Pressure Ulcers

Front 1

Wounds

Back 1

- A wound creates an alteration &
disruption of the skin
- Can be created:
1- Intentionally [surgeon’s knife]
2- Accidental trauma [motor vehicle crash]
3- Chronic forces [pressure ulcer]

Front 2

Wound biology

Back 2

- On injury, the body immediately begins the
process of restoring its integrity & the
physiologic functions of the skin
- 7 Physiologic functions of the skin
protect, insulate, sense, excrete, communicate, vit D, shape

Front 3

Wound healing

Back 3

- Regeneration: replacement of lost cells of same type
- Repair: healing as a result of lost cells being replaced by CT

Front 4

3 Phases of wound healing

Back 4

1- Initial [aka inflammatory] phase 3-5 days
2- Granulation [aka proliferative] phase 5 day-3 week
3- Maturation [aka remodeling] phase several months/years

Front 5

Initial [aka inflammatory]phase

Back 5

- Lasts for several days
- Occurs immediate after injury – vascular & cellular events
- Platelets aggregrate to form a plug (hemostasis)
- Tissue injury (histamine released) – vasodilation & capillary permeability
- Release of prostaglandin & kinins - pain
- Macrophages engulf & remove debris

Front 6

Granulation (aka proliferative) Phase

Back 6

4 Major events in this phase
include:
1- Epithelialization
2- Collagen formation
3- Granulation tissue formation
4- Contraction

Front 7

Maturation [aka remodeling] phase

Back 7

- Can last up to 2 years
- During this last phase, collagen reorganization and incr tensile strength of the scar

Front 8

Methods of wound closure

Back 8

- Rate of healing dependent on method used to closed wound
- This depends on:
1 amount of tissue damage
2 potential for wound infection
Methods include:
- Primary
- Secondary
- Tertiary

Front 9

Primary intention

Back 9

- Refers to closing the wound by mechanical means, e.g sutures, tape
- Method used when there is:
1- Minimal tissue loss
2- Skin edges are well approximated
3- Clean lacerations, most surgical incisions closed using primary intention
4- 3 phases of healing occur quickly with minimal scarring
- can clean with saline
- sutures usu left in

Front 10

Secondary Intention

Back 10

- red
- Wounds that heal by secondary intention usually are large wounds with either:
- Significant tissue loss/damage
- Bacterial contamination
- Examples include open abdominal wounds, dehisced sternal wounds, stage III & IV pressure ulcers
- Take more time to heal than do wounds healing by primary intention – use same phases of healing
- granulates broader scar, gauze drainage, slow, daily wound care to encourage wound debris removal
IE gingivectomy: tooth extraction sockets

Front 11

Secondary wound healing

Back 11

- keep clean, pack wound, solution + gauze, moist

Front 12

Tertiary Intention [delayed primary intention]

Back 12

- Is a method of wound closure that uses a combination of primary & secondary intention
- Wound is left open for few days to allow edema & exudate to resolve, then closed by primary intention
- intentionally left open
IE healing by tissue grafts, suturing with new tissue

Front 13

Wound classification

Back 13

1- By their cause [surgical or nonsurgical]
2- By depth of tissue affected
- Superficial – epidermis
- Partial thickness - dermis
- Full thickness – subcutaneous, fascia & underlying muscle, tendon or bone
3- By color of the wound [red, yellow, black]

Front 14

Red wound

Back 14

- Can be superficial or deep if it is clean & pink in appearance

Front 15

Yellow wound

Back 15

- Has nonviable necrotic tissue – ideal for bacterial growth

Front 16

Black wound

Back 16

- Is covered with thick, dry black necrotic tissue called eschar eg gangrenous ulcers

Front 17

Factors that affect wound healing

Back 17

- Oxygenation/tissue perfusion
- Nutrition
- Age
- Diabetes
- Medications
- Obesity
- Blood chemistry
- Moisture
- Antibiotics & infection

Front 18

Complications of Healing

Back 18

- Wound infection
- Hypertrophic Scars
- Keloid Formation
- Contracture
- Dehiscence
- Excess Granulation Tissue
- Adhesions

Front 19

Infection

Back 19

- Ranges from superficial cases of cellulitis to deep-seated abscesses
- What leads you to suspect a wound infection?
warm, red, swell
- What organism is the biggest culprit for surgical wound infections?
staph aureus

