Wound Care Management Update 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 1- Direct method (Ruler) Measure wound surface area By measuring the maximum length (along the longest axis = L) and width (smaller axis perpendicular to L = W) directly on the wound using a sterilized ruler for one-time use. 2-Tracing method Calculation of surface area Complete boxes were counted, and incomplete boxes were approximated that were covering the entire wound area. Each square equal to 1 mm2 Disadvantage ❖ Inaccurate in the presence of a skin fold ❖ Difficulty identifying the edge of irregular wound ❖ Lower interrater reliability 3- Volumetric measurement By measuring wound size through measuring the amount of Dental impression material or silicone molding (Wound molds) Or Saline required to fill the wound cavity. Disadvantages wound contamination. 4- Tunneling and undermining Tunneling is a channel or tunnel that extends from the wound base in a unidirectional manner. ✓ It is caused due to the destruction of subcutaneous tissue in a linear fashion ✓ There is a potential for abscess formation in tunneling. Tunneling is not easily visualized (sinus tract) Undermining ✓ Occurs when the tissue under the wound edges becomes eroded, resulting in a large wound with a small opening ✓ Undermining occurs in more than one direction. Photographic measurement, or Computer based software Computer based software are used to measure either the wound surface area or volume Advantages: It is relatively easy Accurate Reliable No risk of contamination 4- Assessment of sensory integrity Treatment options for the management of chronic wounds 1- Invasive 2- Noninvasive Compression Negative Electrical Hyperbaric bandaging pressure wound stimulation oxygen therapy therapy therapy Antibiotic therapy Polarized light Ultrasound therapy Laser therapy Wound dressing Wound Skin substitute debridement therapy  Synthetic commercial wound dressing Debridement Purpose Decrease bacterial concentration within the wound bed and the risk of infection Increase the effectiveness of topical antimicrobials Improve the bactericidal activity of leukocytes Shorten the inflammatory phase of wound healing Decrease the energy required by the body for wound healing Eliminate the physical barrier to wound healing Decrease wound odor. Method Procedure Selective Sharp ▪ The use of forceps, scissors, or a scalpel to selectively remove devitalized tissue, foreign material, and debris (involves the removal of specific Autolytic ▪ Maintaining a warm and moist wound environment to allow endogenous areas of enzymes to digest necrotic material. devitalized tissue) Enzymatic ▪ The use of exogenous enzymes to remove devitalized tissue Biological ▪ The use of maggots, Lucilia sericata (green bottle fly), that are grown in a sterile environment and digest dead tissue and pathogens Nonselective Mechanical ▪ The use of force to remove devitalized tissue, foreign material, and debris. ▪ EX. Water or saline irrigation, hydrotherapy, wet-to-dry dressings, and an (the removal of abraded technique. nonspecific areas of devitalized surgical The use of scalpels, scissors, or lasers in a sterile environment by a physician or tissue) podiatrist to remove necrotic tissue, foreign material, and debris  Types of wound debridement l Autolytic Biological Sharp enzymatic page 39.. Water irrigation (pulsed Hydrotherapy lavage with suction) whirlpool Mechanical debridement page 40 Electrotherapy modalities  Electrical stimulation in the management of chronic wounds Therapeutic effect Disadvantages Contraindication Restores the current of Untreated osteomyelitis. injury More time consuming Should not be used in Causes galvanotaxis Risk of contamination combination with topical Increases blood flow Cannot be used on agents containing heavy Combats infection extensive wound metal ions. Reduces edema Patients with sensory neuropathy. Enhances autolysis Reduce wound related pain Increases angiogenesis  Electrical stimulation Method Frequency: 80–125 Hz Intensity: 75–200 volts, submotor Polarity Cathodal stimulation for infected wounds; may also be used for the first 3 days of treatment to help reduce wound bioburden. Anodal stimulation to promote granulation tissue formation and epithelialization 45–60 minutes 3–7 days per week or 30 minutes twice a day Direct technique for electrical stimulation Techniques of application Periwound Technique Direct technique Immersion technique  Ultrasound in the management of chronic wound Therapeutic effect Indications Contraindication Enhances all three Adjunct for chronic General precautions for phases of wound healing wounds ultrasound. Increases collagen Untreated osteomyelitis. deposition, granulation Wounds with active, profuse tissue formation, bleeding. angiogenesis Severe arterial insufficiency. Enhances wound Deep vein thrombosis. contraction Direct technique may not be Improves scar pliability effective with highly necrotic wounds  Ultrasound Recommended Parameters Frequency ° Superficial wounds: 3.0 MHz ° Deep wounds: 1.0 MHz Intensity ° Pulsed, 0.5–1.0 W/cm2 for open wound. ° Continuous, up to 1.5 W/cm2 to assist with remodeling of closed wounds Time: ° 2–3 minutes per zone ° Two times per day to three times per week Techniques of application Direct technique for ultrasound Contact technique: use hydrogel sheet on the wound and then