Modalities Flashcards
1
Q
When should modalities be considered?
A
Chronic wounds
Wounds that fail to respond to standard care
2
Q
Problems with Research to Support Adjunctive Interventions
A
Patient-related variables Wound-related variables Treatment-related variables Research-related problems Manufacturer-sponsored research
3
Q
Modalities and Physical Agents
to Enhance Wound Healing
A
Wound irrigation Whirlpool Pulsed lavage Electrical stimulation Ultrasound Ultraviolet Diathermy Low-intensity laser Monochromatic infrared Negative pressure wound therapy Hyperbaric oxygen
4
Q
Purposes of wound irrigation:
A
Removes loosely adhered debris, bacteria, exudate, residual topical agents
Facilitates debridement
5
Q
Irrigation after whirpool:
A
removes 4x more bacteria than whirlpool alone
6
Q
Indications for wound irrigation:
A
Standard component of treatment for all wound types (Our standard cleanser is Vashe)
Good for use in narrow tunneling wounds
7
Q
Contraindications/Precautions for wound irrigation:
A
Wounds with active, profuse bleeding
Be careful with splash back
8
Q
Method of wound irrigation:
A
35-mL syringe and a 19-gauge angiocatheter
Pressurized saline canister
Waterpik at lowest setting
9
Q
Pressure of irrigation:
A
Irrigation pressure of 4–15 psi
10
Q
Irrigant:
A
saline or tap water
11
Q
Advantages of wound irrigation:
A
Simple Quick Inexpensive Effective Can use for wound in any location Can use in any setting
12
Q
Disadvantages of wound irrigation:
A
Messy
May not use adequate amount of irrigant
Splash back
13
Q
Purposes of whirpool:
A
Removes loosely adhered debris, bacteria, exudate, topical agents
Facilitates debridement by softening and loosening necrotic tissue
Promotes circulation
Decreases pain
Makes range of motion exercises easier
Helps remove adhered dressings
14
Q
Indications of whirpool:
A
Infected wounds
Thick eschar or slough
Thick or heavy exudate
Pain management
15
Q
Contraindications/ Precautions
of whirpool:
A
Clean, granulating, or epithelializing wounds (no evidence)
Active bleeding
Need to reduce temperature with arterial insufficiency ulcers due to difficulty with heat dispersion
Patients who are hydrophobic, confused, combative, with seizures
Dependent position may increase edema
May cause drying of surrounding skin
Impaired sensation
16
Q
Temperature of non thermal whirpool
A
80-90 F
17
Q
Temperature of neutral whirpool
A
92-96 F
18
Q
Temperature of thermal whirpool:
A
96-104 F
19
Q
Treatment time for whirpool
A
10-20 mins
20
Q
Advantages of whirpool
A
Comfortable, pain control
Effectively removes debris
Warms tissue promoting perfusion of tissue
21
Q
Disadvantages of whirpool:
A
Can’t calibrate irrigation pressure
Potential for maceration, edema, cross-contamination
Time intensive for setup and cleanup
Expensive
22
Q
What are primary goals of whirpool if used on infected and necrotic wounds?
A
reduction of bioburden and removal of non-viable tissue are primary goals.
23
Q
Evidence against whirpool:
A
Additives may be cytotoxic, however limited evidence shows proper concentrations are not significantly cytotoxic
Force from jets may be traumatic however limited evidence indicates less force than pulsavac
24
Q
Pulsed Lavage
A
Removes dirt and foreign contaminants
Softens necrotic tissue
Removes toxic residuals from topical agent
25
Pressure of Pulsed Lavage:
4-15 PSI
26
What kind of debridement is pulsed lavage?
Nonspecific mechanical debridement
27
Concerns with pulsed lavage:
Aerosolization of contaminants, requires clean room
| Protect granulation tissue
28
What is pulsed lavage with concurrent suction?
Delivery of irrigant under controlled pressure with handheld device
Applies negative pressure to wound bed
29
Benefits of pulsed lavage with concurrent suction?
Facilitates debridement
| May enhance granulation tissue formation, epithelialization, and tissue perfusion
30
Indications of pulsed lavage:
Wounds requiring irrigation or debridement
| Wounds with tunneling/ undermining
31
Contraindications/ Precautions
| of pulsed lavage:
```
Exposed deep tissue, body cavities
Facial wounds
Recent surgical procedure
Latex allergy/sensitivity
Precaution: anticoagulants
Precaution: deep tunnel, insensitivity
```
32
Method of pulsed lavage:
Irrigation pressure of 4–15 psi
Handheld device with tubing attached to irrigant reservoir and suction device/canister
1–3 liters of normal saline
Time: typically takes 15–30 minutes
33
Must do with pulsed lavage:
Wear appropriate PPE to protect from splash injury and aerosolization (all people in treatment room)
Room with four walls and a door, cover IV sites/open areas not being treated, wipe down all horizontal surfaces
Use surgical drape an PPE
34
Advantages of pulsed lavage:
Encourages thorough irrigation
Can use in any setting (requires clean room) and on wound in any location
Ergonomical
35
Disadvantages of pulsed lavage:
```
Messy
More expensive than simple irrigation
Not appropriate for large wounds
Tips and some tubing designed for one-time use
Aerosilization contaminates environment
```
36
Jet lavage:
Mist of saline delivered by pressurized oxygen
Gentle to wound
Rehydrates necrotic tissue and gently debrides
37
Electric Stimulation
Effective in treating wounds of all depths.
