Wounds & Wound Assessment (1).pdf

Wounds & Wound Assessment Assis. lec/ Asmaa Rizk Outline ✓ Brief skin anatomy ✓ Definition of wound ✓ Wound classifications ✓ Physiology of wound healing ✓ Types of wound healing ✓ Complications of wound healing ✓ Factors affecting wound healing ✓ Wound assessment Skin Anatomy...

Wounds & Wound Assessment Assis. lec/ Asmaa Rizk Outline ✓ Brief skin anatomy ✓ Definition of wound ✓ Wound classifications ✓ Physiology of wound healing ✓ Types of wound healing ✓ Complications of wound healing ✓ Factors affecting wound healing ✓ Wound assessment Skin Anatomy Definition of Wound A wound is a break in the integrity of the skin or tissues often, which may be associated with disruption of the structure and function  Classification of Wounds Cause of Wound Thickness of skin Status of skin integrity loss Cleanliness of Wound Duration of Wound Classification of Wounds Based on Cause of Wound Intentional wound Unintentional wound Classification of Wounds Based on status of skin integrity Open wounds Closed wounds Types of Closed wounds Contusion/ Bruise Abrasion Types of Closed wounds Hematoma Types of Closed wounds Contusion/ Bruise Types of Open wounds Incised wound Lacerated wound Types of Open wounds Avulsion Types of Open wounds Penetrating wound Classification of Wounds Based on Cleanliness of Wound (berard wound classification) Clean wound Clean contaminated wound Contaminated wound Dirty wound Clean wound ✓ Elective, primarily closed; no entrance of normally colonized body cavities; no break in sterile technique. ✓ Examples are—hernioplasty, thyroidectomy, surgeries of brain, joints, and heart. ✓ Infective rate is less than 2%. Clean contaminated wound ✓ Controlled opening of a normally colonized body cavities or minimal break in sterile technique. ✓ Infective rate here is up to 30%. ✓ Examples are appendicectomy, pancreatic and biliary surgeries. Contaminated wound ✓ Acute inflammation; break in sterile technique; penetrating trauma less than 4 hours from injury. ✓ Examples are acute abdominal conditions as burst appendicitis ✓ Infective rate is up to 60%. Dirty/ infected wound ✓ Purulent abscess or traumatic wounds with retained dead tissue. ✓ Examples are abscess and intentional wounds created in situations where purulent drainage was present ✓ Infective rate is more than 60%. Classification of Wounds Based on Thickness of skin loss Superficial epidermal wound Based on Thickness of skin loss Partial thickness wound Based on Thickness of skin loss Full thickness wound Classification of Wounds Based on time elapsed/ Duration of Wound Acute wounds: are generally defined as those that progress through the normal phases of healing and typically show signs of healing in less than 4 weeks Classification of Wounds Based on time elapsed/ Duration of wound Chronic wounds: A wound is considered chronic if healing does not occur within the expected period according to its etiology and localization Physiology of Wound Healing Wound healing is complex process to achieve anatomical and functional integrity of disrupted tissue by various components like neutrophils, macrophages, lymphocytes, fibroblasts, collagen; in an organized staged pathway. It consisting of four continuous, overlapping, hemostasis, inflammation, proliferation, and tissue remodeling Physiology of Wound Healing Phases of wound healing Hemostasis phase (seconds to few minutes) 1) Constriction of the blood vessel. 2) Formation of a temporary “platelet plug." 3) Activation of the coagulation cascade. 