Objective• Types of wounds• Mechanisms of wound Causation• Wound healing –Phases• Chronic Wounds• Identification and classification of chronic wounds• Description of chronic wounds for the purpose of documentation
Wounds Acute Wounds Chronic WoundsCuts, Abrasions,Lacerations Fail to passContusions through normalPunture healing processSkin flaps andBitesBenbow ( 2005) Any wound > 3/12 considered a chronic woundThey passesthrough thenormal healingprocess readily
acute wounds• heal very easily• It passes phases of wound healing – Inflammatory phase – Collagen building phase – Remodelling Phase
Aim of management of acute wounds• Healing without complications such as infection and disfiguring• Wound care – Remove FB – Dry or wet to dry dressing to cover the wounds – Suturing if acute – Bites - Prophylaxis
Antibiotics in acute wounds• Only indicated if contaminated or evidence of infection is demonstrated• Evidence of infection (local) – Redness – Warmth – Swelling – Tenderness – Local Lymphadenopathy
Acute wounds with abscess formation• If abscesses are large need to be drained• Smaller once – can manage with antibiotics• Betadine*, Hydrogen Peroxide*, Saline, Spirit can be used to cleanse the wound• For chronic wounds * ********* may interfere with granulation and epethelilised tissues
Healing of acute wounds• Wounds with minimal gaping – heals readily with scarring• Wounds with gaping or skin loss – heals with Scar tissue formation and retraction
How do wounds heal• Haemostasis• Inflammation• Proliferation or Granulation• Remodelling or Maturation
When Does a Wound Become Chronic?• healthy individuals with no underlying factors an acute wound→ heal within three weeks remodelling → over the next year or so• When wound does not follow the normal trajectory it may become stuck in one of the stages and the wound becomes chronic.
Chronic Wounds• Working Definition – wound lasting >3 months• Chronic wound – Fail to heal due to various local and systemic causes – Healing process arrests at different levels of healing – Wound may appear at different colours
Chronic woundsThe wound healing cascade impairs and arrests at different stagesHemostasis CHRONIC WOUND Platelet Aggregation Neutrophil Immigration Monocyte Immigration Granulation Re-epithelialization Wound Closure Scar Formation Remodeling Minutes Hours Days Weeks Months Years Time
Chronic wounds• Normal healing process impaired – Arrest at different levels – – Remains at same stage without progressing to wound healing• Often an underlying cause remains and undetected
Local and systemic factors that impede wound healing• Local factors • Systemic factors • Advancing age and general immobility **• Inadequate blood supply ** • Obesity ***• Increased skin tension • Smoking• Poor surgical apposition • Malnutrition ***• Wound dehiscence • Deficiency of vitamins and trace elements ***• Poor venous drainage ** • Systemic malignancy and terminal illness Shock of any cause• Presence of foreign body and foreign body • Chemotherapy and radiotherapy reactions • Immunosuppressant drugs, corticosteroids, anticoagulants• Continued presence of micro-organisms & Infection ** • Inherited neutrophil disorders, such as leucocyte adhesion deficiency• Excess local mobility, such as over a joint 18 • Diabetes and CRF***
Characteristics of a chronic wound• May appear different colours at any given time
Necrotic tissue• Necrotic tissue= Dead tissue = when it is dry and hard known as eschar• It prevents wound healing – Removal is necessary – May lead to infection• Once removed healing starts• Removal needs to asses wound staging and it mask the true size of the wound
Necrotic wounds• Fails to heal• Masks the true size and staging• Prevents antibiotics from reaching the site• Provide foothold for microbes to grow and evade antibacterial or neutrophils – Bio film
Necrotic wound• often appears black,• may also appear brown or grey when hydrated.• Necrotic → initially be soft,• dead tissue → lose moisture and become dehydrated with the surface becoming hard and dry
Sloughy wounds• Slough – yellowish/Yellow brown fibrous tissues which tightly adherent to the wound base (dead cells and wound debris)• cannot be removed by washing• slough is not necessarily indicative of clinical infection.• Slough can be found as patches across the wound bed.• Exposed tendons may mistaken for slough.• Effect of slough in wound healing – Presence of slough delays wound healing – Predispose to infection –provide Foot hold to organisms to attach – Prevents antibiotics/Antimicrobial agents from reaching the site
Slough in wounds• should be removed to enable healing to take place.• referred to as ‘de-sloughing’.
