Intention for wound healing.....

Necrotic Tissue

DEAD, DEVIATED TISSUE THAT IS ADGERENT TO VIABLE TISSUE

Hyperbaric Oxygen

The delivery of oxygen at pressure greater than 1 atmosphere is a form of therapy capable of inducing revascularization of damaged tissue Optimal environment for rapid tissue healing Negative consequences - vasoconstriction, toxicity and tissue destruction

Eczema

"Dermatitis" = a group of disorders that cause chronic skin inflammation typically d/t an immune system abnormality, allergic rxn or external irritant. E: based on the particular form of disorder. Infants and children are at higher risk for eczema=may outgrow it S/S: Red or brown-gray, itchy, lichenifiled skin plaques that may be exacerbated by some topical agents such as soap and lotions; may have oozing/crusing of the patchy areas of irritation. Tx: Topical or oral conticosteroids; oral antibiotics; antihistamines; cold compresses to ↓ itching; Stress mngmt techniques; avoid extreme T⁰'s

Wet Gangrene

"Wet" if there is an associated bacterial infection in the affected tissue; may develop as a complication of an infected intreated wound. Swelling resulting from the bacterial infection causes a sudden stoppage of bld flow. E: can develop after a severe burn, frostbite or injury and requires immediate tx since it tends to spread very quickly and can be fatal. cessation of bld flow that starts a chain of events including invasion by bacteria at the affected site. WBC are unable to fight the infection d/t poor bld flow. S/S: swilling/pain; ∆ in skin color from red to brown to black, blisters that produce pus, fever and general malaise. Tx: Immediate Med. attention; surgical debridement; IV antibiotics.

Tertiary intention

(delayed primary closure) is intentional closure after a delay of days to weeks. Similar to secondary intention, the wound is allowed to heal open for a period of time. However, the wound is then closed once the risk of infection has decreased Remains open until all risks for infection are gone

Dermis

A layer of connective tissue underneath the epidermis of the skin. The dermis contains blood vessels, lymphatic vessels, nerves, sensory receptors, and glands.

Hypertrophic Scar

Abnormal scar resulting from excessive collagen formation during healing. A hypertrophic scar is typically raised, red, and firm with disorganized collagen fibers, raised scar that remains within bounds of original wound

Anticipated Deformities bas on Burn location and type of splinting

Anterior Neck=Flex w/possible lat flex Soft collar, molded, Philadelphia Anterior Chest/Axilla=Shldr add/ext/med rot Airplane splint/Shldr abd splint Elbow=flex and pron. Gutter Splint/3 pt. splint/conforming splint Hand/Wrist=ext/hyperext of MP jts; flex of IP jts; Add and flex of thumb; flex of wrist Wrist splint; thumb spica splint;Palmar/dorsal extention splint Hip: Flexion and adduction Anterior hip spica, Abduction splint Knee: flexion Conforming splint, 3 point splint, air splint Ankle: Plantar Flexion Post foot drop splint; posterior ankle conforming splint, anterior ankle conforming splint

Silver Nitrate

CAUSES A CHEMICAL BURN TO STOP CAPILLARY BLEEDING- ANTI-INFECTIVE ADVANTAGE:Broad-spectrum non-allergenic dressing application is painless DISADVANTAGE:, Poor penetration, discolors, making assessment difficult. Can cause severe electrolyte imbalances Removal of dressing is painful,

Superficial Wounds

Causes trauma to the skin w/ the epidermis remaining intact. (non-blistering sunburn) Will typically heal as part of the inflammatory process shearing, friction, burning - only epidermis

Integumentary pathology

Cellulitis Contact Dermatitis Eczema Gangreen (wet/dry) Plaque Sporiasis

Plaque Psoriasis

Chronic Autoimmune disease of the skin; most common of the 5 types of psoriasis. T cells trigger inflammation w/i the skin and produce an accelerated rate of skin cell growth. The skin cells accumulate in raised red patches on the surface of the skin E: Genetic predisposition; injury to skin, insufficient or excess sunlight, stress, excessive alcohol, HIV, smoking and certain meds Tx: 1⁰ goal is to control the symptoms and prevent 2⁰ infection. topical applications to synthetic meds and phototherapy. Life-long condition; can be effectively managed and controlled.

