Integumentary Notes PTS 645
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This 112 page Bundle was uploaded by Stephanie Colas-Salgado on Monday February 2, 2015. The Bundle belongs to PTS 645 at University of Miami taught by Dr. Mandel in Fall. Since its upload, it has received 140 views. For similar materials see Integumentary Disorders and Treatment in Psychlogy at University of Miami.
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Date Created: 02/02/15
Integumentary Anatomy Normal Wound Healing IN TEGUMEN TARY ANATOMY Normal Wound Healing NOOWN m Why is skin important Physical Therapists are specialists in Neuromuscular and Musculoskeletal function and rehabilitation Why as Physical Therapists do we need to learn about skin Could be a vascular disorder traumatic burns temperatures frost bite sun burns Where does skin play a role ROM 0 The skin crosses joints so we need to maintain ROM Infection Control Pain 0 The skin has a lot of nerve receptors ADLS Positioning 0 Bed 0 Standing devices Seating 0 Wheelchairs Transfers o Slideboard O Shear Ambulation 0 Weight bearing 0 Gait pattern 39 Outdoor Activity 0 Exercise 0 Sports quotIt keeps people from seeing the insides of your body which is repulsive and it prevents your organs from falling out onto the ground where careless pedestrians might step on them Dave Barry FACTS Approx 1 of the general population and 55 of people over 65 have Venous Leg Ulcers 0 Estimated cost per episode 40K 25 million Pressure Ulcers treated annually 0 Continues to rise as our population gets older 22 to 56 Billion in Hospital costs for Pressure Ulcers 17 million in the US have Diabetes 0 15 will develop at least 1 Foot Ulcer 56 of the 125000 LE Amputations annually are due to Diabetes Largest Organ in the Body Adults have from 1820 square feet about 2 square meters of Skin Weighs about 16 of total Body Weight 0 180 lbs male 6 501bs 156 kg 39 Ranges from 05 to 60mm in Thickness 39 Receives 15 of resting Cardiac Output 0 It takes a lot of blood to keep the skin healthy The integument is the largest organ system of the body and receives roughly onethird of the resting cardiac output The skin is connective tissue that consists of cells bers and an extracellular matrix organized into an outer epidermis and an inner dermis Beneath the dermis is a supportive subcutaneous connective tissue layer Open wounds involve a break in skin integrity such as abrasion laceration or ulcer Clinicians must be able to identify the extent of tissue involvement in order to classify open wounds and assess wound healing Basic Functions of Skin 39 Protection 39 Environmental Barrier O Allows temperature regulation Metabolism 39 Sensation 39 Thermoregulation O Vaso constrictiondialation in the dermis Layers 8 Structures of lhe Skin EPIDEMIS corneum r Seboceous gland DERMIS 39 r Oulor root Ha39r bulb shoah Imm moi dumb Emma sweat glmd SUBCUTANEOUS TISSUE Skin Structure 39 Two Primary Layers O Epidermis O Dermis 39 Subcutaneous Fat 39 Deeper are Muscles Tendons Ligaments and Bone Epidermis Dermis Subcutaneous layer Epidermis True skin Tough leathery 006 to 06mm Thickest in Palms and Soles Avascular Strati ed Squamous epithelial cells Outermost cells keratinocytes contain water resistant protein known as keratin Dynamic layer Constant turnover 0 constantly aked off Replaced by division of cells from deeper layers Provides Protection from O Desiccation bacterial entry toxins Cell Membranes thicken as they get pushed closer to the outer layers Tight junctions between cells help quotWaterproofquot the skin The epidermis is the tough leathery outer surface of the skin ranging in thickness from 006 to 06 mm with the thickest portions located on the palms of the hands and the soles of the feet The epidermis is arranged into five layers that represent different stages of cellular differentiation The deepest layer the stratum basale is attached to the dermis by a thin acellular basement membrane The epidermis is avascular receiving its blood supply through the diffusion of nutrients from the dermis across the semipermeable basement membrane THE EPIDERMIS f quot w r TRAT u 5 1 ORNEUUM I gtI Cx 39 smruu amp Lv v 5 GRANULOSUM a 7asm gge 1 6v T V I 9 if PRICKLE LAYER quotquot5 neumocvv nk mw as Ps ll Q BASAL must i 39 5amp6 o a K N 39 s a quotS 39 quot h 39 0 Y 9 4 39 0 39 r 5 layers of Epidermis Super cial Stratum o T Stratum Lucidum T Stratum Granulqsum T Stratum Spinosum Deepest Layer Stratum Basale 39 1421 days for cells to migrate from the Basale layer to the Corneum layer Stratum Basale aka Stratum Germinativum SG gLe Undulating layer of Columnar and Cuboidal cells 39 Undulations produces Finger prints 39 Provides germinal Keratinoc es for regeneration of epidermis Single row of keratinocytes continously dividing cells that produce the protective protein keratin quot 0 l9961a5mnwmum139 SS Stratum Spinosum quotSpinyquot Appearance under microscope due to keratin laments Progressive maturation and migration of germinal cells It consists of several rows of more mature keratinocytes which appear shiny under a light microscope because of the keratin laments t 9 h o 1996 Jasmll Mum SGR Stratum Granulosum 5 5 Layers of cells extruding granules containing lipid molecules Acts as quotCaulkquot to form a waterproof barrier 39 Prevents fluid loss 0 Preventing water from coming in and preventing your body from dehydrating out This layer contains three to five attened cell rows with increasing concentrations of keratin As keratinocyctes are pushed farther up and away fro their dermal blood supply they slowly die g o d 9 o 1996 Jasmnjtwnsm Stratum Lucidium Clear layer of Dead flattened Keratinocytes 39 Thicker and Most prominent in Palms and Soles Contains a few layers of flattened dead keratinocytes which appear clear through a light microscope 9 1m Jast Manon SC Stratum Corneum 0 Horny outermost layer 0 Dead Keratinocytes sloughed off 0 2050 cells thick 0 54 thickness of the epidermis Callus forms from pressureshear at this layer The outermost layer or horny layer consists entirely of dead keratinocytes It can be 2050 cells thick and accounts for up to threequarters of the thickness of the entire epidermis The many layers of the stratum corneum serve as a physical barrier protecting the body from trauma and infection The tight junctions between cells waterproof the skin thereby helping regulate the body s uid content Dead cells of the SC are constantly abraded and replaced by cells from below A cell s journey from the SB up through the SC takes 14 21 days Occasionally there is a localized buildup of cells of the SC due to pressure or friction This is known as a callus I 399 1996 Jason R Swanson Epidermal Cells Melanocytes pigment UV protection Merkel cells light touch mechanoreceptors Langerhans Cells ght infection Cells that can survive without having blood supply Ninety percent of the epidermal cells are keratinocytes The epidermis contain three other main cell types melanocytes Merkel cells and Langerhans Melanocytes located in the stratum basale produce the pigment melanin Melanin protects the skin from harmful effect of UV radiation from the sun and gives the skin its color Skin containing higher quantities of melalin appears darker in color whereas skin with less melanin appears lighter Merkel cells are specialized mechanoreceptors attached to keratinocytes by desmosomes that provide information on light touch sensation Langerhans Cells present in the deeper layres of the epidermis help fight infection by attacking and engulfing foreign material Epidermal Appendages Epidermal cells extend down into the Dermis along Hair Follicles Hair is soft keratin O Helps determine the blood supply If there is no hair on the leg then they have potentially low blood supply Also aids with determining depth 39 Sebaceous glands Lubricate skinhair 39 Sudoriferous glands Sweat H HK Why is this important for wound healing Aids with healing of the wound The epidermis has three appendages located within the dermis hair glands and nails Hair follicles are present everywhere except in the palms and soles Hair composed of soft keratin helps regulate body temperature by trapping air between the hair and the skin s surface Each hair follicle contains a sebaceous gland that secretes sebum If the more superficial epidermis is damaged as with an abrasion the deeper epidermal cells that line hair follicles serve as a source of epidermal regeneration Sebum is an oily substance that lubricates the skin and hair Sudoriferous glands present everywhere except the lips and ears secrete sweat into ducts that lead to the skin s surface The evaporation of sweat from the skin s surface helps cool the body In addition the oily sebum secreted by these glands may slow the growth of bacteria thus helping reduce infection Nails located at the dorsal tips of the digits consist of hard keratin Nails arise from cells within the stratum germinativum protect the terminal digits and assist with function Epidermis 39 Replacement of the epidermal layer by this regenerative process takes 2 to 5 weeks Cues and biologic stimuli at the wound surface are necessary to direct proper orientation and mitotic response of the epidermal cells Many of the cues come from dermal elements matrix proteins Basement Membrane Acellular Attaches Stratum Basale to the Dermis Scaffolding for the epidermis Filters substances moving between epidermis and dermis Semipermiable nutrients from dermis quotBlistersquot occur here due to friction between the Basement Membrane and the Papillary Dermis O Rubbing of the epidermis on top of the basement membrane a pocket develops and uid moves within The basement membrane acts as a scaffolding for the epidermis and a selective lter for substance moving between the epidermis and the dermis BOX 1 1 Functions of the Epidermis 39 Provides a physical and chemical barrier 39 Regulates uid 39 l rovides light touch sensation 39 Assists with thermoregulation 39 Assists with excretion 39 Lritical to endogenous vitamin 1 production Contributes to cosmesisappearance Dermis 39 Vascularized O Capillary beds 0 Rosypink color 39 When looking at a wound and it looks pink then you know there is no epidermis remaining 39 Lymphatic system 0 Returns H20 proteins other substances to blood 39 High water content 20 40 mm thick The dermis is 2 4 mm thick Although its layers are much less de ned than those of the epidermis the dermis can be described as consisting of two layers The thin super cial papillary dermis consists of loosely woven bers embedded in a gelatinous matrix called ground substance The deeper reticular dermis makes up 80 of the dermal thickness and consists of dense irregularly arranged connective tissue The many thick bers of the reticular dermis provide increased structural support to the skin The dermis is highly vascular with many capillary beds providing nutrition to both the dermis and the overlying avascular epidermis The dermal capillaries provide the dermis with its characteristic color ranging from pale pink to rosy red Healthy dermal tissue should have a shiny or moist appearance because of its high water content and a pink or rosy color due to its high vascularity Collagen elastin and moisture make the dermis elastic and pliable Layers amp Structures of the Skin EPIDERMIS Sum 39quot4 Sebaceous glen DERMIS 39 l 39 Outer root 39 39 Hai bulb eu 3 Inner root sheath SUBCUTANEOUS TISSUE Anisry Vein Functions of the Dermis Nutritional support to epidermis Houses epidermal cells and growth factors for epidermal replication and dermal repair after trauma 39 Thermoregulation 0 through control of skin blood flow Contains immune cells defense against foreign invaders passing through epidermis O Macrophages white cells and etc Sensory assist to epidermis for information on the environment BOX 12 Functions of the Dcrmis 39 Supports and nourishes epidermis Ilouses epidermal appendages 39 Assists with infection control Assists with thermoregulation l rovitles sensation Because the skin has so many important functions loss of skin integrity can lead to serious and wide ranging problems For example an individual with a deep burn covering the trunk and face would have an increased risk of infection and would lose massive amounts of fluid without intravenous fluid replacement Once skin integrity is restored the patient would be unable to sweat in the involved area leading to skin that is easily abraded and traumatized Loss of skin over such a large surface area would also decrease the patient s ability to dissipate heat by the evaporation of sweat from the skin s surface Loss of melanocytes would increase the risk of sunburn and make the new skin pale in color and loss of nerve endings would decrease the ability to perceive light touch The resultant scars would alter the patient s physical appearance potentially affecting selfesteem The astute clinician remembers the link between skin structure and function when working with patients with integumentary injuries such as this Holistic care should address not only the shortterm problems associated with the loss of skin integrity but also the longterm issues such as scar management and skin care to prevent secondary complications Dermal Cells 39 Fibroblasts Collagen Elastin 39 Macrophages 39 WBC Mast cells Histamine O Vasodilation 0 Signal WBC macrophages Fibroblasts are the main cells found within the dermis These cells produce the collagen and elastin fibers that give the dermis its characteristic strength and flexibility respectively Macrophages and white blood cells within the dermis help fight infection by engulfing harmful substances and releasing destructive enzymes Mast cells are specialized secretory cells throughout the dermis They produce chemical mediators of inflammation such as histamine These substances cause vasodilation and attract other cells to the area to help fight infection or repair injury The dermis also contains several types of sensory receptors that provide information on touch pressure vibration and temperature