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 Wound ◦ Breach in the continuity of skin or mucous membrane  Ulcer ◦ Persistent breach in the continuity of skin or mucous membrane associated with.

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Presentation on theme: " Wound ◦ Breach in the continuity of skin or mucous membrane  Ulcer ◦ Persistent breach in the continuity of skin or mucous membrane associated with."— Presentation transcript:

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2  Wound ◦ Breach in the continuity of skin or mucous membrane  Ulcer ◦ Persistent breach in the continuity of skin or mucous membrane associated with cell death

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8 Wounds Acute Wounds Cuts, Abrasions, Lacerations Contusions Punture Skin flaps and Bites Benbow ( 2005) Any wound > 3/12 considered a chronic wound They passes through the normal healing process readily Fail to pass through normal healing process Chronic Wounds

9  Haemostasis  Inflammation  Proliferation or Granulation  Remodelling or Maturation

10 Time Hemostasis Platelet Aggregation Neutrophil Immigration Monocyte Immigration Granulation Re-epithelialization Wound Closure Scar Formation Remodeling Minutes Hours Days Weeks Months Years The wound healing cascade impairs and arrests at different stages Chronic wounds CHRONIC WOUND

11 Normal Healing Process

12  They are poly peptides, stimulate wound healing, promote chemotaxis, miotgenesis of fibroblasts and smooth muscle cells  Platelet derived growth factor  Insulin like growth factor  epidermal growth factor  fibroblast growth factor  transforming growth factor 1

13  Normal healing process impaired  Arrest at different levels  Remains at same stage without progressing to wound healing  Often an underlying cause remains and undetected

14  Inadequate blood supply **  Increased skin tension  Poor surgical apposition  Wound dehiscence  Poor venous drainage **  Presence of foreign body and foreign body reactions  Continued presence of micro-organisms & Infection **  Excess local mobility, such as over a joint

15  Systemic factors  Advancing age and  General immobility **  Obesity ***  Smoking  Malnutrition ***  Deficiency of vitamins  and trace elements ***  Systemic malignancy and terminal illness  Chemotherapy and radiotherapy  Immunosuppressant drugs, corticosteroids, anticoagulants  Inherited neutrophil disorders, such as leucocyte adhesion deficiency  Diabetes and CRF***

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17 approach has been criticised for being too simplistic as wound healing is a continuum and wounds often contain a mixture of tissue types.

18 Wound Healing Continuum (Gray et al. 2005) have been developed. This tool incorporates intermediate colour combinations between the four key colours

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23  The presence of multiplying organisms within a wound that overwhelm the host immune response with associated clinical signs and symptoms. (Kingsley 2001) Organism Density

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25  1. The quantity of micro-organisms  2.quality –Virulence and antibiotic resistance  3. The patients resistance to the level of bacteria in the wound( immune response)  Microbial bio-burden within wounds can range from contamination, colonisation, critical colonisation and infection.

26 Wound Surface 2.Organisms from GIT and GUT Gram Negatives such as E.coli, Klebsiella, Enterobacter, Anerobes 1.Organims from surrounding skin- Regional flora- Deptheroids, Anerobes 3.Organisms from External environment- through direct or indirectly – Pseudomonas, Multiresistant organisims etc Wound Contamination Wound Colonization Critical Colonization Wound Infection Advance Wound Infection Fecal and urinary management systems Hand hygeine

27  Classical Signs 1.Increased pain 2.Copious amounts of exudate 3.Malodour 4.Cellulitis 5.Pyrexia 6.Abscess Formation

28 ◦ Increase in size of wound ◦ Delayed wound healing ◦ General unwellness ◦ Dark discoloured granulation tissue ◦ Increased friability ◦ Pocketing at base of wound. (Cutting and Harding 1994).