Full Thickness Wounds

Extends thru the dermis into deeper structures such as subcutaneous fat. Wounds deeper than 4 mm are typically full-thickness and heal by 2ndary intention

Partial Thickness wounds

Extends thru the epidermis (top layer) and "possible" into (but not thru) the dermis (2nd layer) Ex: abrasions, blisters and skin tears Will typically heal by re-epithelialization or epidermal resurfacing depending on the depth of injury.

Cellulitis

Fast spreading inflammation that occurs as a result of a bacterial infection of the skin and connective tissues. Can develop anywhere under the skin; typically the extremities. E: Bacterial infections: Streptococci or staphylococci. more likely w/ increased age, immunosuppression, trauma, the presence of wounds or venous insufficiency S/S: localized redness-spreads quickly; skin is warm or hot to the touch; local abcess or ulceration, tenderness to palpation, chills, fever and malaise. Tx: Systemic antibiotics. Need differential diagnosis to r/o DVT and contact dermatitis. May need PT for wound care. can get sepsis/gangrene if not treated.

Desensitization Techniques

Indications: Pts with burns Include variable texture, pressure, and vibratory sensations applied to affected area by either rubbing tapping or rolling motions. The use of particle contact (container of dry beans, popcorn kernels or fluidotherapy) can be beneficial in desensitizing the distal extremities. Compression and TENS have also shown to have clinical applications for desensitization goals. Perform 5-10 minutes, 3-4x's daily. Go from slightly irriating, but tolerable=>more noxious stimuli. Texture progression: Feather-cotton ball-chamois cloth-soft terry cloth-cordoury cloth-rough cloth-wool

Characteristics of LE Ulcers Venious Insufficiency Ulcers:

Location: Proximal to Med. Malleolus Appearance: Irregular shape/shallow Exudate: Moderate/Heavy pain: Mild to Moderate Pedal Pulse: Normal Edema: Increased Skin Temp: Normal Tissue Changes: Flaking, dry, brownish discoloration Misc: Leg elevation decreases pain

Characteristics of LE Ulcers Neuropathic Ulcers

Location: areas of the foot suseptible to pressure/sheer forces during wt. bearing Appearance: Well defined oval/circle; callused rim; cracked periwound tissue; little to no wound bed necrosis w/good granulation Exudate: Low/Moderate Pain: None; dysesthesia may be reported Pedal Pulse: Diminished/absent; unreliable ABI Edema; Normal Skin Temp: Decreased Tissue Changes: dry, inelastic, shiny skin, decreased or absent sweat or oil production

Characteristics of LE Ulcers Arterial Insufficiency Ulcers:

Location: lower 1/3 of leg, toes, web space (dist. toes/dorsal foot/Lat Malleolus. Appearance: Smooth edges, well defined; lack gran. tend to be deep Exudate: Minimal pain: Severe Pedal Pulse: Diminished or Absent Edema: normal Skin Temp: Decreased Tissue Changes: Thin/shinny/hair loss/yellow nails Miscellaneous: Leg elevation ↑'s pain

Slough

Moist or stringy or mucinous, white/yellow tissue that tends to be loosely attached in clumps to the wound bed.

Modalities and Physical agents

Negative pressure wound therapy (NPWT) Hyperbaric Oxygen

Iontophoresis Related Burns

Occur when the skin pH inc/dec beyond the normal range of tolerance. Chemically induced pH levels below 3 or greater than 5 can result in Acidic or Alkaline rxn's. More sever under the (-) electrode where pooling of the alkaline medium can occur. Can create a pH exceeding 9 which will quickly begin to erode the insulating epidermis. Electrical current increases as a result and further accelerates skin erosion. Caused By; Treatment delivered w/excessive current prolonged duration, and electrode placement over defective skin areas w/ lower resistance