Granulating Wounds• Granulation tissue fills the wound as it is healing.• The tops of the capillary loops make the wound appear red and granular.• It is firm to the touch, painless and does not bleed easily.
Unhealthy Granulating Tissues• Bright red granulation tissue, which bleeds easily, may indicate infection (Bale and Jones 1997).
Epethilialized wounds• Epithelial tissue is formed in the final stages of healing.• This tissue forms the new epidermis.• Epithelial tissue is superficial pink/white tissue that migrates across the wound from the wound margin, hair follicles or sweat glands.• It will cover the granulating tissue.• In shallow wounds with a large surface area, islets of epithelialisation may be seen.
Infected wounds• Wound infection is the most troubling wound complication (Cutting 1998).• Avoiding infection is vital in good wound management.• Therefore it is good practice to recognise the contributing factors that precede a diagnosis of infection.
Wound Infection Continuum• The Wound Infection Continuum (Gray et al. 2005) recognises the various levels of bio- burden in the wound – Wound Contamination – Wound Colonization – Critical Colonization – Wound Infection – Spreading wound infection – Wound Sepsis
Wound 1.Organims from sorrounding Contamination skin- Regional flora- CONS, Deptheroids, Anerobes H Wound an Colonization d 3.Organisms from External hy environment- HCW through direct or Wound Surface ge indirectly – in MRSA, Pseudomonas, Multiresistant Critical e organisims etc Colonization Fecal and urinary management systems Wound 2.Organisms from GIT and GUT Infection Gram Negatives such as E.coli, Klebsiella, Enterobacter, Aner obesAdvance Wound Infection
Wound Infection • The presence of multiplying organisms within a wound that overwhelm the host immune response with associated clinical signs and symptoms. (Kingsley 2001)OrganismDensity
Factors which influence wound infection• 1. The quantity of micro-organisms• 2.quality –Virulence and antibiotic resistance• 3. The patients resistance to the level of bacteria in the wound( immune response)• Microbial bio-burden within wounds can range from contamination, colonisation, critical colonisation and infection.
Additional Signs– Increase in size of wound– Delayed wound healing– General unwellness– Dark discoloured granulation tissue– Increased friability– Pocketing at base of wound. (Cutting and Harding 1994).
Investigations for wound infection• When wounds are not healing in the expected way and display signs and symptoms of infection or for the presence of multi-resistant bacteria such as MRSA (Gilchrist 2001).• Three types of Investigations – Deep tissue biopsy –During surgery(Bowler et al 2001). – Wound Fluid Sampling Aspiration using aseptic technique from deep – Wound Swabs
Indications for wound swabs• Wound swabs are generally preferred when – Wound fails to heal as anticipated – When evidence of infection present – Suspecting drug resistance
Care depends on• Type of wound• Amount and type of of Exudate• Presence of critical colonization or evidence of infection
Care of necrotic wound• Necrotic wound• As areas of necrosis interfere with healing process, need to remove it through any of the following means – Mechanical Debridement –Wet to dry dressings – Autolytic Debridement- Occlusive dressing and wound exudate will debride by its enzymatic relations – Enzymatic Debridement –By sofetneing slough by using enzymes –Iruxol and Papaya – Bio logical Debridement –Maggots therapy – Surgical Debridement –Surgeons blades
Care of Exudative wound• Dry wound• Mildly exudative wound• Moderately exudative wound• High exudative wound• Care of periwound area
Care of Sloughy wound• De-sloughing• Prevention of slough formation• Enhance granulation
Care of granulating wounds• Care of granulation tissue – avoid dry or wet to dry dressings• Prevent over granulation• Prevent infection• Exudate management and care of peri-wound area• Skin grafting or skin substitutes
Care of Epethelialized wounds• Same as in granulating wounds
Care of infected wounds• Reduce bio burden –Cleansing, reduction of necrotic and sloughy tissue• Local antiseptics – rotational• Local antiseptics- cedoxomer iodine, crystalline silver, PHMB• Exudate management• Care of periwound area
Antibiotics• For spreading infection and or evidence of systemic infection• Take blood cultures• Treated with Broad Spectrum antibiotics intravenously.• Topical antimicrobials - used to reduce wound bio burden (EWMA 2006).
Antimicrobials• Topical antiseptics/Antibacterials• The range of topical antimicrobial agents currently used includes – chlorhexidine, – products containing iodine (cadexomer iodine and povidone – iodine) and – products containing silver (silver sulfadiazine and silverimpregnated – dressings) (EWMA 2006). – The antiseptic/antimicrobial polyhexamethylene biguanide (also known as polyhexanide or PHMB)• .
