Wound Healing Restoration of that disruption Types of Wounds Surgical Wounds intentional Traumatic Wounds accidental Chronic Wounds persistent result of underlying condition Surgical Wounds ID: 754443
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Slide1
WOUND HEALINGSlide2
Wound
: Any disruption of cells, be it tissue or skin
Wound Healing
: Restoration of that disruptionSlide3
Types of Wounds
Surgical Wounds (intentional)
Traumatic Wounds (accidental)
Chronic Wounds
(persistent)
-
result of underlying conditionSlide4
Surgical Wounds
Patient sustains this type of wound any time a surgeon cuts into the skin to perform a surgical procedure
Are classified according to the
CDC:
Class 1 (clean)
-
Carries low risk of infection <5%
- Conditions are ideal (aseptic without prior break in skin)
- Primary closure
- Drains placed in wound are closed systems
-N
o
respiratory, alimentary,
oropharyngeal
, or genitourinary
system
entry
-Does include blunt trauma that is non-penetratingSlide5
Surgical Wounds Continued
Class 2 (clean-contaminated)
- infection risk 8-11%
- respiratory, alimentary, or
genitourinary tracts are entered
under
aseptic
, controlled conditions
- no infection or break in aseptic technique
- drains placed in wound are closed systems
- examples: biliary, appendix (prior to rupture),
vagina
,
oropharynx.Slide6
Surgical Wounds Continued
Class 3 (contaminated)
- infection risk 15-20%
- traumatic, fresh, open wounds
<
4 hours old
- inflammation may be present
- injury could have resulted in spilling of
organ contents
-Includes spillage of GI tract content or
break
in sterile technique intra-operativelySlide7
Surgical Wounds Continued
Class 4 (dirty/infected)
- infection risk 27-40%
- infection was present before the
surgical procedure
- includes traumatic wounds
>
4 hours old
- can be a ruptured or perforated organ (ex. ruptured appendix)
- tissue may appear necrotic, (dead),
have a purulent (pus) drainage, and foul
odor
Slide8
Traumatic Wounds
Chemical, thermal, physical, or outside force that has caused injury to the body tissue
Types of traumatic wounds:
abrasion laceration
avulsion perforation
chemical puncture
contusion thermal
crushed Slide9Slide10Slide11Slide12Slide13Slide14Slide15Slide16Slide17
Incised Wound Cont.Slide18
Chemical Wound/Burn
The chemical burn is a part or an entire destruction of the molecules, the cells or the structure of the skin due to an irritant or corrosive chemical product. The importance of the tissue modification will characterize the degree of the burn.Slide19
Thermal Burn
This patient received a thermal burn to the buttocks, and there was complete destruction of the skin and some of the underlying fat. This shows the exposed fat after the MD
debrided
the necrotic skin. Normal fat appears yellow.Slide20
Traumatic Wounds Continued
Classifications of:
Closed
- outside skin intact, tissue
under skin is not
Open
– outside skin broken
Simple
Complicated
Clean
ContaminatedSlide21
Closed Wounds
Simple fractures
Torn ligaments
Blisters Slide22
Open Wounds
Simple
Skin interruption without loss or destruction of the underlying tissue
LacerationsSlide23
Open Wounds
Complicated
Skin and underlying tissue injury or destroyed
Burns
Crushing injury
Foreign object (bullet or foreign object that is present such as knife or nail)Slide24
Complicated WoundSlide25
Complicated Wound cont.
Pt. from Nigeria.
Machete wound to the scalp.
Patient survived wound and surgery. Slide26
Open Wounds
Clean
Object or conditions surrounding injury were clean
Wound cared for within 6 hours of injury
Heals by primary intention
Cut that happens when loading a dishwasherSlide27
Open Wounds
Contaminated
Conditions surrounding injury not clean or care given 6 hours after injury
Heals by 2
° or 3° intention
Injury occurs when handling feces from an animal or personSlide28
Chronic Wounds
An underlying condition of the patient is causing their wound to not heal
Delayed healing results from persistent infection or disease processes:
Diabetes (gangrenous ulcer)
PVD
MRSA/VRSA
Pressure sores
Immuno-compromised (Cancer/chemotherapy/AIDS/steroid therapy)Slide29
Wound Healing/Closure
Types of:
Primary Intention/First Intention
- Surgical wound
- Edges are closely approximated
- Closed by suture, staples, or
adhesive tapes/gels
- No tissue lost
Slide30
Healing by First or Primary IntentionSlide31
Healing by First or Primary Intention? Maybe not!Slide32
Wound Healing/Closure
Secondary Intention/Second Intention
Trauma or Chronic wounds
Wound is not closed
A. Wounds that cannot be re-approximated
B. Infection risk too high to close by 1
° intention
Must remove dead or necrotic tissue by process of debridement prior to allowing healing by this means
Healing occurs from the inside out and is prolonged as a result
Tissue is lost
Slide33Slide34
Wound Healing/Closure
Tertiary Intention/Third Intention
Surgical, Trauma, or Chronic wound
Closure by primary intention must be delayed due to swelling, inflammation, contamination, or patient’s condition (unstable)
May require debridement before closure
Closure delayed 4 to 6 daysSlide35Slide36