Structures Within the Dermis 39 Sweat glands 39 Hair follicles begin deep in dermis 39 Pacinian corpuscles amp Free Nerve Endings vibrationpressuretemp 39 Erector Pilae muscle 0 goosebumps Sebaceous glands Subcutaneous Tissue 39 quotHypodermisquot 0 Anything below the dermis Adipose tissue 4125121 9125th yellow 0 Stores energy amp Vitamins A D E K O Cushioning over bony prominences 39 Fascia Fibroud white 0 Separates structures facilitating movement Subcutaneous tissue sometimes called the hypodermis supports the skin It consists of adipose tissue and fascia Adipose tissue is highly vascular loose connective tissue that stores fat which provides energy cushioning and insulation Fatsoluble vitamins A D E and K are stored in adipose tissue Healthy adipose tissue has a glistening white to pale yellow appearance but may appear darker if dehydrated Fascia is highly fibrous connective tissue that may be regularly or haphazardly arranged Fascia separates and surrounds structures and facilitates movement between adjacent structures including muscle tendon and bone Deeper lymphatic vessels are located within the subcutaneous tissue as well Subcutaneous tissue provides cushioning over bony prominences such as the greater trochanter of the femur thus decreasing the risk of pressure ulcers Deeper Tissues Muscle Bloody Red is normal Tendons White regularly arranged fibers 39 Ligaments White regularly arranged fibers 39 Joint Capsule White irregularly arranged fibers 39 Bone Milky White Hard when probed Muscles consist of regularly arranged fibers surrounded by fascia Muscle has a rich vascular supply making it appear dark red in color and bleed readily if traumatized In contrast nonviable muscle will appear gray or black in color Tendons are regularly arranged collagen fibers that may be enclosed in a fibrous sheath Ligaments and joint capsules consist of dense connective tissue Ligamentous fibers are regularly arranged whereas joint capsules have fibers running in varied directions When healthy these tissues are glistening white in appearance If nonviable these tissues will appear dry or leathery will be dark in color andor may no longer be continuous Healthy bone will have a shiny smooth and milky white appearance and will feel hard when probed Abnormal appearances include a motheaten irregular surface or a bruised or dark discoloration Severe pressure ulcers diabetic ulcers or burns such as electrical burns are likely to involve deeper tissues The extent of tissue involvement is typically categorized as superficial partialthickness or fullthickness Superficial Thickness Wounds 39 Epidermis only 39 Wounds caused by shearing friction and mild burn 39 Healing occurs by regeneration of epithelial cells on wound surface amp migration of epidermal cells across the surface Usually minimal to no scarring Superficial wounds affect only the epidermis An example of a superficial wound would be an abrasion where the top layer of the integument has been removed revealing the top layer of the dermis Partial Thickness Wounds Epidermis and part of the dermis are removed Accessory structures spared Heals similarly to Super cial Thickness wounds Eschar dessicated necrotic tissue may form Excess Inna 0 Unconc folio colonization 0 Excess mu Partialthickness wounds involve the epidermis and part of the underlying dermis A seconddegree burn such as a deep sunburn that results in blistering and peeling is an example of a partialthickness wound Full Thickness Wounds Epidermis Dermis and into Subcutaneous tissue layer Muscle tendon and bone can be involved In fullthickness wounds tissue injury extends through both the epidermis and dermis to the subcutaneous tissue layer Fullthickness wounds may be further categorized as subcutaneous or subdermal tissue wounds if deeper tissues such as tendon muscle andor bone are involved A categorystage IV pressure ulcer with exposed bone in the wound bed is an example of a fullthickness wound TABLE 1 1 Depth of Tissue Involvement in Open Wounds Epidennis Dennis Subcutaneous tissue Muscle Extent of Wound Tissues Involved Examples Super cial Epidennis Abrasion Super cial rstdegree burn Partialthickness 0 Epi dennis Dermis Blister Super cial and deep partial thickness seconddegree burn Stage 1 pressure ulcer Vagner grade 1 ulcer Full thickness Epi dennis 0 Dennis Subcutaneous tissue 39 May extend into deeper tissue layers also called subdermal Fullthickness burn Cate gory stage III pressure ulcer Vagner grade 1 ulcer Subdertnal fourthdegree burn Vagner grade 2 5 ulcer Depth of injury extends at least to this layer Partial thickness Fu thickness39 Biomechanics of Skin 39 Normal skin has elastic tensile and viscous properties 39 Much of elasticity comes from viscous elements viscoelastic 39 In contrast Tendons are very stiff and elongate very little 0 Due to parallel arrangement of very thick bundles of collagen 0 Also due to different proportions of glycosaminoglycans Biomechanics Elasticity 39 Three dimensional interaction of collagen bers and the attachment of elastic bers made of Elastin provide ability of skin to recoil when stretch applied Ground Substance glycominaoglycans amp water also provides elasticity to skin 39 Elderly individuals tend to be more dehydrated then younger individuals Biomechanics of Skin 39 Turgor ability of skin to recoil when pinched decreases with dehydration Skin with decreased turgor remains elevated after being pulled up and released Anatomy Question 1 If a wound extends only into the epidermis will it bleed profusely Why or why not 0 No avascular region 0 No the epidermis does not have a blood supply of its own rather it relies on diffusion from the underlying dermis Anatomy Question 2 Your patient presents with an open blister on the posterior heel secondary to poor tting shoes What tissues are involved with this type of injury 0 Blisters occur at the junction between the epidermis and the dermis Therefore the epidermis and the super cial papillary dermis are involved Anatomy Question 5 Your patient s foot ulcer measures 50 cm length X 56 cm width X 08 cm depth What tissues are involved in this ulcer o The epidermis ranges in depth from 006 to 060 mm while the dermis ranges in depth from 20 to 4 0 mm Therefore the wound likely involves at least the epidermis dermis and subcutaneous tissue CHAPTER SUMMARY The skin consists of an outer epidermis and an inner dermis The epidermis consists of five morphologically distinct layers of keratinocytes The epidermis provides a physical and chemical barrier helps regulate fluid and temperature provides sensation assists with vitamin D production plays a role in excretion and contributes to selfimage Open wounds with damage only to the epidermis are called super cial wounds The dermis supplies the epidermis with nutrition and support houses the epidermal appendages assists with infection control and thermoregulation and provides sensation Open wounds involving the epidermis and dermis are called partialthickness wounds The subcutaneous tissue consisting of fat and fascia lies beneath the dermis The subcutaneous tissue provides cushioning insulation and support to the overlying tissues is an energy storehouse and facilitates movement between structures Wounds that extend into or beyond the subcutaneous tissue layer are called fullthickness wounds Clinically it is important to correctly identify structures within a wound to know the depth of tissue injury and to provide appropriate interventions REVIEW QUESTIONS 1 Label the lefthand side of Figure FIGURE 1 3 Skin slruclurc 2 State the depth of tissue injury if a wound extends to level A B or C as noted on the righthand side of Figure A is an example of a super cial wound B is an example of a partialthickness wound C is an example of a fullthickness wound 5 How does the dermis assist with temperature regulation If the body is cold the super cial vasculature within the dermis constricts to divert more blood to the body core Conversely if the body is hot dermal vessels dilate allowing heat to be dissipated into the environment 4 Your patient presents with a burn on his right arm after accidentally submerging his arm in a deep fat fryer Based on the normal functions of the integument describe the implications this injury will have acutely The skin serves as a physical and chemical barrier therefore the patient is at risk for infection The epidermis helps regulate fluid levels The loss of such a large amount of skin will cause the patient to become dehydrated if the fluid loss is not replaced with intravenous fluids The skin helps regulate body temperature With the loss of such a large amount of skin the patient may complain of being cold and require blankets or warmer air temperature The patient s sense of light touch will be impaired in the affected area making him unaware of excess pressure from bandages or splints The patient s selfimage may be altered as a result of the current wounds and the fear of future scarring Skin Anatomy Identify the Components Sweat Pores Stratum Hair COmeum Epidermis Stratum Granulosum 39 Stratum Spinosum Stratum Basale Dermal Papillae Meissner39s Corpuscle Sebacceous Gland Hair Follicle Papilla of Hair Dermis h Subcutaneous Layer Sweat Gland Cutaneous 39 Nerve PaC39n39an Erector Pili Corpuscle 18 17 16 15 14 13 12 11 1O 9 Normal Wound Healing Normal Wound Healing 39 Hemostasis 39 In ammation 39 Production of granulation tissue Wound contraction Re epithelialization 39 Remodeling of scar tissue Normally the epidermis is electronegative with respect to the dermis creating a bioelectric field or skin battery A break in skin continuity not only lowers the skin s electrical resistance but also disrupts this skin battery making the wound electropositive compared to the surrounding tissues It is thought that this local change in polarity or endogenous current of injury triggers the wound healing cascade Super cial wounds heal without scar tissue formation by simply regenerating the damaged epithelium However the healing of deeper wounds consists of three phases in ammation proliferation and maturation and remodeling Overlapping Phases of Wound Healing Ad oun Contraction Y I Tissue In ammation Collagen accumulation Remodeling 0 l 03 l 3 10 30 100 Days Normal wound healing is an organized and predictable process consisting of three overlapping phases in ammation proliferation and maturationremodeling Together these three phases are sometimes called the inflammatory process The body s first response to injury is inflammation Inflammation allows the body to control blood loss and fend off bacterial invasion It also signals the cells needed to restore the integument to the injured area During the second phase of healing the proliferative phase new tissues are built to fill the gap left by damaged and debrided tissues In addition epithelial integrity is restored and the wound is considered closed The nal phase of healing maturation and remodeling lasts up to 2 years after wound closure During this time scar tissue is reorganized according to Wolff s law from a haphazard ber arrangement to being oriented along the lines of tissue stress until reaching maXimum strength and function Unfortunately even after remodeling scar tissue is less elastic than the original tissue and may only achieve a maXimum of about 80 of the original tissue strength A wound is considered healed after it is resurfaced and maximal attainable tissue strength is achieved Scar tissue healing becomes of increased concern when a wound recurs in the same location as is common with wounds due to venous insufficiency and neuropathic wounds If this second generationquot wound heals its maximal strength will be 64 80 of 80 of the original tissue strength Phase 1 Inflammation Phase Exuaativevphase for hemostasis and ghting infection 0 Coagulation and brin formation 39 Controls bleeding 0 Neutrophils Macrophages Mast Cells 39 Assist with destruction and removal of bacteria amp cellular debris secrete in ammatory mediators 39 phagocytosis and proteolysis 0 Increase in cell division and broblast migration 0 Erythema Edema 4 Temperature Pain Inflammation involves both a vascular and a cellular response of living tissue therefore in ammation does not occur in dead tissues or in tissues without adequate blood flow The inflammatory phase assists with controlling bleeding and combating infectious agents that may be present Inflammation also sets the stage for further healing by signaling the cells necessary for repair and regeneration to come to the site of injury PHOTO C3 Patient with a wound in the in ammatory phase of wound 139 healingNoticetheedemaofthegreat 39 toeaswellastheerythemaextending l39 from the wound dorsally down to the area of the metatarsophalangeal joint The wound bed is covered with a thin layer of yellow slough The great toe feels slightly warm to the touch Additionally the patient reports the toe is tender to the touch Focal redness versus distal redness If redness spreads outside of the injury site then that is signs for infection Cardinal Signs of In ammation Swelling Tumor Redness Rubor Warmth Calor Pain Dolor 39 Decreased function Functio Laesa Phase 2 Proliferation Proliferative Phase 39 Begins as early as 4 8 hours 39 1 Angiogenesis sprouting of capillaries 0 Tiny red dots in wound bed 0 2 Granulation tissue lls wound 0 Temporary matrix formation broblasts 0 red beefy shiny granular buds 5 Wound contraction actin rich myo broblasts pull wound margins together 39 4 Epithelialization keratinocytes migrate O Slowed by debris Cleanmoist facilitates movement As the in ammatory phase progresses and the cells necessary for repair and regeneration reach the site of injury the proliferative phase of healing begins The phases of healing overlap and there is no one de ning characteristic for progression between stages In healthy individuals it is possible for proliferation to begin within 48 hours of injury The proliferative phase consists of four crucial events angiogenesis granulation tissue formation wound contraction and epithelialization