34 Second Intention Wound Healing

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Questions and Answers

In second intention wound healing, what is a crucial aspect of successful management?

  • Relying solely on advanced technology for wound care.
  • Having a comprehensive understanding of the distinct phases of wound healing. (correct)
  • Maintaining a consistently moist wound environment throughout the healing process.
  • Immediately applying potent antimicrobials to prevent infection.

What principle should guide daily assessment and adjustment in second intention wound healing?

  • Determining what is happening in the wound, and what is needed to progress the wound to the next stage. (correct)
  • Focusing on long-term cosmetic outcomes rather than immediate healing needs.
  • Following a predetermined treatment protocol regardless of the wound's appearance.
  • Ensuring the wound is consistently treated with the same topical medication.

In the inflammatory phase of wound healing, what is the correct order of the vascular events that occur?

  • Vasoconstriction, increased vascular permeability, vasodilation
  • Vasodilation, vasoconstriction, increased vascular permeability
  • Increased vascular permeability, vasodilation, vasoconstriction
  • Vasoconstriction, vasodilation, increased vascular permeability (correct)

Why is it important to avoid hydrotherapy on fresh wounds undergoing second intention healing?

<p>Fresh tissues can imbibe water, leading to edema and potential complications. (D)</p>
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Why is the use of systemic antimicrobials not indicated once a wound bed has fully granulated?

<p>Granulation tissue serves as an impervious barrier against bacterial penetration. (C)</p>
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What is the rationale for using sweat bandages to manage limb edema during the inflammatory phase of wound healing?

<p>They control limb edema, preventing the limb from granulating in an edematous shape. (B)</p>
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A granulation tissue bed with areas of the wound with no granulation tissue indicates which of the following?

<p>The tissue is not viable and will require further attention. (B)</p>
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What is the primary concern regarding exuberant granulation tissue?

<p>It impedes wound contraction and epithelization, prolonging the healing process. (D)</p>
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What is the most important aspect to consider when choosing a wound medication during the contraction and epithelization phases?

<p>Avoiding medications that are toxic to the cells causing contraction and epithelization. (C)</p>
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During which phase of second intention wound healing is skin contraction observed?

<p>Fibrosis phase (B)</p>
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During the fibroplasia phase of wound healing, what key cellular activity is essential for successful tissue repair?

<p>Fibroblast deposition of collagen to create a granulation tissue matrix. (B)</p>
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What could the the lack of an epithelial rim during wound healing indicate?

<p>Exuberant granulation tissue or a toxic wound medication. (A)</p>
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A practitioner observes bone exposed within a horses's heavily granulated wound. What are the primary concerning processes that would need to be addressed?

<p>Avascular bone and infection (D)</p>
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What is the maximum rate that skin contraction should be occuring, in mm/day?

<p>0.6 (D)</p>
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Why is second intention healing often the least preferred method of wound healing?

<p>It is the most protracted and least cosmetic (A)</p>
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Under which condition will a wound undergoing second intention healing usually not become exuberant?

<p>If it is left unbandaged and allowed to form a scab (B)</p>
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An owner is concerned about limb edema. What bandage should the practitioner recommend to remove the swelling?

<p>A sweat bandage (B)</p>
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What can you expect if an animal's limb is large and edematous when granulation tissue begins to form?

<p>The wound will granulate in that shape (C)</p>
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After contraction ceases, how is the remainder of the wound covered?

<p>Epithelium only (D)</p>
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What is FALSE about epithelization?

<p>Epithelium migrates as multiple cell layers and is difficult to remove. (C)</p>
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What type of contact layer should be used when a wound is epithelizing?

<p>Non-adherent (A)</p>
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What is the next action be taken if a wound is contracted and epithelizing?

<p>Leave the wound alone (A)</p>
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You are presented with a 2 week old wound that has exposed bone in the wound bed. What is the MOST likely underlying reason for the exposed bone?

<p>Avascular bone with secondary infection (C)</p>
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All of the following medications are toxic to the cells causing contraction and epithelization, EXCEPT:

<p>Silvadene (D)</p>
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After assessing a skin wound, what is the BEST question to ask yourself before applying any topical medication?

<p>What do I need this medication to do? (A)</p>
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Which of the following phrases is the BEST discharge instruction when discussing how to care for a second intention skin wound?

<p>Do not put anything on this wound without contacting me first. (A)</p>
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Which characteristic of second-intention healing contributes most significantly to its higher cost compared to primary intention healing?

<p>The prolonged duration of treatment and care required. (A)</p>
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What is the MOST important initial step when managing a fresh wound during the inflammatory and debridement phases?

