Bohomolets 2nd year Surgery Wounds


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Bohomolets 2nd year Surgery Wounds

  2. 2. Wounds can be classified in many ways, by acute or chronic , by cause (e.g., pressure, trauma, venous leg ulcer, diabetic foot ulcer), by the depth of tissue involvement, or other characteristics such as closure (primary or secondary intention) Wound depth is classified by the initial level of tissue destruction evident in the wound: superficial , partial-thickness , or full-thickness
  3. 3. Descriptions of wounds must include the nature of the wound , ie whether it is a bruise, abrasion or laceration etc the wound dimensions , eg length, width, depth etc. It is helpful to take a photograph of the wound with an indication of dimension (eg a tape measure placed next to the wound), and for measurements to be taken of the wound as it appears first, and then with wound edges drawn together (if it is a laceration etc) the position of the wound in relation to fixed anatomical landmarks, eg distance from the midline, below the clavicle etc the height of the wound from the heel (ie ground level) - this is particularly important in cases where pedestrians have been struck by motor vehicles
  4. 4. THE MAIN TYPES OF WOUNDS abrasions bruises/ contusions lacerations incised wounds punches kicks bite marks defence injuries
  5. 5. ACUTE WOUNDS When a surgeon makes an incision or the skin is otherwise cut, an acute wound is created. By definition, an acute wound is acquired as a result of trauma or an operative procedure and proceeds normally in a timely fashion along the healing pathway with at least external manifestations of healing apparent in the early postoperative period without complications. Acute wounds are usually successfully managed with local wound care. Surgically created wounds include all incisions, excisions, and wounds that were surgically debrided. Nonsurgical wounds include all skin lesions that occurred as a result of trauma (e.g., burns, falls), as a result of an underlying condition (e.g., leg ulcers), or as a combination of both
  6. 6. CHRONIC WOUNDS Wounds that fail to heal in the anticipated time frame and often reoccur are considered chronic wounds . These wounds are visible evidence of an underlying condition such as extended pressure on the tissues, poor circulation, or even poor nutrition. Pressure ulcers, venous leg ulcers, and diabetic foot ulcers are examples of chronic wounds. Successful management of chronic wounds demands treatment of the whole person, meticulous local wound care, an understanding of the wound healing process, a working knowledge of modern wound dressings, and correction and management of the patient’s underlying condition
  9. 9. <ul><ul><ul><ul><li>CLEAN WOUNDS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria </li></ul></ul></ul></ul>
  10. 10. <ul><ul><ul><ul><li>CLEAN WOUND </li></ul></ul></ul></ul>
  11. 11. CLEAN-CONTAMINATED WOUNDS Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category provided no evidence of infection or major break in technique is encountered
  12. 12. <ul><ul><ul><ul><li>CONTAMINATED WOUNDS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Includes open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category </li></ul></ul></ul></ul>
  13. 13. <ul><ul><ul><ul><li>DIRTY OR INFECTED WOUNDS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Includes old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation </li></ul></ul></ul></ul>
  16. 16. FOR THE PURPOSES OF DRESSING SELECTION, WOUNDS MAY BE CLASSIFIED Black and necrotic - covered with a hard dry layer of dead skin Sloughy/necrotic - covered or filled with a soft yellow slough Clean and granulating with significant amount of tissue loss Epithelialising
  17. 17. BLACK NECROTIC WOUND Dead dehydrated tissue, easily recognisable by a black or brownish appearance. Necrotic areas may completely cover a wound, forming a dry eschar or, alternatively, may present as small patches in the base or margins of a wound bed
  18. 18. SLOUGHY WOUND Slough is the formation of a viscous, predominantly yellow layer of tissue
  19. 19. <ul><li>GRANULATING WOUND </li></ul><ul><li>Granular appearance, glossy red and bleeds easily </li></ul>
  20. 20. <ul><ul><ul><li>EPITHELIALISING WOUND </li></ul></ul></ul>
  21. 21. CAVITY WOUND A cavity wound can be acute or chronic, eg a dehisced surgical wound or a pressure ulcer. They may be present with a wound bed of differing tissue type ie clean, infected, sloughy , granulating , or a combination. The tissue type and amount of exudate will affect treatment
  22. 22. The terms superficial, partial-thickness, and full-thickness refer to wound depth The deeper a wound, the more tissue that needs to be replaced or repaired and the longer it will take to heal
  23. 23. SUPERFICIAL WOUNDS When a wound is superficial, as is the case in most abrasions and blisters, only the epidermis is affected and has to be replaced. A truly superficial wound does not bleed and heals within a few days
  24. 24. PARTIAL-THICKNESS WOUNDS A partial-thickness wound does bleed, because the epidermis and part of the dermis are no longer present or have been affected. If left uncovered, a blood clot will cover the wound and a scab will form. The missing tissue will then be replaced, followed by regeneration of the epidermis. A partial-thickness wound can take from several days to several weeks to heal, depending on the patient and the wound treatments chosen
