Wound◦Breach in the continuity of skin or mucous membrane

Ulcer◦Persistent breach in the continuity of skin or mucous membrane associated with cell death

Wounds

Acute Wounds

Cuts, Abrasions, LacerationsContusionsPuntureSkin flaps and BitesBenbow ( 2005) Any wound >

3/12 considered a chronic woundThey passes through the

normal healing process readily

Fail to pass through normal healing process

Chronic Wounds

Haemostasis

Inflammation

Proliferation or Granulation

Remodelling or Maturation

Time

Hemostasis

Platelet Aggregation Neutrophil

ImmigrationMonocyte ImmigrationGranulation

Re-epithelialization

Wound Closure

Scar FormationRemodeling

Minutes Hours Days Weeks Months Years

The wound healing cascade impairs and arrests at different stages

Chronic wounds

CHRONIC WOUND

Normal Healing Process

They are poly peptides, stimulate wound healing, promote chemotaxis, miotgenesis of fibroblasts and smooth muscle cells

Platelet derived growth factor Insulin like growth factor epidermal growth factor fibroblast growth factor transforming growth factor 1

Normal healing process impaired

Arrest at different levels

Remains at same stage without progressing

to wound healing

Often an underlying cause remains and

undetected

Inadequate blood supply ** Increased skin tension Poor surgical apposition Wound dehiscence Poor venous drainage ** Presence of foreign body and foreign body reactions Continued presence of micro-organisms & Infection ** Excess local mobility, such as over a joint

Systemic factors Advancing age and General immobility ** Obesity *** Smoking Malnutrition *** Deficiency of vitamins and trace elements ***

Systemic malignancy and terminal illness

Chemotherapy and radiotherapy

Immunosuppressant drugs, corticosteroids, anticoagulants

Inherited neutrophil disorders, such as leucocyte adhesion deficiency

Diabetes and CRF***

approach has been criticised for being too simplistic as wound healing is a continuum and wounds often contain a mixture of tissue types.

Wound Healing Continuum (Gray et al. 2005) havebeen developed. This tool incorporates intermediate colour combinations between the four key colours

The presence of multiplying organisms within a wound that overwhelm the host immune response with associated clinical signs and symptoms. (Kingsley 2001)

Organism Density

Organism Density

1. The quantity of micro-organisms2.quality –Virulence and antibiotic resistance

3. The patients resistance to the level of bacteria in the wound( immune response)

Microbial bio-burden within wounds can range from contamination, colonisation, critical colonisation and infection.

Wound Surface

2.Organisms from GIT and GUTGram Negatives such as E.coli,

Klebsiella, Enterobacter, Anerobes

1.Organims from surrounding skin- Regional flora-

Deptheroids, Anerobes

3.Organisms from External environment- through direct or

indirectly – Pseudomonas, Multiresistant organisims etc

Wound Contamination

Wound Colonization

Critical Colonization

Wound Infection

Advance Wound Infection

Fecal and urinary management systems

Hand hygeine

Classical Signs

1. Increased pain

2. Copious amounts of exudate

3. Malodour

4. Cellulitis

5. Pyrexia

6. Abscess Formation

◦Increase in size of wound

◦Delayed wound healing

◦General unwellness

◦Dark discoloured granulation tissue

◦Increased friability

◦Pocketing at base of wound. (Cutting and

Harding 1994).

Simple◦Skin

Complex◦Deeper

Rank & WakefieldTidy◦Surgical incisions

Untidy◦Crushing, tearing

Open◦Incised◦Abrasion◦Lacerated◦Crush◦Penetrating

Closed◦Contusion◦Hematoma

Surgical Wounds

◦Clean

◦Clean Contaminated

◦Contaminated

◦Dirty

Crushing of Muscles>Extravasation of

blood>Myoglobin release

Earthquakes, Industrial accidents, Air crashes

Renal failure, Toxemia, Septicemia, Gas

gangrene

Rx- Multiple deep incisions, Mannitol,

NaHCO3, Hemodialysis

Pathological◦Specific

◦Non-Specific

◦Neoplastic or Malignant

Tropical ulcersTuberculosisBuruli ulcers- myco ulceransSyphilis- trp pallidiumYaws- treponema pertenueActinomycosis

Traumatic Ulcers of Vascular origin

VenousArterialPressure sores Neurotropic (trophic) ulcers

LeprosyDiabetic neuropathies

Cord lesions

• Ulcers with metabolic or systemic disease

• Diabetic ulcers• Haemoglobinopathies

• Infective (pyogenic)

Cryopathic

Squamous cell carcinoma

Rodent

Malignant melanoma

Kaposis’s sarcoma

Grade 0- Preulcerative/HealedGrade 1- SuperficialGrade 2- Deeper to subcutaneousGrade 3- Abscess formationGrade 4- Gangrene of part of tissue

