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Wound Care. Wound Care Historical Perspective 1867 first antiseptic dressing 1900 true sterilization WW I nonadherent dressings WW II more absorptive.

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Presentation on theme: "Wound Care. Wound Care Historical Perspective 1867 first antiseptic dressing 1900 true sterilization WW I nonadherent dressings WW II more absorptive."— Presentation transcript:

1

2 Wound Care

3 Historical Perspective
1867 first antiseptic dressing 1900 true sterilization WW I nonadherent dressings WW II more absorptive dressings 1960’s and 70’s moisture 1980’s moisture acceptance

4 Goals of Wound Care Minimizing infective risks
Removing dead and devitalized tissue Allowing for wound drainage Promoting wound epithelialization and contraction Tissue perfusion Adequate nutrition

5 Factors That Delay Wound Healing:
Intrinsic Factors Extrinsic Factors

6 Factors That Delay Wound Healing: Intrinsic
Wound infection - Bacterial count - Colonization VS infection - Assessment of infection Foreign bodies Adequacy of blood supply Wound infection: the inflammatory response is prolonged and healing is delayed. Wounds will not heal while infection is present. If defense mechanisms are weakened, a normal bacterial load can become overwhelming. In healthy patients, the critical number of bacterial count is 100,000 bacteria per gram of tissue. Above that number the body loses control over bacterial proliferation and invasion and infection is present. Except streptococcus B, which can cause infection in lesser quantities. Wound culture takes hours to process so most will be placed on a broad spectrum until results are back Foreign bodies may be a cause of wound infection. Such as dirt, bone fragments. Colonization: large number of organisms loosely attached to devitalized tissue, but ther is not movement of bacteria into viable tissue and no host immune response. Infection is definded as the process by which organisms bind to tissue, multiply invade viable tissue and elicit a host immune response. Suspect wound infection: heat, redness, swelling and pain occur. Send culture for sensitivity and gram stain. Prevention, preparation of surgical site, proper wound dressing, hand washing. Adequate blood supply is essential for all aspects of wound healing. Any disorder of the lungs, heart, blood vessels can interfere with healing. Hypoxia impairs the delivery of oxygen and nutrients to the wound and the various cells that defend the body. Neutrophils require oxygen to generate hydrogen peroxide to kill the pathogens. Adequate H/H to maintain oxygen levels, Phagocytosis is inhibited by elevated soudium and glucose levels. Fibroblast and collagen proliferate are slowed. The only aspect of wound healing that can proceed in hypoxic states is angiogenesis.

7 Factors That Delay Wound Healing: Extrinsic Factors
Smoking Elderly Malnutrition Diabetes Medication Obesity Smoking causes vasoconstriction and hypoxia because of the carbon monoxide in the smoke. Smoking increases atherosclerosis and platelet aggregation, further restrict the amount of oxygen in the wound. Malnutrition Protein malnutrition dereases the synthesis of collagen and leukocyte. Fat and carbohydrate malnutrition slows all phases of healing because protein is broken down for energy. Vitamin deficiency leads to slowed production of collagen, immune responses and coagulation. Elderly decreased initial inflammatory responses, which slows the process of healing. The aged client may have decreased circulation, which delays WBC migration to the site and phagocytosis . The aged may already be malnourished and have concurrent disorders that retard healing. Diabetes predisposes many patients to difficulty in wound healing because of impaired collagen synthesis, angiogenesis and phagocytosis Atherosclerosis especially of small vessels is also common in diabetics and impairs tissue oxygen delivery Diabetic neuropathy further impairs healing by interupting the neurological control of healing Medications Use of steroids slows healing by inhibiting collagen synthesis,, decreased wound strength inhibited contraction and impeded epithelization. Others are chemotherapy agents, immunosuppressive agents and anticoagulantants Obesity, greater than 20% of ideal body weight are more prone to dehiscence, herniation and infection. Adipose tissue is difficult to suture and puts the patient at risk for dehiscence. Teach patient to splint when coughing, use of binder.