29  Simple ◦ Skin  Complex ◦ Deeper

30  Rank & Wakefield  Tidy ◦ Surgical incisions  Untidy ◦ Crushing, tearing

31  Open ◦ Incised ◦ Abrasion ◦ Lacerated ◦ Crush ◦ Penetrating  Closed ◦ Contusion ◦ Hematoma

32  Surgical Wounds ◦ Clean ◦ Clean Contaminated ◦ Contaminated ◦ Dirty

33  Crushing of Muscles>Extravasation of blood>Myoglobin release  Earthquakes, Industrial accidents, Air crashes  Renal failure, Toxemia, Septicemia, Gas gangrene  Rx- Multiple deep incisions, Mannitol, NaHCO3, Hemodialysis

34  Pathological ◦ Specific ◦ Non-Specific ◦ Neoplastic or Malignant

35  Tropical ulcers  Tuberculosis  Buruli ulcers- myco ulcerans  Syphilis- trp pallidium  Yaws- treponema pertenue  Actinomycosis

36  Traumatic  Ulcers of Vascular origin Venous Arterial Pressure sores  Neurotropic (trophic) ulcers Leprosy Diabetic neuropathies Cord lesions Ulcers with metabolic or systemic disease Diabetic ulcers Haemoglobinopathies Infective (pyogenic) Cryopathic

37  Squamous cell carcinoma  Rodent  Malignant melanoma  Kaposis’s sarcoma

38  Grade 0- Preulcerative/Healed  Grade 1- Superficial  Grade 2- Deeper to subcutaneous  Grade 3- Abscess formation  Grade 4- Gangrene of part of tissue  Grade 5- Gangrene of entire limb

39  Edge Sloping – non specific Undermined – tuberculous/ decubitus Punched out – syphilitic/neuropathic  Floor – what is seen  Base – what is palpated

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42  Regular  Irregular  Rounded, Oval

43  Granulation ◦ Red ◦ Pale & Smooth ◦ Pink, Punctate, ◦ Nodular – suggestive of malignancy Discharge Serous Purulent Sero-purulent Bloody Sero-sanguinous Sulpher granules

44  On which the ulcer rests  Palpated  Indurated in malignancy

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46  Tropical Ulcers  Caused by synergy of F fusiformis / Borrelia vincenti  Starts as septic blisters  Tropical Countries – poor hygeine,  malnutrition, walking barefooted  In the chronic phase the ulcer becomes non specific

47  Bursting of Caseous LN  Slightly painful  Neck, Axilla, Groin  Undermined thin reddish-blue edge,  Sero-sanguinous discharge & induration  Enlarged LN  Lupus Vulgaris- Cutaneous TB- Face & Hands  Check the lungs- CXR

48  Treponema Pallidum  Hard Chancre- Ext Genitals  Punched out edges  Painless, indurated base(button Like)  Nipple, lip, tongue, anal canal  Secondary- Mucus patches, Condylomas  Tertiary – Gummatous (Subcut bones)  VDRL/ biopsy

49  Causes are many  Sloping edge  Phases 1. Acute or infective phase 2. Transition phase 3. Reparative or healing phase 4. Chronic, indolent or callous phase 5. -secondary infection, poor circulation, fB

50  Anywhere on body  Diagnosis is based on history & sloping edge  Limbs-Shin, Malleoli, Joints  Chronic- Staph  Eg ◦ Plaster Sores, Skin burns, Caustic ulcers

51  Occurs in theMedial lower 3 rd leg  Due to venous stasis- poor oxygenation/nutrition  Leg oedema,Surrounding skinPigmentation  varicosities  Causes ◦ Varicose veins-Perforator incompetence, Stasis ◦ DVT-Valveless Recanalisation after DVT

52  Inadequate skin circulation  Limbs- Repeated pressure/trauma  Causees ◦ Atherosclerosis- Ant & lat legs, Dorsum, Heels ◦ Buerger’s disease- Painf, Claudication, Punched out ulcers ◦ Raynaud’s disease ◦ The skin is shiny, hairless & hypoaesthetic ◦ Dorsalis pedis/ post tibial pulses are absent

53  Neurologic deficit, Impaired blood supply & nutrition  Sites - trochanter ◦ Sacrum, Heel, Buttocks, Occiput  Bedsores, Perforating Ulcers  Causes ◦ Diabetic Neuropathy, Paraplegia, Leprosy, Spinal injury, Peripheral injury, Peripheral neuritis

