Wound Care Notes Wk 3 PDF

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The surgical wound & debridement & skin suture techniques...

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Week 3 The Surgical Wound Wound Classification…  clean  

wounds made under aseptic surgical conditions wounds that do not enter genitourinary (genital/urinary), respiratory or alimentary (nourishing) tracts or oropharyngeal cavity

 clean/contaminated 

wounds that are contaminated by the resident flora or the cavities but there is no host reaction

 contaminated  

biofilm contaminated by bacteria with no host reaction

 infected 

clinical signs of infection present with increased leukocyte and microphage levels

Langer’s Lines…  natural liner pathways along the skin which has least flexibility (significant for direction of surgical incisions)

Sutures…  absorbable sutures 

natural = made from purified collagen (plain or chromic) 

plain = gut rapidly absorbed with a tensile strength lasting 7-10 days



chromic = gut is treated with a chromium salt solution to resist body enzymes (prolonged absorption time of 10-14 days

 Synthetic Sutures 

absorbable    



non-absorbable   



polyglycolic acid (dexon) polyglactin (vicryl) polydioxone (PDS) polyglyconate (maxon)

polyamide (nylon) polyester (dacron) polypropylene (prolene)

vicryl 

tensile strength ^ ^ ^





65% @ 14 days 40% @ 21 days 10% @ 35 days

absorption complete by 70 days

polydioxone 

tensile strength ^ ^ ^



70% @ 14 days 50% @ 28 days 14% @ 56 days

absorption complete by 180 days

Wound Healing by Primary Intention…  principles 

    

protect the wound from physical or pathogenic assault absorb exudate maintain wound temperature maintain body temperature oxygenation avoid stress – pain relief

Dressing the Suture line…  generally, only for 24-48 hours unless drains in situ

 dry low-adherent dressings only eg:    

Island dressings Semi-permeable film Hydrocolloid Foams

Surgical Wound Complications…  types of complications:          

haemorrhage – primary or secondary haematoma seroma oedema infection occlusion of blood supply - necrosis dehiscence sinus tracking evisceration adhesions

 haemorrhage  

primary = bleeding immediately following surgery secondary = bleeding that develops 24 hours + after the original injury/surgery (often caused by an infection or dislodged clot

 fluid collection 



seroma = a localised collection of serum within the tissues (contains blood plasma) oedema = excessive water in the tissues

 sinus formation & tracking   

sinus is cavity or track into the tissues aim is to heal the cavity from the base upwards in order to eliminate dead space in wound cavity wounds are gently packed to facilitate controlled wound closure

 dehiscence 

separation of tissue layers in a surgical wound generally as a result of infection, haematoma, fluid collection or local trauma

 evisceration   

protrusion of viscera or bowels through a surgical incision or traumatic wound keep covered with sterile moistened pads or drapes surgical emergency

 fistula    

a fistula is a track connecting one body cavity to another cavity or the skin surface can result from a leaking surgical anastomosis or spontaneous rupture due to obstruction, disease, trauma or radiotherapy damage a fistula can be internal or external types of fistulas:        

Enterocutaneous (intestine – skin) - external Vesicovaginal (bladder – vagina) - internal Enterocolonic (intestine – colon) - internal Colocutaneous (colon – skin) - external Enterovaginal (intestine –vagina) - internal Colovesical (colon-bladder) - internal Rectovaginal (rectum-vagina) - internal Vesicocutaneous (bladder-skin) - external

 

assessment:     

type of fluid identifies organs involved eg faeces, urine, saliva, gastric fluids, bile etc amount of fluid – high output >500 mls in 24 hrs, low output < 500 mls in 24 hrs. pH of fluid odour and gas X-ray with radio-opaque medium to identify position and tracking