In general terms this phase consists of rapid cell growth and replication production of an extracellular matrix to ll the wound defect and resurfacing of the wound bed TABLE 2 2 Key Cells ml the l mlileraliw Phase Cell Function Angioblast Forms neu blood vessels Fibroblast Builds granulation tissue Myo broblast Causes uuml contraction Kemtinocyte Reepithelinlizes uund surface Capillary spmuhwg o Mum network Phase 5 Maturationmemodeling DWereIztiationvphase maturation of collagen scar formation and epithelialization O Collagen bers thicken reorganize and mature collagenases 0 Induction Theory Mimic surrounding tissues 0 Tension Theory Stresses force realignment of bers 0 9 days to 2 years after injury to ll a wound 0 Tissue only 80 of original strength 39 This tissue is more at risk of breaking down again reinjury O Decrease in Vascular supply Wound healing is not finished once the wound bed has been resurfaced The granulation tissue matrix laid down during the proliferative phase must be strengthened and reorganized to t the surrounding tissue Collagen synthesis continues at a rapid rate after wound closure A rosy pink scar is still in the remodeling process whereas a scar that is pale or more closely approximates the surrounding tissue color is fully remodeled Collagen fibers transform from immature Type III collagen to mature Type I collagen and reorient along the lines of stress Two theories exist to explain the forces behind this reorientation The induction theory postulates that scar tissue tries to mimic the tissue surrounding it Thus if the scar occurs in dense fibrous connective tissue the scar will be made of dense fibrous connective tissue In contrast the tension theory hypothesizes that internal and external stresses force collagen fibers to realign When physical therapists and physical therapist assistants apply forces to scar tissue to attempt to change its qualities they are following the tension theory Range of motion exercises and scar tissue mobilization techniques such as crossfriction massage are grounded within the tension theory Both the induction and the tension theory are supported by research It is likely therefore that scar maturation results from both internal and external influences Remodeling continues up to 2 years following wound closure with the greatest amount of change occurring within the first 6 12 months Unfortunately even once fully remodeled scar tissue is at most only 80 of the original tissue s strength and elasticity In addition the repaired tissue cannot function the same as the tissue it has replaced For example the scar that appears after a fullthickness burn is unable to sweat due to a loss of sweat glands is less sensitive to touch and temperature and may have a different skin tone due to lack of melanin Therefore clinicians must consider that closed wounds may need continued protection and a gradual increase in stress to prevent future problems such as dehiscence and recidivism Normal Wound Healing Simple partial thickness wounds heal by reepithelialization Full thickness wounds heal by primary or secondary intention 0 Closure of the wound More involved wounds require delayed primary or third intent intention Primary closure is generally the simplest and fastest type of wound closure as this occurs when the wound edges are able to be approximated with little or no granulation tissue formation Secondary closure requires the body to build a matrix of granulation tissue and therefore requires more time to reach wound closure Delayed primary closure involves a combination of closure by primary and secondary closure This type of wound closure may be preferable in patients with large wounds that are initially infected or that fail to successfully close by secondary closure Primary Intention Closure Surgical closure Clean Smooth closely abutting incision wounds Good Vascularization Fastest closure method Minimal in ammatory phase Proliferation is mainly epithelialization The edges of the incision are physically approximated and held in place with adhesive tapes biologic tissue adhesives sutures or staples leaving only a small defect to be repaired Consequently the body does not need to build a large granulation tissue matrix This decreases the distance that new blood vessels and keratinocytes must migrate and minimizes bacterial contamination Figure 3 Mary AlburyNoyes b Incorrect Figure 3 lrrpro er wound closure a leaves dead 3 ace a cavrty where ematoma or Infection can deyelop h proper wound closure g dead space 3 ellmnated by placrng deep absorba e suture such as those made rom poryglycollc acrd Secondary Intention Closure When tissue defects have to be re lled Infection present Granulation tissue has to be generated to close the dermal defect Increased healing time Increased scarring Allowing the wound healing process When the wound edges cannot be approximated closure occurs by secondary closure also called healing by secondary intention A granulation tissue matrix must be built to fill the wound defect Wound contraction to decrease the size of the defect plays a more important role in healing by secondary closure In addition epithelialization must be greater to bridge the wound margins Whereas primary closure involves principally regeneration and resurfacing of the wound wounds healing by secondary closure heal by wound repair Wound repair is a combination of granulation tissue formation which eventually is converted to scar tissue wound contraction and epithelialization from the wound periphery Epidermis Scab quot or devi t talized 39 tissue O V De rmis Epithelial 2 391 cells b Scab formation and epithelialization Scar tissue a 9 9 Granulation 00 tissue 39 formation r c Scar tissue formation d Maturation and remodeling Tertiary Intention Delayed Primary Closure Combination of Primary and Secondary Smooth surgical wound that needs cleansing of infection prior to closure EX Infected appendectomy incision Keep the wound open and allow the wound to heal by secondary intention then later the physician closes the wound by primary intention If a wound is contaminated this technique may be used to decrease the chance of infection The wound is initially cleansed and observed for several days Once the wound appears clean it is surgically closed Type of Wound Closure Description Normal Progression Primary Vound is cleaned of foreign material and edges Vound should be closed in 1 H days are physically approximated 39 Also called healing by primary intention Secondary 39 Vound repair follows the three phases of normal Signs of progression through the phases wound healing of wound healing are noted 39 Also called healing by secondary intention 0 Acute wounds within 3 weeks Chronic wounds within 50 days Delayed Vound is cleaned and observed for signs of Vound should he closed within primary infection then closed primarily with sutures 1 3 weeks ol suturing 39 Also called healing by tertiary intention Abnormal Wound Healing Absence of in ammation 0 Unable to cleans wound O Immune compromised steroids 0 In ammation is a necessary and desirable part of wound healing The goal of the in ammatory phase is to cleanse the wound of debris and set the stage for further healing by calling cells necessary for repair to the injured area If an individual is unsuccessful in building this in ammatory response healing cannot progress or will be delayed Reduced or absent in ammation may be seen in patients who are taking high doses of steroids patients who are malnourished patients who are elderly and patients with immune system disorders such as HIV or AIDS Clinically these wounds present with decreased or absent signs of in ammation local rubor calor tumor dolor and functio laesa It may be necessary to promote an in ammatory response in these wounds using debridement and using electrotherapeutic modalities and physical agents Chronic in ammation 0 0 Foreign body repetitive trauma cytotoxic agents Prevention of progression to Proliferative phase Body unable to kill germs preventing healing process In contrast to an absence of in ammation chronic in ammation is the excessive or prolonged expression of the cardinal signs of in ammation and may be accompanied by brosis Chronic in ammation may continue for months or even years Chronic in ammation can be selfperpetuating Lymphocytes and macrophages signal more in ammatory cells into the area more in ammatory mediators and lysosomal enzymes are produced and so on The body cannot build functional healthy new tissue in a chronically in amed environment By preventing the wound from progressing into the proliferative phase chronic in ammation causes more harm than good There are three common causes of chronic in ammation First the presence of a foreign body in the wound bed may result in chronic in ammation The body s attempt to cleanse the wound of items such as a wisp of cotton or debris from a traumatic wound prolongs the in ammatory response as long as these items are present Second repetitive mechanical trauma such as applying a wetto dry gauze dressing to a healthy granulating wound bed constantly reinitiates the in ammatory process By allowing the dressing to dry out the gauze becomes adhered to the fragile granular tissue When the dressing is removed the granulation tissue is torn away from the wound bed as well reinitiating the in ammatory process Third the use of cytotoxic agents substances that are poisonous to human cells involved in the wound healing process may the in ammatory response When solutions created for use on intact skin such as hydrogen peroxide and povidoneiodine Betadine are applied to open wounds in ammation is prolonged Hypogranulation pothole defect O 0 Lack of filling prevents epithelium from migrating across wound surface Wound repair may be halted by the absence of a successful proliferative phase A wound that is hypogranular fails to build enough granulation tissue to fill the wound defect resulting in a potholetype wound Without the support of a granular matrix epithelial cells cannot bridge the gap to achieve wound closure and repair is suspended Sometimes epithelial cells continue to multiply and attempt to turn the corner and migrate down the sides of the pothole When the epithelial cells contact the oor of the pothole or each other by making a lip over the edge of the pothole epibole the keratinocytes believe their migration has been successful and epithelialization is arrested Hypogranulation seems to occur more frequently in patients with diabetes or malnutrition Hypergranulation extends above epithelium O O Epithelial cells do not climb well Silver nitrate cauterize Compression wrap local ischemia Surgically remove Hypergranulation is when granulation tissue formation continues after the wound defect has been filled A hypergranular wound appears as a mound of granulation tissue sometimes termed proud esh that extends above the surface of the surrounding epithelium The presence of hypergranulation is a deterrent to epithelialization as epithelial cells have difficulty climbing up the mound of granular tissue which can result in a rolled epithelial border Hypergranulation can be prevented by protecting fragile epithelial cells from trauma Types of trauma include inappropriate whirlpool use maceration too frequent dressing changes or adhesives Certain types of dressings namely hydrocolloids have been linked to an increased risk of hypergranulation Hypertrophic Scarring O 0 Over production of collagen tension Long proliferative phase Compression Scar mobilization Gel pads increase temp and collagen lysis Steroid injections Mederma Surgery Hypertrophic scarring is due to the overproduction of immature collagen during the proliferative and maturationremodeling phases of healing Hypertrophic scars appear as red raised fibrous lesions that stay within the confines of the original wound Hypertrophic scarring is more likely to occur in wounds that cross lines of tension in the skin or in wounds with a prolonged in ammatory phase such as large or infected wounds Burns are also more likely to result in hypertrophic scarring because of their lengthy proliferative phase Hypertrophic lesions are often associated with contractures because of the random overproduction of collagen Darkerskinned individuals have a higher predisposition to hypertrophic scarring than those with lighter skin tones Failure to move through the in ammatory process or to do so in an untimely fashion results in chronic wounds or abnormal wound healing Abnormal wound healing is assessed clinically if progression is slower than expected or by observing wound and periwound characteristics for an abundance or a reduction of the typical characteristics of each phase of wound healing Chronic wounds have senescent cells cells that are mitotically active but are minimally or nonresponsive In contrast to acute wounds chronic wounds contain greater numbers of inflammatory cytokines and the chronic wound cells within do not respond to growth factors Keloids Nodular masses of collagen randomly arranged in swirls or clusters More common in highly pigmented individuals Extends out a lot more Different from Hypertrophic scarring because keloids extend beyond the confines of the original wound and rarely regress on their own Associated with tissue Trauma O Laceration 0 Surgery 0 Tattoo 0 Ear piercing 0 Burns Like hypertrophic scarring keloids result from excessive immature collagen synthesis and are more common in individuals with more highly pigmented skin and areas of increased tissue tension However unlike hypertrophic scarring keloids extend beyond the confines of the original wound and rarely regress independently Keloids are characterized by a growth phase followed by a period of stabilization with possible intermittent periods of growth later on Keloids are commonly associated with tissue trauma such as a laceration surgery tattoo ear piercing or burn There is a familial predisposition for keloid scarring Keloids appear as nodular masses of collagen randomly arranged in swirls or