Wound healing and Wound care. - University of Medical ...oer. NOTES/1/2/OM-Oluwatosin---Wound-healing...Wound…

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Wound healing andWound care.

Odunayo M. Oluwatosin, FMCS (Nig)Department of Surgery

Learning outcomeby the end of this presentation, you should be able to:

Describe the process of wound healing.

Discuss complications of wounds healing.

2

Learning outcomeby the end of this presentation, you should be able to:

Discuss the total care of a patient whopresents with a wound / ulcer

Compare the present mode of wound carewith the past

Contrast the present mode of wound carewith the past

3

A wound is an area of thebody whose normal integrity

has been compromised

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Wound can be found in: Skin, Mucosa, Bone, Brain

Can be: Acute Chronic

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Acute wound Trauma Surgery Infection Inflammation

Chronic wound Poorly treated trauma Vascular disease Haematological disease Pressure Infection Endocrine Malignancy

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Aetiology

Traumatic wounds on the face

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Phases of wound healing

haemostasis inflammation proliferation maturation

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Haemostasis microvascular injury leads to extravasation of

blood, activation of coagulation cascade, constriction of injured vessels, clot formation, platelet aggregation. Fibrin, fibronectin, vW (von Willibrandt) factor,

and thrombospondin, provide initial matrix forcellular migration

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Inflammation

Initial inflammatory exudate contains mainlypolymorphs that later gets replaced bymonocytes and lymphocytes.

Monocytes must be present to trigger offfibroblast invasion of the wound as well asproliferation

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Proliferation

Fibroplasia Epithelialisation Angiogenesis

commences 3 days into wound healing lasts weeks depending on the size of wound, and type

of tissue involved. replacement of provisional fibrin/fibronectin matrix by

a more definitive framework comprises

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Fibroplasia

commences 2-4 days after wounding. fibroblasts are attracted to site by PDGF and

TGF- they proliferate and construct new

extracellular matrix (ECM) which initiallycomprises fibronectin and hyaluronan butlater, collagen and proteoglycan.

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Fibroplasia

During the first three weeks, all wounds gainstrength at the same rate

thereafter the gain in strength becomesvariable depending on the tissue.

for the skin, peak tensile strength is achieved60 days after injury.

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Epithelialisation

Epithelial mobilisation, migration, division,and differentiation are stimulated by anapparent loss of contact inhibition.

EGF stimulates mitogenesis and chemotaxis

-FGF and keratinocyte growth factor (KGF)stimulate epithelial proliferation.

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Epithelialisation

Advancing cells bridge the wound

Cellular differentiation from the base to thesurface occurs.

The rate of epithelialisation increases if:the wound does not require debridement,the basal lamina is intactthe wound is kept moist.

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Angiogenesis Stimulated by:

TGF- and PDGF from plateletsTNF- and -FGF from macrophages.

The capillary sprouts invade fibrin to formgranulation tissue network

With time, blood vessel density reduces andscar tissue develops.

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Maturation orremodelling

Balance develops between collagenformation and degradation

This reaches a steady state at 21 days afterwounding.

The eventual tensile strength achieved is only80% of normal.

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Maturation Collagen degradation is by matrix

metalloproteinases (MMPs)

Produced by: fibroblasts, granulocytes,macrophages.

Tissue inhibitors of MMP (TIMP) deactivateMMPs.

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MMP TIMP

While early collagen deposition isdisorganised, local forces cause the laiddown collagen to orientate in an organisedfashion.

Subsequently, activity of MMPs decreases

Tissue inhibitors of MMP (TIMP) activityincrease.

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Maturation

macrophage, and fibroblast density becomesreduced by apoptosis

capillary outgrowth stops

acellular and avascular scar results

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Maturation

Complications of wound healing

Wound infection Systemic infections Chronic wounds and ulcers

Scars and contractureskeloidsLymphoedemaBone complications: osteitis, osteomyelitisMarjolins ulcer

Tetanus Pressure ulcers

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R. Gary Sibbald, Kevin Woo, ElizabethA. Ayello. Increased Bacterial Burdenand Infection: The Story of NERDS andSTONES. ADV SKIN WOUND CARE2006;19:447-61

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Acutewound

Chronicwound

Repetitive traumaLocal tissue ischaemia

Necrotic tissueHeavy bacterial burden

Tissue breakdown

Differences between acute andchronic wound healing

In a chronic wound, the timely and orderlymanner of acute wound healing enumeratedpreviously is disrupted.