<p>Preventing further trauma and contamination by bandaging. (A)</p>
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When managing a wound on the distal limb of a horse, why should exuberant granulation tissue be addressed by a vet as soon as possible?

<p>It disrupts the migration of keratinocytes, preventing epithelization. (D)</p>
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What characteristic of granulation tissue makes it an impervious barrier to bacteria?

<p>The tightly-knit extracellular matrix. (A)</p>
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Which factor is MOST important to consider when deciding whether to bandage a wound?

<p>The phase of wound healing and the presence of exuberant granulation tissue. (B)</p>
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A practitioner advises a client to apply a sweat bandage. What does the bandage wrap accomplish?

<p>Removal of peri-wound edema. (D)</p>
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A horse that is known for being difficult with bandaging has a heavily granulated wound. What is MOST important for the practitioner to consider?

<p>It can be safely left uncovered. (D)</p>
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Which of the following is NOT a key aspect of second intention wound healing in horses?

<p>All phases of healing require the same treatment plan. (A)</p>
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What should a practitioner do if there is a deficiency of fibroblasts in a wound?

<p>There may be infection or improper would care. (A)</p>
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Why is knowledge more important than technology when treating second intention wounds?

<p>Knowledge of wound healing phases guides appropriate intervention. (A)</p>
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What is the MOST important consideration when managing a wound in the inflammatory and debridement phase?

<p>Preventing further trauma while removing contamination. (C)</p>
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When should hydrotherapy be implemented during second-intention wound care?

<p>Once a healthy bed of granulation tissue is present. (D)</p>
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What is the MOST likely underlying reason why a practitioner observes exposed bone within a heavily granulated wound?

<p>Bone sequestrum with infection. (A)</p>
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What feature of the wound, once present, eliminates the need for systemic antimicrobials?

<p>A fully granulated wound bed. (A)</p>
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Why should limb edema be addressed aggressively during the inflammatory phase of second-intention wound healing?

<p>The wound may fibrose in the shape of the edematous limb. (B)</p>
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You observe areas of granulation tissue are absent in the wound bed. What is the MOST likely explanation?

<p>Avascular non-viable tissue. (A)</p>
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What is the MOST important step to prevent against exuberant granulation tissue in distal limb wounds?

<p>Excising tissue at the level of the dermatologic margins. (B)</p>
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Why is it important to avoid medications containing copper sulfate on wounds undergoing contraction and epithelialization?

<p>Copper sulfate is caustic and will reduce the rate of contraction and epithelialization. (A)</p>
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What is the therapeutic goal when managing wounds undergoing second-intention healing?

<p>Providing optimum conditions for each phase of wound healing. (D)</p>
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Why is daily assessment and adjustment crucial for second-intention wound healing?

<p>To provide optimum conditions for each unique phase of wound healing. (A)</p>
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If a visible epithelial rim is absent, what are the possible underlying causes?

<p>Exuberant granulation tissue, toxic wound medications, and adherent contact layer that removes epithelium at bandage changes. (A)</p>
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What information should be included in dischage instructions for an animal that requires second-intention wound healing?

<p>A prompt to contact their vet before applying anything on the wound. (D)</p>
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What determines when contraction ceases?

<p>The availability of skin. (B)</p>
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While using a sweat bandage, what is MOST important to consider in addition to edema removal?

<p>The wound will fibrose in the shape of the limb. (A)</p>
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What should you assess before applying a topical medication?

<p>What do I need the medication to do (A)</p>
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What causes a lack of available skin that diminishes contraction other than the initial injury?

<p>Inappropriately managing wound edema in the early phase of wound healing. (D)</p>
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What factors should be considered when managing a horse with a heavily granulated wound that is difficult with bandaging?

<p>The environment is safe to leave unbandaged. (C)</p>
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What wound medications are MOST toxic to cells causing contraction and epithelization?

<p>Petrolatum, alcohol, nitrofurazone, steroids, copper sulfate (B)</p>
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For what type of wound is IV Abx LEAST indicated?

<p>An open non-synovial wound. (D)</p>
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What can occur if granulation tissue is visible above the level of the exterior dermatologic margin?

<p>Epithelization and contraction will cease. (B)</p>
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Why is contraction cosmetically and functionally superior when resurfacing a wound?

<p>Contraction occurs through full-thickness skin sliding. (A)</p>
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What should a practitioner tell a client about bandaging and exuberant granulation tissue?

<p>Bandages promote unwanted granulation tissue. (A)</p>
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How does epithelization occur after contraction?

<p>By regenerating epithelium that migrates as a single-cell layer. (D)</p>
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Given two wounds that are fully granulated, what can you suspect when only one is contracting and epithelializing?