apply ultrasound Noncontact low-frequency ultrasound 20–60 seconds per cm2 or a minimum of 4 minutes for wounds 16 cm2, 2–3 times per week  Negative pressure wound therapy (NPWT) in the management of chronic wound (vacuum-assisted wound closure) Therapeutic effect Indications Contraindication Increase local blood flow Adjunct for chronic Necrotic wounds Remove exudate. wounds Body cavity wounds Decrease wound/ periwound Post-surgical wounds and Untreated osteomyelitis edema grafts Exposed blood vessels Increase granulation tissue Caution with patients on formation anticoagulants Increase angiogenesis Cannot be used on Increase epithelialization extensive wound. Decrease wound bioburden Promote cellular proliferation Maintain moist, warm wound environment Negative pressure wound therapy(NPWT) Method Irrigate and debride wound bed if needed Cut foam pieces to size of wound and place within wound bed. Protect periwound with hydrocolloid or skin sealant. Place tubing within wound bed and connect to canister. Cover with semipermeable film drape; ensure air-tight seal. Unclamp tubing and turn pump on Parameters Negative pressure: 50–175 mm Hg. Constant or intermittent Treatment time: 12–72 hours Negative pressure wound therapy  Hyperbaric Oxygen Therapy in the management of chronic wounds Therapeutic effect Indication Contraindication Increases oxygen Gas gangrene DVT concentration gradient Acute traumatic peripheral Chronic heart failure (CHF) May reduce bacterial ischemia Claustrophobia growth Acute peripheral arterial COPD May enhance angiogenesis, insufficiency Pregnancy collagen synthesis, Crush injury Severe arterial insufficiency granulation tissue Grade 3 or worse lower formation, epithelialization, extremity diabetic wounds and wound contraction Progressive necrotizing May reduce edema infection Chronic refractory osteomyelitis  Hyperbaric Oxygen Therapy Method Systemic HBO involves the application of oxygen in a pressurized chamber, typically 2.0–2.5 Atm. N.B. If a 50% reduction in wound surface area is not noted after 10 HBO treatment sessions, the wound is unlikely to respond to this modality and alternative interventions should be considered. Parameter ▪ Pressure is equal to 2.0–2.5 Atm. ▪ Treatment frequency: from twice daily to three times per Week. ▪ Patient require from 10 and 60 sessions with an average of between 37 and 44 sessions.  LOW LEVEL LASER THERAPY in the management of chronic wounds Therapeutic effect Indication Contraindication Increased cell proliferation Adjunct for all types of Eyes leads to damage (Keratinocytes, Fibroblasts & Monocytes) chronic wounds of the retina. Simulated mitochondria Pregnancy may cause Decreased inflammation abortion. Bactericidal effect Photosensitive skin. Wound Bio stimulation On fontanelles of Stimulated growth factor production and growing children. release Nausea and vomiting Increased collagen synthesis, organization, and maturation Increased angiogenesis Increased granulation tissue formation Increased epithelialization Faster wound contraction Higher wound tensile strength Laser therapy Treatment dosage Energy (Joule) = effect (Watt) * time (seconds) Recommend dosage is 1-4J/cm2 The duration of treatment is detected according to the power of the device. Laser treatment is given once daily or at alternate days. Example : for A 30 mW unit, the treatment probe can be used to irradiate each square for a total of 50 sec and to deliver 1.5 J /cm2 in noncontact mode. Wavelength and types of laser ▪ Helium–neon (HeNe, 632.8 nm), Gallium–aluminum–arsenide (GaAlAs 830 nm laser), Gallium–arsenide (GaAs, 904 nm) lasers Application techniques of laser therapy for wound healing ( contact or noncontact) Methods of application 1- Spot treatment of wound margins 2- Gridding technique (open wound) 3- Scanning (Manual or automatic according to device) Noncontact technique N.B In noncontact technique, The distance between the probe and wound should be 0.5 – 1 cm.  Polarized light Therapy in the management of chronic wounds Therapeutic effect Indication Contraindication Cellular and subcellular effects: Adjunct for all types of There are no absolute acceleration of the production of the chronic wounds contraindications for adenosine triphosphate (ADP) in this kind of physical mitochondria, return to normal cell therapy membrane potential which was disturbed, Stimulation of the regenerative processes. Additionally, Stimulate fibroblast proliferation and deposition of collagen Systemic effects: improving microcirculation, diminishing inflammation, improving tissue oxygenation, enhancing of the wound healing, accelerating epithelialisation of wound. Improving quality of early scar tissue formation.  Polarized light therapy Polarized light therapy, a kind of phototherapy, is a linearly polarized and polychrome light therapy. This light therapy contains a whole spectrum of visible rays, infrared A and B rays as well. Polarized light comes from refraction of common light through the specific laminated mirrors and admitted this light through photo filter system. Method A linear polarized light source (Bioptron lamp)used on the wound with the following technical characteristics : Parameters Wavelength: 400–2000 nm Degree of polarization: > 95% Power density: 40 mW/cm2 light energy: 2,4 J/cm2. six min daily, at a distance of 10 cm, five times a week Thank you