This disruption occurs in most cases in theinflammatory and the proliferative phases

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Differences between acute andchronic wound healing

The disruption manifests in: alterations in protease activity, alteration in cytokine profile and

inflammatory response, changes in cellular profile and activity, changes in the composition of extracellular

matrix and environment,

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Pro-inflammatory

cytokines

TNF-IL-1bIL-2IL-9

MMP

TIMPAnti-

inflammatorycytokines

IL-4IL-10TGF

Differences between acute andchronic wound healing

The disruption manifests in: presence of free radicals and role of nitric

oxide, accumulation of necrotic tissue and slough, presence of micro organisms, disease specific pathological change.

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Keloid

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Bone complications

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Lymphoedema

Total care of a patient who presentswith a wound / ulcer

Identify and treat the cause

Address patient-centeredconcerns

Provide local wound care

Denis Okan, Kevin Woo, Elizabeth A. Ayello, R. Gary Sibbald. The Role of Moisture Balance inWound Healing. Adv Skin Wound Care 2007; 20: 39-53 35

Identify and treat the cause

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Venous leg ulcers Arterial ulcers Pressure ulcers Diabetic foot ulcers Malignant ulcers and Marjolins ulcer

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Identify and treat the cause

Address patient-centered concerns

Provide emotional support Assess and consider financial situation Provide patient and family education Assess and provide/facilitate optimum

health care

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Otherpatient

concerns

Frequentdressings/

odour/discharge

Anxiety/distress/

depression

Socialisolation

Polypharmacy

Work andwalking

concerns

Decreasein physical

activity

Fear ofamputation/

lifeadjustment Change of

bodyimage/

deformity

Pain

Woundinformation

Is tetanus-prone Is not tetanusprone

Time since injury >6 hours 1 cm < 1 cmMechanism ofinjury

Crush, burn,gunshot,frostbite,penetrationthrough clothing

Sharp cut

Dead tissuepresent

Yes No

Foreign material(grass, dirt, etc.)contamination

Yes No

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Pain management

Injury pain (immediate, severe, regressive),background pain which is prolonged untilwounds are healed

Procedural pain (dressing changes,physiotherapy, post operative) which issevere and repetitive.

WHO pain ladder Appropriate timing

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Total care of a patient who presentswith a wound / ulcer

Identify and treat the cause

Address patient-centeredconcerns

Provide local wound care

Denis Okan, Kevin Woo, Elizabeth A. Ayello, R. Gary Sibbald. The Role of Moisture Balance inWound Healing. Adv Skin Wound Care 2007; 20: 39-53 42

Provide local wound care

Determine the potential for healing

Assess the wounda) Obtain the wound historyb) Assess and monitor the physical characteristics of

the woundc) Assess and manage wound pain

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Local Wound Carea) Tissue concernsb) Infection/Inflammation concernsc) Moisture concernsd) Edge concerns

Determine the potential for healing

Blood supply

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Determine the potential for healing

Risk factors and co-morbidities that mayaffect wound healing:a) Drugs i.e. immunosuppressive agents and systemic

steroidsb) Periwound edema in a chronic woundc) Serum albumin:

Treat the wound

Determine the potential for healing

Assess the wounda) Obtain the wound historyb) Assess and monitor the physical characteristics of

the woundc) Assess and manage wound pain

46

Local Wound Carea) Tissue concernsb) Infection/Inflammation concernsc) Moisture concernsd) Edge concerns

Local Wound CareWound Bed Preparation:

47

To accelerate endogenous healing

To facilitate the effectiveness ofother therapeutic measures

TIME principles of Wound BedPreparation

TIME

TISSUE

INFECTIONINFLAMMATION MOISTURE

EDGEOF

WOUND

Wound cleansing(from page 12 of UK policy doc.)

Normal saline High quality pure water Chlorhexidine gluconate 0.015 - 0.05% w/v Povidone-iodine 10% Cetrimide 0.15%

49

The effects of water compared withother solutions for wound cleansing

Water is frequently used for cleaning wounds toprevent infection. This can be tap water, di