<p>Contraction is inhibited in one (motion/tension, exuberant granulation tissue, medications). (D)</p>
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If you see a granulation tissue bed with areas of the wound with no granulation tissue, what should you do?

<p>Evaluate the unhealthy state of the tissue, as well as the bandage compression. (C)</p>
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What is the BEST next step be when a wound is contracted, with an advancing epithelial rim?

<p>Use a Telfa pad (C)</p>
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During second intention wound healing, how does skin resurface after contraction?

<p>By undergoing epithelization with migration. (C)</p>
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Flashcards

Second Intention Healing

The process of healing when skin closure is not possible, resulting in a slower, less cosmetic outcome.

Primary Healing

Faster, cheaper, and more cosmetic than second intention healing.

Successful Wound Management

Requires a thorough understanding of wound healing phases and their specific needs.

Therapeutic Goal in Wound Healing

To create optimal conditions for each wound healing phase.

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Daily Wound Assessment Question

What is happening in this wound today?

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Guiding Question

What actions are needed to advance the wound to the next stage of healing?

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Inflammatory Phase

The initial phase involving vasoconstriction, vasodilation, and increased vascular permeability.

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Debridement Phase

The removal of dead tissue and contaminants from the wound.

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Proliferative Phase

A phase characterized by wound contraction and epithelization to close the wound.

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Wound Contraction

The reduction in wound size by the movement of skin towards the center of the wound.

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Epithelization

The process of epithelial cells migrating across the wound surface to close the defect.

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Wound care variation

Optimal conditions cannot be provided by one type of bandage or wound medication.

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Treatment Timing

There are indications to begin treatments... and indications to stop them

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Medication Timing

Medications that are beneficial in one phase may be detrimental in others.

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Bandage Adjustment

Bandage techniques need to be adjusted as wounds progress from one stage to the next.

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Hemostasis

To control bleeding during the inflammatory phase.

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Prevent Trauma

Preventing additional injury to the wound site.

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Cleaning Wounds

Removes debris and bacteria to promote healing.

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Fresh Tissue Hydration

Imbibe water; use isotonic fluids when possible.

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Granulation Tissue

Does not absorb water.

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Antimicrobial Ingredients

Chlorhexidine, Povidone iodine, Silver sulfadiazine, Nitrofurazone, Polymixin, neomycin, bacitracin

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Debridement

This should be done to remove devitalized and contaminated tissues.

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Dakin's solution

A saline-based solution with antimicrobial properties used for wound irrigation

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IV Antibiotics

IV Abx may not be indicated in open non-synovial wounds

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Tetanus Toxoid

Always indicated

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Granulation Tissue

An impervious barrier to bacterial penetration.

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Manage Wound Edema

To minimize excessive swelling.

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Edema Management Methods

Pressure bandages, NSAID's, Sweat bandages, Restrict motion

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Fibrosis

Begins when fibroblasts appear in the wound bed on day 5.

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Granulation Tissue Bed

Requires a least 7 days to see a complete bed of granulation tissue

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Areas lacking granulation tissue

Requires evaluation for viability.

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Bone Sequestrum

A piece of dead bone that has separated from healthy bone.

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Bone Sequestrum Requirements

Avascular bone and Infection.

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Factors that favor exuberant granulation tissue

Bandaging, Moist environment, Ointments, Infection, Bandages changed infrequently, Motion

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Overgranulation Management

Exuberant granulation tissue should be Removed immediately.

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Exuberant Tissue Removal

Sharp scalpel excision.

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Second Intention Healing Without Bandage

Usually does not become exuberant if left unbandaged and allowed to form a scab.

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Healing Beneath Scab

Contraction and epithelization will proceed underneath the scab

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Topical Question

ask “What do I need this medication to do?”

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Medication Justification

Do not use any wound medication without a specific indication.

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Read The Labels!

Know what is in the medications

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Ingredient Research

Research the ingredients to find out what they actually do.

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Marketing

Do not rely on marketing information.

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Conditions Needed

A wound is ready to epithelize when the wound bed is granulated to the level of the skin

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Wound Contraction

Process by which a wound diminishes in size by sliding of full thickness skin

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When is Wound Contraction Applicable?

Does not begin until the wound bed is granulated level with the skin

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Contraction Resistance

Wound contracts until skin tension exceeds contracting force

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Skin Amount Matters!

Amount of contraction depends on available skin.

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Contraction Rate

Approximately 0.5 mm / day

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Skin Flaps

DON'T CUT OFF THE SKIN FLAP!!!

