarePlan(WCP)

Pa#entCantered–dealingwithpersonwitha

chronicwound

Holis#c–Totalcare-Notonlywounditself-needtoaddressptsotherneeds,diseases,andpsychosocialwellbeing

Inter-disiplinaryNeedsPar>cipa>onofmul>tudeofdisciplines

Pa#entsName–RMW67yrDiabe#cptFromMaharagamaAre#redClerkDateofClerking-21/5/2012

Wound–MedialsideofthertlegExtendingfromMedialMaleolusregion

MaximumLength–13cmMaximumWidth-8cmMaximumDepth2mmSurfacearea-39cm2

Stage11PeriwoundArea–blackDiscoloraFon+

NounderminingNotunnelling

Exudate–MucoidMildNoevidenceofinfecFonSmell–NotoffensiveColourofthewoundbed–Mixed

Necrosis5%GranulaFon30%Slough15%Epethelialized5%

NoevidenceofRednesssurroundingskinNoregionalLymphadenopathyVenousInsufficiencyGeneral–MobileptAfebrileNotanemic-9.8g/dl


BASIC WOUND CARE

▸ Cleanse debris from the wound

▸ Possible Debridement

▸ Manage Exudate

▸ Promote Granulation & Epithelialization

▸ Possibly Treat Infections

▸ Minimize Discomfort

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CLEANSE DEBRIS: “THE SOLUTION TO POLLUTION IS DILUTION”

▸ Wound irrigation (N/S): most effective method

▸ Pressure : high (5-70 psi) >> low (0.5-1 psi)

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POSSIBLE DEBRIDEMENT

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SURGICAL AUTOLYTIC ENZYMATIC

BIOLOGICAL MECHANICAL (VERSAJET)


MANAGE EXUDATES: DRESSING

▸ Dry to Dry: primary closed wounds

▸ Wet to Dry: untidy/infected wounds

▸ Wet to Wet: clean open wounds/granulating surfaces

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KEEP MOIST TISSUE MOIST & DRY TISSUE DRY!

Nature of Exudate

Type of wound

Aim of exudate management Method /Agent

No exudate Dry Keep the base moist

Hydrocoloid agent Intrasite

Need occlusive and non occlusive dressing

Mild exudate Moist Keep the wound moist Absorb moisture

Moderate Wet Keep the wound in moist state by reducing exudate

Absorb moisture Form dressing

Heavy Wet +++ Keep the wound moist Absorb


MANAGE EXUDATES: INACTIVE DRESSING MATERIAL

▸ Guaze

▸ Polyurethane film

▸ Vaseline tule

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MANAGE EXUDATES: ACTIVE DRESSING MATERIAL

▸ Hydrogel

▸ Hydrocolloid

▸ Calcium Alginate

▸ Foam

▸ Collangenase

▸ Antimicrobials

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Hydrogeldressing:Autoly1cdebridementbyrehydra1ngthewoundandfacilitathealing.Usedinwoundwithsmallamountofescharandpredisposedtodessica1on,infectedwounds,requiresecondarydressingontopofit.



▸ Hydrogel

▸ Hydrocolloid


▸ Foam

▸ Collangenase

▸ Antimicrobials

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▸ Hydrogel

▸ Hydrocolloid


▸ Foam

▸ Collangenase

▸ Antimicrobials

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Alginatesusefulinwoundswithsignificantexudatedfluids,theycanabsorbfluids20:mestheirdryweight,nottobeusedonnonexuda:vewoundsastheywilldryupthewound.Ifusedfordrywoundtheyshouldbehydratedwithsalinepriortoapplica:on



▸ Hydrogel

▸ Hydrocolloid


▸ Foam

▸ Collangenase

▸ Antimicrobials

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FoamdressingHighlyabsorp.veandactslikeawickmakingitusefulinhighlyexuda.vewounds.

▸ Hydrogel

▸ Hydrocolloid


▸ Foam

▸ Collangenase

▸ Antimicrobials



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CadexomeriodineSlowreleaseiodineforcosistentbactericidallevelswithoutthewoundcelldamagingeffectsseenwithpyodine-iodineproducts

An#microbialdressingsMostbeneficalagentisSilver,broadspectruman#microbialagentincludingVRE,MRSA.


PROMOTE GRANULATION & EPITHELIALIZATION

▸ Granulation enhancers

▸ Minimal dressing changes to reduce disturbances to the granulation

▸ Avoid usage of substances which impede granulation tissues

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TREAT INFECTIONS

▸ Systemic antibiotics

▸ Local antiseptics to the wound

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ADVANCED WOUND CARE

▸ Growth Factors

▸ Bioengineered Tissue

▸ Curative Surgery

▸ Cellular Tissue Products

▸ Negative Pressure wound therapy

▸ Hyperbaric oxygen therapy

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WOUND CARE: SUMMARY

THANK YOU.

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wound care

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