54  Ischemia from prolonged pressure bw Bed and body prominences  those unaware of warning signals of discomfort eg unconscious patient,  Maceration of skin from sweat, urine  Poor nutritional status  Reflection of nursing care

55  Diabetic Neuropathy-Trophic  Atherosclerosis-Arterial  Glucose laden tissues-Infective

56  Marjolin’s ulcer ◦ SCC from chronic scar  Malignant ◦ Lips, cheeks, penis, vulva, mouth, oesophagus ◦ 40 yrs+ ◦ SCC, BCC, Melanoma

57  Soft Chancre- Ducreys ◦ Painful, Ext genitals, with Bubo  Meleney’s Ulcer ◦ Post-op- Perforated viscus, ◦ Empyema Thoracis ◦ Strepto & Staph, Abdomen  Martorell ◦ Hypertensive, Old age ◦ Post calf  Bazin’s

58 MANAGEMENT Wound Care Plan (WCP)

59 Patient Centered – dealing with person with a chronic wound Holistic –Total care -Not only wound itself- need to address pts other needs, diseases, and psychosocial wellbeing Inter-diciplinary Needs Participation of multitude of disciplines

60  Mode of onset  Duration  Painful or painless  Discharge  PMH suggestive of systemic illness  DM, TB, SCD, Neuropathy,  Peripheral ischaemic symptoms  arterial disease – intermittent claudication ◦ Previous interventions ◦ Treatment

61  Venous ◦ Varicose veins ◦ DVT/thrombophlebitis ◦ Sclerotic changes ◦ Oedema  Vasculitis ◦ History of autoimmune disease ◦ Painful ◦ Lack chronic arterial occlusive symptoms ◦ Systemic symptoms of autoimmune disease

62  Neoplastic ◦ Chronicity ◦ Previous malignancy ◦ Risks  Exposures  UV radiation  Ionising radiation

63  Inspection  Size & Shape  Number  Position ( anatomical site)  Edge, Margin, Floor  Discharge  Surrounding area Palpation Tenderness Edge & margin Base Depth Bleeding Surrounding skin

64  Lymph Nodes  Peripheral pulsations  Nerves  Joints for mobilty  Systemic examination

65  Routine-  urine &Blood :  FBC, ESR, FBS,  Genotype, mantoux  Renal & Liver functions  wound swab

66  Specific ◦ VDRL, ◦ X-ray of part/ CXR ◦ Edge biopsy ◦ FNAC of LN ◦ Colour Doppler  Connective disease profile  Angiography

67  Dressings ◦ Encourage healing  Moist  Reduce oedema  Remove pathogens  Protect healing tissue  Debridement  Necrotic tissue  Slough  Foreign bodies  amputation

68  Vascularise  Angioplasty  Bypass  Optimise cardiac circulation  Eliminate venous hypertension  Varicose vein surgery  Venous valve replacement  Sclerotherapy  Venous bypass

69  Wound closure  Secondary intention  SSG  V.A.C.  Plastic surgery flaps  Systemic treatment  Steroids  Diet  Trace elements  Avoid cross contamination

70  Healing without complications such as infection and disfiguring  Wound care ◦ Remove FB ◦ Dry or wet to dry dressing to cover the wounds ◦ Suturing if acute ◦ Bites - Prophylaxis

71  Resuscitation of patient  Cleaning, Dressing  Hemostasis  Splint  Fluids  Inj TT

72  Incised ◦ Primary Suturing  Lacerated ◦ Excision & Primary Suturing  Crushed ◦ Debridement, excision ◦ Delayed Primary Suturing  Deep devitalised ◦ Debridement ◦ Secondary Suturing/ Grafting

73  Treatment of cause  Correction of Deficiencies  Blood transfusions  Pain Mangement  Debridement, Cleaning, Dressing  Antibiotics  Suturing, Grafts, Flaps

74 Cleansing agents ◦ Flowing Water –Requesting pt to bath before dressing change ◦ Normal Saline*** ◦ Commercial Cleansers ◦ Hydrogen Peroxide ◦ Povidone iodine ◦ Hypochlorite solution ◦ Sterile vinegar solution ◦ Mechanical Cleansers –Whirl pools ◦ Salt dips ◦ Honey

75  Mechanical  Autolytic  Enzymatic  Biological  Surgical

76  Protect from bacterial invasion  maintain optimum humidity  absorb serum from wound site  protect granulation tissue  reduce pain

77  Debridement – Mechanical / surgical / biological / enzymatic  Off loading foot wear.  Antibiotics  Appropriate wound care.