Care Planning . Overall strategy and scope of the treatment plan depends on patient’scondition, prognosis, and reversibility of the wound.
Appropriate Goals• Prevent complications or the deterioration of an existing wound• Prevent additional skin breakdown and protection of the surrounding skin• Minimize harmful effects of the wound on the patient’s overall condition• Promote wound healing and achieve cure• Prevention of wound from recurring and life style modification
Patient Cantered – Holistic –Total care -Not onlydealing with person with a wound itself- need to address chronic wound pts other needs, diseases, and psychosocial wellbeing Wound Care Plan (WCP) Inter-diciplinary Needs Participation of multitude of disciplines
Basic elements in wound care plan• Cleanse Debris from the Wound• Possible Debridement• Manage Exudate• Promote Granulation and Epithelialization When Appropriate• Possibly Treat Infections• Minimize Discomfort
A. Cleanse Debris from the Wound Cleansing agents – Flowing Water –Requesting pt to bath before dressing change – Normal Saline*** – Commercial Cleansers – Hydrogen Peroxide – Povidone iodine – Hypochlorite solution – Sterile vinegar solution – Mechanical Cleansers –Whirl pools – Salt dips Aims• Reduce bio burden• Reduce dead and dying debris• Clean the wound
2. Possible Debridement• Mechanical• Autolytic• Enzymatic• Biological• Surgical
C. Manage Exudates• Identify the level of moisture• Manage exudates by dressingsNature of Exudate Type of wound Aim of exudate Method /Agent managementNo exudate Dry Keep the base Hydrocoloid agent moist Intrasite Need occlusive and non occlusive dressingMild exudate Moist Keep the wound Absorb moisture moistModerate Wet Keep the wound in Absorb moisture moist state by Form dressing reducing exudateHeavy Wet +++ Keep the wound Absorb moist
D. Promote Granulation and Epithelialization• Granulation enhancers• Minimal Dressing changes to reduce disturbances to the granulation• Avoid usage of substances which impede granulation tissues
E. Treat infections• Systemic antibiotics• Local Antiseptics to the wound• Rotational antiseptics etc
F. Minimize discomfort• Pain relief• Psychological support• Family education and create conducive environment• Social support
WCP include• Initial Assessment and Documentation• Identifying the risk factors• Optimize Local wound care – Selection of Dressing• Systemic therapy and nutritional supplementation – Diabetes control – Antibiotics if indicated• Follow up and progress assessment periodically• Change the plan if not improving• Re-asses• Empower the pt and family members
Assessment and documentation• It is ongoing process• Initial assessment – at the time of first presentation• At every dressing changes – need to asses and document the state of wound to monitor progress
WCP-Step two• General Assessment of pt characteristics• Ht, Weight, QI, BP, Skin color• Past medical history• Investigation done previously• Drug and allergic history
Chronic Wound Care: 10 Pearls for Success!! Dr. Gary Sibbald, BSc, MD, MEd, FRCPC (Med), FRCPC (Derm), MACP, FAAD, MAPCA1. For those with Diabetes for wound healing and further prevention: A - Check A1c - greater than 9% will affect wound healing. Recommended is less than 7%. B – Blood Pressure C - Cholesterol D - Diet E - Exercise F - Foot care - Check both feet at each appointment, shoes should be professionally fitted, consider chiropody. S- Smoking
• 2. For those with Venous Ulcer Disease - Compression bandaging is for treatment, stockings are for prevention. – (Exudate/creams will damage the integrity of the stockings). – COMPRESSION IS FOR LIFE! The right compression is the one the patient will wear
3. For those with any distal neuropathy - Shoes should be professionally fitted.4. Smoking Cessation -IMPORTANT FOR ALL! - each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours5. If wounds not decreased by 30% in size by week 4, unlikely to heal by week 12. Consider biopsy or a comprehensive re-assessment
6.Query Infection? Culture using the Levine technique (Compress wound with normal saline for 10 minutes, press swab into a clean granulated area to express fluid and rotate 360 degrees7. Treat the cause! Consider all the possible contributors to non-healing: Drugs, Occult, Diabetes, Systemic Disease (e.g. diabetes anemia, vascular disease), smoking, non-adherence
• 9. Treat the wound! Debridement, Infection, Moisture Balance, and then Edge• 10. Interdisciplinary collaboration - Physicians, Nursing, Chiropody, OT, PT, Dieticia n, and Caregivers.
