Wound Care 1 Flashcards
(48 cards)
1
Q
What is the definition of wound?
A
- A physical injury to the skin or underlying tissues or organs caused by a loss of continuity of the epithelium including breakage of
the external skin or mucous membrane. - Breakdown in the protective function
- Unintentional or incidental to a surgical operation or procedure down in the protective function of the skin
2
Q
What is wound care?
A
- Assessing the patient’s condition and background such as any health, lifestyle and other factors which may slow the healing process
- Providing an appropriate environment for healing of a wound by both direct and indirect methods to prevent skin breakdown
3
Q
Describe the process of Haemostasis (1st step in wound healing)
A
- Blood leaks out of the body within 5 to 10 minutes
- Function: promotes clotting to prevent blood loss
3 major events in blood clot formation
1. Vascular Spasms: smooth muscle layer will contract in the presence of a damaged blood vessel
2. Platelet Plug formation: activated after passing a damaged wall - change shape - release of granules - spiked and sticky: result: clump together to form a platelet plug
3. Coagulation: formation of a fibrin mesh that holds the platelet plug in place
4
Q
List the 4 phase of wound healing
A
- Haemostasis
- Inflammation
- Proliferation
- Maturation/Remodelling
5
Q
Describe the process of Inflammation (2nd step in wound healing)
A
- Happens in the first 3 days
Function: Phagocytosis, prevents infection
Events: vasodilation occurs, increased permeability, release of neutrophils, macrophages and lymphocytes
Presentation: heat, erythema (redness) , oedema (swelling)
6
Q
Describe the process of proliferation (3rd step in wound healing)
A
- Happens in the first 2-24 days
Function: wound bed filling, wound closure, network of newly formed cappilaries, collagen, extracellular matrix to repair wound
Characteristics: uneven texture, pinkish red skin, edges of the wound contract and epithelial cells grow inward from the edges
7
Q
Describe the process of remodelling/maturation (4th step in wound healing)
A
Happens anytime from 24 days to 1 year
Function: skin develops tensile strength
Events:
- Collagen and extracellular matrix remodelling under the influence of growth factors
Characteristics: may have a scar
8
Q
What is an acute wound and provide examples?
A
Acute wounds progress through the phases of normal healing, resulting in closure
* Examples: skin tears, blisters, animal or insect bites, abrasions, lacerations, and burns e.g. chemical and heat burns
9
Q
What is a chronic wound and provide examples?
A
- Wound that has not healed in 6 weeks
- Wound has not improved or not reduced in area by 40% in 4 weeks of standard care following an appropriate treatment pathway
Examples: venous leg ulcers, diabetic foot ulcers, arterial insufficiency, pressure ulcers, neoplasia (cancer), chronically infected wounds and incontinence associated dermatitis
10
Q
List the processes involved in dry wound healing (dry wound healing is considered a disadvantage as it delays proper healing
A
- Dermis dries out and forms a scab/crust (=dehydrated exudate+dying dermis) which impedes epithelial cell migration
- Epithelial cells must travel further to repair the wound site
- Scabs may fall off causing scarring or reinjury (disadvantage)
- Gauze may adhere to wound and cause trauma on removal (disadvantage)
11
Q
List the processes involved in moist wound healing
A
- Application of dressing promotes a moist wound bed
- No scab formation allows the epithelial cells to effortlessly migrate across the wound which encourages cell growth, division and migration and faster formation of tissue
- Wound heals 3-5x faster compared to dried out wounds
12
Q
List the benefits of moist wound healing
A
- Wound healing takes less time
- Keritinocyte cells function more easily
- Facilitiates autolytic debridement - enzymes are able to break down dead tissue much easily
- Decreases incidence of wound infection - wound is protected by dressing so bacteria cannot get in
- preserves growth factors in wound fluid
- stimulates collagen synthesis
- Reduces pain - less stress response - patient feels less fatigued
13
Q
Identify intrinsic factors that affect wound healing
A
- Health Status - An individual with anaemia lacks sufficient oxygen in blood and so less oxygen is provided to tissue which can hinder proper wound healing
- A decrease in immunity can decrease white blood cells –> decrese in the ability to fight infection
- Diabetes
- Delayed capillary response to injury
- Reduced cellular function at injury site -
- Defects in collagen synthesis
- Hyperglycaemia delays healing - Age
Increase in Age:
- Decrease in sensory and secretory cells
- Decrease in moisture and flexibility