Infection…  clinical signs of wound infection 

local:     

pain heat oedema erythema (redness) exudate (change to purulent or increase amount)



systemic:   

elevated temperature elevated leukocyte levels malaise

 risk of infection         

age (elderly or very young) aetiology – planned surgery, trauma number of comorbidities or control of same pre-op skin preparation peri-operative hypoxia, pain, anxiety, cold length of operation method of wound closure (bucknall, 1981 showed silk & braided sutures increased reaction) post-op care – infection control principles, wound drainage, dressings, shower, activity nutritional status

 recommended dressing for restoring bacterial balance      

Cadexomer iodine powder/paste, sheet dressing. Povidone iodine impregnated tulle gras Chlorhexidine impregnated tulle gras Wound honey Silver impregnated dressings Polyhexamethylene biguanide (PHMB) products.

Skin Grafts…  what is it? 

a skin graft is a segment of dermis and epidermis which has been completely separated from its blood supply and donor site attachment before being transplanted to another area of the body

 types of skin grafts:  

Autografts = transfer of tissue from one site to another on the same person. Allografts/Homografts = transfer of tissue from one person to another (eg skin, bone, organs).

  

Xenografts/Heterografts = transfer of tissue from one species to another (eg pig skin) Tissue Culture = epidermal cells cultured in the laboratory Bio-engineered Skin = Dermagraft, Apligraf

 taking a skin graft



split thickness  



can be thin, intermediate, or thick and contain all of epidermis and variable depth of dermis. thin = contracts within the first few months. No hair. Higher survival rate as vascularisation occurs easily. thick = less contraction. usually contains some hair follicles

 full thickness  

contains all of epidermis & dermis donor site has to be directly closed or grafted

 factors which inhibit graft take      

poorly vascularised recipient bed shearing movement fluid collection beneath the graft (eg haematoma, seroma, pus, debris) infection inadequate graft support when dependent patient factors

 shearing forces

 

movement between the graft and the recipient bed causes damage to the capillaries growing into the graft and prevents revascularisation nursing interventions:   

pain splinting (eg thermoplastic splints) patient education (eg keeping graft site immobilised) stabilised dressings (cotton tulle gras, silicon dressings, tie-over, compression)

 fluid collections beneath the graft  

good contact between the graft and the recipient bed is essential for vascularisation nursing interventions: 



Seroma/Haematoma: regular graft care (dependent on exudate level), nicking/pricking any blisters that form, haemostasis if bleeding, evacuation of haematoma preparation of the recipient bed to remove non-viable tissue

 infection  

pre-graft recipient bed preparation post-grafting:   



infection control aseptic technique infection results in increased exudate which lifts the graft off its bed

nursing interventions:   

identification of signs and symptoms of infection compliance with the treatment plan if infected graft care: removal of accumulated exudate and crusts, trimming of graft once taken

Flaps…  what is it?  

flap is a surgical relocation of tissue from one p art of the body to another part in order to reconstruct a primary defect flaps are described as skin or cutaneous flaps and composite flaps

 types of skin grafts:



skin or cutaneous  consisting of skin and superficial fascia (small defects)



composite tissue:   

fasciocutaneous flap (subcut tissue and deep fascia – more blood for larger defects) myocutaneous flap (layer of muscle – for bulk or functional muscle ) osteomyocutaneous flap (bone e.g. In jaw reconstruction)

 free flap 

relocation of skin & subcutaneous tis sue as a complete segment with an anastomosis of the blood supply

 pedicle flap  

a transfer of skin and tissue to another site blood supply to the flap is maintained via a vascular pedicle

 rotational flap  

a ‘Z-plasty’ used to free up tissue & rotate to an adjacent site

 stabilisation 

uses external fixators

 flap observations     

warmth - reduction in temperature change in tissue: prune-like or hollow if arterial occlusion. tense, swollen and distended if venous occlusion. skin colour changes bleeding decrease or increase in capillary refill time

 nursing care

 

follow post-op orders observe vital signs, preferred range:   

    

