wound hand out

8/12/2019 WOUND Hand Out

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WOUND

Titis Kurniawan

Learning Outcomes

Perticipant will able to explain:

1. Wound definition

2. Wound etiologies & pathology

3. Wound classification

4. Wound healing process

5. Wound complication

6. Wound healing related factors

7. Wound care principles


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Anatomi & Fisiologi Kulit

Fakta

Ketebalan 0,5 6 mm

Organ terbesar

Epidermis terbarui tiap 26 42 hari

15% BB

Menerima 1/3 vaskularisasidarah tubuh

Fungsi:

Proteksi

Immunity

Thermoregulasi

Sensasi

Komunikasi

Metabolisme

Wound

Adalah = terkoyaknyajaringan kulit akibattrauma; Biologis

Mekanik

Suhu

Kimiawi


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Wound Grading

Methods; classified based on their aetiology, location, type of injuryor presenting symptoms, wound depth and tissue loss or clinicalappearance of the wound.

1. General Wound Superficial (loss of epidermis only)

Partial thickness (involve the epidermis and dermis)

Full thickness (involve the dermis, subcutaneous fat and sometimesbone)

2. Healing Time Akut = 2 Minggu 6 bulan; luka operasi, trauma, luka

bakar Kronik = > 6 bulan; pressure/leg/diabetic ulcer

....Wound Grading


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....Wound Grading

....Wound Grading


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....Wound Grading

Wound Healing Process

1. Haemostasis (0 several hourse) Immediately after wounding

Vasoconstriction platelet aggregation degranulation, and fibrinformation /clothing

2. Inflamation (0 3 days) Vasodilatation antibody, WBC (monocytes, neutrophils,

lymphocytes, macrophag), growth factors (transforming growth factor(TGF)-, platelet-derived growth factor (PDGF), fibroblast growthfactor (FGF), and epidermal growth factor (EGF), pro-inflamatorycytokines

Inflamatory signs; rubor, calor, dolor, tumor, functiolaesia

Neutropils & macrophag clearance of invading microbes andcellular debris in the wound area

Macrophag clear apoptotic cells undergo a phenotypictransition to a reparative state that stimulates keratinocytes,fibroblasts, and angiogenesis to promote tissue regeneration


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.................Wound Healing

..............Wound Healing Process

3. Proliferation (3 24 days) Follows and overlaps with the inflammatory phase, and is

characterized by epithelial proliferation and migration overthe provisional matrix within the wound (re-epithelialization).

In the reparative dermis, fibroblasts and endothelial cells arethe most prominent cell types present and support capillary

growth, collagen formation, and the formation of granulationtissue at the site of injury.

Within the wound bed, fibroblasts produce collagen as wellas glycosaminoglycans and proteoglycans, which are majorcomponents of the extracellular matrix.(ECM)

Healthy granulation tissue is granular and uneven in texture;does not bleed easily and is pink/red in colour.

Dark granulation tissueindicative of poor perfusion,ischaemia


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..............Wound Healing Process

4. Maturation (24 days 1 year)

Following robust proliferation and ECM synthesisfinal remodeling phase, which can last for years.

Regression of many of the newly formed capillaries vascular density of the wound returns to normal.

Critical feature of the remodeling phase is ECM

remodeling to an architecture that approaches that ofthe normal tissue


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....Wound Healing

.........Wound Healing


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Wound Healing



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.........Wound Healing


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.......Wound Healing Primary Intention; most clean surgical wounds and recent

traumatic injuries are managed by primary closure. The edges of thewounds are approximated with steri strips, glue, sutures and/orstaples. Minimal loss of tissue and scarring results.

Delayed Primary Intention; is defined as the surgical closure of awound 3 -5 days after the thorough cleansing or debridement of thewound bed. Used for 1. Traumatic wounds, 2. Contaminated surgicalwounds.

Secondary intention; occurs slowly by granulation, contraction andre-epithelialisation and results in scar formation. Commonly used for

1. Pressure Injuries 2. Leg ulcers 3. Dehisced wounds

Skin Graft; removal of partial or full thickness segment of epidermisand dermis from its blood supply and transplanting it to another siteto speed up healing and reduce the risk of infection.