  25. 25. FULL-THICKNESS WOUNDS A full-thickness wound involves the epidermis and the dermis. The underlying fatty tissue, bones, muscles, or tendons may also be damaged. If full-thickness wounds cannot be sutured, the healing process will create new tissue to fill the wound, followed by regeneration of the epidermis. The full-thickness wound takes substantially longer to heal than does a partial-thickness wound, sometimes as long as several months
  26. 26. . HAIR FOLLICLES GROW MORE THAN HAIR One of the most important differences between partial-thickness and deep, full-thickness wounds is that in partial-thickness wounds not all hair follicles have been destroyed. Because hair follicles are surrounded by epidermal cells, small islands of epidermis remain in the wound bed of partial-thickness wounds. Thus, even though the epidermis may have been destroyed, the &quot;islands&quot; of epidermal cells in the wound bed will help the wound replace the epidermis more quickly than in a full-thickness wound, where the epidermal cells have to migrate in from the edges of the wound
  27. 27. Wound assessment should include an evaluation of the skin surrounding the wound. Whether acute or chronic, sutured or not sutured, the condition of the periwound skin provides vital information relating to the status of the wound. When the periwound skin is red, it may be the result of prolonged pressure; it may indicate ongoing or chronic inflammation or irritation from contact with feces or urine; or it may merely be evidence of increased blood supply to the area as part of the early healing process. Redness, tenderness, warmth, and swelling of the surrounding skin are also the classic clinical signs of an infection. If the surrounding skin is light colored but pink, it may be newly formed epithelium. However, if the skin is white or gray, it is likely that maceration has occurred. In addition to looking for signs of maceration, inflammation, and infection in leg ulcers, look at the surrounding skin for information about the etiology of the wound itself
  28. 28. <ul><li>WOUND BED </li></ul><ul><li>To evaluate the condition of the wound bed, assess for: </li></ul><ul><ul><ul><ul><li>Necrotic tissue (usually black and hard, sometimes soft with a tinge of yellow) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fibrinous tissue or slough (yellowish and threadlike denatured proteins that cannot be removed when rinsing) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Granulation tissue (red, beefy tissue that may bleed easily) </li></ul></ul></ul></ul><ul><li>Note whether or not there is any debris or other foreign materials (e.g., suture remnants) and quantify your findings </li></ul><ul><li>Other wound characteristics that should be assessed include the odor of the wound and the amount, and color and consistency of exudate </li></ul>
  29. 29. <ul><ul><ul><li>WOUND HEALING </li></ul></ul></ul><ul><li>The process of wound healing involves three overlapping phases: </li></ul><ul><li>Inflammation – involves scab formation and infiltration of damaged tissue by white blood cells. These are responsible for removing dead tissue and ingesting bacteria </li></ul><ul><li>Proliferation – involves development of granulation tissue, contraction of the wound and growth of epithelial cells under the dried scab </li></ul><ul><li>Maturation – wound becomes less vascular and is strengthened by the rearrangement of collagen fibres. </li></ul>
  30. 30. FACTORS AFFECTING WOUND HEALING Age The physiological changes that occur with ageing place the older patient at higher risk of poor wound healing. Reduced skin elasticity and collagen replacement influence healing. The immune system also declines with age making older patients more susceptible to infection. Older people can also present with other chronic diseases, which affect their circulation and oxygenation to the wound bed Dehydration This leads to an electrolyte imbalance and impaired cellular function. It is a particular problem in patients with burns and fistulae
  31. 31. Hand Washing Effective hand washing greatly reduces the risk of transferring pathogenic organisms from one patient to another by direct contact or by contamination of inanimate objects that are shared Infection Infection has been defined as the deposition and multiplication of organisms in tissue with an associated host reaction. If the host reaction is small or negligible then the organism is described as colonising the wound rather than infecting it. It is important to distinguish between colonisation and infection since colonised wounds will heal without the need for antibiotics
  32. 32. PREVENT/CONTROL INFECTION All wounds are contaminated with a variety of microorganisms; however, most chronic wounds do not become infected. When pathogenic microorganisms invade the tissues, at least one or two of these classic symptoms of infection can be observed: erythema, warmth, swelling, and/or odor, purulent exudate, and fever When an infection is suspected, the wound should be cultured. Currently, researchers have not decided which culture method is most likely to lead to identifying the infection-causing organism. Some favor obtaining a biopsy, others suggest that wound fluid aspiration is the method of choice, and a third group maintains that swab cultures are reliable