T, 36.5-37.5oC P, 100mm Hg

monitor fluid intake - IV and oral monitor urinary output, 0.5ml per Kg/hr oxygen therapy and continuous saturations maintain 96% or > observation of flaps observations of drains and dressings

 donor sites 

complications   



nursing interventions   



infection bleeding delayed healing

observation of donor site dressing donor site observation (eg pain, bleeding, malodour, cellulitis, purulent exudate) protect healed wound

donor site dressings     

alginates hydrofibre hydrocolloids foams retention dressings (eg. fixomull)

Debridement What is it? …  the removal of all foreign material and all

contaminated and devitalised tissue from or adjacent to a traumatic or infected lesion until healthy tissue is exposed

Necrotic Tissue …  factors:      

hinders assessment of tissue dama ge interferes with granulation inhibits wound contraction obstructs epithelial migration promotes bacterial proliferation may cause odour

Debridement Methods …  use TIME CDST         

surfactant surgical conservative sharp mechanical autolytic enzymatic chemical biological or parasitic ultrasound

 surgical debridement 

under aseptic conditions by surgeon

 mechanical debridement 

use of wet to dry dressing or irrigation under pressure

 autolytic debridement 



hydration of the wound to promote autolysis (destruction of cells or tissues by their own enzymes) of necrotic tissue eg. hydrogels, hydrocolloids

 chemical debridement

  

cadexomer iodine wound honey hypertonic saline

 biological/parasitic debridement    

secrete collagenases & trypsin - extracorporeal digestion antimicrobial activity including Clostridium welchi ,MRSA & Pseudomonas slight pyrexia may result during lysis of bacteria by maggots how it is done:



conservative sharp wound debridement (CSWD)  

the removal of loose avascular tissue without pain or bleeding contraindications:    



densely adherent necrotic tissue when interface between viable and nonviable tissue cannot be clearly identified. impaired clotting mechanism. increased risk of bleeding eg. malignant wounds. non-infected ischaemic ulcer covered with dry eschar when tissue oxygenation is insufficient to support infection control and wound healing eg. diabetic ulcers with dry gangrene

guidelines:          

assess the wound and decide if CSWD is appropriate use sterile sharp instruments identify type and amount of avascular tissue to be removed be aware of underlying and adjacent anatomical structures avoid all vascular structures and any tissue not clearly identified as avascular exercise caution at periphery of wound be conservative flush the wound with sterile saline following debridement control bleeding ensure a distinct boarder between the viable & the non-viable tissue

 ultrasound debridement        

low frequency ultrasonic debridement (LFUD) non-invasive non-painful (although may use topical anaesthetic e. g. Emla to reduce sensitivity) minimal blood loss good wound bed preparation N/S streams through sonotrobe head with ultrasound waves, creates oscillating micro bubbles streaming steady mechanical forces wash away unhealthy tissue, also antibacterial effect healthy tissue stimulated into healing process

Skin Suture Techniques Simple, Square Interrupted Sutures…  suture inserted 1cm apart & 1cm across incision

Mattress Sutures…  suture inserted vertically or horizontally

Continuous Cuticular Suture…

 continuous suture from start to end of the wound

Skin Staples…

 metallic clips

 used for primary closure

Tension Sutures…  provide added support for distended abdomens or when anticipated wound breakdown

Wound Closure Strips…  steri-strips  non-invasive Skin Glue…

     

glue binds the wound together non-invasive are safe & effective method cost effective helps prevent infection ideally for wounds less than 4cm, not contaminated or infected & have skin edges that are not under tension  dehiscence is slightly higher with skin glue than with sutures  cosmetic outcome is comparable & it is painless  contraindications for skin glue:     

jagged lacerations bites, punctures or crush wounds mucosal surface axillae & perineum (high moisture areas) hands, feet & joints (unless kept dry & immobilised)

 disadvantages to skin glue:    

4% of wounds reopen with skin glues compared to 1-2% for sutures poor technique poor wound selection breakage of bonds & sloughing from skin...