8 Nutrition and Wound Healing
Anabolic process Immune response Vitamins C, A, B6 B1, B2, zinc, and copper, fatty acids Tissue repair is an anabolic process that requires energy and adequate nutritional building blocks. Patients who are malnourished or actively catabolic, show impaired healing. Inadequate nutrition also retards the immune response limiting opsonization of bacteria and sterilization of wounds. Several vitamin and mineral deficiencies also have been described that predispose to altered wound repair. Vitamins C, A, B6 each are required for collagen synthesis and cross-linking. Deficiencies in vitamins B1 and B2 , zinc and copper cause syndromes associated with poor wound repair. Essential fatty acids are required for cell synthesis, particularly in areas of high cell turnover such as healing wounds. Failure of tissue rather than failure of suture material or surgical knot.

9 Acceleration of Wound Healing
Wound dressing Oxygenation Adequate nutrition Preparation of the wound Future

10 “Three Healing Gestures”
Washing the wound Making plasters-herbs,oils and ointments Bandaging the wound

11 Mechanism Shearing (perpendicular division of tissue) Tearing (<90 degree angle) Compressive (perpendicular with ragged edges)

12 Environment Household – generally “clean”, but not “sterile” Outdoor – contaminated in varying degrees (the barn, industrial machinery) Bites (human, animal) – highly contaminated

13 Modifying Factors Age of wound: Rule of Thumb +/ - 12 hr. Wound: Type (mechanism, sharp vs blunt object) Location and vascularity (face, scalp >12hr.?) Contamination Comorbid factors

14 Co morbid Factors Age Medical hx. – anemia, nutrition, DM, PVD, ETOH, uremia, immuno compromised Medications – steroids, NSAIDS, anticoagulants, anti-neoplastics

15 Tetanus Status > 5yr. < 10yr. Hx. primary series, Need: toxoid > 10yr. Need: toxoid, homotet and toxoid in 60da. No primary series, Need:toxoid, homotet, and toxoid in 60da.

16 Wound Healing Neovascularization Inflammation Epithelialization
Granulation Contraction Remodeling

17 Phases of Wound Healing
Hemostasis hours Inflammatory 0- 3 days Proliferation days Maturation 21 days to 1.5 years Platelets enter to control bleeding macrophages fibroblasts to collagen marix Maturation wound healing Wounds in the non-compromised host progress through the phases of healing without delays In compromised host chronic wounds stagnant between the inflammatory and the prolifertative phases

18 Preoperative Management
Debridement & Irrigation Instrumentation Anesthesia Incision planning Patient consultation

19 Intraoperative Precautions
Incision placement Undermine where necessary Meticulous hemostasis Dead space obliteration **Dermal closure** Suture type & placement Anti-tension taping of wound

20 Postoperative wound care
Topical emollients for moisture Frequent cleaning with H2O2 Early dermabrasion of irregular wounds Avoidance of sun, water Steroid creams, retinoids, etc.

21 Goals of scar revision Flat scar, level with surrounding skin
Good color match with local tissue Narrow Parallel to the patient’s RSTL Absence of straight, unbroken lines

22 ASSESSMENT

23 Neurovascular Pulses, capillary refill, motor/sensory Musculoskeletal Muscle, bone, tendon, joint Foreign Body Visualize/x-ray (radiopaque materials)

24 PREPARATION Hair Clip, not shave Shaving increases incidence of wound infection NEVER SHAVE EYEBROWS

25 Volume 250 – 1000 + ml. NS 60ml. Syringe and 16 – 18 ga. intracath
Irrigation Volume 250 – ml. NS 60ml. Syringe and 16 – 18 ga intracath

26 Irrigation Do not scrub wounds or use full strength Betadine for irrigation (denatures protein, impairs wound healing) : 1 solution for irrigation or temporary dressing

27 Repair Sutures Act as splints Should be Passive
Aim to Return Tissues to Original Position New preplanned Position

28 Sutures Immobilize Tissues to Allow Rapid healing Primary intention
Less bleeding Reduced haematoma Reduced oedema Reduced discomfort Reduced risk of infection

29 Sutures May Aid haemostasis By direct vessel ligation
By compression of vessel against bone edge By retaining a pack or dressing

30 Suture Needles Eyed Swaged Straight/Curved Large/Micro Taper/Spatula
Round Bodied/Cutting/Reverse Cutting

31 Sutures Physical Properties Size Strength Elongation Elasticity
Torsional Stiffness Flexibility Surface Capilliarity

32 Selection of Sutures How long is a suture to be responsible for wound strength? Is absolute fixation required? Is there a risk of infection? How does the choice of sutures affect the tissues?