78  No role for ◦ Hydrogen peroxide ◦ Boric acid ◦ EUSOL ◦ Dakin solution (hypochlorite ) ◦ Iodine As they are toxic to the tissues

79  Poly urethane films ◦ transmit water vapour, oxygen, carbon dioxide ◦ non absorbent ◦ useful for healing wounds with minimal drainage  Foams and Hydrocolloids ◦ Permeable, easy to apply, minimum re injury when removing the dressings ◦ 60-95% water content maintains the moist atmosphere

80  Alginates ◦ Sea weed preparation ◦ absorb exudates ◦ useful for exudative wounds  Cultured keratinocytes ◦ Cells are cultured and transferred to petroleum gauze ◦ labour intense and expensive

81  Nutrition-proteins, zinc, vitamin c  Pain management  Change of dressings  Removal of slough- hydrogels, varidase  decrease the bacterial load – iodoflex  Reduction of exudates- alginates  Odour – iodoflex, silver, metronidazole  Eczema- steroids

82  Bacteria can secondarily colonize the wound and general tendency is to over treat.  Not necessarily indicate infection  wound bacteria may be transient and may not be detected on random swabs  Fever /erythema /swelling / increased pain / leucocytosis

83  Only indicated if contaminated or evidence of infection is demonstrated  Evidence of infection (local) ◦ Redness ◦ Warmth ◦ Swelling ◦ Tenderness ◦ Local Lymphadenopathy

84  For spreading infection and or evidence of systemic infection  Take blood cultures  Treated with Broad Spectrum antibiotics intravenously.  Topical antimicrobials - used to reduce wound bio burden (EWMA 2006).

85  Granulation enhancers  Minimal Dressing changes to reduce disturbances to the granulation  Avoid usage of substances which impede granulation tissues

86  Pain relief  Psychological support  Family education and create conducive environment  Social support

87 Chronic Wound Care: 10 Pearls for Success

88 1. For those with Diabetes for wound healing and further prevention: A - Check A1c - greater than 9% will affect wound healing. Recommended is less than 7%. B – Blood Pressure C - Cholesterol D - Diet E - Exercise F - Foot care - Check both feet at each appointment, shoes should be professionally fitted, consider chiropody. S- Smoking

89  2. For those with Venous Ulcer Disease - Compression bandaging is for treatment, stockings are for prevention. ◦ ( Exudate/creams will damage the integrity of the stockings). ◦ COMPRESSION IS FOR LIFE! The right compression is the one the patient will wear

90 3. For those with any distal neuropathy - Shoes should be professionally fitted. 4. Smoking Cessation -IMPORTANT FOR ALL! - each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours 5. If wounds not decreased by 30% in size by week 4, unlikely to heal by week 12. Consider biopsy or a comprehensive re-assessment

91 6.Query Infection? Culture using the Levine technique (Compress wound with normal saline for 10 minutes, press swab into a clean granulated area to express fluid and rotate 360 degrees 7. Treat the cause! Consider all the possible contributors to non-healing: Drugs, Occult malgnancy Systemic Disease (diabetes anemia, vascular disease), smoking, non-adherence

92  Definition  Problem – How big is it ?  Types  Pathophysiology of venous, arterial, diabetic ulcers  Assessment / Evaluations  Treatment options – Dressing agents, surgical options

93  Chronic ulcers results when sequel of repair is disturbed at one or more stages of inflammation  proliferation,  re epithelialization,  remodelling  common organisms colonizing the ulcers  Staph aureus, Strep pyogens, Strep fecalis, E coli

94  Surgeon  Wound Care Practioner  Nursing officer  Physician  Physio-therapist  Nutritionists  Attendant

95 Department of Orthopaedics General Hospital Marina, Lagos


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