Front 20

Hypertrophic Scars & Keloid Formation

Back 20

- A HT scar is large, red, raised, confined to wound edeges
- keloid increase tissue extends beyond edges tumor like formation, increased collagen

Front 21

Contracture

Back 21

- Excessive wound contraction may result in deformity or contracture,
especially if the wound is near a joint

Front 22

Dehiscence

Back 22

- Is the separation & disruption of previously joined wound edges
- 3 contributing causes:
1- Infection causing inflammatory process
2- Granulation tissue not strong enough to withstand external forces
3- Obese individual with adipose tissue interfering with healing

Front 23

Evisceration with a patient example

Back 23

- Evisceration occurs when wound edges separate to
the extent that intestines protrude through the wound

Front 24

Adhesions

Back 24

- Adhesions are filmy bands of scar tissue that may occur within the abdomen
- Most adhesions cause no symptoms at all
- serious complication is intestinal obstruction

Front 25

Clinical assessment of wound healing

Back 25

- Preexisting health problems
- Inspection
- Measurement of wound
- Presence of exudate or drainage
- Appearance of wound tissue
- Inspection of wound edges
- Skin color of surrounding skin
- Assessment of tissue perfusion/oxygenation
- Assessment of immunologic status
- Assessment of nutritional status
- drainage
- lined up

Front 26

Principles of Wound Management

Back 26

- Cleaning a wound to remove any dirt or debris from the wound bed
- Treating infection to prepare the wound for healing
- Protecting a clean wound from trauma so it can heal normally

Front 27

Sutures, skin closures, fibrin sealant

Back 27

- Sutures – provide the mechanical support to maintain closure (wide variety of suturing material)
- Skin tape
- Fibrin sealant:
- applied topically to help control bleeding
- used to stop oozing from small, sometimes inaccessible blood vessels during surgery
- when conventional surgical techniques are not feasible

Front 28

For wounds healing by primary intention

Back 28

- A dry, sterile dressing may be used
– removed when drainage stops or in 2 to 3 days
- A transparent film on the skin may be used
- Sometimes left uncovered

Front 29

Gauze & nonadherent dressings

Back 29

Gauze
- provides absorption of exudates
- supports debridement if applied & kept moist
- used to maintain moist wound surface or as a filler dressing
Nonadherent dressings
– may be impregnated with:
saline, petrolatum or antimicrobials
- minimally absorbent
- Examples: Adaptic, Vaseline gauze
- mainly used on minor wounds or as a secondary dressing

Front 30

Tubes & drains

Back 30

- used if actual or potential accumulation of fluid in naturally occurring or surgically created spaces
- Drainage tubes classified as:
1- Simple drains
e.g penrose, t-tube
2- Closed suction drains
e.g. Jackson Pratt, Hemovac
3- Sump drains
e.g Salem Sump

Front 31

For wounds healing by secondary intention

Back 31

- can be described as the red-yellow-black concept

Front 32

1Red wound

Back 32

- be superficial or deep if it is clean & pink in appearance
- Clean wound – keep slightly moist & protect from further trauma
- Use transparent films e.g. Opsite, Tegaderm
- Wet to moist dressing using normal saline solution
Normal Saline
- Normal saline (0.9 NaCl) is most commonly used solution
- Aids in mechanical debridement
- Does not damage granulation tissue

Front 33

2Yellow wound

Back 33

- Has nonviable necrotic tissue
– ideal for bacterial growth
– use a dressing that removes nonviable tissue & absorbs excessive exudate
Alginates
- Highly absorbent dressing made from seaweed material
- Requires a second dressing
Hydrocolloid
e.g. DuoDerm, Tegasorb
- Occlusive dressing facilitates autolytic debridement of small, noninfected yellow wounds

Front 34

3Black wound

Back 34

- Is covered with thick, dry, black necrotic tissue called eschar
- Immediate treatment is debridement of the nonviable, eschar tissue
- Different debridement methods
- Surgical
- Mechanical e.g. wet-to-dry dressing
- Autolytic
- Enzymatic

Front 35

Negative-pressure wound therapy

Back 35

- Or vacuum-assisted wound closure (VAC) uses ……
uniform neg pressure = macrostrain(edge closer), decr wound volume, edema, control exudate, control inflamm/free radicals