PTA 221 Wound Care - Lecture notes and handout information from PTA 221 class on Physical Therapy PDF

Preview

Summary

Lecture notes and handout information from PTA 221 class on Physical Therapy Procedures IV....

Description

PTA 221 Wound Healing and Care Management AK anatomy Integumentary System: “skin” largest organ of the body Protects the body form fluid loss Protects the body from invasion of microorganisms Layers of the skin Epidermis: consist of 4 to 5 layers Outermost layer of stratum corneum Non vascular Sloughs off and replaced every 28 days Function is to protect from UV light and external environment Sensation, temp control, chemical exchange Vit D Layers of skin Dermis: makes up the “bulk” of skin Contains hair follicles, glands, nerve fibers, bld vessels and lymphatic vessels Composed of collagen and elastin fibers Collagen bundles anchor skin to subcuntaneous tissue Function: provide strength, stretch, sensation, nourishment, hair and sweat production anatomy Subcutaneous tissue: located below the dermis anchors the skin to underlying organs. Functions to protect absorption, insulates and store energy Why wounds occur Injury to the skin Trauma injury due to external force such as: laceration, surgical incision arterial insufficiency Venous insufficiency Pressure wounds

Neuropathic ulcers due to neuropathy Chronic wound An injury to the skin that has failed to heal in the general predictable events that occur through the phases of healing Need to identify and control the factors that delay healing as best as possible Factors that delay healing: aging, temp, nutrition, co morbid diseases, trauma, infection and necrotic tissue Also inadequate microcirculation, prolong pressure from interstitial tissue, type of ulcer, medication and blood supply Signs that a wound is not healing Odor Fever Edema Erythema Colored discharged A clean wound should show progress in 2-4 weeks Phase one of wound healing Inflammatory response Days 1-6 Vasoconstriction: occurs 5-10 minutes Platelets deposited to form a plug scab formation to adhere opposing surfaces Followed by Vasodilation: leakage and pooling of exudates Histamine from mast cells, basophils,platelets, water increases permeability of wall of small vessels Phase one Edema: Transudate:water and electrolytes (clear) serous drainage Exudate: proteins and leukocytes (cloudy) serous drainage Pus/scab: desiccation of dried blood which impedes epidermal cell migration Stage two Re-epithelization and contraction phase

Days 6-20 Granulation: granulation tissue reduces size of wound through production of collagen and new capillaries. Deep thickness wounds must fill in with granulation tissue Granulation tissue is bright read and granular in appearance Granulation tissue Non granulating wound Phase two Re-epithelization: epithelial cells divide and migrate across the wound providing coverage. Wound bed must be healthy for this to occur Phase two Contraction: wound edges are pulled together by myofibroblast and wound size decreases Phase three Remodeling phase 20 days up to 2 years Remodeling collagen bundles are organized into a pattern and a scar is formed scar Scar maturation: wound ages to gain tensile strength by 10-12 weeks 70-80% of original strength is achieved Hypertrophic hyper granulation if occurs lays down excessive collagen tissue in original wound Keloid scar excessive collagen formation beyond the original wound bed examination History: age, sex, occupation PMHx Current medications Social Hx. How long has the wound been present Location of wound Onset: insidious/trauma Progression since found Previous intervention

examination Subjective: Pain symptoms Relieved/aggravated by elevation, rest, activity Arterial insufficiency: increase pain with movement and elevation Venous insufficiency: pain decreases with movement and elevation Factors Affect Wound Healing Age Nutrition Lifestyle Cognition Self Care Ability Vascular Status Medical Status Medications **Health individuals acute wounds close 3 to 6 weeks** objective Wound assessment: Location Shape Size length measure in centimeters Wound depth STAGING OF WOUND: superficial: only epidermis partial: epidermis and part of dermis full: epidermis, dermis and may involve subcutaneous tissue, muscle,bone Another Pressure Ulcer Staging Stage 1: Intact skin that is redden and does not blanch

Stage II: Shallow open ulcer partial loss of dermis without slough Stage lll: dermis, epidermis and subcutaneous tissue involvement but no ms, tendon Stage IV: All the structure is stage III plus ms or tendon or bone exposed Unstageable: Slough or eschar is covering full thickness loss objective Color of wound and surrounding tissue Infection, inflammation and vascular status Pink tissue: recent epithelized tissue Red: indicates current healing Black: eschar is thick and leathery dead tissue, avascular Yellow: tissue infection Green/gray: slough necrotic tissue loss and is stringy in texture objective Tunneling: wound has penetration deeper Exudate: also know as drainage A/ serous: clear thin seen in a healthy healing wound Serosanguineous: contains blood may be seen in healthy healing wound Purulent: thick white pus like may indicate an infection. Need to get a culture Yellow/green: indicate infection. Need culture to determine type of infection to determine appropriate antibiotic Amount of drainage: absent, minimal, moderate, heavy Odor: absent, mild, foul, sweet, intensity Special test Rubor of dependency Assess arterial blood flow Looking for redness < 15 seconds normal > 30 seconds arterial insufficiency Venous special test