Effective in managing necrotic tissue, inflammation, & infection
Facilitates wound contraction and wound resurfacing.
Enhances lymphatic and venous drainage, blood flow
38
What does estim attract?
Attracts macrophages and neutrophils
| Promotes epithelialization, wound contraction, ATP generation, and collagen synthesis
39
Negative pole (cathode) of estim:
Moves fluid from area, Dilates capillaries, Stimulates nerves, Retards microorganism growth (bactericidal), liquefies proteins, softens tissue, stimulates granulation, decreases edema, fibroblasts proliferate and make collagen, basic environment, promotes angiogenesis, attracts neutrophils when infection present, attracts fibroblasts
40
Postive pole (anode) of estim:
constricts capillaries, sedative to neurons, facilitates healing , attracts macrophages, neutrophils, and epidermal endothelial cells, acidic environment, coagulates protein, hardens tissue
41
Indications for estim:
Adjunct to healing for chronic or recalcitrant wounds that are clean or infected
CMMS: category III/IV that fail to respond after 30 days of standard care
42
Contraindications/precautions for estim:
General precautions for electrical stimulation
Untreated osteomyelitis
Not in combination with topical agents containing heavy metal ions
Precaution: sensory neuropathy
43
Advantages of estim:
Can use in any setting/ universally available
Does not cause pain (often reduces pain)
Extensive research supports use as adjunct to enhance wound healing
44
Disadvantages of estim:
Time consuming
Risk of contamination
Not appropriate for large wounds
45
Frequency for estim:
80-115 Hz
46
Intensity for estim:
75-200 V
47
Interpulse interval for estim:
50-100 microseconds
48
Active cathode:
infected, to reduce bioburden
49
Active anode:
promote granulation and epithelialization
50
Polarity change for estim:
every 3 days
51
Time for estim:
45-60 mins
52
How often to do estim?
3–7 day/wk for 30 min/day
53
Ultrasound during inflammatory phase:
stimulates release of growth factors from platelets, mast cells, and macrophages which are chemotactic to fibroblasts and endothelial cells. Accelerates inflammatory phase to speed proliferative phase. US is most effective when initiated in this phase
54
Ultrasound during proliferative phase:
stimulates fibrobast migration and proliferation. Also stimulates endothelial cells and angiogenisis. May also facilitate wound contraction
55
Ultrasound during epithiliazation phase:
stimulates release of growth factor necessary for regeneration of epithilial cells and promotes circulation
56
Ultrasound during remodeling:
improves scar extensibility if initiated in the inflammatory phase
57
Contraindications for ultrasound:
Infected wounds, osteomyelitis, DVT, Malignancy, Severe athersclerosis
58
Protocol for US for acute wounds:
initiate during the inflammatory phase to achieve benefit of increased tensile strength of scar by speeding proliferation. 1 minute/ cm2 with maximum of 15 minutes three times per week. .5 watts/ cm2 pulsed if impaired circulation.
59
Protocols for US chronic:
initiate as soon as possible. 1 minute/ cm2 with maximum of 15 minutes three times per week. Intensity .5-1 pulsed. Recommend initial treatment at 1.2 then decrease to lower range to stimulate inflammatory response. Can apply with hydro gel or film dressing and coupling gel or in a plastic basin of water. Limit to 14 treatments, improvement should be noticeable within 3-4 treatments
60
Benefits of US:
```
Collagen deposition
Granulation tissue formation
Angiogenesis
Enhances wound contraction
Improves scar pliability
```
61
Noncontact low-frequency ultrasound:
Debridement and decrease wound bioburden
62
Indications for US:
Adjunct for chronic or recalcitrant wounds
63
Contraindications/Precautions for US:
```
General precautions for ultrasound
Untreated osteomyelitis
Wounds with active profuse bleeding
Severe arterial insufficiency
Deep vein thrombosis
```
64
US Superficial
3.0 MHz
65
US Deep wound:
1.0 MHZ
66
US Pulsed:
0.5-1.0 W/cm2
67
Remodeling closed wound:
Continuous: ≤1.5 W/cm2
68
Time for US:
2–3 minutes per zone
69
How often for US?