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Early Support

Improperly managing wound edema in the early phase of wound healing leaves a larger leg with insufficient skin to cover the defect

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Contraction Inhibitors

Panolog, MultiCare

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Non Adherent Layer

You must use a non adherent contact layer when a wound is epithelizing

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Toxic Wounds

Most wound medications are toxic to the cells causing contraction and epithelization

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Wound Completion

If a wound is fully granulated in, it should be contracting and epithelizing.

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Study Notes

Second Intention Healing

  • Primary intention wound healing will always be faster, cheaper, and more cosmetic compared to second intention healing.
  • Success in second intention healing requires knowledge of the phases of wound healing and their requirements.
  • The therapeutic goal is to provide optimum conditions for each phase of wound healing.
  • Daily assessments and adjustments are needed for proper healing.
  • One should ask what is happening in this wound today and what can be done to make this wound progress to the next stage.
  • All wounds heal by the same processes.

Inflammatory Phase

  • The first phase of normal wound healing entails hemostasis.
  • It is characterized by vasoconstriction, vasodilation, and increased vascular permeability

Debridement Phase

  • The body uses collagenase and elastase in the debrisment phase to remove dead tissue.

Proliferative Phase

  • In the proliferative phase wounds are closed.

Facts About Wound Care

  • Optimal conditions cannot be provided by one type of bandage or wound medication.
  • There are indications to begin treatments and indications to stop them.
  • Medications that are beneficial during one phase, may be detrimental in another.
  • Bandage techniques need to be adjusted as wounds progress from one stage to the next

Cleaning Wounds

  • Fresh tissues imbibe water, so isotonic fluids should be used for irrigation when possible.
  • Granulation tissue will not absorb water.

Common Ingredients in Antimicrobials

  • Chlorhexidine
  • Povidone iodine
  • Silver sulfadiazine
  • Nitrofurazone
  • Polymixin, neomycin, bacitracin
  • All antimicrobials are suitable for wounds during inflammatory and debridement phases.
  • Antimicrobials are available as ointments, solutions, as well as generics.

Healing Phases

  • Wound management during the inflammatory and debridement phases should focus on preventing further trauma ensuring the wound remains clean
  • In the inflammatory phase the wound should be kept bandaged
  • Administer Tetanus Toxoid
  • Keep wounds clean.

Fibrosis

  • Begins when fibroblasts appear in the wound bed on day 5.
  • Requires at least 7 days to see a complete bed of granulation tissue.
  • Areas without healthy granulation tissue should be evaluated for viability.

Factors Favoring Exuberant Granulation Tissue

  • Bandages
  • Moist environment
  • Ointments
  • Infection
  • Infrequent bandage changes
  • Motion

Second Intention Healing of Exuberant Granulation Tissue

  • Remove exuberant granulation tissue immediately.
  • Use sharp scalpel excision.

Second Intention Healing - Important Considerations

  • Wounds will usually not become exuberant if left unbandaged and allowed to form a scab
  • Contraction and epithelization will proceed underneath the scab.
  • Make sure before applying any medication, what is needed from the medication.
  • There are four wound medication guidelines:
  • Do not use any wound medication without a specific indication.
  • Know what ingredients are in the medications by reading the labels.
  • Research the ingredients to find out what they actually do.
  • Do not rely on marketing information.
  • It is important not to treat wounds topically without veterinary guidance.

Granulation Tissue

  • Granulation tissue is an impervious barrier to bacterial penetration

Things to Manage

  • Manage wound edema using:
  • pressure bandages
  • NSAID's
  • sweat bandages Restrict motion

Bone Sequestrum Requires

  • Avascular bone
  • Infection

Contraction and Epithelization

  • Contraction and epithelization are independent but may take place simultaneously.
  • Contraction is superior cosmetically and functionally.

Wound Contraction

  • It is the process by which a wound diminishes in size by sliding of full thickness skin.
  • Contraction does not begin until the wound bed is granulated level with the skin.
  • Wound contracts until skin tension exceeds contracting force.
  • The amount of contraction depends on available skin.
  • Contraction occurs at approximately 0.5 mm / day.
  • Proper Edema management is important to consider due to the lack of available skin other than the original injury

Things That Inhibit Contraction

  • Exuberant granulation tissue
  • Motion or too much tension
  • Medications

After the Wound Bed is Filled Wound Must Be Resurfaced By:

  • Contraction
  • Epithelization
  • Skin grafting
  • Surgical closure
  • The presence of epithelium at the wound periphery indicates the wound is ready to be resurfaced

Epithelization

  • Epithelization wound is ready when the wound bed is granulated to the level of the skin.
  • A non-adherent contact layer when a wound is epithelizing must be used, as well as caution with using medications that are toxic

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