Grade 5- Gangrene of entire limb

EdgeSloping – non specificUndermined – tuberculous/ decubitus

Punched out – syphilitic/neuropathic

Floor – what is seen

Base – what is palpated

Regular

Irregular

Rounded, Oval

Granulation◦Red◦Pale & Smooth◦Pink, Punctate,

◦Nodular – suggestive of malignancy

• Discharge• Serous• Purulent• Sero-purulent

• Bloody• Sero-sanguinous

• Sulpher granules

On which the ulcer rests

Palpated

Indurated in malignancy

Tropical UlcersCaused by synergy of F fusiformis / Borrelia vincenti

Starts as septic blistersTropical Countries – poor hygeine,malnutrition, walking barefooted

In the chronic phase the ulcer becomes non specific

Bursting of Caseous LNSlightly painfulNeck, Axilla, GroinUndermined thin reddish-blue edge, Sero-sanguinous discharge & induration

Enlarged LNLupus Vulgaris- Cutaneous TB- Face & Hands

Check the lungs- CXR

Treponema PallidumHard Chancre- Ext GenitalsPunched out edgesPainless, indurated base(button Like)

Nipple, lip, tongue, anal canalSecondary- Mucus patches, Condylomas

Tertiary – Gummatous (Subcut bones)

VDRL/ biopsy

Causes are many Sloping edgePhases1.Acute or infective phase2.Transition phase3.Reparative or healing phase4.Chronic, indolent or callous phase 5.-secondary infection, poor circulation, fB

Anywhere on bodyDiagnosis is based on history & sloping edge

Limbs-Shin, Malleoli, JointsChronic- StaphEg◦Plaster Sores, Skin burns, Caustic ulcers

Occurs in theMedial lower 3rd legDue to venous stasis- poor oxygenation/nutrition

Leg oedema ,Surrounding skinPigmentation

varicositiesCauses◦Varicose veins-Perforator incompetence, Stasis

◦DVT-Valveless Recanalisation after DVT

Inadequate skin circulationLimbs- Repeated pressure/traumaCausees◦Atherosclerosis- Ant & lat legs, Dorsum, Heels

◦Buerger’s disease- Painf, Claudication, Punched out ulcers

◦Raynaud’s disease◦The skin is shiny, hairless & hypoaesthetic

◦Dorsalis pedis/ post tibial pulses are absent

Neurologic deficit, Impaired blood supply & nutrition

Sites - trochanter◦Sacrum, Heel, Buttocks, Occiput

Bedsores, Perforating Ulcers CausesCauses◦Diabetic Neuropathy, Paraplegia, Leprosy, Spinal injury, Peripheral injury, Peripheral neuritis

Ischemia from prolonged pressure bw

Bed and body prominences those unaware of warning signals of discomfort eg unconscious patient,

Maceration of skin from sweat, urinePoor nutritional statusReflection of nursing care

Diabetic Neuropathy-Trophic

Atherosclerosis-Arterial

Glucose laden tissues-Infective

Marjolin’s ulcer◦SCC from chronic scar

Malignant◦Lips, cheeks, penis, vulva, mouth, oesophagus

◦40 yrs+◦SCC, BCC, Melanoma

Soft Chancre- Ducreys◦Painful, Ext genitals, with Bubo

Meleney’s Ulcer◦Post-op- Perforated viscus, ◦Empyema Thoracis◦Strepto & Staph, Abdomen

Martorell ◦Hypertensive, Old age◦Post calf

Bazin’s

MANAGEMENT Wound Care Plan (WCP)

Wound Care Plan (WCP)

Patient Centered – dealing with person with a

chronic wound

Holistic –Total care -Not only wound itself- need to address pts other needs, diseases, and psychosocial wellbeing

Inter-diciplinaryNeeds Participation of

multitude of disciplines

Mode of onsetDurationPainful or painlessDischargePMH suggestive of systemic illnessDM, TB, SCD, Neuropathy, Peripheral ischaemic symptomsarterial disease – intermittent claudication

◦ Previous interventions◦ Treatment

Venous◦Varicose veins◦DVT/thrombophlebitis◦Sclerotic changes◦Oedema

Vasculitis◦History of autoimmune disease◦Painful◦Lack chronic arterial occlusive symptoms

◦Systemic symptoms of autoimmune disease

Neoplastic◦Chronicity◦Previous malignancy◦RisksExposuresUV radiation Ionising radiation

InspectionSize & ShapeNumberPosition ( anatomical site)

Edge, Margin, Floor

DischargeSurrounding area

• Palpation• Tenderness• Edge & margin• Base• Depth• Bleeding• Surrounding skin

Lymph NodesPeripheral pulsationsNerves Joints for mobiltySystemic examination

Routine- urine &Blood : FBC, ESR, FBS, Genotype, mantouxRenal & Liver functionswound swab

Specific◦VDRL,◦X-ray of part/ CXR◦Edge biopsy◦FNAC of LN◦Colour Doppler

Connective disease profile Angiography

Dressings◦ Encourage healing

Moist Reduce oedema Remove pathogens Protect healing tissue

Debridement Necrotic tissue Slough Foreign bodies amputation

Vascularise Angioplasty Bypass Optimise cardiac circulation

Eliminate venous hypertension Varicose vein surgery Venous valve replacement Sclerotherapy Venous bypass