2x/day or 3 day/wk
70
US mist
Mist created by US
Rehydrates necrotic tissue and gently debrides
May provide benefits of US for wound healing as well as debride
71
Low Frequency Contact US
Utilizes current with saline spray as coupling medium
| Low frequency US is powerful enough to liquefy adipose tissue and disrupt biofilm
72
Advantages of US:
```
Can use in any setting
Quick
Less setup/cleanup time
Does not hyperhydrate
Does not require dependent positioning
```
73
Disadvantages of US:
Less research support
Not appropriate for large wounds
May be painful or difficult to perform
Risk of contamination
74
Ultraviolet C
Enhances cell proliferation
Promotes growth factor release
Stimulates granulation tissue formation
Promotes exfoliation enhancing healing through induction of erythematous response in the skin
75
What does Ultraviolet C facilitate healing in:
Venous or arterial insufficiency ulcers
Pressure ulcers
Neuropathic ulcers
76
Laser Therapy:
For seeping wounds that need drying,
Does not come in contact with the patient
Reduces pain and inflammation
Synthesis and repair of DNA and RNA
Increases collagen synthesis, organization/tensile strength, and maturation
Proliferates nerve growth and sprouting
Increases all portions of proliferative phase of healing
Releases/discharges lymphatic congestion
Diminishes scar tissue and adhesion formation
Increases ATP production
77
Monochromatic Infrared Energy
Delivers near-infrared energy at 890 nm wavelength to the skin by way of flexible diode pads
Purported to improve blood flow to treated area by up to 400%
Slight improvement in diabetic neuropathy
78
Negative Pressure Wound Therapy (NPWT)
Sub-atmospheric pressure (suction) applied to the wound via open celled foam sponge in the wound
79
Negative Pressure Wound Therapy (NPWT) Benefits:
Increases local blood flow, capillary filling, and lymphatic flow
May help approximate wound edges and facilitate contraction and closure
Currently, insufficient evidence that NPWT is superior to standard care
Beneficial heavily draining and cavernous wounds.
80
NPWT contraindications:
malignancy, untreated osteomyelitis, necrotic tissue with eschar present, and over exposed blood vessels or organs? ( special systems used for open abdomens)
81
NPWT precautions:
active bleeding, anticoagulants
82
Purpose of NPWT
```
Increases local blood flow
Decreases wound/periwound edema
Increases granulation tissue formation
Increases angiogenesis
Increases epithelialization
Decreases wound bioburden
Promotes cell proliferation
Maintains moist, warm wound environment
```
83
Indications for NPWT:
Adjunct for chronic wounds
Postsurgical wounds and grafts
Wounds with exposed deep tissue or hardware
Traumatic wounds
84
Contraindications for NPWT:
```
Necrotic wounds
Body cavity wounds
Untreated osteomyelitis
Exposed blood vessels
Caution: patients on anticoagulants
```
85
Pressure for NPWT:
50-175 mmHg
86
Disadvantages of NPWT:
```
No standard for use
Pain
Noisy
May hinder patient mobility
Difficulty obtaining air-tight seal
May cause skin damage
Costly
```
87
Advantages of NPWT:
May cost less over time
Can use in any setting
Moist wound environment
88
Hyperbaric Oxygen
Primary mode of treatment for air or gas embolism, decompression sickness and CO2 sickness. Adjunctive therapy for radiation tissue damage, gas gangrene, compromised skin grafts, crush injury, compartment syndrome, acute traumatic ischemias, necrotizing soft tissue infections, refractory osteomyelitis, and problem non-healing wounds
89
Puposes/Effects of Hyperbaric Oxygen:
Increases oxygen concentration gradient
May reduce bacterial growth
May enhance angiogenesis, granulation tissue formation, epithelialization, and wound contraction
May reduce edema
90
Indications of Hyperbaric Oxygen:
```
Gas gangrene
Peripheral ischemia
Crush injury
Wagner grade 3 or higher ulcer
Progressive necrotizing fasciitis
Osteomyelitis
Osteoradionecrosis
```
91
Contraindications of Hyperbaric oxygen:
```
DVT
CHF
Claustrophobia
Pregnancy
Severe arterial insufficiency
Noncomplicated wounds
```
92
Method of hyperbaric oxygen:
Patient in chamber breathing 100% oxygen at 1.5–2.5 ATM
Treatment time: 90–120 minutes
Treatment frequency: 2x/day–3x/wk
Treatment length: 10–60 sessions
93
When is wound unlikely to respond to HBO?
if 50% decrease in wound surface area not noted after 10 treatments
94
Advantages of HBO
TCOM test can help predict efficacy
| May prevent limb loss
95
Disadvantages of HBO:
Extremely high cost
Extensive treatment time
Average patient requires 37–44 Rx costing $75,000