clusters of collagen fibers Abnormal Wound Healing 39 Contractures O O Wound crosses joint Burns Positioning Splinting ROM A contracture is the pathological shortening of scar tissue resulting in deformity Contractures are more likely to occur in patients with wounds especially burns crossing a joint The patient assumes a position of comfort during wound healing in an attempt to decrease the stress to the healing integument and the surrounding soft tissue This promotes adhesions and adaptive shortening of muscles tendons and joint capsules ultimately limiting the patient s movement and potentially inhibiting function of the scarred area Dehiscence O 0 Where the wound opens up due to a space not being filled during healing Poor tensile strength of collagen Areas of tension Sternum Abdomen groin Long term steroid users Diabetics Dehiscence is caused by insufficient scar formation Dehiscence is the separation of wound margins due to insufficient collagen production or tensile strength A common misconception is that wound infections cause dehiscence However it is more likely that the wound edges dissociate before an infection can be established Perhaps because of decreases in collagen tensile strength or synthesis longtime steroid users and patients with diabetes mellitus or malnutrition have increased rates of dehiscence Factors Affecting Healing Mechanism Location 39 Dimensions 39 Temperature 39 Hydration 39 Foreign body 39 Infection 39 Circulation 39 Sensation 39 Mechanical Stress Necrotic tissue Nutrition 39 Infection Comorbidities Medication 39 Compliance Certain wound characteristics are known to affect the rate of wound healing including mechanism of onset time since onset wound location wound dimensions temperature wound hydration necrotic tissue or foreign bodies and infection CHAPTER SUMMARY Normal wound healing involves three overlapping phases inflammation proliferation and maturation and remodeling The inflammatory phase controls bleeding combats infectious agents that may be present and attracts cells vital for repair to the zone of injury The macrophage is vital to this phase of healing Inflammation is characterized by localized redness heat swelling pain and decreased function The proliferative phase involves angiogenesis granulation tissue formation wound contraction and epithelialization The maturation and remodeling phase reorganizes and increases the strength of the scar tissue up to 2 years after wound closure Wound closure may be 1 primary where the wound edges are approximated 2 secondary where the wound defect must first be filled with granulation tissue or 5 delayed primary closure a combination of the two Abnormal wound healing is slower than expected or characterized by changes in the typical characteristics of each phase of wound healing Clinicians must be able to identify both normal and abnormal wound healing characteristics to effectively manage patients with open wounds CHAPTER SUMMARY An acute wound is induced by surgery or trauma in an otherwise healthy individual A chronic wound is a wound induced by varying causes whose progression through the phases of healing is prolonged or arrested because of underlying conditions Patients with chronic wounds pose a special challenge to medical professionals Several factors have been associated with delayed wound healing Wound characteristics local and systemic factors and inappropriate wound care can each affect wound healing Some of these factors such as infection and the presence of necrotic tissue are modifiable whereas others such as age and wound dimensions are not What may be considered helpful but not critical interventions for uncomplicated wounds may be essential to the healing process for patients with chronic wounds Clinicians must recognize and address the factors known to affect wound healing in order to improve delayed wound healing By staying abreast of current research clinicians can increase the likelihood of successful outcomes Wound Healing Question 1 Your patient sustains a partial thickness chemical burn How do you think the body will re epithelialize the defect O Re epithealization O A partialthickness wound involves the epidermis and part of the dermis Therefore epithelialization can occur from the wound margins and from the epidermal appendages located within the dermis Wound Healing Question 2 You are working with a patient who had a TKA Five days after surgery the knee becomes infected and is surgically debrided One week after the debridement the surgeon decides to surgically close the wound What type of healing is this an example of O Tertiary Intention o This scenario describes delayed primary closure also known as healing by tertiary intention Wound Healing Question 5 You have been working with a patient with a pressure ulcer daily for the last 5 weeks Initially the wound appeared as a crater and was 10 cm deep Today when you remove the dressing you notice the granulation tissue has risen above the skin surrounding the wound 0 How would you describe this tissue 39 The wound is now hypergranular 0 What can you do to improve the wound bed 39 Physical therapy treatment options include applying pressure or silver nitrate to the hypergranular tissue In addition if a hydrocolloid dressing is being used a different type of dressing should be selected Healing Question 4 Does wound pain correlate with wound severity Explain O No A patient may have a severe lifethreatening wound that is painless because of sensory nerve dysfunction Examination of Patients with Open Wounds 2215 907 PM The examination consists of obtaining a history performing a systems review and administering tests and measures During the history the clinician must obtain the patient s general demographic information lifestyle and functional status general medical information and past and current wound history Next the clinician performs a brief review of body systems before focusing on the open wound The clinician then selects and performs appropriate tests and measures including wound characteristics periwound and associated skin characteristics circulation and sensation to establish a diagnosis to determine a prognosis and to select appropriate interventions The goals of the examination are to determine the physical therapy diagnosis to identify factors that may contribute to ulceration or abnormal wound healing and to assist with making a wound healing prognosis Examination of the Integumentary System 39 A MultiSystem assessment including 0 0 History Taking Mobility Orthotic protective and supportive surfaces Pain 39 May be a sensory issue Ventilation Respiration and Circulation 39 Guides clinician tests and measures Identifies characteristics that will affect the outcome of treatment 0 O O 0 Demographics 39 Age 39 Sex Patient Family caregivers Living arrangements Cultural beliefs Resources financial transportation 39 Race ethnicity Language Prior level of function Occupation work requirements 0 Because the prevalence of many disease processes varies by age gender or ethnic background it is important to obtain general demographic information Physical therapists should also know the patient s or caregiver s education level By knowing this information the therapist can present information and instructions at an appropriate level to maximize learning Age 39 Macrophages Less Efficient 39 Capillary Frailty Decreased Contraction Remodeling and Epithelialization 39 Decreased Function Wound History Physical therapists should question the patient or caregiver about past and current wound history as this information can provide valuable insights into wound etiology interventions and healing potential Wounds of acute onset may be due to trauma and generally heal quickly and in accordance with the phases of wound healing whereas chronic wounds or wounds with an insidious onset generally heal more slowly These wounds may also signal underlying medical conditions such as venous insufficiency or diabetes How did it happen How long has it been occurring Onset How has it been managed until now Medications Dressings Surgeries What preventative measures have been taken to relieve pressure See Myers Tables 4 1 and 4 5 Medical History BOX 41 Sample General Medical History Screening Questions Do you have a history of the following medical conditions lligh blood pressure Diabetes or high blood sugar lleartdisease or heart 39 lancer condition Peripheral vascular 39 HIVAIDS disease 39 Stroke or 39IlA 39 Breathing difficulties 39 Unexplained weight loss Neuropathy or nerve damage Are you allergic to any of the following substances Latex 39 Sulfa 39 dhesives 39 Animal products Please list any other allergies you have Do you smoke 39 Numberof packs 39 Numberof years per day Do you drink alcohol 39 Number ofdrinks per day smoking Do you take drugs not prescribed by a physician 39 Name of drugs 39 Frequency and amount of drug use Please list all medications not previously mentioned that you are currently taking BOX 42 Sample Past and Current Wound History Screening Questions 39hen did the wound begin low did the wound occur lave any tests been performed wound culture blood tests xmy bone scan arteriogram venous Doppler 39ere you previomly or are you currently taking any medications such as antibiotics r this wound Is your wound painful How would you rate the pain on a 0 H pain scale hat medication do you take for pain nunagement How much pain medication do you take and how often Does the medication control your pain Does the pain change with elevation dependency acti vity 39hat is currently being done for your wound hat if anything are you putting on or around your wound How are you wrapping the wound 1 low often do you change the bandage Ian you do this by yourself or is someone helping you Are you seeing another health care worker to help manage your wound hat interven tions have been performed in the past hat impact did these interventions have Is your wound improving staying the game or get ting worse Have you had any wounds in the past here was the previous woundts How did the previous woundlis occur Did the wounds heal in a timely fashion Did you need to see a medical professional for wound management Vhat inte rventions were performed Physical therapists must obtain information regarding the patient s past and current general medical history to identify conditions that may adversely affect wound healing Diabetes 39 Gastrointestinal disorders 0 GI disorders may impair nutrition aspect of wound care therefore length of time in healing that wound would vary Regardless of wound etiology inadequate nutrition increases the risk of wound infection and delays wound healing Likewise optimal nutrition intake or supplementation is vital to prevent skin breakdown and enhance wound healing for all patients Therefore it is important for physical therapists to obtain information regarding the patient s gastrointestinal system including fecal continence 39 Cardiopulmonary Vascular disorders 0 The review of the cardiovascularpulmonary system should consist of measuring heart rate blood pressure and respiratory rate and assessing for edema Because wounds will not heal without adequate circulation physical therapists should assess peripheral pulses in patients with extremity wounds Likewise since wounds will not heal without adequate oxygenation physical therapists should perform pulse oximetry measurements in patients at risk for impaired oxygenation 39 Incontinence 0 Because of the relationship between incontinence and pressure ulcers the National Pressure Ulcer Advisory Panel also strongly recommends assessment of the urogenital system for all patients with or at risk for pressure ulcers Another reason for physical therapists to include urogenital system screening in their examination is to identify a key clinical sign of undiagnosed or poorly controlled diabetes or urinary tract infections Both of these conditions may adversely affect wound healing and warrant further assessment by a physician 39 Mobility disorders 0 Impairments in the musculoskeletal system may limit the patient s ability to change positions or create areas of increased pressure 39 Immunosupression 39 Current Medications 0 Some medications such as steroids and chemotherapy adversely affect wound healing whereas others such as cilostazol or pentoxifylline Trental may assist with wound healing Additionally patients may be taking medication for a medical condition not previously disclosed The patient may not realize the potential impact this condition or treatment for this condition may have on the examination Risk Factors Medical history Body type Mobility Diet 0 May limit nutrition and production of collagen Personal hygiene Stress Age Medications Cognition Smoking Chart Review Gene Dmgmphlcs Measurng Hletay Ounmt Commotion oAge Cadmasque Oompunqo Sex 0 EMocmemetmoic 0 Concemsthetled he Raoeeemnow Gastromeslnal mlmmlenl b seek me o anmy language Gennoomay semoes 01 a physcal heinous 0 Edwaton oGynecdogml Conoemsa neeosot Iniegumentary petmmlent who remres the Social Malay Muscuiodteetd semoes o a physcal Maps 0 Cultural De es and benawons o Nauromusmlm o Curran thetepeutc Famly and wegmel Obstehml menentons resources Pno musone o Mechanans 01 may or 0 Soon Inbredom soon sugenes and pteeumrg Geese muting date 01 8mm andsmoon sys1ems medcal and one heam mseandcme otevents re ned commms 0 01861800 penem o EmploymmMork o Psydwlogoal symaoms JothhooVPhy 0 Pulmonary Patelmth tamly sgndoem o Curreni and poor wot abet and oaregwet pascnoouaeyj conrmnny apectatms and goes lat he and Ieaure actms tasks 0 hermeutc mavenon amoes o PatenacImt Iamty sgnatcam abet and wegwet percep Gtth and Development ions 01 patenrsnenfs 0 W131 mm anotona remonselome O Hand dommmoe amen clnaca sumon Prevms oocwenoe oiche Lwhg Bwiomem oon39pImnMS 0 Demesand equmeni eg o Pm mermeutc mervmtms assem adapwe omotc ptaecwe suppmrve Functional some and Actva pcoshetcj Level Lmng enwonment and Guam and 900 tmctonal ooman charme mans In senwe and home Progcied teenage management munn9 