4) Formation of “fibrin plug” or the final clot Hemostasis phase Inflammatory phase (lasts for 72 hours average) 1) Mast cells releases histamine & active amines 2) Neutrophil infiltration 3) Monocyte infiltration and differentiation to macrophage 4) Neutrophils and macrophages release cytokines & growth factors that activates fibroblast& epithelial cells Inflammatory phase (lasts for 72 hours average) Proliferative phase (it begins from 3rd day and lasts for 3–6 weeks) Granulation tissue formation ECM& collagen synthesis through fibroblasts Angiogenesis Re-epithelialization Granulation tissue Epithelization Remodeling/ Maturation phase It begins at 6 weeks and lasts for 6 months to 1 or 2 years. Collagen remodeling Increased wound tensile strength (collagen type III becomes type I) Vascular maturation and regression (reduced wound vascularity) Remodeling/ Maturation phase Scar tissue regains its 80% of strength but not as strong as original tissue  Types of wound healing Primary healing/ first intention  Types of wound healing Secondary healing/ second intention Tertiary healing After wound debridement and control of local infection, wound is closed with sutures or covered using skin graft Tertiary healing or delayed primary closure Complications of wound healing Infection Hemorrhage Fistula Wound dehiscence Wound evisceration Wound dehiscence & evisceration Wound dehiscence Wound evisceration Factors affecting wound healing Local factors ✓ Infection ✓ Presence of necrotic tissue and foreign body ✓ Tissue hypoxia locally reduces macrophage and fibroblast activity ✓ Venous or lymph stasis ✓ Recurrent trauma Slough & necrotic wound& infected wound Wound infection: Infection prolongs inflammatory phase, releases toxins and utilizes vital nutrients thereby prevents wound epithelialization Factors affecting wound healing Systemic factors ✓ Age and gender ✓ Smoking & alcohol ✓ Stress ✓ Obesity ✓ Malnutrition: zinc, copper, manganese ✓ Vitamin deficiency (Vit C, Vit A) ✓ Metabolic Diseases: diabetes ✓ Anemia, hypoxia ✓ Steroids and cytotoxic drugs ✓ Immunocompromised conditions: malignancy, HIV Age: In younger age group wound healing is faster and better. In elderly healing is delayed due to reduction in collagen synthesis, epithelialization, growth factors and angiogenesis Smoking: interferes with oxygen supply, causes peripheral vasoconstriction, impaired WBCs migration and reduced fibroblast proliferation Stress: suppresses inflammatory phase of wound healing and immune responses, inhibit migration of leukocytes to injury site. Gender: sex hormones as estrogen may play role in gender differences Alcohol consumption decreases the phagocyte response and pro-inflammatory cytokine release; diminishes host response and thus, increasing the infection rate. Anemia: Hemoglobin less than 8 g% causes poor oxygenation of tissues preventing healing of the wounds. Hypoxia: Hypoxia prevents fibroblast proliferation and collagen synthesis; it also promotes bacterial invasion into the wound Obesity causes hypoperfusion, reduced microcirculation, increased wound tension and hence reduces wound healing. Drugs Steroids interfere with activation of macrophages, fibroblasts and angiogenesis in the early phase of healing (proliferative). Nonsteroidal anti-inflammatory drugs: (NSAIDs) decrease collagen production Chemotherapeutic agents used inhibit cellular proliferation, protein synthesis Nutrition Food ✓ Adequate vitamin, trace elements, sources fatty acids and proteins are essential for wound healing ✓ Vitamin A deficiency affects monocyte activation, inflammatory phase, collagen synthesis and growth factor actions Nutrition Food sources ✓ Vitamin K deficiency affects synthesis of prothrombin (II), coagulation factors VII, IX and X Nutrition ✓ Vitamin E being an antioxidant stabilizes the cell membrane. ✓ Vitamin C deficiency impairs collagen synthesis, fibroblast proliferation and angiogenesis; increases the capillary fragility and susceptibility for infection. Nutrition ✓ Zinc is an essential cofactor for RNA and DNA Polymerase ✓ Magnesium is a co-factor for synthesis of proteins and collagen ✓ Copper is a required co-factor for the optimal cross- linking of collagen ✓ Iron is required for the hydroxylation of proline and lysine  Wound Assessment ✓ Site of wound ✓ Type of wound ✓ Mode of injury ✓ Foreign body ✓ Severity of pain or bleeding  Wound Assessment Assess length, width & depth of wound  Wound Assessment ✓ Viability of tissues in and around wound (wound base)  Wound Assessment ✓ Presence of wound drain or tube Closed system drain Open system drain  Wound Assessment ✓ Wound exudates/ drainage Serous Serosanguineous Purulent Sanguineous Drainage