Dry Gangrene

Referred to as "dry" when there is a loss of vascular supply resulting in local tissue death. Fingers, toes, and limbs are most affected. Hardened tissue is not painful; may be significant pain in the line of demarcation. Develops slowly and may result in auto-amputation E: bld vessel disease (DM, atherosclerosis); bld fow to an area is impaired d/t poor circulation. Infection not typical w/ dry gangrene; can progress to wet-gangrene if infection occurs S/S: dark brown/black nonviable tissue; becomes a hardened mass (mummified). Pt. may complain of cold or numb skin; may present w/ pain. Tx: Immediate medical attention; meds, surgery and hypobaric O₂ therapy

Normotrophic scar

Scar characterized by the organized formation of collagen fibers that align in a parallel fashion

Dehiscence

Separation, rupture or splitting of the layers of a wound closed by 1mary intention ; may be partial, superficial, or complete disruption of the surgical wound

Silver Sulfadiazine

Silvadene® Cream topical antimicrobial agent used to treat second and third degree burns to prevent wound sepsis. ADVANTAGES: can be used w/or w/o dressings; painless; can be applied to wound directly; broad spectrum; effective against Yeast DISADVANTAGES: Does not penetrate into eschar

Topical agents used in Wound Care

Silver Sulfadiazine Silver Nitrate Povidone-iodine Mafenide Acetate Gentamicin Nitrofurazone

maceration

Skin softening and degeneration that results from prolonged exposure to water and other fluids. continued exposure to moisture. this leaves the skin more susceptible to forces of shear pressure and friction

Contact Dermatitis

Superficial irritation of the skin resulting from localized irritation (poison ivy, latex, soap, jewelry sensitivity); acute or chronic; occurs at any age. E: exposure to mechanical, chemical, environmental or biological agents (Nickle, rubber, latex and topical antibiotics are common precipitating agents) S/S: Intense itching, burning and red skin in area corresponding to the location of the topical irritation. Edema may also occur in the area of sensitivity and symptoms can expand beyond the initial point of irritation. Tx: ID and remove source of irritation; topical steroid application

Epidermis

Superficial, avascular epithelial layer of skin that includes flat, scale-like squamous cells, round basal cells and melanocytes which produce melanin and give skin its color

Tugor

The ability of the skin to return to it's normal shape when it is squeezed or gently pinched. indication of elastically and hydration. slower in older adults

Skin Care Products for At risk wound pt.s

Therapeutic moisturizers-replace moisture Moisture Barriers-Petrolium jelly (keeps moisture out) Liquid skin protectants-skin sealant Skin cleansers-for incontinent/risk for breakdowns Wound cleansers: Saline=>Complex comp w/cytotoxicity

Secondary Intention

This type of healing is in wounds with extensive tissue loss/infection & wounds in which the edges cannot be approximated (closed). Would is left open and granulation tissue gradually fills in the deficit. Susceptible to infection. Wet to dry dressings. Ex: Pressure Ulcer Associated w/ pathology = diabetes, ischemia, pressure damage in inflammation (Neuropathic, arterial, venous, full thickness, chronic inflammation) Require ongoing wound care - larger scares

Gentamicin

Topical agents used in burn care: antibiotic ADVANTAGE: Broad-spectrum, may be covered or left open to air DISADVANTAGE: Has caused resistant strains, ototoxic, nephrotoxic,

Povidone-iodine

Topical agents used in burn care:Betadine topical ointment Antiseptic germicide/anti-disinfecting /cleansing agent ADVANTAGES: Broad-spectrum, antifungal, easily removed with water DISADVANTAGES: Not effective against pseudomonas, may impair thyroid function, painful application,

Hyperkeratosis

Type of necrotic tissue that is white/gray in color and can vary in moisture. Often called a callus

Wound Assessment

Wounds that are not categorized as pressure or Neuropathic are classified based on DEPTH OF TISSUE

Eschar

a black leathery crust (slough) that forms over burned tissue; eschar can harbor microorganisms and cause infections

Erythema

abnormal redness of the skin resulting from dilation of blood vessels (as in sunburn or inflammation)