- Decrease in vasculature within skin - Obesity
More adipose tissue - poorly vascularised –> decreased oxygen and nutrients to wound site - Poor nutritional status can delay wound healing - right amount of proteins/carbs/fats/vitamins/fluids is required
- Depression –> poorer self-care behaviour
14
Q
Identify extrinsic factors that affect wound healing
A
- **Mechanical Stress **(i.e through pressure, friction and changing the wound dressing too frequently) - delays wound healing
- ** Debris** (e.g. slough, eschar, scab, dressing residue, guaze fibres, sutures)
3.** Temperature **
* Optimal body temperature is 37 degrees to heal the wound
* If temp decreases –> peripheral vascoconstriction –> decreases blood flow to site of wound –> delays wound healing - **Dessication (i.e. too dry) **
- exposed dry wounds are more inflamed, painful, itchy -
Maceration (i.e. too wet)
- incontinence, perspiration, excessive exudation - Infection
- **Chemical Stress: **
* Antiseptics and cleansing agents kill healthy cells as well as bacteria - **Systematic Medications **
* Vaso-constrictors (e.g. NSAIDS, anticoagulants)
15
Q
Identify lifestyle factors that affect wound healing
A
- . **Alcohol **
* Causes digestive problems –> malnutrition and anaemia
* Liver damage patient –> decrease in platelet levels –> decrease in blood flow - **Smoking ** - VERY BAD
* Nicotine, carbon monoxide, cyanide inhibits healing
* Nicotine reduces RBC, fibroblasts and macrophage levels
* Carbon monoxide sticks to the haemoglobin –> takes away the oxygen –> ischaemia
* Hydrogen cyanide: inhibits enzyme systems and oxidative metabolism
16
Q
What is TIME and what does it stand for?
A
An acronym or clinical decision tool that provides systematic assessment or **documentation of wounds **
T - tissue: removing non-viable slough or necrotic tissue (dead tisse)
I - Infection or Inflammation: Infected tissue should be treated with an appropriate anti-microbial
M - Moisture Balance: Moist environment optimises cell growth. However “wet” tissue can cause maceration and hence excessive exudate should be removed
**E - Edge of Wound: **Wound edge must be healthy to allow wound contraction
17
Q
Describe the “TIME” principle
A
Descriptors used to identify the tissue found in wounds:
* Necrotic eschar (Black)
* Necrotic slough (Yellow)
* Infective (Green)
* Granulation (Red)
* Hypergranulation
* Poor quality granulation
* Epithelium (Pink)
* Macerated (wrinkly white skin)
18
Q
Epithelial and Granulating tissue needs to be protected. Is this statement true or false?
Concept: “Time” principle
A
True
19
Q
Slough and Necrotic Tissue needs to be removed. Is this statement true or false?
Concept: “Time” principle
A
True
20
Q
Describe the “Infection or Inflammation” principle
A
A red swollen, hot, sore wound **does not **indicate an infection as it could be the inflammatory process itself (which takes places within the first 3 days from injury)
21
Q
Describe the International Wound Infection Institute (IWII) Wound Infection Continuum (IWII-WIC) and the signs and symptoms of a wound infection
A
The image is on google docs (week 4 notes)
22
Q
Discuss the role of antimicrobial use in wounds
A
- Antimicrobials decrease bacterial burden and promote wound healing
- During the contamination and colonisation stage no antimicrobials are needed
If patient has a local infection: topical antimicrobials or antimicrobial dressings needed - If patient has a spreading or systemic infection: both systemic and topical antimicrobials needed
- To prevent microbial burden and infection appropriate wound cleansing and dressing selection should be carried out at an earlier stage
- Antimicrobials are NOT routinely recommended
23
Q
Describe the “moisture” principle
A
- If the wound is too dry or desiccated moisture needs to be added
- If the wound is too moist or macerated the moisture needs to be absorbed (i.e. choose a dressing that is designed for moderate to heavy drainage)
- Removal of excessive exudate
24
Q
Describe the “Edge of Wound” Principle
A
- Edge of wound must be healthy to allow wound contraction
- If the edges are not advancing –> not healing
- If the edges are advancing –> healing
25
Describe the role of the pharmacist in wound care
**Wound specific clinical Role**: Assess, manage and refer the wound
**Wound related non-clinical role: **managing inventory and supply as well as documenting the service
**Non-wound specific clinical roles**: Vaccination, medication reviews, comorbidities, medication advice
**Non-wound specific non-clinical roles:** Staff training, Interprofessional practice, health promotion, contributing to research
26
Describe how to clean a wound
- Remember most wounds are non-infected the time when injury occurs.
