HHBS Wound care Education

By S BanerjeeKolkata

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Wound Care by S Banerjee 12/19/14

Wounds can be classified as being either acute or chronic, and further defined as partial or full thickness depending the degree of tissue that is lost.

Wounds can occur from an injury, a surgical intervention, or caused from mechanical trauma such as unrelieved pressure. Wounds can also occur from underlying disease processes such as Diabetes or venous hypertension/ insufficiency.

When a wound is sutured closed this is called healing by primary intention and when the wound is left open to heal it is called healing by secondary intention.

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An acute wound is a wound that is expected to heal in a timely manner, moving through the phases of healing. However, when the natural progression of wound healing is interrupted, a chronic wound results. When this happens it is important to recognize that wound management needs to shift to a more holistic approach.

Common types of chronic wounds include pressure ulcers, venous, arterial and diabetic neuropathic ulcers. Seeking the support of a wound clinician to assist in the healing process of chronic wounds is recommended. Experts in wound healing can provide comprehensive assessments and develop plans of care to support healing.

There are also wounds that are not expected to heal or not healable called maintenance wounds. The goals of care shift from healing to comfort and odour management while reducing the risks of infection and other factors than may cause further deterioration of the wound.

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Healing with secondary intention, from injury to repair, occurs in three overlapping phases known as the

inflammatory, proliferative and maturation phases of healing.

Inflammatory Phase This phase begins at the time of injury and lasts between three to five

days. The body attempts to stop bleeding that occurs at the time of injury through vasoconstriction and blood cells called platelets that stick together to form a clot. This is called hemostasis. This temporarily covering reduces loss of blood and protects the wound from the outside environment.

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Over the next few days the body attempts to clean up the wound and protect itself from bacterial invasion. White blood cells called neutrohpils and macrophages, migrate to the wounded site and start remove bacteria and debris through a process called autolytic debridement.

The skin surrounding the wound will appear red (Rubor), develop edema or swelling (tumor) feel warm to the touch (Calor) and pain may be present (Dolor). There may be a moderate to large amount of exudate during this phase of healing.

It would be important to pack the wound cavity , or dead space, and cover the wound with a highly absorptive dressings during this phase. If the signs of inflammation continue beyond five days a wound infection could be occurring.

Once the wound has been effectively cleansed the healing process moves into the second phase of healing.

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Proliferative Phase This is a very active phase and requires an orchestration of many events

to repair the wound. This phase begins on day three to five and can last from three weeks to a month depending on the severity of the wound

The clinical signs of inflammation disappear evidenced by a reduction in swelling, redness and heat. Pain may still be present or may start to diminish. Vasodilatation occurs and various cells proliferate at the wound site to rebuild new tissue and capillaries. This process begins to replace the lost tissue from the injury. Wound heal from the bottom up to the level of the skin. As the depth decreased the wound begins the process of covering over the deficit. When the wound is fully covered is closed, but not yet healed.

It is important to note that in full thickness wounds the body does not regenerate lost tissues but replaces what was lost with something similar.

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This phase involves several cells and growth factors. The macrophage cell is a key player and has several functions. This cell

engulfs and destroys foreign material and micro-organisms to reduce the risk of infection, use enzymes to assist in debridement, attract fibroblasts to the wound and make growth factors.

Another cell is the fibroblast cell that begins the production of Type III collagen and stimulates the growth of new capillaries. The forming of new blood vessels is called angiogenesis

The wound deficit is filled with granulation tissue or scar tissue. This tissue contains the new blood vessels, collagen and fibroblasts. It has a red granular appearance, hence the name granulation tissue. This tissue is fragile and bleeds easy so care must be taken when cleaning the wound between dressing changes.

Long wear dressings that support moist wound healing is recommended during development of granulation tissue.

As the wound fills in and the depth decreases, contraction begins to occur. This process pulls the edges of the wound together, reducing the wound size.

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Point of emphasis Measuring wounds during the healing process can be important to identify

healing. Wound healing = change/over time. If an acute wound is getting progressively smaller over an expected time period, it is healing. If there is no change in the wound size over a two week period it is stalled and if the wound becomes larger or deeper the wound is deteriorating. At this point an acute wound becomes a chronic wound.

When a wound stalls or starts to deteriorate bacterial load may be a cause. Other signs may appear to suggest infection such as an increase in wound exudate, pain and redness around the wound. Seeking timely professional assistance is recommended. The wound can be assessed for infection and treated appropriately.