Pressure Ulcers

aka bedsores or decubitus ulcers. They are localized areas of tissue necrosis that tend to develop when soft tissue is compressed between a bony prominence and an external surface. Caused by ischemia. Commonly found on heals, sacrum, hips, ischium, pinna of ears & elbows. Recommendations; Repositioning every 2 hours in bed Management of excess moisture Off-Loading with pressure relieving devices Inspect skin daily for signs of pressure damage Limit shear, traction and fricton forces over fragile skin

Contusion

an injury to underlying tissues without breaking the skin and is characterized by discoloration and pain

Gangrene

death of tissue due to obstruction of blood flow to a particular area of the body , death of tissue caused by loss of blood supply followed by bacterial invasion

Hyperpigmentation

excessive pigmentation in a body part (esp. the skin)

Subcutaneous wound

extend through integumentary tissues and involve deeper structures such as subcutaneous fat, muscle, tendon or bone, typically require healing by secondary intention

Negative pressure wound therapy

healing by secondary and teriary intenyion. Specialized pump, negative pressure is placed on a wound packed with gauze or foam. (WOUND VAC) the negative pressure promotes granulation tissue formation by "stretching" cells and stimulating blood vessel growth and wound perfusion. RISK: if next to large vessel could cause arterial break

Keloid

hypertrophic scar that grows beyond the boundaries of the original wound and does not regress, most common in African-Americans. Comprised of irregularly distributed collagen bands. exceeds the boundaries of the original wound appearing red, thick, raised, and firm

Hypergranulation

increase granulation tissue above the surface of wound

Hematoma

localized accumulation of blood, usually clotted, in an organ, space, or tissue due to a break in or severing of a blood vessel (bump on the head)

Monofilament testing

lower extremity sensation, small flixible wire attacted to handle, bends at 10 g pressure. Use for pt.s with peripheral neuropathy. Reliable method of assessing and documenting changes in protective sensation Failure to perceive the application of 10 mg monofilament indicates loss of protective sensation (rock in shoe) Failure to perceive 75 mg = no sensation

Venous Insufficiency Ulcers

occur secondary to inadequate functioning of the venous system resulting in inadequate circulation & eventual tissue dammage & ulceration Recommendations: Limb protection Risk reduction education Inspect legs and feet daily Compression to control edema Elevate legs above the heart when resting or sleeping Attempt active exercise including frequent ROM Wear appropriate sized shoes w/seamless socks

Arterial Insufficiency Ulcers

occur secondary to ischemia from inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis General Recommendations: Rest Limb Protection Rick reduction education Inspect Legs and feet daily AVOID UNNECESSARY LEG ELEVATION Avoid heating pads or soaking feet in hot water Wear appropriate sized shoes w/seamless socks

Ulcer

open sore or lesion of skin or mucous membrane, can have inflammed necrotic tissue sloughing.

Neuropathic Ulcers

secondary complication usually asscoiated with a combination of ischemia and neuropathy; most often associated w/diabetes; frequently found on the plantar surface of the foot, beneath the metatarsal heads Recommendations; Limb Protection Risk Reduction Education Inspect legs and feet daily Inspect footwear for debris prior to donning Wear approp. sized off loading footwear w/clean, cushioned , seamless socks

Ecchymosis

the escape of blood from ruptured blood vessels into the surrounding tissue to form a purple or black-and-blue spot on the skin = a burise

Mafenide Acetate

used to prevent pseudomonal infections in burn patients, not effective for established infectionsTopical agents used in burn care: ADVANTAGES: Broad-spectrum, penetrates eschar, may be used with/without occlusive dressings DISADVANTAGES: May cause metabolic acidosis, may compromise respiratory function, may inhibit epithelialization, painful application,

Nitrofurazone

used to prevent skin grafts and donor sites from becoming infected ADVANTAGES: Bactericidal; Broad-spectum DISADVANTAGES: may lead to overgrowth of fungus and pseudomonas; painful application

Primary intention

wound healing with skin edges that are approximated, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented (similar to a surgical wound) Most common = Acute wounds; minimal tissue loss = surgical wounds and superficial partial thickness (abrasions/blisters) Minimal scaring heal quickly Uncomplicated