Physiological Consequences
Of A Wound
Sympathetic Nervous System Response (Fight or Flight):
↑ HR hyperventilation
↑ BP ↑ mental status
↑ clotting ↑ muscle tension
* Results in vasoconstriction and decrease in blood being delivered to the abdominal organs as bleeding is attempted to be minimized by the body and delivered to vital organs
Slide37
Wound Healing
Natural and Spontaneous Phenomenon
If cannot occur naturally, must remove dead tissue or foreign bodies, treat for infection, and re-approximate the tissue until healing can take place
May occur with sutures, stapling devices, clips, steri-strips, or topical adhesive
(Derma-bond)Slide38
Tissue
Collection of cells that are similar as well as the intercellular substance around them
Four Tissues of the Body:
Epithelium
Connective tissue (blood vessels, bone, and cartilage)
Muscle
Nerve Slide39
Stages of Normal Wound Healing
Lag (Inflammatory) Phase
Healing (Proliferative) Phase
Maturation (Remodeling) PhaseSlide40
Lag/Inflammatory Phase
Lasts 1 to 4 days
Fluid called exudate, containing blood, fibrin, and lymph accumulates in wound
Clotting begins as the exudate binds the wound edges together
Inflammation, a vascular and cellular reaction gets rid of bacteria, foreign matter, and dead tissue
Inflammation causes site to be red, swollen, warm, and painful
Scab (dry, protective layer) forms
Wound strength limited at this timeSlide41
Healing/Proliferative Phase
Begins day 5, lasts two weeks
Epithelialization, new cell formation
Strength of wound increases due to collagen fibers that are produced
Directly related to tensile strength of the wound
Edges of wound continue to be brought closer together Slide42
Tensile Strength
Affects ability of tissue to withstand injury
not
how long it takes the wound to
heal
This is the term referring to the pull strength of a wound or the ability to resist rupture.
As
collagen forms, tissue strength rapidly increases, but it may take months for a plateau to be reached
Until that plateau is reached, wound tissue requires extrinsic support, usually sutures to bring it back togetherSlide43
Remodeling/Maturation Phase
Begins after 2
nd
week of wound and lasts about 4 weeks and can last over a year if the wound is extensive
Scar tissue forms (collagen formation becomes dense)
Scars have limited vascularization, hence they are pale in color
Ultimate strength of wound is 80% of the nonwounded tissueSlide44
Physiological Consequences
Of A Wound Continued
Contamination/Potential Infection
Hemorrhage and Excessive Clot Formation
Complete or total loss of organ function
Cell or Tissue DeathSlide45
Factors Influencing Wound Healing
Wound Type
Patient’s Physical Condition
Type of OperationSlide46
Wound
Complications
Adhesions –
abnormal attachments
Debridement
–
the process of removing devitalized tissue
Dehiscence –
the breakdown of suture lines
Evisceration –
the spillage of bowel from the abdominal cavity.
Fistula
–
pathway between two normally separate surfaces
Gangrene
-
Localized
death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection.
Granulation
-
new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process
Hematoma -
A solid swelling of clotted blood within the tissues
Hemorrhage –
MASSIVE
blood loss (((regular)) blood loss comes from a paper cut)Slide47
Wound
Complications
Herniation -
the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains
it.
Infection
Ischemia –
loss of blood flow to an area
Keloid –
abnormal scar formation
Necrosis
–
tissue death
Proud Flesh -
the swollen tissue around a healing wound or ulcer
Sinus
–
cavity with only an exitSlide48
Other Wound Terms
Cicatrix –
normal scar formation
Collagen -
The main structural protein found in animal connective
tissue.
Serous -
thin, watery
liquid, usually clear
Sero-sanguinous -
A serum-like exudate which is blood-stained (i.e. Pink fluid)
Sanguinous –
fluid containing mostly blood (i.e. Red fluid)
Tensile strength
–
the pull-strength of tissue or suture.Slide49
Patient’s Physical Condition
Smoking
Circulation
Age
Nutritional status
Obesity
Immunologic status
Pre-existing disease
processes:
Respiratory
Diabetes
Drug therapies
Cancer
Anemia
CardiovascularSlide50
Type of Operation
Aseptic technique
Handling of tissue involved
Methods of achieving hemostasis
Security of the wound
How the wound was approximated
Where the wound is anatomicallySlide51
Surgical Site Infections
Incisional
- at the site of incision
Deep Wound
- within the tissue or in the cavity where the operation occurred
Nosocomial
- acquired while in the hospitalSlide52
Wound Care
Aseptic Technique
Prophyllactic
antibiotics
Antiseptics/antimicrobials
used for skin
prep
Adequate
oxygenation
of tissues by maintaining patient oxygenation
Closed wound drain systems
when drains are used
Sterile technique/supplies
with dressing changes
Dressings secured
with clean tape or sterile packaged dressings (tegaderm/primapore) Slide53
Summary
Definitions
Physiological Consequences of a Wound
Wound Types
Mechanisms of Wound Healing
Stages of Wound Healing
Factors Influencing Wound Healing
Surgical Site Infections
Wound Care