As the depth of the wound fills in, the wound resurfaces with epidermal cells in a process called epithelialization. Epidermal cells proliferate and migrate across the granulation tissue from the wound margins. These cells eventually meet, interconnect and resurface the wound with a fragile scar. The epithelial cells mature into keratinocytes giving strength to the scar tissue.

It important that the fragile scar tissue is protected. Applying a long wear film dressing at this stage of healing is recommended. The dressing is clear ( see through) and the wound can be visualized without removing the dressing. This type of dressing protects the fragile scar (30 % tensile strength). The dressing can be left in place 7 days or longer making it a cost effective choice. 9


Remodelling & Maturation Duration of this phase is dependent on the individual’s age, type of

wound, depth, location of the wound and duration of the inflammatory phase and can last up to 2 years.

Remodelling occurs once the wound is closed over and the scar tissue filling the wound is restructured. The initial Type III collagen is replaced by Type I collagen and is reorganized creating more stable bonds between the fibres, increasing the strength of the tissue. It is important to know that the scar tissue is only 80% as strong as the skin before injury.

During the maturation phase, the scar softens, flattens and changes colour, fibroblasts leave the wound site and vascularisation is reduced.

This describes how an acute wound heals. When there is a disruption the a healing phase the wound stalls and becomes a chronic wound.

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In summary

When an injury is sustained and a loss of skin and lower structures is lost, the body attempts to restore itself through three coordinated overlapping healing phases:

Inflammatory Phase · constricting blood vessels to control bleeding · forming a clot · inflammation, the body’s natural response of the immune system to an injury occurs as evidenced by

heat, swelling, redness and pain · white blood cells clean the wound of debris and bacteria · This takes about 5 days

Proliferative Phase · Special cells called fibroblasts make collagen to fill in the wound. · New blood vessels form · Granulation tissue fills in the deficit · The wound gradually contracts ( gets smaller) and is covered over by a new layer of skin

Maturation Phase The wound is now closed but is not yet healed Collagen is reorganized and restructured to increase the tensile strength of the area The scar will change colour and become soft

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Local factors: condition of the wound environment Infection or presence of a large number of bacteria in the wound Lack of oxygen to the tissues Necrotic or dead tissue in the wound bed Sustained pressure over the wounded area Repeated trauma to the area Systemic factors Co-morbid conditions such as Diabetes or immunodeficiency’s Malnutrition Dehydration Medications: steroids, anti-inflammatory agents immunosuppressives and anticoagulants Other Factors Age Lifestyle choices such as smoking Inappropriate treatment choices Assessing and treating a wound that has stopped healing (stalled) or is deteriorating is can be complex. Wound

healing can be improved by optimizing the wound environment and the individual as much as is possible by identifying the factors impacting healing and addressing the cause.

A compromised wound can often be identified by: the size of the wound is no longer getting smaller there may be an increase in exudate increased discomfort in the wounded area may be expressed the wound bed tissues may start to bleed with minimal manipulation Timely treatment to address the cause of non-healing is essential to take the wound back into a healing projectory.

Referral to a wound clinician when these signs appear is recommended. This can reduce the time to wound closure. The longer a wound remains open the harder it is to turn it back into a healing wound. This can be costly for the individual related to Quality of Life and financial resources 12


1. Determine if the wound is healable. Healable wounds will have a different treatment approach to non-healable wound. Acute healable wounds may also be treated differently than chronic healable wounds. Therefore it is important to identify the etiology of the wound and establish if the wound is healable, healable but not healing or not healable

2. Identify and address any factors that may impact healing 3. Gentle cleaning of the wound to remove debris and loosly adherent nonviable

tissue 4. Use moist interactive healing approaches for healable wounds. When utilizing

moist wound healing the dressing should retain enough moisture to stimulate healing but not cause maceration of the surrounding tissues.

5. Treat Infection: an infected wound will not progress to healing until the infection has been treated

6. Fill in the dead space. Apply appropriate primary dressings into the cavity of the wound. A secondary dressing will be needed to cover both the wound and the primary dressing.

7. Remove necrotic tissue in healable wounds. There are several forms of debridement but most frequently autolytic debridement is utilized. Experts in the field may use other debridement options.

8. Assess the wound on a regular basis. This should include measuring the longest by the widest linear measurement in cms, the gold standard. Depth should also be measured.

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Treatment Choices: Wound Care Dressings Caring for a wound involves more than applying a dressing. The role of a wound

dressing is to provide an optimal environment to support healing. Choosing the most appropriate dressing depends on the findings from a

comprehensive assessment as well as the characteristics of the wound bed and the phase of healing.

There is a myriad of wound care products/dressings on the market. It would be important to understand the form and functions of dressings in order to choose dressings that address the needs of the wound and the phase of healing so that an appropriate treatment approach is utilized to support healing.

