WOUND CARE “ the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed” – Richard L. Lammers (Roberts and Hedges)
GOALS of wound care
Decrease tissue loss
Promote wound healing
Minimize scar formation
Wound healing : PATHOPHYSIOLOGY
1.) Inflammatory Phase
Initial response (Day 1-4 post injury)
rubor, tumor, dolor, calor
Platelet aggregation and activation
Leukocyte (PMNs, macrophages) migration, phagocytosis and mediator release
a biologic debridement
In wounds closed by primary intention, lasts 4 days
Indications :- infected or unhealthy wounds with high bacterial content,
-wounds with a long time lapse since injury, or -wounds with a severe crush component with significant tissue devitalization.
Wound edges are approximated within 3-4 days
tensile strength develops as with primary closure.
wound preparation (debridement,cleansing, etc.)
dress with saline soaked fine mesh gauze
follow up in 72-96 hours for debridement
repeat cleansing and closure if no evidence of infection
Factors that affect wound healing
Patient factor : Age
- renal failure
Medications –systemic steroids/ other immunocompromising drugs i ncreased infection rates
Wound Characteristics - Time , Location , Etiology , Mechanism of injury , Laceration width
Factors that affect wound healing
In general, remember “DIDN'T HEAL”
D = Diabetes : -diminishing sensation and arterial inflow ++ acute loss of diabetic control diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.
D = Drugs : Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis.
N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc.
T = Tissue necrosis , from local or systemic ischemia or radiation injury. Blood supply is important.
H = Hypoxia : -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hypothermia sympathetic overactivity local vasoconstriction Inadequate tissue oxygenation.
E = Excessive tension on wound edges local tissue ischemia and necrosis.
A = Another wound : Competition for the substrates required for wound healing.
L = Low temperature : (relatively) distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.
Wound Evaluation -HISTORY
identify all extrinsic and intrinsic factors that jeopardize healing and promote infection
– mechanism of injury
– time of injury (accelerated growth phase of bacteria starts at 3 hours post wound)
– environment in which wound occurred
potential contaminants, foreign bodies
– species of animal if bite wound
– pt’s medical problems (allergies to medication) / immune status
tetanus immunization status
Bleeding disorder.Prolonged bleeding-. Hematoma can serve as culture medium for wound infection.
Peripheral vascular disease
Mechanism of injury FORCE OBJECT DAMAGE WOUND shear Sharp Minimal Linear compression Blunt Right angle Moderate (+) Stellate Jagged tensile Blunt Oblique angle Moderate (+) Triangular Flap
TYPES of wound
Abrasions Superficial layer of tissue is removed
Avulsions A section of tissue is torn off (partially or totally)
Lacerations Ti ssue is cut or torn. Sharply demarcated borders.
Puncture Small opening and of indeterminate depth.
Contusion forceful blow, outer layer of skin intact ; minimal wound care ; evaluate for possible hematoma
– amount of tissue destruction
– degree of contamination
– damage to underlying structures
• Body Location
– Proximity to Other Structures
– Joints –Nerves –Tendons –Vasculature
– Test integrity of each structure
• Assess laxity/muscle and tendon function
• Assess 2-point discrimination
• Assess vascular supply
– importance in the risk of infection
– high endogenous bacterial counts in hairy
scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails
– wounds in areas of high vascularity more
easily resist infection (scalp, face)
Wound Preparation - Anesthesia
Solution or paste
1% lidocaine with or without epinephrine
Bupivicaine or sensorcaine for longer acting anesthesia
Local infiltration proximally in order to avoid tissue disruption
Smaller amount of anesthesia required
Solely / with local infiltration
Most effective : face and scalp (high vascularity)