Wound care management update-1-28.pdf

Wound management By Dr. Reham Elkalla Lecturer of physical therapy for surgery, BUC By the end of this lecture the student will be able to Define Phases of wound healing Recognize Factors affecting wound healing Classify...

Wound management By Dr. Reham Elkalla Lecturer of physical therapy for surgery, BUC By the end of this lecture the student will be able to Define Phases of wound healing Recognize Factors affecting wound healing Classify wound according to healing time Objectives Differentiate between different types of ulcers Conduct the proper assessment for each wound the therapeutic effect of different physical Recognize therapy treatment modalities Formulate the treatment program for each type of ulcers Wound is a separation or discontinuity of the skin, mucous membrane or tissue caused by physical, chemical or biological insult. Wound healing is the process of restoration of structure and function of injured or diseased tissues. Phases of wound healing  Factors affecting wound healing I. general 1. Age: good healing in young age , and slow in old age 2. General condition : malnutrition , starvation 3. Vitamin : Vit. C synthesis of ground substance , maturation of collagen Vit. D new bone formation Vit. A epithelization 4. Minerals : zinc , copper , Mag , helping for healing 5. Vit. B complex , co-enzymes in protein synthesis 6. Anemia impaired wound healing 7. Diabetes impaired wound healing due to glucose tissue Ischemia ( micro & macro angiopathy atherosclerosis) body immunity infection 8. Uremia , jaundice , corticosteroids wound healing 9. Others : Associated systemic disease Malignant disease. General infection Associated injuries. Hypoxia Cytotoxic drugs II. Local factors 1. Type of wound 8. Poor blood supply 2. Site 9. Repeated trauma 3. Hematoma , seroma 10. Local radiation 4. Necrotic tissue 11. Impaired venous or lymphatic drainage 5. Tissue tension 12. Adhesion to bony surface 6. Local infection 13. Missed underlying pathology e.g T.B , malignant disease 7. Foreign bodies Continuum of wound infection  Acute wound Chronic wound Definition Occurred in last 4-6 weeks ▪ Present for longer than 6 weeks. ▪ Caused by endogenous mechanisms related to a predisposing condition or Classification risk factors of wound Examples Surgical wounds-bites- Leg/foot ulcers and pressure sores-likely burns -abrasions- from arterial, vascular insufficiency or according to traumatic wounds neuropathy. time for Treatment Expected to heal within 1- Wound dressing healing predictable time frame. 2- Antimicrobial agents Clear and minor 3- footwear minimal intervention 4- Physical therapy Sever and contaminated 5- Educational strategies 1- Surgical debridement 6- Optimize treatment for co-morbidities 2- Antimicrobil therapy 7- Pressure sores: pressure relieving 3- wound lavage mattresses and cushions 8- Venous leg ulcer: compression therapy In this lecture we will discuss chronic wound 1- Arterial 2- Venous 3- Pressure insufficiency insufficiency ulcers ulcer 4- Neuropathic ulcer Risk factors contributing to Arterial ulcers Arterial ulcer Pressure ulcer Common areas to develop pressure ulcer Diagram showing how shearing forces can develop ulceration Pressure ulcer Interdisciplinary prevention of pressure ulcer  Stages of pressure ulcers  Stage 1 Stage 2 Stage 3 Stage 4 Intact skin with a Partial-thickness loss Full-thickness loss of Full-thickness skin localized area of non- of skin with exposed skin, in which fat and tissue loss with blanchable erythema, dermis. The wound may be visible in the exposed or directly which may appear bed is viable, pink or injury and palpable fascia, differently in darkly red, moist and may granulation tissue, muscle, tendon, pigmented skin. also present as an and rolled wound ligament, cartilage, or Color changes do not intact or ruptured edges are often bone in the injury. include purple or serum-filled blister. present. Slough Slough and/or eschar maroon discoloration Fat and deeper tissues and/or eschar may be may be visible. which may be an are not visible. visible. The depth of Epibole, undermining indication of deep Granulation tissue, tissue damage varies and tunneling often tissue injury. slough and eschar are by anatomical occur. Depth varies not present location. Those with by anatomical a large body mass location. Venous ulcers Neuropathic ulcer  Patient examination Wound treatment Referral Wound treatment & referral Decision making chart 1- Patient history American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Phys. Ther.2001;81(1):S36.  Test Indication Pulse examination All open wounds located on the extremities Clinical assessment Lower leg ulcer for vein thrombosis Lower leg edema Clinical Suspected venous insufficiency Guideline for Tests and Segmental pressure Suspected arterial insufficiency in an ulcer proximal to Measures for measurements the ankle ulcer Decreased or absent proximal pulses Ankle-brachial index Decreased or absent pulses Signs and symptoms of arterial or venous insufficiency History of peripheral vascular disease  Test Indication Capillary refill Digital ulcer Abnormal Doppler ultrasound or ABI Venous filling time Unable to tolerate ABI ABI 1.1 2- Clinical History of diabetes or vessel calcification Guideline for Suspect concomitant arterial insufficiency Tests and Measures for Doppler ultrasound To differentiate normal venous flow from vein ulcer incompetence or obstruction Trendelenburg test To differentiate deep or perforating vein incompetence from superficial vein incompetence Rubor of dependency Unable to tolerate ABI ABI > 1.1 History of diabetes or vessel calcification 3- Wound Characteristics 1- Wound location 2- Wound size 3- Wound drainage 5- Wound 6- Wound edges characteristics Attached/unattached 4- Wound odor Granulation tissue Indistinct/well defined Necrotic tissue Thickened or rolled Other structures Hyperkeratosis Interpterion of wound drainage  Typical characteristics of various types of ulcers are described using the “5PT” method to facilitate identification of ulcer and integument integrity 5PT Wound Pain Position Pulse Periwound Temperature presentation  1-Wound measurement 1- Direct method (ruler) 2- Tracing method 3- volumetric measurement 4- Wound tunneling and undermining 4- Photographic and Computer based software