Wound Care Chapter #3 In Book

Front 1

Although it is not possible to accelerate wound healing, it is possible to improve delayed healing by eliminating deterrents to wound healing and addressing factors complicating wound repair

Back 1

4 Categories of Deterrents to expedient wound healing:

1. Characteristics to the wound itself
2. Local factors within the wounded area
3. Systemic factors related to the individual
4. Inappropriate wound mgmt

Front 2

Acute surgical wounds are much easier to heal than traumatic wounds because their is normally more cell and tissue destruction

Insidious wounds are normally d/t and underlying pathology such as AI or VI--which is often not known until the wound fails to heal

Back 2

A wound that occurred a longer time ago has a worse chance of being helped through the healing process than one that occurred more recently

Front 3

Give 3 main areas where wounds heal more slowly
1. Areas with decreased vascularity (lateral malleoulus)

2. Over bony prominences (increased tissue tension caused by the prominence)

3. Areas where the skin is thicker (Need to rebuild more tissue)

Back 3

Circular, full-thickness wounds heal the slowest bc the body needs to repair and rebuild more tissue

Front 4

37-38 degrees C is the optimal temperature that wounds heal because the vasculature dilates, tissues are less vulnerable to infection, and tissue O2 levels are increased

At lower temperatures wound healing decreases

Back 4

Dry wounds become dehydrated and leave a crust consisting of dead cells, proteins such as fibrin, and debris on top of the wound bed

This dessication slows epithelial cell migration by increasing the distance epithelial cells must travel and requiring greater enzyme production to break down the crust--ultimately delaying healing

Front 5

B/c epithelial cells can only migrate over viable tissue, necrotic tissue is an impediment to wound healing & promotes infection

Dead tissue within a wound can change a colonized wound into an infected wound by providing food for the microbes present

To facilitate healing and decrease the risk of infection , both necrotic tissue and cellular debris should be debrided from the wound bed

Back 5

Wound infection is the invasion and multiplication of microorgansism in body tissues

Normal intact skin may have 10^3 microbes/g of tissue--this microbes are protective and actually limit the invasion of pathogenic microorganisms

When the amount of microbes present reaches a critical level (10^5 microbes/g of tissue) healing will be impaired

High concentrations of microbes adversely affect wound healing by competing with body cells for O2 and energy and by secreting cytotoxic substances

Infection prolongs inflammation, promotes wound dehiscence, increases scarring, and slows wound healing

Wound infection causes the body to mount an immune response against the invading organisms--as a result the cardinal signs of inflammation are disproportionate to the size and extend of a wound during an infection

Front 6

One major difference with chronic wounds is that their cells are senescent--while still metabolically active --these cells proliferate at a reduced rate, synthesize fewer proteins, respond less to chemical mediators, and migrate much slower than cells within acute wounds

They have a dramatic increase in the number of inflammatory mediators such as TNF-a & MMPs--leading to an increase in the breakdown of ECM and inhibits granulation tissue formation

As a result, epithelialization is reduced or arrested

Another key difference is chronic wounds have a greater bioburden than acute wounds

Back 6

Inadequate blood flow increases the risk of infection

Circulation is controlled by the SNS--when the SNS is triggered by pain, fear, or cold their is peripheral vasoconstriction--which potentially slows the wound healing process

Thus keeping the patient comfortable, warm, and pain free are key to maintaining adequate blood flow

Front 7

3 Local factors affecting wound healing
1. Circulation
2. Sensation
3. Mechanical factors

Back 7

5 Systemic factors that affect wound healing
1. Age
2. Nutrition
3. Co-morbidities
4. MEDS
5. Behavioral risk taking

Front 8

Problems with skin associated with aging:
1. Macrophage and fibroblast function is impaired--slower immune response

2. Decreased collagen synthesis and strength

3. Decreased cellular turnover--slows repair and regeneration

4. Epidermal & dermal atrophy--secondary to decreased dermal vasculature--makes skin thinner

5. Pain perception is decreased

Back 8

Active cells require energy to function--with Carbs being the preferred source

If not present the body will burn amino acids from protein for energy

Bc protein is reqd for cellular repair and regeneration, protein depletion will impair inflammation, immune response, proliferation, and maturation/remodeling

Front 9

Describe 3 issues that can be caused by co-morbidities that affect wound healing
1. Decreased O2 perfusion--many processes in wound healing require O2

2. Immunocompromization

3. Activity limitation

As a PT dont just directly treat the wound--but be sure to work on the aspects or symptoms of a pt's co-morbidities that are affecting wound healing
-i.e. if a pt is deconditioned they cannot get up to get pressure off of a wound

Back 9

Steroids (esp high doses) and Chemotherapy drugs are detrimental to wound healing

NSAIDs may be problematic bc they decrease inflammation

Front 10

Alcohol leads to wound healing via malnutrition

Smoking affects wound healing by 3 mechanisms

1. Nicotine causes peripheral vasoconstriction

2. Nicotine increases platelet aggregation and clot strength--making the body work harder to dissolve the clot

3. CO binds with hemoglobin, reducing sites available to carry O2--lowers O2 levels in the blood and therefore the amt of O2 available for injured tissues