An ideal dressing should have the following characteristics Removes excess exudate Provides a moist wound environment Allows for gaseous exchange Provides thermal insulation Protects against secondary infection Does not stick to the wound bed Does not cause pain on removal

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Types of Dressings listed in alphabetical order. This is not an inclusive list of advanced wound care dressings classifications but includes dressings commonly used by wound care clinicians.

Antimicrobials

Broad spectrum topical antimicrobials to reduce localized bacteria in superficial compartment infections

Does not replace systemic antibiotics for deeper tissue infections Not to be used if known hypersensitivities to any of the product components

Sliver compounds Cadexomer iodine Medical honey

Biologics Stimulate the wound bed Applied by skilled health care professionals Should not be used on infected wounds, sinus tracts with excessive exudate Cultural or ethical issues mayy affect usage

Skin equivalents Platelet derived growth factor gel

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Calcium alginates Primary dressing to wick and absorb exudate Hemostatic properties Comes in sheets or ropes Derivative of seaweed Used on exudating wound Bioreabsorable Requires a secondary dressing Should not be used on dry wounds Low tensile strength avoid packing into narrow deep sinuses

Charcoal Odour management

Some products include a silver component Composites

Multilayered combination dressings to increase absorbency Use with wounds with moderate to large amounts of drainage Can protect the wound margins from maceration

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Films Semi-permeable adhesive sheets Impermeable to liquid and bacterial infiltration Can help reduce friction to fragile skin or vunerable areas such as the

heels Use on donor sites or partial thickness wounds or a newly closed wound

in the early maturation phase of healing Should not be use on draining or infected wounds

Foams Non-adherent or adherent polyurethane May have occlusive properties depending on the outer layer Some have additional properties such as low tac, antimicrobial action or

pain control Used on moderate or heavily exudating wounds Foams with silver may be indicated for use on infected wounds Occlusive foams without silver should not be used on infected wounds

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Hydrocolloids Sheet dressing that are occlusive Barrier to outside contamination of bacteria A characteristic odour may be noted with dressing changes but this should not be confused with

infection Moisture retentative Supports sutolytic debridement Creates an occlusive barrier against bacterial invasion Use with caution on fragile skin Should not be used on heavily draining or infected wounds Different HDC products have varying absortive capacities. Small to moderate absorption

Hydrogels

Polymers with high water content Available in gels, soild sheets or embedded into gauze Adds moisture to dry wound beds Can absorb a small amount to exudate Prevents drying of the wound bed Periwound protection may be needed to prevent maceration Requires a secondary dressing Available with a silver component

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Hydrophilic Fibres Sheet or packing strip of sodium carboxymethylcellous Converts to a ge; when activated by moisture Supports Autolytic debridement Best for moderate amount of exudate Low tensile strength avoid packing into narrow or deep sinuses Should not be used on dry wounds

Hypertonics Gauze ribbon wafer or gels impregnated with salt concentrate Use on wounds with moderate to large amounts of drainage Requires a secondary dressing Used in wounds with necrotic tissue May be painful to wear due to the salt content Use wound cleanser vs normal saline to cleanse wounds Not to be used on dry wounds

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Negative Pressure Wound Therapy (NPWT) Consists of a wound dressing (foam or gauze) vacuum pump, canister and

tubing Applies localized negative pressure to the wound bed and wound edges Assists in moving fluids fro the wound Has an antimicrobial dressing (sponge or gauze) if needed Usually applied by a skilled professional Several contraindications for use

Non-adherents

Low adherence to wound tissues Serves as a contact layer that allows transfer of exudate to the secondary

dressing Can be composed of silicone, medicated or non-medicated tulles Use with wounds that are painful or friable Usually requires a secondary dressing

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Pain control dressing Foam dressing with continuous release of ibuprofen Low tack for easy removal Indicated for painful exudating wounds Not to be used with known hypersensitivities to any of the product

components Not to exceed recommended dose

In Summary To successfully treat wounds, whether they are acute or chronic, healable,

not healing but healable or maintenance wounds, it is important to understand the physiology of wound healing, identify any risk factors that may impact healing, identify signs of infection and enhance the wounded individual to optimize their healing potential. Choosing appropriate dressings based on the needs of the wound will support healing or meet the goals of the maintenance wound.