deema ons sewnes 01 only um All ma natumental amtes a Central Helm Sam M hang IADL Se wan Fanny Roped 0 Oman and pno 1mctonal Cueglm Report sums n wont mommy Geneva beam perceaon oonmunny and heme o Physcal tunaon eg maxim muons team 0 awnes steep pauens estraed bed days cautions Psychotognd tunaon eg muons moment memocy reasmang am common depressonenxety 0 muons paevmsrytahen Role Iuncton leg comma1y btcurent ootmon lemresooal M 0 Me oetons blomet 0 Soon tuxcton eg soon Mm amny soon niecacton sooal suppm OM Clch Tests 0 Labomtoq and anagnoac tests 80am than 0 Renew 01 avenue recoms Patent Omen oeg medcal eOmaton o Helmnae Mann nae eg surges mung drug abuse 0 Renew 01 oma anneal 0 Level 01 physcal tness hangs leg mamon and hydra0N Foamy notary 0 Partial heart rate Lab Values Easily available to Acute Care Clinician WBC O Tells you about infection and What phase of healing you are in RBC 0 Tells you about the oxygenation of the tissues Glucose Levels Creatinine Blood Urea Nitrogen BUN Platelets Prothrombin Time Myers Table 4 2 TABLE 4 1 Reference Values for Laboratory Tests Test Normal Value Possible Signi cance of Abnormal Values Total red blood cell count I lematocrit 0 I Iemog lobin 39 Total white blood cell count Platelet thrt mtbmyte count 0 Total lymphocyte count TL I Serum albumin Serum prealbumin 0 Serum transferrin Blood glucose 0 Urine glucose 0 BUN blood urea nitrogen 0 Ireatinine V39ome n 40 S 5 millionmm t Men 4 2 mt ll ionmm Vomen 38 46 Men 42 54 Vomen 1 2 1 6 ill Men 14 18 gdL 4500 1 1000mm 1 500004X000mm 39 l 800 cells mm quot 35 55 gdL 16 40 mgdL 39Zr 1 70 mgdL 70 110mgdL Nega tivc 80 20 mgdL 08 12 mgdL If low may be anemic or may have lost blood volume If high may be dehydrated or at risk for blood clots If low may have anemia blood loss or malnu trition If high may be dehydrated or at risk for blood clots If low possible blood loss or nutritional deficiency If high possible dehydration or risk for blood clot Iflow at risk for infection Ifhigb possible infection inflammatory response or anemia If low delayed clotting If high potential for blood clots If low decreased immune function may have protein deficiency can delay wound healing If low may be malnourished may cause tissue edema may be sign of metabolic stress or in ammation Low levels are correlated with pressure ulcer severity If high may be dehydrated If low may be malnourished may be sign of metabolic stress or inflammation Mortality rate increases as prealbumin decreases If low may have protein deficiency or be mal nourished If high may have iron deficiency If high may have poorly controlled diabetes If present may have poorly controlled diabetes or kidney disease If high may have kidney disease or be dehy drated High levels associated with delayed wound healing Ifhigh may have kidney disease Decreases with malnutrition 39Note this is only a very preliminary list of possible causes of almomtal values Any abnormal values may adversely affect wound healing Please refer to other sources for more complete informad on White Blood Cell Count Leukoc osis exceeds normal range 0 In ammation Infection Cancer Leukopenia below the normal range 0 Viral infection bone marrow disease chemotherapy 0 Technique to prevent infection WBC s Neutrophils elevated with bacterial infection 0 Monoc es destruction of debris and marked cells 39 Eosinophils elevated with allergic response Basophils release histamine mediating inflammation RBC39s 39 Transport oggen to the wound 39 Anemia Vitamin amp iron deficiencies 39 Erythropoietin given to assist wound healing Cop ht 2001 Dennis Kunkel Microscopy Inc I Dennis Kunkel Hemostasis Why is it important 39 Concern for bleeding 0 Check for clotting time PT time Sharp Debridement 39 Frequent dressing changes 39 Drainage Dressing selection 39 Pressure management Deep Venous thrombosis Platelets 39 Major role in hemostasis First step in acute wound healing 39 Thrombocytopenia de ciency of platelets RBC Platelet WBC Hemostasis Coagulation process Where Thrombin traps red blood cells forming a clot 39 Partial Thromboplastin Time PTT an index of the effectiveness of the conversion of fibrinogen to fibrin Normal value 2540 seconds Prothrombin Time PT screen for coagulation disorders and effectiveness of anticoagulation therapies 0 Normal range 1215 seconds corrects for variations in testing methods by using a ratio of PT to reference values 0 Normal range 0911 Vitamin K deficiency Electrolytes Sodium effects fluid volume swelling edema Potassium determinant of membrane potentials depolarization of nerves arrhythmias Heavy draining wounds 39 Burns Renal Function M balance between production of Urea and breakdown of protein 0 Normal range 80 20 mgdL Sign of breakdown of tissue muscle GI bleed dehydration Creatinine a product of muscle tissue Normal range 0812 mgdL 0 Plasma concentration of creatinine will decline with decreasing muscle mass Erythropoeitin is synthesized by renal cells People With renal disease have decreased erythropoeitin and typically also have anemia Meduna Renal pelvis Cortex Renal uein 39 artery ureter Microsoft Illustration Glucose Normal range 7 01 10mg dL Blood glucose in excess of 126 mgdL on at least two measurements is diagnostic of DM eDiabetic wounds will heal only When glucose levels are stable in the normal range Physical Examination Gross Appearance of Wound Clues concerning the cause of the wound and prognosis for healing C0101 0 Strong indication of vascular supply 0 Wound Bed Color 39 Red Healthy 39 Yellow Slough 393 Body sending fibroblasts in the area but it is not being laid down correctly O Surrounding Skin Color 39 Melanin and Hemoglobin primary determinants of skin color m suggests m insuf ciency Purplish hue due to desaturated hemoglobin 393 Severe arterial insuf ciency 393 Severe CHF or pulmonary disease Reddish Errythema in ammation infection 39 Arterial Insuf cency 393 Pale Cold Painful 39 In heavily pigmented skin hyperemia excessive blood ow produces Violet or eggplant color 39 Look at Ligand nail beds 39 Physical Exam Skin Surrounding Wound 393 Hemosiderin Staining Very predictive of Venous hypertension Indicative of repetitive trauma When seen around chronic wound Pressure ulcer 393 White Maceration Too much drainage 0 Of the tissue surrounding the wound itself 393 Trophic changes are indications of poor arterial circulation Dry Scaly Leathery skin Brittle Nails Hair loss epidermal appendage l I O Detectable odor indicative of infection 39 wounds have typically have No Odor 39 M Fruity suggests Pseudomonas 393 Along with a greenish color 39 Lul Fecal like indicates gram negative bacteria 0 May have odor after removal of certain types of dressings Wound odor is a highly subjective measure and therefore should only be described as either present or absent Conversely wound odor may be disguised or exacerbated by certain dressings deodorizers or topical agents Wounds with necrotic tissue are likely to have at least a mild odor Despite its subjective nature wound odor should be recorded because it is one of the indicators of wound infection Drainage 0 Thick creamy drainage indicative of infection 39 Is there drainage on the primary wound dressing How much 393 will help determine what type of dressing the individual would need 39 Is there breakthrough drainage on the secondary dressing 39 Is the drainage due to breakdown of the wound dressing alginate hydrocolloid 393 Understand the properties of the dressing you are using to determine how much drainage there is 0 Amount 39 Heavy Moderate Minimal Scant None 393 Heavy Bloody 0 1m Serous clear thin water Sanguinous Tan thin with blood mixed Purulent Thick Pus foul n Thick Purulent Drainage 3 4 v 39 The type of wound drainage is generally described as one or a combination of the following serous sanguinous or purulent Serous exudate is a proteinrich fluid with a few white blood cells that is generally seen in the inflammatory phase of wound healing It ranges in color from clear to pale yellow and has a watery consistency Sanguinous drainage is red in color when fresh or dark brown if allowed to dehydrate and has the consistency of blood or slightly thickened water Sanguinous drainage results from bleeding at the wound site Purulent drainage 0 Color Shape ranges in color from white to pale yellow and has a viscous or creamy consistency Purulent drainage is generally an indicator of wound infection Red bloody Yellow Brown Green indicates Pseudomonas infection 393 L Erythema is an indicator of in ammation but if out of proportion to the size and extent of the wound may indicate infection Nonblanchable erythema indicates ischemic damage due to unrelieved pressure Skin that appears lighter or paler than surrounding tissue may indicate decreased blood supply or newly formed scar tissue that has not yet regained normal pigmentation Skin that is blue in color generally represents areas of severe andor prolonged ischemia Long standing venous insufficiency may cause hyperpigmentation of intact skin 0 May indicate cause of wound Highly Regular shaped Oval or Circular typically associated with Pressure Irregular shape associated with Vascular Insufficiency Extremely Irregular with peninsulas and bays areas of healthy tissue surrounded by necrosis associated with Venous Insuf ciency 393 Regular Round Pressure Ulcer O has a peninsula TABLE 42 Documentation and Interpretation of Wound Drainage Drainage Description Interpretation Type Serous Normal transudate Sanguinous Normal acutely or in msponse to trauma Serosangmimus Normal I urulent Possible infection Seropurulent Possible infection Color Ile a r Normal Pale yellow Normal Red Fresh blood Dark brown Dried blood Blue g re en Probable Pariahmoms i nf ec tion Consistency 39lliin watery Normal 39Iliick Possible infection Amount None Desiccated wound bed Minimal or moderate lopious Normal however wounds with drainage that is disproportionate to the amount ofnecrotic tissue may be infected Possible infection especiall ifout of proportion to wound size BOX 43 Wound Characteristics to Include within the Examination of a Patient with an Open blind 39 Vound location Vound size Voundcharacteristics o Granulation tissue 0 Necrotic tissue 0 tlte r structures 39 inmd edges 0 ttacl1ed unattached o lndisti netwell defined a 39l liickened or rolled o l nierke ratosis bunddrainage blind odor Temperature Check severity of the in ammatory response by monitoring skin temperature surrounding the wound Dramatic increase in skin temperature can be indicative of developing cellulitis or infection Cold indicative of Arterial Insuf ciency Wound Bed Temperature 0 T Temperature indicative of infection 0 l Temperature delays healing by reducing oxygen release Infrared Wound Temperature Measurement Medscapei i wwwmedscapecom Medscape39ilquot wwwmedscapecom 39 The physical therapist should assess periwound temperature An increase in temperature an indicator of in ammation or infection Whereas a decrease in temperature may re ect impaired circulation Wound Measurement Size Length and Width 0 Tape measure 0 Trace wound on Acetate 39 Wound Tracing r plantar fascia siough undermining 08 cm FIGURE 4 10 Woundtracing39 with completed documentation Patient name John Doe Date va I W 39 quot a u o A n no a 0 o h IO 39 v 39 ul quot quot u 393 Photographic assessment has two key advantages over direct wound measurements and tracings First photographic assessment avoids contact with the patient s wound Second the photograph provides additional information including periwound and wound hed characteristics Greatest Length by Greatest Width Method 0 PUSH tool uses this method Skin FIGURE 4 2 Measurement of wound size by direct wound measurement Note there is no change in wound measurements despite a Visually appreciable change in 39 wound area 393 Direct measurement of wound size is performed by measuring the longest length of the wound and the Widest Width perpendicular to this length Wound surface area is computed by multiplying length by Width Depth Undermining Tunneling 0 Cotton tip applicator 39 Mark on the cotton tip applicator Where it rst reappears from under the skin Then pull out the applicator and measure it With a tape measure Document the different depths of the tissue using the clock method 0 Tunneling stick FIGURE 4 8 Cross sectional schematic of a wound with tunneling Documentation must include the tun nel s depth and position within the wound bed most quot8quotquot quot3 395 WWW quot4 Mmmnm39 tun nuand mum ouan quotHMquot R In I nun had commonly using clock terms Wound tunnels 19 cm Mm I at 3o c lock position 0 Undermining Calibrated measuring stick Extent of undermining Skin surfaoeg Undermined area Undermining 12 cm FIGURE 4 9 Cross sectional schematic of a wound With undermining Documentation must include the extent of undermining as well as the position Within the wound bed most commonly using clock terms Under mining 12 cm from 9o clock to lo clock positions 0 Report using Clock Method 39 For the foot 12 toes 0 quotquotquotquot Also Measure the Surrounding skin mm Key is consistency and document how and where you measure and what tool was used Wound Measurement Volume 0 1 Fill the wound cavity with Hydrogel from a syringe O 2 Subtract the volume remaining in the syringe from the original amount m39 0 5D Cameras input to computer to measure size depth volume of wound Resulting DSM of pressure sore N V a quot22 06m cm O 20 05 22 39 39 i w x cm Limb Girth O Circumferential measurements with a tape measure 0 Must document landmarks to make the measurements reproducible in the future 0 Fitting or rm Limb Volume 0 Water displacement by the lower leg is used to quantify edema Over owed water is collected and measured There are several problems with volumetric wound measurements however Molding is time consuming and can be painful to the patient In addition it is unclear if the molding material or extrication may have detrimental effects on wound healing Calculating wound volume by measuring the amount of saline to fill the wound void is also time consuming