Back 10

Whirlpool treatment is appropriate for wounds with thick exudate, slough, or necrotic tissue

B/c it increases edema, traumatizes granulation tissue, and retards epithelialization--whirlpool is contraindicated on clean wounds

Front 11

Contamination-- presence of normal non-replicating microbes

Back 11

3 natural defenses against infection
1. Resident microflora protect the body from pathogenic causing organisms

2. Skin-- normal pH of 5.5 creates a slightly acidic environment discouraging microbial growth--layer of epithelial cells also provide a protective barrier

3. Immune system--immune cells such as macrophages, langerhans cells, and PMNs defense the body

Front 12

Colonization- the microflora adhere to the body's surface and replicate--but do not adversely affect the individual or cause a host response

Critical Colonization is a theoretical turning point at which the increasing number of bacteria becomes a bioburden and adversely affects the individual or causes a host response

Finally, infection occurs when microorganisms multiply and invade viable body tissues

Back 12

Other than # of bacteria, what other factors can predict an infection
1. How virulent (detrimental) the strain of bacteria involved is
2. Host resistance (immunocompromised individuals have decreased host resistance

Front 13

4 way excessive microbes adversely affect the host
1. Compete for O2

2. Toxins released from bacteria can be cytotoxic--inactivating of modifying host cellular processes

3. Bacterial toxins may activate host inflammatory processes

4. Delay or prevent wound healing

Back 13

Nosocominal infection--acquired while in the hospital

Front 14

What are some host characteristics that can increase risk of infection:
1. Diabetes
2. Obesity
3. Malnutrition
4. Immunocompromised
5. Steroid use

Back 14

3 Local factors causing infection

1. Ischemia

2. Necrotic tissue or foreign debris in the wound

3. Chronic wounds

Front 15

If the wound is infected the cardinal signs are typically excessive or disproportionate to the size and extent of integumentary damage d/t the increasing wound bioburden

A decline in wound status despite appropriate care is an additional clue that infection may be present

Back 15

Pts with infected wounds generally do not feel well systemically--they may have lower than normal energy levels or a feeling of malaise

Front 16

Infected wounds have thick, viscous, purulent, or creamy drainage--purulent drainage is commonly seen with Staphylococcus Aureus infections

Back 16

Who are 2 types of individuals that may suffer from a "silent infection"
1. Immunucompromised
2. Inadequate perfusion
Less likely to exhibit classic signs of infection

Front 17

Abscess-- localized collection of pus composed of devitalized tissue, microbes, and WBC's within body tissues

Body is able to contain the microbes and prevent them from spreading but is unable to destroy the microbes

Back 17

When a silent infection is suspected a clinician should assess for systemic effects:
1. Elevated WBC count
2. Fever
3. Inc HR
4. Inc RR
5. Faigue
6. Increase pain reported when infection first arises

Front 18

Biofilms are communities of microorganisms that attach to the wound surface encasing themselves in glycocalyx

The glycocalyx allows microbes to survive in wound environments that would otherwise be unfavorable by protecting microbes from antiseptics and anitmicrobials

Bc biofilms are multimicrobial, the different types of bacteria work synergistically

Biofilms are generally found on devitalized tissue and implanted devices

Back 18

An infection should be suspected if:
1. Cardinal signs of inflammation are disproportionate to the size and extent of the wound
2. Drainage is purulent, copious, malodorous, or has uncharacteristic color

3. Sudden increase in pain

4. Wound fails to heal in a timely manner

Front 19

Gold standard for culturing is tissue biopsy

Back 19

key disadvantage of a swab culture is that results may only reflect surface contamination or colonization rather than the infecting microorganism

Front 20

Bacteriocidal agents cause irreparable damage to bacteria resulting in bacterial cell death

Bacteriostatic agents inhibit bacterial cell growth

Back 20

Bacteria are considered resistant to a drug if they continue to multiply in its presence--bacteria are sensitive to the drug if they discontinue replication

Front 21

An antiseptic agent is an antimicrobial solution that prevents infection by killing microorganisms

However, antiseptics are also cytotoxic to fibroblasts, keratinocytes, & neutrophils

Thus, they increase the duration and intensity of the inflammatory response, delay epithelialization, and retard wound contraction

Back 21

Regular debridement of necrotic tissue and removal of exudate from the wound surface helps reduce bacterial bioburden and can transform a chronic, infected wound into an actively healing wound

Front 22

Universal precautions (blood and body fluid precautions)--approach to infection control in which all blood and body fluids are managed as if they are contaminated

Standard Precautions incorporate the concept of universal precautions along with hand washing and person protective equipment to reduce the risk of transmission of microbes

Back 22

Sterilization is a procedure that destroys all microbes from the area of interest

Only sterile items may contact the pts wounds

Sterile= environment free of microbials

Front 23

Clean technique is defined as procedures designed to reduce the overall number of microorganisms or prevent the risk of transmitting microorgansisms from one locale to another

Clean= free of gross contamination

Disinfect= clean a surface with an antimicrobial--not sterilizing

Back 23

4 keys to preventing infections in open wounds:

1. Hand Washing
2. Personal protective equipment
3. Appropriate use of a clean or sterile technique
4. Proper wound care procedures