Inert substances are appropriate in cleaning non-infected wounds such as:
* Irrigation with 0.9% normal sterile saline solution (remember to pick the **saline that is used for irrigation** only not saline for injection or saline used to wash contact lens, )
* Irrigation with tap water
If there is dirt, sand, gravel -** soap free products** (i.e QV wash, Dermaveen wash, Cetaphil wash)
27
List the reasons why anti-septics can interfere with wound repair/healing
1. Older generation anti-septics can interfere with wound repair as they kill both good and bad bacteria (i.e. non-selective - kills all microbes)
2. Some are **cytotoxic ** (i.e damages all cells on contact including cells involved in wound healing processes e.g. neutrophils, macrophages
3. Some anti-septics are inactivated by organic material (e.g. pus, necrotic tissue) --> cannot carry out its function
4. DO NOT USE antiseptic powders
28
When are anti-septics indicated?
1. To prevent a high risk of infection at the surgical site (e.g traumatic and contaminated wounds)
2. Local or spreading wound infection
3. In conjunction with surgical debridement with sharp instruments
29
Describe examples of anti-septics
1. **Medical grade honey **
* Anti-inflammatory, anti-fungal, anti-bacterial
* supports autolytic debridement
* no toxicity or risk of resistance
2. **Povidone-iodine ** (betadine)
* need to leave on skin for 3-4 minutes and then need to wash it off
3. neonates, iodine sensitivity, thyroid or renal disorders and large burns CANNOT USE BETADINE
30
Describe the features of an ideal dressing
1. removes excess exudate without drying the woud (i.e. promotes moisture balance in wound)
2. Allows gaseous exchanges
3. Insulates the wound to keep core temperature at approx 37 degrees (effective wound healing processes take place)
4. Protects agains micro-organisms, particulates and toxic contaminants
5. Protects granulating tissue from further trauma and damage
6. Not adhere to the wound
7. Be comfortable and conformable
8. Requires only infrequent changes
9. Non-toxic, non-allergenic and non-sensitising
10. removes or contains odour
31
List the considerations when it comes to selecting a dressing
1. Allow 2-3 cm dressing around the wound
2. Place a third of the dressing above and two-thirds below the wound
3. Follow the manufacturer’s direction of the packaging
4. Advise when to change the dressing
5. Remove with care with elderly patients with fragile skin
6. Minimise tissue disturbance- too frequent dressing changes leads to delayed healing
32
What is a primary dressing?
a dressing that is placed in direct contact with the wound
33
Discuss the role of anti-septic use in wound care
Antiseptic use can interfere with proper wound healing however they are indicated for use in specific situations.
1. Older generation anti-septics can interfere with wound repair as they non-selective (kill both good and bad bacteria)
2. Some are **cytotoxic ** (i.e damages all cells on contact including cells involved in wound healing processes e.g. neutrophils, macrophages
3. Some anti-septics are inactivated by organic material (e.g. pus, necrotic tissue) --> cannot carry out its function.
The situations where they are indicated:
1. To prevent a high risk of infection at the surgical site (e.g traumatic and contaminated wounds)
2. Local or spreading wound infection
3. In conjunction with surgical debridement with sharp instruments
Examples of antiseptic include Medical Grade Honey and povidone-iodine
34
What is a secondary dressing?
covers and secures the primary dressing, absorbing exudate and protecting the wound
35
Identify the common types of dressings found in a pharmacy
1. **Hydrogels** (amorphous and sheets)
2. **Island dressings** (fabric island and film island)
3. **Foam dressings** (silicone border)
4. **Calcium Alginate dressings **
36
When it comes to hydrogels, what key concepts do you need to recall as a pharmacist
1. Contains up to 96% water
2. Purpose: *treats dry scabby wounds --> donates water and promotes a moist wound bed. Also cools and soothes burns*
- Amorphous hydrogels: need to apply frequently
- Sheet hydrogels: can be left for 1-2 days
37
When it comes to island dresssings what key concepts do you need to recall as a pharmacist?