inaccurate and problematic Although volumetric assessment may potentially provide a more complete illustration of wound size by portraying the wound in three dimensions in contrast to the twodimensional representations of the previously described methods it is unclear whether this additional information is useful or necessary in determining changes in wound characteristics or making a wound healing prognosis Wound Edges Attached quicker to heal 39 Unattached slower to heal 39 Rolled signs of chronic wound 39 Callused diabetic Epithelial Appendages 39 Are there any in the wound 39 Are there any on the limb or adjacent tissue 39 Why is this important to know 0 The physical therapist should assess for the presence and quality of epithelial appendages including hair and nail growth Prolonged ischemia also increases the risk of nail fungal infections making them appear thick and yellow However because trophic changes alone are insufficient to diagnose arterial insufficiency these findings should be confirmed with further testing Vascular Testing 0 Palpation Dorsalis pedis Posterior tibial and Popliteal pulses Capillary re ll Dependent Rubor test Super cial ABI Ankle Brachial Index 0 Measure BP at arm and ankle at rest and during exercise 0 Divide ankle pressure by arm pressure 0 Normal index is 10 0 Less than 95 narrowing 0 Less than 80 intermittent claudication Physical Exam 0 Do you have pain in your legs when you slip at night 39 Does it hurt with elevation 39 Helps with circulation to sleep in chair 0 Does it improve with standing and hanging legs off side of bed 0 Do you sleep in chair 0 Do you have pain with walking 0 Do you have numbness and tingling Diminished or absent pulses likely represent more proximal arterial occlusion and indicate poorer wound healing outcomes Physical Exam Comprehensive Strength amp ROM Sensory testing Re ex testing Mobility Coordination Balance Infection Control 2215 907 PM Geeze Mom I just washed 39em yesterday Sources of Organisms 39 Many normal flora colonize your skin sweat glands hair follicles amp mucosa O Staphylococcus Pseudomonas Streptococcus Acinetobacter 0 You have normal bacteria on your body preventing bad bacteria from entering 39 Infection occurs when the organisms proliferate and become virulent when introduced in body tissue Intestinal flora can be introduced via fecal incontinence or poor hygiene O Enterococci Proteus Klebsiella Health care workers improper hand washing and aerosol inhalation Effect of Bacteria on Wound Healing Tissue levels via tissue biopsy gt 100000 105 organismsgram of tissue indicates infection 39 Presence of StrepB in lower quantities can indicate infection Table 61 Myers has good comparison between normal inflammation and infection 0 Important to know the difference Predisposing Factors to Infection Secondary Immunodeficiencies DM depressed neutrophil production when poorly controlled 0 Affects how your cells respond 39 Kidney disease Burns Malnutrition 39 Alcohol ampor drug abuse 39 Cancer especially of the immune system 39 Immunosuppressive drugs Predisposing Factors to Infection Alterations in the Microenvironment 39 Presence of Necrotic tissue 0 Part of debridement process is too remove these tissues Use of antibiotics can reduce competition for the local microenvironment 0 Can allow resistant organisms to proliferate Postoperative Infections Infection rate has not been correlated with quantity of bacteria present in the air present in the wound at the time of surgery or with post op infections 0 The longer the wound is open during surgery the greater risk of infection Strongest factor seems to be duration of surgical procedure 0 56 in procedures lt 50 minutes 0 164 in procedures gt 5 hours 39 Infection in another area of body Ts risk three fold 0 When cleaning multiple wounds clean the uninfected wounds FIRST Posttraumatic Infections of organisms recovered from traumatic wounds Ts rapidly with time 0 The longer it takes to get treatment the more chance for infection 39 5 hours from injury 100 100000 organismsgram tissue 39 5 hours from injury gt100000 organismsgram tissue NERDS Superficial Infection localized in the epidermis and dermis Non Healing 39 Exudative Wound 0 Excessive draining 39 Red and Bleeding granulation tissue 0 Bleeding alot Debris in the wound Yellow or Black Necrotic tissue on wound surface Smell unpleasant odor from the wound 39 Delay in healing is lst sign no change in wound size Exudate on surface due to in ammatory response to surface tissue damage Bleeding occurs due to bacterial stimulation of vascular endothelial growth factor VEGF resulting in new blood vessels and granular tissue growth on surface 39 Results in bleeding of the wound Key inforlnation to know Nonhealing wound DThe wound is nonhealing despite appropriate interventions healable wound with the cause treated and patient centered concerns addressed Bacterial damage has caused an increased metabolic load in the chronic wound creating a proinflarnmatozy wound environment that delays healing Exudacive wound 0 D An increase in wound exudate can be indicative of bacterial imbalance and leads to periwound maceration Exudate is often clear before it becomes purulent or sanguineous x wound bed tissue is 39jrigh t red with emberanti granulation tissues and bleeds easily baCterial imbalance can Suspected 39 i I of H a a d s b dw s o aquot j39 39Lquot39 Figure 4 NERDS super cial increased bacterial burden Gram class of bacteria 1st Gram Bacteria Gram Bacteria 2nd Con1rnents DDTO deterrnine a healing trajectory the wound size should decrease 20 40 after four weeks of appropriate treatn ient to heal by week l2 DIf the wound does not respond to topical antimicrobial therapy consider a biopsy after 4 to l2 weels to rule out an unSUSpected diagnosis such as vasculitis Pyoderma gangrenosum or noalignancy Dlncreased exudate needs to trigger the clinician to assess for subtle signs of infections D Protect periwound area using the LOWE memory jogger liquid film forming acrylate ointments vvindowed dressings external collection devices fbr skin barrier for wound margins m gla ori tissuefsheuldbe pih39l aana nniThe exuberantng I Ul39atiom ssu e that is loose and bteeds easily bacterialx am ge f6 hg caliargen mama ihCl aS d vasculatur e39 oi th39equot tissue u m Anaerobic Bacteria 5rd STONES Deeper tissue Infection 39 Size is bigger 39 Temperature is increased 39 Os probe to exposed bone Osteomyelitis 0 Risk of infection in the bone New or satellite areas of breakdown 39 Exudate Erythema Edema 39 Smell Remember STONES sink to the bottom deeper tissues are affected Size is bigger IIIauntquot Temperature increased Os probes to or exposed bone 1 Size as measured by the longest length and widest width at right angles to the longest length Only very deep wounds need to have depth measured with a probe D An increased size may be due to deeper and surrounding tissue damage by bacteria or alternately because the cause has not been treated or there is a systemic or local host factor impairing healing With surrounding tissue infection temperature is increased his may be performed crudely by touch with a gloved hand or by using an infrared thermometer or scanning deviceThere should be a high index of suspicion for infection if gt3 F difference in temperature exists between 2 mirror image sites There is a high incidence of osteomyelitis if bone is exposed or if the clinician can probe to the bone in a person with a neurotrophic foot ulcer An MRI is probably the most discriminating diagnostic test when available and considered necessary for diagnostic dilemmas Clinicians need to have a consistent approach to measurement An increased size from bacterial damage is due to the bacteria spreading from the surface to the surrounding skin and the deeper compartmentThis indicates that the combination of bacterial number and virulence has overwhelmed the host resistance It is important to distinguish between infection and the other 2 potential causes of temperature change A difference in vascular skin supply decreased circulation is colder Inflammatory conditions are not usually as warm but they can demonstrate a marked increase temperature with extensive deep tissue destruction acute Charcot joint Radiographs and bone scans are less reliable for diagnosis of osteomyelitis with loss of bone mass that occurs with neuropathy Radiographs of well calcified bone such as pressure ulcers of the pelvis may be more reliableThe majority of ulcers that probe to bone in other locations are less likely to be associated with osteomyelitis o o onbboafou39ooooooudoh39 occoi ao39oooooooconoouoo oaooo quotcoooococooooccococoonnoonoocooooc 39 i 93 lgt 39r v quot1 Culturing Wounds Gold Standard Tissue biopsy Physician Swab Cultures Quanti es the number and type of organisms present PT Nurse 0 Simple O No trauma 0 Super cial aerobic Fig 64 Myers 0 Deep anaerobic Routine Swab cultures of Chronic wounds not recommended AHCPR 0 Chronic wounds eXpected to be colonized culture would grow organisms that are not creating problem in wound O Swabbing can miss organisms that are growing beneath surface of wound 0 Wrong antimicrobial agent can be chosen slowing wound healing and having adverse effects on pt locally or systemically CDC Recommendations 0 Draw wound fluid through needle aspiration or tissue biopsy Physician AHCPR Guidelines 0 Two week trial of topical antimicrobials if a clean ulcer is not healing or exudate continues despite optimal care for 24 weeks evaluate for osteomyelitis Proper Handwashing Technique 39 Avoid touching sink with hands 39 Use clean paper towels to touch faucet controls 39 Avoid contact with outside of paper towel dispenser Universal Precautions 39 Wear gloves with anticipated contact with blood secretions mucous membranes non intact skin amp moist body substances 39 Wash hands between patients 39 Change gloves between patients 39 Wash hands for at least 10 to 15 seconds with soap and friction rinse with running water AHCPR Recommendations for Body Substance Isolation Precautions 39 Use clean gloves for each patient When treating multiple ulcers on same patient 0 Treat the most contaminated ulcer last 0 Change gloves if any fear of cross contamination Sterile Technique Definitions Sterile complete absence of viable microbes Contamination process in which sterile item comes in contact with non sterile surface or item Shelf life length of time that sterilized and packaged item considered to be sterile as long as package unopened General Rules 0 Sterile towel can be used for sterile eld but only one side of towel sterile O border around towel considered Not sterile 0 Any wet surface considered to be contaminated O M of sterilized package considered sterile O Sterile gowns considered sterile from waist up in front and elbows to hands O Edges of containers un sterile 39 cap tops must be removed before sterile gloving and left inside up Clean Technique Designed to reduce the overall number of organisms and to prevent transmission from one locale to the next Clean boxed gloves Clean field Warranted for most wound care Sterile technique required for 0 Deep wounds 0 Large Area Burns O Immunosuppressed individuals OSHA Regulations Gloves are to be worn whenever there is potential for hand mucous membrane or non intact skin contact with blood or other infectious materials g when handling or touching contaminated items or surfaces Disposable gloves are to be replaced as soon as practical when contaminated Whenever s lashes s ra s or dro lets of blood or otentiall infectious material has the P P y P P y potential for coming in contact with eyes nose or mouth masks in combination with eye protection device must be used Goggles glasses with solid side shields chin length face shields Head coverings especially with Splashing Wash hands immediately after removal of gloves amp protective equipment All sharps must be placed in a closable puncture resistant leakproof and labeled container All equipment and environmental and working surfaces are to be cleaned and decontaminated after contact with blood or other potentially infectious material 39 Handling of contaminated laundry should be minimized amp bagged at location Where it was used Selective and Nonselective Debridement 2215 907 PM Purposes for Debridement Decreases bacteria content of wound Improves ability of topical agents Increases activity of immune cells Allows healing to move past in ammatory phase Improves Energy Efficiency of wound Q If there is less dead tissue then the body can put its energy into healing Allows wound to Epithelialize and Contract Decreases Odor and improves patient Self Esteem Red Yellow Black System Myers Table 51 BOX 51 Purposes for Debridement Decrease bacterial concentration within the wound bed and the risk of infection 39 Increase the effectiveness of topical antimicrobials Improve the bactericidal activity of leukocytes 39 Shorten the in ammatory phase of wound healing Decrease the energy required by the body for wound healing 39 Eliminate the physical barrier to wound healing 39 Decrease wound odor Red M 0 Healthy granular tissue Protect it to continue to proliferate Yellow slough moist Debride Black eschar dry leathery Debride Red Yellow Black Questlon You are evaluating a patient admitted for CHF to the hospital The patient presents with a chronic ulcer on the medial surface of his lower leg with 7 0 yellow slough and 50 red granulation tissue Based on the red yellow black system What are your treatment goals 0 Debridement of the 7 000 slough and protection of the healthy tissues Four Types of Debridement Autolytic Enzymatic 0 Enzyme eats away the bad tissue Sharp Mechanical Selective Debridement Things that specifically go in and get rid of the bad tissue 0 Autolytic 0 Enzymatic 0 Sharp 39 Serial Instrumental forceps scissors 39 Selective sharp Scalpel bleeding Autolytic Debridement Uses the body39s endogenous enzymes to slowly rid a wound of necrotic tissue Selective only necrotic tissue is lique ed Moistureretentive dressings Provides