wound healing for the plastic surgery nurse -...
TRANSCRIPT
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Wound Healing for the
Plastic Surgery Nurse:
Wound Healing 101
Valentina S. Lucas, PhD, APRN-BC
VCUHS Plastic and Reconstructive Surgery
VCUHS Wound Healing Center
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Course Objectives
Describe principles of wound healing
Develop a plan of care based on wound assessment
Develop a framework for product selection that is goal
based and patient centered.
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Wounds
Typically classified as either acute or
chronic
Surgical wounds are often considered
acute wounds but can develop into
chronic wounds
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Normal Wound Healing Stages
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There are over 4,000 wound care
products!
How do we choose?
Shotgun approach is
not acceptable
Begins with patient
assessment
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Patient Assessment
Accept that no two patients or two wounds are going to be the same
ROS
Past Medical Hx/Treatment Hx
Diabetes, Hypertension, Respiratory Disorders, Connective Tissue Disorders
Past Surgical Hx
Social Hx
Risk/Healing Obstacles
Allergies
Physical Exam, including full assessment of wound
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Wound Assessment
Partial thickness vs. full thickness (acute or
chronic)
Only pressure ulcers are staged
Location
Size
Description of wound and periwound tissue (pay
attention to scars, radiation damage, atrophy,
pigment changes)
Note bone, tendon, joint, hardware, foreign
bodies etc
Drainage/exudate
Odor
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Partial Thickness Wounds
Shallow wound that extends through the epidermis and may partially extend to the dermis
Painful
Usually highly exudative
Examples include Stage II PU, second degree burns, blisters, road rash
Usually heal by epithelial proliferation and lateral migration
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Full Thickness Wounds
Deep wounds that extend through the epidermis and dermis and to or into the subcutaneous tissue or further
Often complicated by necrotic tissue and/or infection
Heal by primary, secondary or tertiary intention
Includes surgical wounds, Stage III and IV PU, diabetic ulcers, full thickness burns
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DIME or BED
DIME
Debridement
Infection Control
Exudate Management
Wound Edges
BED
Bioburden
Exudate Management
Debridement
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Exudate Management
Exudate management
means maintaining a
moist wound
environment while
controlling excess
wound drainage.
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A Moist Wound Environment . . . .
Promotes granulation
and collagen synthesis
Prevents eschar
development which
slows healing
Allows faster
epithelization
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Products to Promote a Moist
Wound Environment:
Transparent Film Dressing
Hydrogel
Hydrocolloid
Continuously Moist Saline Gauze
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Transparent Film Dressing-Provides Moist
Environment
Vapor permeable
Impermeable to bacteria and contaminants
Allows wound’s own drainage to keep the wound moist
Examples-Op-Site, Tegaderm, Polyskin
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Hydrogels-Promotes Moist Environment
Available in gels,
sheet dressing or
impregnated gauzes
Water or glycerine
based
Examples-Carrasyn
Gel, Intrasite Gel,
Dermagel, Elasto-Gel,
Vigilon, SoloSite Gel
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Chronic Venous Insufficiency
Note dryness and eschar development,
began using hydrogel
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Hydrocolloid-Promotes Moist
Environment
Composed of gelatin, pectin and carboxymethyl-cellulose
Allows wound’s own drainage to keep the wound moist
Occlusive
Do not use with infected wounds
Examples-DuoDerm, Restore, Tegasorb
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Continuously Moist Saline Gauze-
Promotes Moist Environment
Gauze must remain moist between dressing changes. Do not confuse this with a wet to dry dressing which can mechanically debride both necrotic and healthy tissue.
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Heavily Draining Wound
Often seen with
chronic, non-healing
wounds.
Often seen with
edema, especially leg
edema.
Drainage often contains
increased proteases
which can harm the
wound bed
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Wound Care Products to
Absorb Excess Drainage
Alginate
Foam
Composite Absorptives
Sodium Chloride Dressing
Wound Drainage Collector
Negative Pressure Wound Therapy
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Alginate-Absorbs Wound Drainage
Can absorb up to 20-
30 times its weight
Derived from
seaweed
Available in rope or
pad
Examples-Carrasorb,
Kaltostat, Maxorb
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Foam Dressings
Made of polyurethane foam
Hydrophilic
Less absorbent than alginate
Examples-Lyofoam, Allevyn, Mepilex
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Moderately Draining Wound
Weeping skin tear
from tape removal
Applied foam with
silicone backing
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Moderately Draining Wound
Blisters secondary
to epidermal
sloughing from tape
removal
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Application of Foam Dressing
Will cover foam dressing with
gauze and porous tape.