Homan’s sign: DF ankle, squeeze calf if painful or pt. reports it feels like it needs to be rubbed out ? DVT Pressure sores Caused by immobility which leads to excessive pressure, occluded vasculation, tissue hypoxia ( cell death), skin breakdown High risk area: sacrum, heels, ischium, trochanter,malleolus Grading/staging Pressure sores Stage I: non blanchable erythema of intact skin. Reversible with intervention Pressure sores Stage II: partial thickness tissue loss involving the epidermis and extending into but not through the dermis Presents of abrasion, blister or shallow crater Pressure sores Stage III: Full thickness tissue loss extending though the dermis to involve subcutaneous tissue but through the underlying fascia. Presents as a deep crater with or without sinus tract formation/tunneling, exudates, necrotic tissue or infection Pressure sore Stage IV: full thickness tissue loss extending through subcutaneous tissue to fascia. May involve ms, bone, or tendons and jt capsules Presents as a deep crater may have sinus tracting Stage 2 Stage 3 Stage 4 Diabetic neuropathic ulcers 2 factors: neuropathy and ischemia Neuropathic: Sensory impairment, motor impairment atrophy/weakness Ischemic ulcers: microcirculation is affected at the arterioles and capillaries Neuropathic ulcers are painless, small deep round ulcers with periwound callous. Usually affects the feet Shiny skin trophic changes Monofilaments can be used to assess the severity of the sensory neuropthy

Arterial insufficient ulcers Present with claudication Pain with activity that decreases with rest Ulcer has pale wound base, well defined edges, absent or diminished pulses, cool temp, thick rigid nails and necrotic tissue Dx: doppler test Ankle/Brachial Index: normal ABI is >1.00, .5-.7 claudication It is not recommended to apply compression with ABI 50% Removes foreign debris/cleans wounds Debrides the wound with agitation of water Dressing removal Pain management Contraindications: superficial wounds with < 50% necrotic tissue, infections may spread,, granulating wounds, active bleeding, active inflammatory conditions maybe exacerbated whirlpool Precautions: clients with systemic conditions such as CHF, PVD, HTN, cardiac instability, resp. instability

Can not tolerate stress produced by generalized heat such as hubbard tank BUT local treatments may be given with caution and adj water temp accordingly Senior a 90 degrees maximum Once wound is clean no need to continue W/P Autolytic debridement Cellular activity of enzymes naturally found in the wound (proteases and collagenases) Break down dead tissue and are held in the wound with retention dressing to preserve fluid Not recommend if signs of infection are present, stage IV wounds requiring surgery Mechanical debridement Removes debris Softens necrotic tissue Cleans wound Examples: whirlpool, wet to dry dressing, irrigation ultrasound Modifies cell permeability Increases blood flow and collagen synthesis Decreases pain and edema Use on venous/arterial insufficient ulcers, pressure sore and stagnant wounds Contraindications: malignancies, over the cranium, spinal cord, gonads, preg uterus, cardiac area, DVT, severe arterial occlusion, hemophiliacs not covered by factor replacement US techniques Direct over wound bed Use hydogel dressing (wound dressing plus coupling agent) Use sheet if stage I or II If wound is deep fill with saline or use rubber glove filled with water or saline into the wound cover with hydogel sheet and coupling medium. Indirect technique: (periwound area) Underwater tech US technique Frequency: 1 MHz for deep wounds, 3 MHz for superficial wounds

Intensity: 0.5-2.0 Wcm2 Acute: .3 watts/cm2 pulsed Chronic .5 watts/cm2 pulsed Time: consider the size of the wound and the size of the sound head. Generally 1 min/1 cm square area Max. treatment time 15 minutes How often: acute injury 1-2 times daily until pain and swelling resolve; eventually decrease to 1 time a week until healed. Chronic ulcers 1-5 times a week until healing is complete Sonoca US combined with irrigation 25kHz freq Aids in fibrin removal Pain reduction Bactericidal effect www.soering.com MIST Therapy Us delivered non contact through a saline mist Aids in fibrin removal Pain reduction Bactericidal effect Celleration.com Monochromatic infrared Anodyne Research peripheral neuropathy increase circulation decrease pain Contraindications: malignancy, preg uterus, over topical applications Ultraviolet Bactericial

Erythemal response Derma wand www.natbiocorp.com compression Jobst Reduces edema Improves venous return and decreases chronic venous hypertension Indication for venous insufficient, edema. Lympedema Time: 30-60 min/day Pressure: 20 mm/Hg below diastolic BP, no greater mm/Hg Electrical stimulation Indications: Stage III & IV wounds, arterial and venous ulcers when edema is controlled, neuropathic foot ulcers Increase blood flow Increase epidermal cell proliferation and migration, collagen secretion Increase phagocytosis Softens necrotic tissue Decrease pain Decrease edema Decrease bacterial growth Electric stimulation Day 1-5 or infection “-” polarity, freq. 150 pps, intensity 50, 60 minutes one time daily Day 6 or without infection “+” polarity, freq 100 pps, intensity 80, 60 minutes one time daily Wet to dry dressing

Indication >70% necrotic tissue, stage III &IV wounds Contraindications: superficial wounds, infections, exposed tendons, bleeding, wounds with...