3Homeostasis – first 24 hours ‘Meat’Illustration of wound healing - as building after a disaster and collapse of a house.This is the sequence in simple terms -- subsequent slides is illustrate more completely the activities associated with subsequent steps.
4‘Mess’ Inflammation 1-4 days Hemostasis Platelets The initial reaction to injury is hemostasis -- the stopping of damage and return to normal.There is no healing at this point.
5‘Full’ Proliferation day 4 - 21 Inflammation Leakage of plasma and WBCsDebridementMacrophagesPhagocytosisNeutrophilsInflammation - is the dilatation of the blood vessels and the rush of the white cells and serum products that will begin 'cleaning' the wounds. -- removal of dead tissue and bacteria.This sets the stage for rebuilding‘Full’
6Fibrin, Collagen Bridge to Skin Yellow, caramel like surface, painGranulation peeking, epithelial starting6
7‘Baby skin’ Epithelialization Proliferation Release of growth factors from macrophagesGranulationLymphocytesNeurocytesAngiocytesContractile proteinsFibroblastsAt this point - growth factors are released and not only the removal of dead tissue takes place but the building blocks of new tissue is laid down.This is a primitive stage and the new tissue will transform to the anatomical structures they will replace as healing progresses.A number of requirements exist at this stage - a moist environment, good nutrition, proper temperature and all of the 'healing' elements.This is the ideal point of using growth hormones or wound stimulants. The wound is clean and ready to close.
8Maturation/Remodeling up to 2 years NormalHypertrophicWith incisionKeloidExtends to normal tissueEpithelializationResurfacing migration of skin cellsEpithelial tissue developmentKeratinocytesEpithialization is the point that the granulation tissue develops a matt finish appearance and is the precursor of skin - as it develops the skin will thicken and become more secure.New epithial tissue is moist but as it develops there will be less drainage until skin is complete. ]Growth hormone products are beneficial until the skin is developed. These products may cause callus formation to be rapid and callus care must be monitored to ensure the wound does not prematurely close with bacteria trapped. If this happens - the wound will breakdown, osteomyelitis or if the patient can resist the bacteria the wound will close.‘stronger’Well healed scar – always a scar…weaker tensile strength
9Individual assessment Potential for HealingIndividual assessmentWoundCareRegulation of Wound HealingCascade of overlapping eventsGrowth factorsCytokinesMatrix metalloproteinases (MMPs)Tissue inhibitors of MMPsHormonesAlthough the wound healing cycles is the same for all patients to some degree. The efficiency of healing is influenced by many factors.Diabetics have delayed wound healing due to missing or reduced healing factors. Fortunately, specific elements which are reduced - may be replaced with another factor in the healing cycle.This is why growth hormones or wound stimulants are used and their exact mechanism is not know.
11Culture Infection Heat Redness Swollen Pain Not with neuropathy Blood Sugars elevatedCulture11
12Infection: Assess Clean Wound Wound CleansingPotable tap waterSalineBoiled cooled waterMild soapDove no dye or perfumeCochrane Review 2011 water for cleansing
13Wound Imperatives and Antimicrobials ProductFunctionCost * CDAPromogranPrisma is above with silverMMP bindingON the wound “let it dance with the wound”Promogran 28 sq cm $ sq cm $55.95Prisma 28 sq cm $26.95Iodosorb cadexomer iodineCochrane level support red. Infection, promote healing, but pain reports may limituseOintment $ GmPaste $58.95not recommendedInadine povidone iodineNon-adherent sheets9.5x9.5cm $2.30Silver dressingsSupport of efficacy lackingExpensive 4x4” $18.95Honey dressingsExpensive $ gmCanadian Diabestes Association Store –
14Eschar: risk infection and delay healing StableWetBlackDryHardDrainageMarblingBreakdownAutoamputation?DebrideIodosorb+ cast paddingInadine PHD
15Debride Unstable Eschar DrainageFluctuanceIodine produce will become paler with release of iodine
22Dressing: think ‘Band Aid’ ‘protect, absorb, hold layers’ FunctionProductCostProtectionSurface protectionSilicon (7 days) severe pain or fragileMepitel $ ”x7”Inadine (antimicrobial+)Inadine $2.30 4”x4”Jelonet (petrolatum mesh)10cmx40cm $3.50Tin 10 cm x 7M $36.00Adaptic non-adherent$3.75 3”x8” 3pkgAbsorbAlginates – lowest absorb., sticks if insufficient exudateHydrocolloidMinimal exudate containment and holdDo not recommendThere are no standards for stating performance of dressings (i.e. absorption). Standard for approval ONLY safety not efficacy.
23FunctionProductCostFoamRated high exudate but generally <5ml 4”x4”protection layerbuilt into dressingFragile skinAdhesive border strength varies and can damage skin, change when drainage at borderMepilex 3”x3” $3.75Allevyn Gentle 3x3 $3.95Tegaderm 3.5”x3.5” $4.59**do not recommend unless dressing one weekAcrylicpoor expensiveDo not recommendAbsorbent DressingClassic Pads- incontinent pad 17x20cm can hold 750ml (stay dry)10x20cm 3 $1.95Ultra 17x40cm 2 $3.00Classic super 50 $33.00Gauze – chronic wound or > 48 hours Clean not Sterilepoor absorptionAdequate cover dry gangrene2x2” 200 $1.954x4” 200 $6.50Non-sterile clean packageCast paddingHolds dressings paddingProtouch 17 rolls $17.59Single roll $1.50
24FunctionProductCostTape – peal factor is tension to remove, adhesive is ability to holdFragile skin may strip or tear.*consider skin strength**how many dressings***how frequentOrder of peal factorTranspore (3M) +++Kind Removal (3M) ++Mepitac silicon +Transpore $1.65 rollKind Removal silicon roll $6.95Mepitac silicon $11.50Stockinet - TubiFastRoll or meter*Blue normal limb adultYellow largerBlue 10M $16.95*Yellow 10M $10M $23.75Tubigrip elasticSize determines pressure – straight may constrict limbSkin barriersIf you need these the products are not appropriateSteroidsGood for immediate skin reactions i.e venous excema