33 Selection of Sutures How does the suture affect the healing process?
What size of suture Is strong enough? Provides adequate fixation?

34 Suture Types Absorbable Organic Synthetic Catgut Polyglycolic Acid
Soft Plain Chromic Synthetic Polyglycolic Acid Dexon Polyglactin 910 Vicryl

35 Suture Types Non Absorbable Single Filament Multifilament Organic
Nylon Multifilament Organic Silk Multifilament Metallic Stainless Steel Silver Multifilament with Sheath Polyamide Supramid

36 Biological Properties of Sutures
Tissue Reaction depends on Material Organic > Synthetic Absorbable Materials Catgut Proteolytic absorbtion Vicryl Hydrolytic absorbtion Non Absorbable Natural but have considerable tissue reaction Synthetic have little tissue response

37 Suture Sterilization Gamma Radiation Electron Radiation Ethylene Oxide
Cobalt 90 Electron Radiation Linear Accelerator Ethylene Oxide Gaseous Liquid

38 Suturing Techniques Continuous Subcuticular Blanket Stitch
Over and Under Interlocking Purse String Interrupted Simple Mattress Vertical Horizontal

39 Suture Tying Techniques
Hand Ties One Handed Two Handed Instrument Ties Minimise trauma by Delicate handling of tissues Not constricting tissues Avoidance of dead space Close but not over approximation of tissue edges

40 Lidocaine Inject in sub-q tissue ( 21 – 25ga. needle)
Anesthesia Lidocaine Inject in sub-q tissue ( 21 – 25ga. needle)

41 Anesthesia Lidocaine with epinephrine (if you must), but Never in digits, nose, ear, penis Skin Prep Betadine (not in wound) Always prep more area than you think you need

42 Primary – suture, staples, glue
Secondary – granulation and re-epitheliazation Delayed primary closure – closure after 48 – 72hr. Interrupted sutures in ED

43 DRESSINGS

44 DRESSINGS Dry sterile dressing – avoid ointments(tend to macerate) Avoid tape on skin if possible Paint skin with tincture of benzoin if you must use tape

45 DRESSINGS Encircling dressing ( ACE) Do not wrap tightly Immobilization Excessive motion impairs wound healing Splinting may be necessary

46 Characteristics of Dressings
Protect wound from bacteria and foreign material Absorb exudates Prevent compression to minimize edema an obliterate dead space

47 Dressings Be nonadherent to limit wound disruption
Create a warm, moist occluded environment to maximize epithelialization and minimize pain Be esthetically attractive

48 ANTIBIOTICS

49 Indications Contaminated wound Areas of marginal viability
Wounds involving joints, open fractures All human bite wounds Most animal bite wounds Generally, wounds > 12hr. old

50 SPECIAL WOUNDS

51 Bite Wounds High risk of infection with involvement of bones, joints, tendons, vessels, nerves Puncture wounds (difficult to irrigate and decontaminate)

52 Dog Bites 75% involve the extremities Most dog bites in children involve an extremity Severe facial lacerations involve the cheeks and lips as they try to "kiss the doggie”

53 Dog Bites Closure Dog bites – scalp, face, trunk, proximal extremities may be closed if superficial Human bites – “ never” close primarily (delay48 –72hr.)

54 Puncture Wounds Never close Irrigate drain, if necessary Foot – shoe on or barefoot? Increased infection risk if shoe on

55 Abscesses Incise, drain, irrigate, loosely pack with Iodoform gauze Return at 24 hrs. for irrigation fresh pack Return at 48 hrs. for pack removal and healing by granulation

56 Abscesses New onset DM may present with abcess Antibiotics may be indicated in addition to I&D

57 Nail / Nail Bed Injury Subungual hematoma, < 40 % nail area, nail bed injury unlikely, but distal phalanx fx. might be present Treatment: Battery cautery to make drainage hole in nail, irrigate with 25ga. needle and 1% lidocaine Nail Bed - requires surgical repair

58 Foreign Bodies Inert – (glass, metal), may leave unremoved if necessary Organic – (wood), must be removed


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