optimal environment for in ammatory phase Procedure 0 Expect to see wound fluid accumulate under the dressing 39 Fluid may be tan in color not a sign of infection Example 0 Light to Moderate exudate O No need for fast results No sepsis risk Advantages 0 Very selective 39 Essentially no damage to healthy tissue 0 Safe process 39 uses body39s own defense mechanisms to clean wound of necrotic debris 0 Effective versatile and easy to perform 39 Little to no pain for patient Disadvantages O Slower process 0 Wound must be monitored closely for signs of infection 0 May promote anaerobic growth if an occlusive hydrocolloid is used Day10 Hydrocolloids Hydrogels Alginates Foam Dressings Films 39 Avoid Macertion from collecting drainage 39 Slight Odor is normal Contraindications O Infected or deep cavity wounds 0 Wounds that require sharp or surgical debridement Termination 0 If necrotic tissue fails to decrease in expected amount of time Enzymatic Biochemical Debridement Chemical enzymes applied to Non viable slough or necrotic tissue Enzymes used to dissolve lyse nonviable tissue eg Collagenase Santyl Often used in facilities Where access to sharp debridement may be limited ounq quot quotc quot o M mom39s couagenaso Study a Iquot mmmem W 39 Enzymes categorized O prote olytics O brinolytics O collagenases O Dependent on tissue component they target 39 Applied only to area of eschar or slough Advantages O Faster acting than Autolytic 0 Minimal or no damage to healthy tissue with proper application Disadvantages O T Cost requires a prescription 0 Requires secondary dressing to hold the enzyme in place one that would not soak up the enzyme 0 In ammation or discomfort may occur Ideal option for patients who can39t tolerate surgery or who are being cared for at home or in longtermcare facilities Compatible with topical antibiotics Cross Hatch Score Eschar with scalpel O Permits debriding agent to penetrate eschar O Myers Fig 55 FIGURE 53 Irnsshalehing an eseharem39cred wound To ernsslureh a sealpel L9 used 0 score eschar or necrotic l39Lssue in lines at an angle 0 one another in order In increase unund surfaee area 393 The yellowish white substance here isn39t sloughit39s a tendon The green in this photo is a debriding agent 393 What is wrong with this picture This is a wound we want to protect and not debride because the white spots are actually tendon and bone Sharp Debridement Dissection of necrotic tissue from viable tissue With a scalpel or scissors or forceps 0 Can be very painful Most rapid and effective method of debridement Very selective complete control over Which tissue is removed and Which is left behind 0 Before 39 After With 80 of eschar removed Day 1 Prior to Debridement Day 17 Post sharp and autolytic debridement Necrolicj Tlssue After General Contraindications for Debridement Red granular wounds Heel ulcers with Eschar if they do amp have edema erythema uctuance and drainage Eschar in ischemic wounds Wounds that require Surgical debridement 0 Need to decide if there is nerve muscle etc involved that you don t want to cut away When area cannot be adequately visualized 0 Don t cut away areas that cannot be seen adequately Material to be debrided is unidenti ed Ischemic ulcers with low anklebrachial indexes Patients who are thrombocytopenic or who are talking Anticoagulants with my delayed clotting times Hypergranular tissue Termination of Sharp Debridement Clinician fatigues Pain is not adequately controlled for patient Decline in patient status or tolerance to technique Extensive bleeding Nothing remaining to debride Nonspeci c Mechanical Debridement Whirlpool Soften amp mechanically debride dead tissue 0 Circulating water around an open wound to clean the area Usually 10 20 minutes QD BID 0 Aggressive cleaning infected wounds 0 Water should be tepid 80 F 92 F 27 C 555 C or neutral 92 F 96 F 555 C to 556 C Whirlpool Precautions O Periwound maceration 0 Risk for waterborne infections such as Paeugomomw 0 Increase risk of crosscontamination multiple wounds 0 To minimize infection risks whirlpool tank must be thoroughly cleaned with a cytotoxic disinfectant after each patient use Nonspeci c Mechanical Debridement Wet to Dry Dressing 39 Not recommended Only for wounds that have 100 yellow slouth because when the dressing dries it will dry into the tissues bad or good which will get pulled away when removing the dressing Moist coarsemesh gauze placed in wound and allowed to dry before removal Necrotic tissue adheres to these dressings and is removed with dressing Nonselective healthy and granulation tissue also removed with dressing Method must be discontinued when granulation begins Mechanical Wet to Dry 39 Painful patients will ask you to wet the dressing prior to removal Specific Mechanical Debridement Pulsatile Lavage Specialized equipment that combines pulsating irrigation uid with suction Wound is cleaned amp debrided at variable irrigation pressures measured in pounds per square inch psi Pulsed Lavage with Suction Choosing the Best NonSurgical Debridement Method How mucb tim6 90 you 56196 to 966196 0 Infected wounds require immediate attention 0 What is patient39s clinical condition 0 How much time can you devote What 6116 66 watt29 cbarackrtbtiw 0 Consider the size depth location amount of drainage presence or absence of infection and etiology of the wound H ow d6l66tiV6 61 11166609 of 96 r696m6nt 24 1266969 0 What is the risk of damage to healthy tissue as necrotic tissue is removed Necrotic tissue Is there ascending cellulitis osteomvelitis extensive necrosis extensive undermining A Surgical debridement if consistent with overall plan of care Foreign material Debris Residual topic agent A Sharp debridement Mechanical debridement Blisters Callus A I Sharp debridement o SignslSvm ptoms of infection present Painful wound or Palliative care b Need for non skilled debridement 4 home health longterm care selfcare Small amount of necrosis r Patient with little Sharp debridement I Enzvmatic debridement with topical antimicrobial I Mechanical debridement I Autolvtic debridement I Littlelno improvement I Enzvmatic debridement Consistent I Sharp debridement plan of care limited with topical liclocaine I Autolvtic debridement I Littlelno improvement I Enzvmatic debridement 4 1 I Sharp debridement I I Autolvtic debridement I Mechanical debridement I Sharp debridement reserve to break I I Enzymatic debridement down necrosis Limited treatment frequencv FIGURE 5 4 Wound debridement algorithm Does it Hurt In most patients Yesl Ask nursing to Premedicate the patient I Autolvtic debridement I Mechanical debridement With or without I Enzvmatic debridement sharp debridement 39 IV Morphine Dilaudid 39 Oral Oxycodone Percocet 39 Topical analgesia Lidocaine Xylocaine Need Physician order for pain medication Question You have a 4 5 year old terminally ill patient at home on Hospice care Discovered to have a pressure ulcer on the sacrum 55cm X 50cm and is 90 covered with eschar What type of debridement do you recommend 0 No need to rush with procedure New CPT codes Selective aelm39Qement 0 Instead of one code for quotselective debridementquot there are now two codes The codes m and m specify that the procedure quotmay include use of whirlpoolquot 97 022 A charge ONLY for the amount of surface area that you debride 97597 Removal of devitalized tissue from wounds selective debridement without anesthesia eg high pressure waterjet withwithout suction sharp selective debridement with scissors scalpel and forceps with or without topical applications wound assessment and instructions for ongoing care may include use of a whirlpool per session total wounds surface area less than or equal to 20 square centimeters 97598 total wounds surface area greater than 20 square centimeters APTA Guide to Practice quotNonselective debridement is the removal of non specific areas of devitalized tissue with prior tissue preparation Non selective debridement may include the use of enzymatic debridement wet dressings wet to dry dressings and wet tomoist dressings quotSelective debridement is the removal of specific areas of devitalized tissue without prior tissue preparation Selective debridement may include use of autolytic or enzymatic agents or sharp instruments Selective sharp debridement which often occurs at the line of demarcation between viable and non viable tissue is the use of sharp instruments for I H tissue removal Therefore according to the Association s current position only physical therapists selectively remove specific areas of devitalized tissue using sharp instruments 39 Florida Practice Act FS 4 86 has nothing in regards to debridement Check your state act and your facility definitions Choosing the Best NonSurgical Debridement Method What metboad are you allo we to We 0 Licensure professional practice act What39d tbe care dating 0 What are available resources in your setting hospital vs home Dressing Selection and Topicals Purpose of Dressings Maintain a Moist wound environment 0 We don t want the wound to dry out because of it does the white cells cannot migrate across and epithelization could not occur Provide thermal insulation at wound site 0 Cold temperatures could cause vasoconstriction and therefore stop the cells from going into the area Physical protection Prevent contamination Promote autolytic debridement Fill dead space to prevent tunnels and abscess formation Manage drainage Role of the Dressing Inflammatory Phase Support the bodily cleansing mechanisms Absorb germ laden exudates Serve as prophylaxis against infections Stimulate physiological secretion Role of the Dressing Proliferation Phase Promote tissue formation by the generation of a balanced moisture level Avoid wound desiccation Act as a barrier to germs Protect the granulation tissue against mechanical irritations Role of the Dressing Epithelialization Accelerate cell migration Accelerate cell division through maintenance of a moist environment Prevent early scab formation Ideal Wound Environment for Healing Growth factor warm moistness oxygen asepsis Primary vs Secondary Primary direct contact with the wound Secondary placed over primary for 0 Protection 0 Cushioning 0 Absorption 0 Holds primary in place Occlusive vs NonOcclusive Transmission of moisture vapor gas and bacteria NonOcclusive Occlusive Dry to Dry Gauze Semipermeable lm Wet to Wet Gauze Semipermeable foam Wet to Dry Gauze Hydrogel Impregnated Gauze Hydrooolloid Contact layer 0 Alglnate Myers Fig 7 3 0 Nonocclusive not occluding gas from coming allows gas exchange 39 If we do not allow oxygen into the wound it would make for an anaerobic environment which will promote germs to grow 39 Alginate turns into a gel when wet O Occlusive will stay on the wound bed for up to 5 days Occlusive Latex Ifydrooolloids Hydrogels sheet Sem39permeable Foam Sem 39permeable Film Impregnabd Gauze Calcium Alginates FineWeave Gauze LooseWeave Gauze Air Se miooclu s39rve Occlusiveness No noqu s39rve Permeanle Sem permeaile Irrpermeable Permeability Gauze Dressings Kerlix FIGURE 7 3 kclusion con tinuum of wound dressings Includes Telfa pads gauze sponges and bandage rolls Permeable to bacteria gas and uid Dry gauze is a fair bacterial barrier Wet gauze can transmit bacteria easily 0 When gauze is soaked with drainage it needs to be changed to prevent transmission of bacteria Highly absorptive Very porous Primary or Secondary Used for wrapping or packing wounds Gauze Dressings Indications Wounds needing debridement Infected wounds Non Occlusive Copious drainage or bleeding Absorption Q Will dry into the tissue Protection of acute wounds Secondary When you cannot use adhesives 0 Patients may be allergic to taping material so you may be able to use guaze Use a cotton tipped applicator to help with packing areas of tunneling and undermining O Packed in loosely to allow granulation Packing Strip Gauze is good for narrow tunneling wounds Available in 14 12 and l widths Also available impregnated with Iodoform an antiseptic Gauze Dressings Problems Sheds readily and can contaminate wound Absorptive and Will dry the surface of the wound Permeable to bacteria Adherent amp Will traumatize wound on removal 0 Damage to granulation tissue 0 Causes pain Gauze Dressing NonSelective Debridement 0 As a Wet to Dry gauze dressing dries the gauze sticks to the wound tissue 0 When you remove the gauze it removes tissue nonselectively 39 Not recommended unless there is 100 slouth Dry gauze dressings that are adherent can damage healthy tissue Use normal saline to moisten dressing to assist removal With the least amount of damage Less painful for patients Aids in patient compliance with dressing changes Impregnated Gauze Dressing Petrolatum Zinc Used to decrease adherence of dressing to wound surface Helps m wound moisture Indications O Frequent dressing changes 0 Application of topical ointments 39 Not for dry gauze which would absorb the medication O Impregnated Gauze Xeroform retains enough moisture to prevent sticking to wound and prevents damaging the healthy granulating tissue Contact Layer Nonstick Small perforations allow evaporation of some moisture Larger molecules are retained preventing the wound from drying out Suitable for acute and infected wounds without the negative aspects of dry gauze Example Telfa pad Pads can be cut to the shape of the wound Less bulky than regular gauze Must secure with a Secondary dressing Semipermeable Film Dressings Have properties of an occlusive dressing Allow autolytic debridment Can only handle minimal drainage Useful for super cial or partial thickness wounds Indicated for minor burns and simple injuries Abrasions lacerations Easy to apply Does not need to be covered by a secondary dressing EX Opsite Tegaderm 0 will adhere to the periwound so you do not need secondary dressing l 39 1 3 5 i f I v1 n z Va I llllllll Semipermeable lm Opsite O Allows visualization of the wound without removing the dressing Removing Semipermeable Film Skin will adhere very strongly to the lm To w a lm dressing 0 Lift a corner 0 Pull tangentially