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Abrasion An injury caused by rubbing or scraping that results in the loss of the superficial layer of skin or epidermis and or dermis and may involve the mucous membrane

Acid Mantle Body’s natural protection of the outer layer of skin having a pH between 4.0 and 5.5. Made from sebum and sweat. Inhibits the growth of harmful micro-organisms and pollutants

Angiogenesis The process of forming new blood vessels. Occurs in the granulation phase of healing in wound repair Arterial Blood Flow Arterial Compromise Arterial Disease

Autolysis The process where devitalized or dead tissue is self digested through the action of enzymes

Bacterial Burden or Load The number and virulence of bacteria in a wound Blanching When pressure is applied to a reddened area ( inflammation) the area under the pressure becomes white Cell Cellulitis Inflammation or infection of the cells in tissues characterized by redness, pain, heat and edema. Firmess of the

tissue may also occur

Champagne Leg (inverted) shape of a leg that looks like an inverted champagne bottle on some legs that have venous disease. The ankle and lower leg are narrow and the upper calf is much wider

Charcot ( Char Coe) Foot a progressive condition affecting the musculoskeletal system of the foot in persons with diabetes. Fractures of the bones in the foot joint dislocation and deformities can occur. The bottom of the foot has the appearance of the hull of a boat due to the arch of the foot collapsing

Claudication (Intermittent)22


Collagen A protein that is the principle component of skin, bone, tendon cartilage and other connective tissue. Collagen is needed in wound repair to provide the scaffolding in which the wound fills in when healing with secondary intention.

Contraction Shrinking is size. In wound healing, contraction occurs around the edges of the wound causing the wound size to become smaller. It is important to measure wounds to identify change over time; healing or deterioration.

Debridement The removal of devitalized or dead tissue and foreign material from the wound bed. A wound should be clear of dead or devitalized tissue to support healing and reduce the risk of infection There are many ways to debride. See appendix on Debridement Types.

Dependent opposite of elevated Dependent Rubor A redness or purple color of a leg when it is in the dependent or

lowered position. If the leg blanches on elevation it may be a sign of lower leg ischemia Dermis the second layer of the skin, under the epidermis. This layer provides blood

supply to the nonvascular epidermis, contains the sweat and sebaceous glands, hair follicles, lymph and blood vessels nerves and pigment cells.

Devitalized (tissue) Edema Swelling

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Enzymes a protein secreted by cells that acts as a catalyst to induce chemical changes capable of breaking down necrotic tissue

Epidermis Outermost layer of the skin Epithelialization the process of epithelial cell formation and

migration from the wound edges ( including hair follicles) that close over the wound

Erythema redness of the skin. Caused by vasodilatation related to inflammation, infection or injury

Eschar necrotic tissue that forms a black thickened covering over wounds ***

Extravasation leakage of fluid from a blood or lymph vessel into surrounding tissue

Extremities Refers to the arms and legs Exudate Fluid that comes from wounds. Can be clear ( serous),

sanguineous (bloody) or purulent (pus)

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Fibrin a protein involved in the blood clotting process. Can also be involved in the granulation phase of healing

Fascia a band or sheet of connective tissue found throughout the body Fibroblast an important cell in wound healing. **** Friable Tissue Tissue that bleeds easily. Then this occurs in a chronic

wound, infection should be suspected (see infection in a chronic wound appendix)

Granulation Tissue tissue that forms in the wound base which fills in wounds with scar tissue as healing with secondary intention. The tissue is red or pink and has a lumpy appearance like small grapes. This tissue is necessary to fill in wounds so that they can heal

Granulation Phase of Healing Growth Factors. Specialized proteins that cause cells to migrate to an area

as well as make other proteins needed in healing. Hematoma a localized collection of blood Hemosiderin Staining amdiscoloration of the lower leg often present in

venous disease. It is caused by the release of iron containing pigment as red blood cells disintegrate. Staining can been seen above the ankle and can be an indicator of venous disease

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Hollistic An approach to care that supports many relationships and disciplines to support a comprehensive treatment plan

Homeostasis the ability of a system such as the human body, to maintain equibrium when changes occur

Hyperkeratosis The thickening of the skin such as callus formation Hypodermis. A layer of cells below the dermis that store fat and anchor the skin to the

underlying structures Induration A process where the skin becomes firm, often surrounds a wound as a

healing ridge or can be a sign of building bioburden Inflammatory phase of healing The body’s initial response to injury and lasts between

two to 4 days. During this phase the body attempts to close off broken blood vessels and clean up the wound

Intermittent Claudication often identified as a pain in the lower limbs related to poor or com-promised blood supply. The pain usually occurs when wlaking and relieved with rest.