Wound closure Secondary intention SSG V.A.C. Plastic surgery flaps

Systemic treatment Steroids Diet Trace elements Avoid cross contamination

Healing without complications such as infection and disfiguring

Wound care ◦ Remove FB◦ Dry or wet to dry dressing to cover the wounds◦ Suturing if acute◦ Bites - Prophylaxis

Resuscitation of patientCleaning, DressingHemostasisSplintFluids Inj TT

Incised◦Primary Suturing

Lacerated◦Excision & Primary Suturing

Crushed◦Debridement, excision◦Delayed Primary Suturing

Deep devitalised◦Debridement◦Secondary Suturing/ Grafting

Treatment of causeCorrection of DeficienciesBlood transfusionsPain MangementDebridement, Cleaning, DressingAntibioticsSuturing, Grafts, Flaps

Cleansing agents◦ Flowing Water –Requesting pt to bath before dressing

change◦ Normal Saline***◦ Commercial Cleansers◦ Hydrogen Peroxide◦ Povidone iodine◦ Hypochlorite solution◦ Sterile vinegar solution◦ Mechanical Cleansers –Whirl pools◦ Salt dips◦ Honey

Mechanical

Autolytic

Enzymatic

Biological

Surgical

Protect from bacterial invasion

maintain optimum humidity

absorb serum from wound site

protect granulation tissue

reduce pain

Debridement – Mechanical / surgical /

biological / enzymatic

Off loading foot wear .

Antibiotics

Appropriate wound care .

No role for

◦ Hydrogen peroxide

◦ Boric acid

◦ EUSOL

◦ Dakin solution (hypochlorite )

◦ Iodine

As they are toxic to the tissues

Poly urethane films ◦ transmit water vapour , oxygen , carbon dioxide ◦ non absorbent ◦ useful for healing wounds with minimal drainage

Foams and Hydrocolloids

◦ Permeable , easy to apply , minimum re injury when removing the dressings

◦ 60-95% water content maintains the moist atmosphere

Alginates

◦Sea weed preparation

◦ absorb exudates

◦ useful for exudative wounds

Cultured keratinocytes

◦Cells are cultured and transferred to

petroleum gauze

◦ labour intense and expensive

Nutrition-proteins , zinc , vitamin c

Pain management

Change of dressings

Removal of slough- hydrogels , varidase

decrease the bacterial load – iodoflex Reduction of exudates- alginates Odour – iodoflex, silver , metronidazole Eczema- steroids

Bacteria can secondarily colonize the wound and general tendency is to over treat .

Not necessarily indicate infection

wound bacteria may be transient and may not be detected on random swabs

Fever /erythema /swelling / increased pain / leucocytosis

Only indicated if contaminated or evidence of infection is demonstrated

Evidence of infection (local)◦ Redness◦ Warmth◦ Swelling◦ Tenderness◦ Local Lymphadenopathy

For spreading infection and or evidence of

systemic infection

Take blood cultures

Treated with Broad Spectrum antibiotics

intravenously.

Topical antimicrobials - used to reduce

wound bio burden (EWMA 2006).

Granulation enhancers

Minimal Dressing changes to reduce disturbances to the granulation

Avoid usage of substances which impede granulation tissues

Pain relief

Psychological support

Family education and create conducive environment

Social support

Chronic Wound Care: 10 Pearls for Success

1. For those with Diabetes for wound healing and further prevention: A - Check A1c - greater than 9% will affect wound

healing. Recommended is less than 7%. B – Blood Pressure C - Cholesterol D - Diet E - Exercise F - Foot care - Check both feet at each

appointment, shoes should be professionally fitted, consider chiropody.

S- Smoking

2. For those with Venous Ulcer Disease - Compression bandaging is for treatment, stockings are for prevention.

◦ (Exudate/creams will damage the integrity of the stockings).

◦ COMPRESSION IS FOR LIFE! The right compression is the one the patient will wear

3. For those with any distal neuropathy - Shoes should be professionally fitted.

4. Smoking Cessation -IMPORTANT FOR ALL! - each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours

5. If wounds not decreased by 30% in size by week 4, unlikely to heal by week 12. Consider biopsy or a comprehensive re-assessment

6.Query Infection? Culture using the Levine technique (Compress wound with normal saline for 10 minutes, press swab into a clean granulated area to express fluid and rotate 360 degrees

7. Treat the cause! Consider all the possible contributors to non-healing: Drugs, Occult malgnancySystemic Disease (diabetes anemia, vascular disease), smoking, non-adherence

Definition

Problem – How big is it ?

Types

Pathophysiology of venous , arterial ,

diabetic ulcers

Assessment / Evaluations

Treatment options – Dressing agents ,

surgical options

Chronic ulcers results when sequel of repair is disturbed at one or more stages of inflammation

proliferation , re epithelialization ,remodelling

common organisms colonizing the ulcers

Staph aureus , Strep pyogens , Strep fecalis , E coli

Surgeon Wound Care Practioner Nursing officer Physician Physio-therapist Nutritionists Attendant

Department of OrthopaedicsGeneral Hospital Marina,

Lagos