to the wound o This allows the lm to stretch and loosen without damage to the tissue 0 Using linger gently push skin down away from lm Semipermeable Film Dressings Discontinue Use When There is too much drainage under dressing O Leads to maceration of the periwound skin When the wound becomes infected Semipermeable Foam Dressing Extremely absorbent E permeable to gas and water than Provide cushioning padding to wound 0 Good for wounds over bony prominences Provide thermal insulation to maintain the temperature of the wound Discontinue use when 0 Heavy exudate cannot be absorbed by the dressing in less than 24 hours Semipermeable Foam Highly absorbent Ideal for heavily exuding wounds or ulcers Nonadherent Hydrogels i rvlynrtlhun loam Dixfry F Two forms Amorphous and Sheet Amorphous primarily used to hydrate the wound Sheets are Soothing on super cial and partial thickness wounds especially abrasions and burns 0 Cooling effect to the wound surface Sheets require taping or secondary Sheets can absorb minimal to moderate drainage if necessary but not meant as absorptive dressing Medicare states Hydrogel should not be used to Q a wound Amorphous Hydrogel placed in healthy wound to keep wound moist and hydrated Hydrogel Sheet 0 Sheets of Hydrogel cover wound 0 Does not liquefy O Maintains wound moisture 0 Needs to be covered by secondary dressing 0 Dressing does not stick to wound surface Hydrogels Indicated for dry and sloughy wounds 39 Rehydrates eschar Enhances autolytic debridement Prevents drying out of tendon tissue 39 Are useful carriers for topical drugs Discontinue when 0 Exudate becomes Excessive Hydrocolloids 39 Most Occlusive type of dressings 39 Barrier urine stool MRSA pseudomonas 39 Indicated for Partial and full thickness wounds Absorb Moderate drainage Use for several days before changing dressing Therapist must be comfortable keeping wound covered for 45 days Cost effective less total number of dressing changes and supplies required Do not be alarmed O Drainage Will have mild odor and resemble purulence due to autolytic debridement O Exudate combines with polymers in dressing to form a gel under dressing Pastes granules spiral sheets are used in wounds for managing drainage and lling cavities Q Can be used to ll the wound Fillers absorb maximal drainage Fillers require a secondary dressing Hydrocolloid sheets 0 Initially originated to protect good skin around ileostomies and colostomies O Requires no secondary dressings 0 Watch skin integrity and maceration O Discontinue When develop increasing granulation tissue 0 Contraindicated in Infected Wounds Duoderm Hydrocolloid Dressing 0 Multiple shapes for multiple uses 0 Sheets gels granules 0 Can cut sheets to t wound 0 Cut to t wound o By appearance of the dressing it could stay in place another 54 days 0 No secondary dressing needed 0 Cannot see through the dressing is a risk if you feel the wound has a high chance for infection Alginates Derived from long chain sugars polysaccharides from seaweed Change from a ber to a gel as it absorbs uid from the wound Reguire a secondary dressing Come in the form of sheets and ribbons Indicated for Heavy drainage 0 Great for deep cavernous wounds Calcium Alginate Calcium Alginate 39 Pack sheets or ribbons into wound cavities to absorb heavy drainage 39 Turns into a gel that may trap bacteria and is easily washed out with normal saline 393 The gel is nonocclusive Alginates 0 Ideal for use in infected wounds with moderate to heavy drainage Discontinue use when exudate decreases to the point where the alginate bers do not turn into a gel Secondary Dressing Objectives Hold primary dressing in place Absorb excess exudate Provide cushion and protection Provide compression Retain warmth Can be used to immobilize a body part Options 0 Gauze sponges 4x4 secured with tape 0 Bandage rolls 0 Adhesive bandages 0 Paper plastic silk tape 0 Montgomery straps 39 A nonadherent dressing 0 Stretch netting Tubigrip Systenet Surgipants 39 Doesn t have the same compressive ability of Ace Wraps 0 Compression wraps O Absorbent Pads are used as a secondary dressing for wounds with moderate to maximal drainage O Gauze Roll Kerlix or Kling used to secure primary dressing and ABD pads 0 Flex Wrap Kendall 39 Compression wrap 39 Does not stick to primary dressing or skin 39 Only sticks to itself Silk Cloth Tape 0 Most adhesive tape used 0 Minimal damage to young healthy skin 0 Easily m fragile elderly skin 0 More expensive than other tapes 39 Should not be used on primary wound dressings 0 Primary use for attaching secondary dressings KE nDALl mm 10 I 1 quot 39Illlf ll b 1 I Plastic Tape 39 Very adhesive Harsh to the skin 39 Tears easily Used for taping secondary bandages only 0 Stronger and when you can apply a lot more compression on the wound Paper tape Less adhesive Hypoallergenic 0 Low cost Removes easily from skin Can tape primary or secondary dressings in place 0 Window box around the frame of the dressing 0 Try to put at least amount of tape on the peri skin Microponz39 Irpnl lay Maul Su xrqlam39na Hmquot mama quothequot M d 39 u l I39llsquot w Foam Tape 0 Best type to place directly on the skin Low adhesion to skin Gentle enough for BID dressing changes Stretches with skin Should not be stretched when placing on the skin 39 More expensive 0 Causes the least amount of damage to the skin Skin Protectant 39 Protects healthy skin from mechanical trauma of adhesives Prevents adhesive from contacting skin directly Results in less damage when remove tape Also act as moisture barriers to decrease chances of maceration Frequently used on fragile unbroken skin and Stage 1 pressure ulcers Prepares the area allows the skin to get tacky to adhere to the skin 0 Also apply to healthy skin prior to applying tape or other adhesive dressing 39 Also acts as a protective layer between the adhesive and the skin during removal Montgomery Straps Used for approximating dehisced wounds Protect wounds from trauma by movement coughing sneezing and frequent dressing changes Premade straps are available but eXpensive Straps can be made with silk tape Wet to dry or Alginate is used as the primary dressing ABD Pad is used as a secondary dressing Choosing the Appropriate Dressing Wounds are Constantly Changing as they progress through the healing process 39 Your Choice of dressing will also Vary as the wound clinically C anges for the better or worse Tissue type Depth and Exudate will vary Decision Making with Wound Dressings 39 Several options M one dressing is the only dressing 39 Follow the properties for that wound 39 Maintain a moist wound environment 39 Protection of tissue 39 Debridement of tissue Dry Wound Nondraining HealthyGranular 39 Treatment Goals 0 Add or maintain moisture 0 Protect tissue Dressing suggestions 0 Hydrogel covered with Telfa pad wrapped with gauze roll 39 Provides moisture O Semipermeable lm 39 If it is a superficial wound that can maintain its own moisture Wet Wound Draining Healthy Granular 39 Treatment Goal 0 Keep wound clean 0 Absorb exudate but also maintain moisture Dressing suggestion O Hydrocolloid sheet 39 If it is not deep 0 Semipermeable foam 39 If it is deep you may need to fill it in with an alginate Dry WoundNondraining Necrotic 39 Treatment Goals 0 Add or maintain moisture O Debride 39 Dressing Suggestions O Hydrogel O Hydrocolloid O Impregnated gauze Wet Wound Draining Necrotic 39 Treatment Goals O Absorb excess exudate but maintain moisture O Debride Dressing suggestion O Alginate dressing covered with ABD pad wrapped with Kerlix roll BID dressing change 39 Absorbs a lot of drainage but keeps the wound moist Orders for Dressings 39 Must come from a Physician nurse practitioner clinical nurse specialist certified nurse midwife or a physician assistant for Medicare to reimburse 39 Physical therapists cannot order dressings However they can make recommendations Wound Cleansers Topical Agents and Antibiotics Toxic Topical Agents Still in Common Use 0 Povidone Iodine Acetic Acid 0 Dakin39s Solution sodium hypochlorite o bleach 39 Hydrogen Peroxide Why should we NOT use these toxic topical agents 39 Solutions are Toxic to Human Fibroblasts and lymphocytes 0 Toxic to healthy tissues 0 Inhibit collagen synthesis 0 Inhibit granulation tissue formation 39 If you must use apply allowing to kill bacteria and then wash wound with saline Do not leave on for prolonged tissues pH range 29 55 Low pH prevents proliferation of cells High concentrations are Bactericidal 39 Used to suppress growth of Pseudomonas Aeruginosa Used in Wet to dry dressings Dakin39s Solution 39 Properties 0 Germicidal Deodorizing Bleaching Inhibits key enzymatic reactions within the cell and denatures and inactivates nucleic acids Retards collagen development Prolongs in ammatory response Leads to capillary shutdown Povidine Iodine Potent antiseptic O Kills gram and gram bacteria fungi protozoa viruses and yeasts Prevention and treatment of surface infections Degerms the skin prior to invasive procedures Inactivated in the presence of blood and organic matter Not approved by FDA for use wounds Iodine Betadine Still frequently ordered by physicians Orders for applying to gauze dressing or using in the whirlpool 0 Call physician and explain why these agents are not good for the wound and request new orders Hydrogen Peroxide Contact with tissues releases molecular oxygen Brief period of antimicrobial action during release Helps remove old blood from skin surface Harmful inside open wounds Will bleach hair if used on a scalp abrasion So then What Solution is SQ to Use O O O 0 Normal Saline Physiologically compatible Nontoxic Readily available and inexpensive Need to discard bottle 24 4 8 hours after opening no preservatives Saf Clens Wound Cleanser Safe for cleaning superficial wounds Saline based Not harmful to tissue Has preservatives so it Will last longer than bottled Saline 1 C q i Recommendation for Cleaning Wounds 0 Healthy clean wound Use Normal Saline Infected Wound 0 Use Normal Saline with Antimicrobialsolution or Antibacterial solution for a course of 1014 days 39 Prolonged use with be bad for wound Topical Antibacterials Systemic antibiotics are used in combination with topical antibacterial agents Bacitracin Gentamicin Metronidazole Danger of developing resistance with frequent use 0 Targeted bad bacterial agents and stay away from healthy tissues DC as 148 BABITRACIN ENC OINTMENT W FIISY AID Tm OHYADG I van munan m 39039 390quot m m n II no Antimicrobials Silver Dressings Silvadene Became popular before antibiotics developed post W W 11 Now with today s resistance to antibiotics these dressings are returning Bacteria are unable to develop a resistance to Sil ions 0 Kills bacteria by positive and negative properties Silver ions reduce the risk of infection Silver ions are positively charged and are attracted to negatively charged pathogens Silvadene discharges silver ions immediately as it comes in contact with the wound Newer silver bonded dressings release silver ions over longer periods of time Results in less frequent dressing changes Silver Sulfadiazine Indicated for 2nd and 5rd degree burns Abrasions diaper rash wounds Kills a wide variety of bacteria Precautions O Allergies to Silver or Sulfa Silvadene Cream 0 O Frequently applied to burns and abrasions Need to cover with a secondary dressing Cream will build up and cake on wound if applied too thick Therapist must thoroughly wash cream off wound between dressings O Topical cream is applied to the wound surface only 0 Then covered with a secondary dressing 39 Provide a thin layer no pictured above Other Silver Dressings Aquacell Ag Intellicoat Acticoat Arglaes Silverlon Silvasorb 39 Occlusive adherent dressings Antimicrobials Silver Dressings Silverlon Silvasorb Antifungals Indication known or suspected fungal infection Contraindication allergy to ingredients Metronidazole has been shown to decrease odor in foul smelling wounds up to 80 in 47 days Nontraditional Wound Treatment Sugar 0 the sugar draws out the bacteria from the wound surface so when you wash the sugar you wash away the germs as well 39 Also honey 0 An Old remedy used for centuries for Infected wounds 0 Turns into a syrupy hypertonic solution that sucks out all the infected fluid Sterile Maggots O Eats dead tissue and in saliva contains growth hormones that facilitate granulation O Secrete proteolytic enzymes which liquidizes dead tissue 0 Increases pH preventing growth of bacteria 0 Used as a last resort for chronic infected wounds O Prereguisite 39 Moist exudating wounds with good oxygen supply 0 Contraindication 39 Dry wounds and open wounds to body cavities Management of Edema Compression wraps Paste Bandage Unna Boot Compression stocking Elevation Unna Boot O Developed in 1880 s by a German physician Paul Unna 0 Cotton gauze impregnated with a nonhardening zinc oxide gelatin and glycerin paste that acts as a compression bandage 39 Prevents the limb from getting further swelling 39 Continue to use it until the leg is at a normal size any 2000 V 0 Actually does not provide compression 0 As the material dries and stiffens the leg cannot continue to swell 0 Change every 47 days 0 Used in treatment of Venous Stasis Ulcers management of edema sprains minor fractures and burns Bandage Wrapping Techniques Spiral to hold primary bandage in place 39 FigureEight for compression and edema control FanFolding for increased absorption and padding How would you Dress this wound O Wound 39 FullthicknessPartial thickness wound mixture of slouth granular and necrotic tissue 39 Tramatic deep wound with debries 39 Heavily draining high risk for infection 0 Dressing 39 Non occlusive dressing 39 Non adhesive dressing 39 Packing Drygauze or alginate 39 Secondary dressing ABD pad using rolled gauze paper tape wrap to adhere the pad 39 Knitting to keep the dressings in place How would You Dress this Scapular Wound How would you dress this Skin Graft O Nonadherent dressing How would you dress this residual limb fullthickness
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