Ischemia a deficiency of blood supply to an area Laceration a wound that is produced by the tearing or slashing of the skin or injury by

an object that causes a tear in the skin Lipodermatosclerosis A thickening in the tissues of the lower legs which feels hard and

woody

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Loss of Protective Sensation (LOPS) occurs in persons with diabetes where feeling in the feet is diminished or absent. This places the area at risk for developing wounds

Maceration A softening and whitish look to the intact skin around wounds caused by excessive moisture. Often occurs when exudate is not well managed by dressings

Macrophage A white blood cell that cleans up the wound, ingesting dead cells, micro-organisms, foreign material and other debris.

Malleolus The ankle bone. Matrix Metalloprotease (MMP’s) An enzyme that breaks wound proteins during wound healing. When found

in large numbers in chronic wounds these enzymes can interfere with healing as they will break down good proteins as well as proteins that can negatively impact healing

Maturation Phase of Healing The final phase of wound healing that begins at about day 21 of the healing process and can last up to 2 years. During this phase collagen is restructured and the scar tissue softens and changes colour. The closed wound is only about 80% as strong as the tissue was before injury.

Moist wound healing

Moisture Vapour Permeability (MVP) Necrotic Tissue dead tissue that usually presents as black or brown and is hard or leathery in texture Neuropathy Any abnormal degenerative or inflammatory state of the peripheral nervous system. Symptoms

include, numbness, tingling or pain in the extremities

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Occlusive when referring to a dressing, it closes the wound from the external environment

Offload to reduce or eliminate pressure from an area Orthotic an orthopaedic applicance such as a form placed in a shoe to

support the foot or redistribute pressure areas Osteomyelitis Inflammation/infection of a bone Oxygenation providing oxygen to an area or system Paresthesia A non-painful abnormal sensation such as numbness tingling,

burning for a feeling of skin stiffness Pathogen An organism that can cause disease such as a virus, bacteria or

othermicro-organism Pathology A condition in the body produced by disease Perfusion The pumping of a liquid into tissues or an organ****** Delayed

wound healing can result is there is inadequate oxygen perfusion to the wounded area

Peri-ulcer ( peri-wound) the tissue the surrounds the wound Phagocytosis The process where cells surround and digest cells debris, micro-

organisms necrotic tissue and foreign bodies.28


Plantar relating to the sole of the foot Pressure reduction a device or surface designed to reduce

pressure over an area Pressure Relief A device or surface designed to provide pressure

relief over an area Proliferative Phase of Healing the second phase of healing

lasting 3 to 21 days. During this phase the wound fills in with granulation tissue, contraction of the wound occurs, and epithelialization takes place. This phase reduces the area and depth of the wound

Purulent Containing or forming pus Qualitative Wound Culture A collection of wound fluid to gather

a specimen from a single point in a wound to be assessed for type and amount of bacteria in the wound. A culture should be taken before antibiotics are prescribed.

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Rubor Red or purple color often accompanied by swelling, heat and pain Semi-permeable when pertaining to wound care dressings, it is a property where certain

type of molecules are allowed to pass through a membrane while other types of molecules are not. For example oxygen molecules may be allowed to pass but bacteria are not. See Moisture Vapour Permeability (MVP)

Sinus Tract A tunnel extending from a wound creating Skin Stripping Loss of the epidermis from removal adhesives in dressings or tapes Slough Dead tissue usually yellow in color and can be stringy in appearance. Can be a

source for bacteria and should be removed. Autolytic debridement is often the chosen approach to remove the necrotic tissue. Should not be mistaken for fibrin

Strike-through refers to wound drainage that becomes visible on the outside of dressings Subkeraotoic Hematoma An area filled with blood under a callus. Often caused by

repeated trauma, over a bone, in a person with LOPS Swab Culture a specimen collection of fluid ( wound ) to determine number and type of

bacteria present. A wound should be cleansed prior to a swab being taken and granulation tissue should be swabbed if possible

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Systemic Relating to an entire system vs individual parts of the system Tensile Strength the strength of a closed or healed wound in terms of the

greatest stress the tissues can bear without tearing. Tissues over a healed wound are approximately 80% as strong pre-injury

Total Contact Cast a fibreglass device/cast often used to support the healing of diabetic foot ulcers ( neuropathetic ulcers) by redistributing the weight along the entire surface of the foot

Ulcer *** a break in the skin or mucous membrance with the loss of the surface tissue

Validated Tool A that accurately measure what it is intended to measure

Vasoconstriction Constriction or narrowing of the blood vessels Vasodilation Dilation or widening of blood vessels Wound

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S Banerjee

Kolkata

[email protected] http://www.hhbs.co.in

12/19/14Wound Care by S Banerjee

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Health & Medicine

HHBS Wound care Education