  33. 33. In most instances, a course of systemic antibiotics, based on the results of the culture, will result in elimination of the infection. Attaining sufficiently high concentrations of medication in the tissues that have been invaded by the pathogenic microorganism may not be possible when using topical antibiotic ointments only Why some wounds become infected when others do not depends on a variety of factors including: the type of wound, the type of organism involved, the wound environment, and the patient's general medical condition and immunological status. For example, acute wounds are more susceptible to infection than chronic wounds. In addition to debridement, adhering to the basic principles of infection control and reducing further wound contamination will help minimize the risk of infection
  34. 34. Finally, providing a wound environment that prevents desiccation (which results in the formation of nonviable tissues), and retains the body's natural defense mechanisms (i.e., white blood cells and macrophages), has also been shown to reduce the rate of wound infections
  35. 35. OPTIMIZE EXUDATE CONTROL; REMOVE NECROTIC TISSUE OR FOREIGN BODIES A wound that contains dead tissue or foreign matter is more likely to become infected than one that does not. Bacteria thrive in the presence of dead tissue. It is postulated that once bacteria have colonized dead or foreign materials, they are less susceptible to host defense mechanisms and antibiotic therapy. Thus, in order to prevent infection, dead tissue or foreign matter must be removed
  36. 36. Loose particles and nonadherent fibrinous materials can often be removed through cleansing. The recommended maximum amount of pressure to cleanse wounds is 5-15 pound per square inch, which can be delivered using a 18-20 gauges angiocath and a 30-35 mL syringe. Is it important to differentiate between solutions designed as skin cleansers and wound cleansers and to select only those cleansing agents specifically designed for use in wounds. Antiseptics as well as many cleansing agents (e.g., povidone iodine, chlorhexidine, etc.) have been found to be toxic to skin cells in commonly used concentrations
  37. 37. Dry, necrotic tissue cannot usually be removed by cleansing alone. When necrotic tissue is present, it has to be debrided. There are four basic methods for debriding wounds. Each method of debridement has its own specific advantages and disadvantages
  38. 38. <ul><li>METHODS OF DEBRIDEMENT </li></ul><ul><ul><ul><ul><li>Mechanical Wet or moist dressings applied and removed when dry </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Direct scrubbing action with a brush, a sponge, or woven gauze </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pulsatile lavage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Whirlpool Slow and painful </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nonselective (removes healthy tissue as well) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgical Using a scalpel, scissors, or forceps to remove dead tissue Quick, effective, and selective if performed by a qualified and skilled professional </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May result in blood loss </li></ul></ul></ul></ul>
  39. 39. <ul><ul><ul><ul><li>Enzymatic Enzymatic debriding agent applied under a dressing Easy to perform </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Selective </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Prescription required </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Some agents may need moisture to work; some may damage surrounding skin </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Discontinue when dead tissue has been dissolved </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Autolytic Moisture retentive dressing is applied, retaining endogenous enzymes Selective </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Easy to perform </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Painless </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Does not harm healthy tissue </li></ul></ul></ul></ul>
  40. 40. PREVENT PREMATURE WOUND CLOSURE Prevention of premature wound closure is particularly important when caring for dehisced surgical wounds or wounds with sinus tracts and undermining. The healing process should be closely monitored to ensure the wound is healing &quot;from the bottom up.&quot; Lightly packing the wound with a dressing that will retain moisture helps prevent premature wound closure
  41. 41. PROMOTE GRANULATION AND CONTRACTION Granulation tissue, a red, beefy-looking tissue that replaces the lost dermis, consists of new blood vessels and fibroblasts to make collagen. Cells can neither live, nor replicate in a dry environment; thus, granulation tissue formation is facilitated when the wound is kept moist. In addition, some dressings have been shown to retain growth factors that stimulate fibroblasts
  42. 42. PROMOTE RE-EPITHELIALIZATION Re-epithelialization, the process by which epidermal cells proliferate and migrate across the wound bed, is also facilitated in the presence of moisture. In the presence of eschar, epidermal cells must travel down and under the eschar before they can migrate across moist dermal tissues, lengthening the time required for re-epithelialization. Wounds covered with moisture retentive dressings re-epithelialize faster than wounds covered with gauze-type dressings or wounds that are left exposed to the air