1. Purpose: provide protection of *dry wounds with nil-low level of exudate*
2. Consists of a low adherant (not going to stick to the wound) pad with an adhesive broder
-** Island fabric dressings**: low-adherent pad with fabric border (not water resistant) - needs to change them daily
- **Island Film Dressing**: low-adherent pad with a water resistant, semipermeable (=permeable to vapour & "breathable") transparent film border
--> do not use **film dressings** for **fragile and elderly skin**
38
When it comes to foam dresssings what key concepts do you need to recall as a pharmacist?
1. Purpose: *treats low to moderate (to high levels) of exudate*
2. Composition: polyurethane foam layers which can absorb fluids. Adhesive border is usually silicone based- gentle, painless, not traumatic on removal THEREFORE suitable for fragile skin
39
When it comes to calcium alginate dressings what key concepts do you need to recall as a pharmacist?
Purpose: stops bleeding, absorbs high level of blood and exudate. *Treats wounds with exudate and minor bleeding (i.e. cuts and lacerations) * --> forms a gel on contact with wound fluid
*Composition: Composed of calcium and sodium salts of alginic acids from brown seaweed*
***- Do not use for dry wounds*** as it will dry it out even further
40
When it comes to wound healing our primary aim is to **MAINTAIN MOISTURE**. True or False
TRUE
41
Outline the steps to manage a cut/laceration
1. Apply pressure to the wound to stop the bleeding
2. Raise injured area above level of heart
3. Clean the cut- saline or soap substitute and tap water
4. Close a deep cut with wound closure strips e.g. steri-strips
5. Protect with low-adherent dressing, secured with secondary dressing e.g. film dressing
6. Check tetanus vaccination status if applicable - risk of tetanus infection with metal cuts
42
Outline the steps to manage an abrasion/gravel rash/graze
1. Clean wound - saline or soap substitute and tap water
2. If required apply povidone-iodine liquid, leave for 3-4 minutes then wash off
- If high exudate: foam dressings
- If low exudate: island dressings
- If dry: apply some hydrogel underneath secondary dressing to create a moist environment
43
Outline the steps to manage skin tears
1. Cleanse the wound with warm saline or soap substitute, pat dry
2. Approximate the skin flap using dampened cotton tip, tweezer, gloved finger. If necrotic, flap needs to be removed
3. Dress wound using** non-adherent dressing **secured with either **non-adhesive silicone interfaced dressing or flexible netting or bandage**
4. Mark dressing with arrow indicating removal direction
* Do not use films, tapes or anything too adhesive on fragile skin!
44
Outline the steps to manage roof-intact blisters
1. Do not burst the blister
2. Use an **island dressing** or **foam dressing** surrounded by adhesive tape
3. Do not put any adhesives onto the actual blister
45
Outline the steps to manage roof-torn blisters
1. Put the flap back into place
2. Use an **island dressing** or **foam dressing** surrounded by adhesive tape
3.
46
Outline the steps to manage de-roofed blisters
1. Hydrocolloid dressings (e.g. duoderm, compeed) or foam dressings
47
Outline the steps to manage burns
1. Hold area under running water (ideally 15 °C) for at least 20 minutes If no running water available, immersion in water or wet cloths acceptable If no water available, apply hydrogel in adults only
2. Keep patient warm and hydrated
3. If blister forms, see blister management section
If no open wound e.g. sunburn, can apply adhesive fixation sheet up to 7 days
Do not apply ice, butter, creams, frozen peas, toothpaste!
48
When to refer for a wound?
* Burns classified beyond minor burns (as per ANZBA criteria)
* Injury with suspected vascular, tendonor nerve involvement
* Fractures, crush injuries, partial amputations of a digit, penetrating wounds
* Recent orafacial trauma or concussive head injury
* Pain cannot be managed with OTC analgesics
* Patients at high risk of infection due to medical conditions (e.g. immunocompromised)
* Signs and symptoms of systematic infection
* Localised infection from non-traumatic wounds
* Water-immersed wounds, bite wounds
* Patients at sign. risk of suicide
* Work-related incidents