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Impregnated Gauze
Gauze
impregnated with
hypertonic sodium
Example-mesalt
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Debridement
The removal of
dead, devitalized,
or necrotic tissue
from the wound.
Debridement is
complete when
100% of the wound
bed tissue is viable.
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Identification of Necrotic Tissue
May be brown, black, gray or yellow
May be stringy, dry leathery or hard
May be loosely or firmly attached
May cover all or part of the wound
Slough – soft & moist, loose, stringy or firmly adherent
Eschar – thick & leathery
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The problem with necrotic tissue:
Germs love to grow in necrotic tissue. Debriding the wound leads to reduction in the bioburden of the wound.
It keeps wounds in the inflammatory phase and retards healing
It prevents new granulation tissue
Resistant biofilms more prone to develop in necrotic tissue
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Types of Debridement
Autolytic
Mechanical
Enzymatic
Sharp/Excisional
Maggot Debridement Therapy/Larval
Therapy/ Biodebridement
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Autolytic Debridement
The use of an occlusive dressing to allow
endogenous enzymes in the wound
drainage under the dressing to debride
necrotic tissue
Do not use with infected or ischemic
wounds
Transparent Film, Hydrocolloid, Hydrogel
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Mechanical Debridement
The use of an external force to remove
the necrotic tissue
Wet to dry dressing
Wound scrubbing
Hydrotherapy, whirlpool or pulsatile lavage
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Enzymatic Debridement
The topical application of proteolytic enzymes to
breakdown the necrotic tissue.
Collagenase Santyl
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Maggot Debridement Therapy
Larval Therapy Biodebridement
Alternative to surgical
debridement for patients
who cannot undergo
surgery
Can be more accurate
than sharp debridement
Secrete proteolytic
enzymes, then eat &
digest necrotic tissue;
stimulate healing and kill
bacteria
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Maggot Debridement Therapy
Beware of YUK factor-
educate staff, patient
and family
Place hydrocolloid
dressing periwound,
apply maggots, cover
with nylon chiffon
dressing, moist dressing,
then dry dressing.
Remove and change
dressing every 48 hours.
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Bacterial Balance
All wounds are
contaminated but
certain organisms are
especially virulent.
They can multiply and
invade the host,
causing systemic
infection.
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Bacterial Burden
Contamination - Infection Continuum
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Signs & Symptoms of Infected
Wounds
Classic Signs
Advancing erythema
Fever
Warmth
Edema/swelling
Pain
Purlence
Secondary Signs
Delayed healing
Change in color of wound bed
Poor quality of granulation tissue
Increased odor
Increased serous drainage
Increased wound pain
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Bacterial Balance-Categories of
Wound Care Products/Treatments
Topical Antibiotics
Topical Anti-microbials
Topical Antiseptics
Antimicrobial Dressings
Systemic Antibiotics
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Antibiotics/Anti-bacterials
Silver Sulfadiazine
Nitrofurazone
Neomycin
Metronidazole
Gentamicin
Bacitracin
Mupirocin
There may be a
risk of resistance
with prolonged
use of antibiotics.
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Antiseptics
Topical agents that inhibit the growth of microorganisms
Examples include povodine iodine, Sodium Hypochlorite, Acetic Acid, Chlorhexidine, Hydrogenperoxide
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Antimicrobials
Silver
Cadexomer Iodine
Honey Products
Methylene Blue
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Silicone Dressings
Non adherent dressings available in many
forms
Fenestrated sheets (washable and
reusable)
May modulate inflammation
Comfortable removal (decrease pain)
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Advanced Wound Care
Products
Growth Factors
Negative Pressure Wound Therapy
Mist Therapy
Compression wrapping
Human and Artificial Skin and Tissue
Substitutes/Tissue Engineering
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Putting It All Together
Wound Factors
Bacterial Balance
Exudate Management
Wound Bed
Prep/Debridement
Patient Factors
COST
Who is doing wound care
How often can someone
do wound care
Compliance and
Accountability
Follow up
H&P
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A Few Tips
Wounds are dynamic and the treatment should change as the wound heals or fails to heal.
If your treatment hasn’t helped in 2-4 weeks, change the treatment.
Clean, aseptic technique is usually adequate. Exceptions-fresh post-op wounds, immuno-compromised patients and deep cavity wounds.
Remember to treat the whole patient, not just the hole in the patient.
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References
Bryant, Ruth A. and Nix, Denise P. Acute &
Chronic Wounds: Current Management
Concepts, Third Edition. Mosby Elsevier, 2007.
Krasner, Diane L., Rodeheaver, George T. and
Sibbald, R.Gary. Chronic Wound Care: A
Source Book for Healthcare Professionals, 4th
Edition. HMP Communications, 2007.
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Thank you
Go forth and
facilitate
wound
healing.
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