Patients Name – RMW67 yrDiabetic ptFrom MaharagamaA retired ClerkDate of Clerking -21/5/2012Wound –Medial side of the rt legExtending from Medial Maleolusregion Maximum Length – 13 cm Maximum Width -8 cm Maximum Depth 2mm Surface area - 39 cm2Stage 11Per-iwound Area –black Discoloration+ No undermining No tunnelling No evidence of Redness surrounding skinExudate – Mucoid Mild No regional LymphadenopathyNo evidence of infection Venous InsufficiencySmell – Not offensiveColour of the wound bed –Mixed General – Mobile pt Afebrile Necrosis 5% Not anemic- 9.8g/dl Granulation 30% Slough 15% Epethelialized 5%
Step Two• General 168cm• 84kg• 160/100 kg• Past medical history – DM for 20 yrs on regular therapy• Past history of similar illness• Drugs- On tolbutamide• HT- No drugs• FBS- 130 mg/dl
Dressings• Objectives – Type of Dressings – Selection of dressings – Dressing recommendation
Dressings• When a wound is infected → expensive dressings useless• Management of exudate, pain is very necessary.• Additionally debridement of necrotic or sloughy tissue can alter the wound environment significantly and help to reduce the overall bioburden and reduce odour (EWMA 2006).
Dressing Selection• Primary Dressing – A dressing that touches the wound• Secondary Dressing – Keeps the primary dressing in site – Fasten it to the wound• Some dressings function as primary dressings only• Some could function as primary and secondary dressings as well - adhesive
Dressing Selection• Depend on – Type of wound – Patient preference/Dr preference – Stage of healing of the wound • Proliferation or Granulation phases • Remodelling or Maturation phases • Presence or absence of Infection or Colonization –Bio film
Dressing Selection• Depending on wound healing passes through its different stages different types of dressings may be required• Normally moist environment will enhance wound healing• Exudate provide moist healing• Too much of exudate, – interfere with wound healing-leads to autolysis by the action of enzymes in the exudate – Inhibits-granulation and epethilization
Ideal wound dressing for moist wound healing need to ensure....• Wound remain moist– not macerated• Wound need to remain free from active infection• Free from toxic materials of the dressing Papaya and Komarika• To maintain the wound at optimum temperature for healing• Undisturbed by the frequent need for dressing changes• Maintain optimum PH conducive to wound healing
Advanced wound dressing• Are designed to control the environment around wound -↑ healing• Mainatainance of moisture balance – Some donate fluid to keep wound moist (ex Hydrogels)- used for dry wounds – Some maintain moisture or retain moisture without donating or loosing (Hydro colloids) – Some designed to absorb excessive moisture (Alginate and foams)• Fight Infection/Critical Colanization/ – Silver impregnated dressings – Iodine containing dressings/powder/cream etc
Practice which need be discouraged• Irritant solutions• Irritant cleansers• Frequent de-sloughing or using de-sloghing agent
Desloughing• Hydrogels, hydrocolloids and medical grade honey can be used to autolytic debridement for difficult to heal ulcers• Sterile larvae- can be used to bio surgical debridement
Dressings• Two types• Inactive Dressings• Active dressings
Inactive dressings• Dry dressings• wet to dry dressings• Polyurethane film dressing –Breathable and non breathable film dressings• Vasline tules• Antibiotic impregnated tules 103
Dry dressing and wet to dry dressing• Gauze dressing• Can be medicated or non medicated• Good for acute wounds
Dry dressings……1. Tend to absorb wound moisture2. Tightly Adherent to granulation Tissue – will break upon removal 105
Film dressings and tules• Not shown to be better than dry dressings• Only advantage – no breaking of granulation tissues
Active dressings• Plays a role in wound healing – Provide a covering, – enhance granulation tissue formation, – Reduce slough formation – Inhibits bacteria – Keep wound moist – Some provide growth factors 108
Examples• Hydrogels –fibre and Foams• Hydrocellular dressings• Foams• Alginates• Crystaline Silver and Slow Iodine releasing materials 109
Hydrogel• Cross linked gel dressing – Flexigel – Intrasite• Keep the wound moist• Suitable to mildly exudating wounds and to dry and necrotic wounds 110
Foam dressing• Suitable for mild to moderate exudating wounds• Adsorbs exudate rapidly and enhance thickness 111
Forms• Used for cavities and fill the dead space (cavitating lesions)• Promote healing from the edge 112