.........Wound Healing Factors

Sistemik Usia

Diabetes

Infeksi

Status kesehatan

Immunitas Nutrisi (Malnutrisi/obesity)

Merokok

Psikologikal faktor

Obat

Chemo/Radiotherapi

Laboratorium

Lokal

Kondisi luka (lokasi,ukuran, tipe, edema)

Kelembaban

Oksigenasi

Infeksi

Nekrosis

Trauma

Tekanan

Vaskularisasi


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Hiperglikemik mengganggu fungsi fagositosis & intracellular killingfaktor (Calhoun et al., 2002)

Temporary Hypoxia pd luka akut menstimulasi cytokines (PDGF,TGF-, VEGF, tumor necrosis factor-(TNF-), and endothelin-1)meningkatkan proliferasi, migrasi, chemotaxis, & angiogenesis(Rodriguez et al., 2008).

Oksigen jaringan < 30 mmHg macrophag menjadi dormant (Black,2005).

Jumlah kuman 102/gram jaringan menghambat pertumbuhan sel baru

dan jika jumlah kuman > reaches 105/gram jaringan meningkatkanpro-inflammatory, cytokines, dan matrix metalloproteases (MMP)serta menurunkan tissue inhibitor of metalloproteases (TIMPs) dangrowth factors memperpanjang inflamasi & menghambatpenyembuhan (Stotts & Wipkie-Tevis, 2001; Stotts, 2003).

.........Wound Healing Factors

Usia tua penurunan respon immunitas (sel T), fagositosismacrophag, re-epitelisasi, growth factor & angiogenesis danpeningkatan sekresi mediator inflamasi, (Gosain and DiPietro, 2004;Swift et al., 2001).

Exercise menurunkan pro-inflamatory cytokine & meningkatkananti-inflamatory responses memperbaiki cutaneous wound healing

(Emery et al., 2005; Keylock et al., 2008).

Stress meningkatkan kortisol menurunkan sistem imun (Glaserand Kiecolt-Glaser, 2005; Vileikyte, 2007) meingkatkan sekresiepinerphin & norepinerphin Hiperglikemic menghambat woundhealing (Calhoun et al., 2002)

Obesity DM, Hypertensi, >>adiposa (adipokin) ,


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Dampak Negatif Komplikasi Luka

Infection & Other physical

problem

Psycho-Socia problem

Economical burden

Poor

Quality of Life

Wound Care

Tujuan

Membersihkan luka

Mengontrol/meminimalisirinfeksi

Mempercepat prosespenyembuhan


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...........Wound Care

Tahapan (Canadian Associationof Wound Care [CAWC], 2006)

Wound assessment

Wound cleansing

Debridement

Inflammation or infection control

Moisture control

...........Wound AssessmentParameter Clinical observation Indicator

Measure Length, width, depth,area

Reduction or increase in woundsurface area and/or depth

Exudates Amount, quality Decreased or increased amountDecreased or increased purulence

Appearance Wound bed appearance,tissue type, and amount

Increased or decreased percentageof granulation tissue

Increased or decreased percentageof necrotic tissue

Friability of granulation tissue

Suffering Patient pain level usingvalidated pain scale

Improved or worsening wound-relatedpain

Undermining Presence or absence Decreased or increased amount

Re-evaluate Monitor all parameterson regular basis everyone to four weeks

Parameters sequentially documentedin patient record

Edge Condition of wound edgeand surrounding skin

Presence or absence of attachededge with advancing border ofepithelium

Presence or absence of erythematicand/or indurations tissue

Presence or absence of maceration


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...........Wound Cleansing

...........Wound Debridement

Debridement the removal of dead, devitalizedor contaminated tissue from within or adjacent to awound and foreign material surrounding healthytissue is exposed (Sibbald et al., 2000).

Tujuan reduces the bacterial load, restorechronic wound to acute wound, release growth

factors that facilitates healing process, andenables to swab for culture purposes (Edmonds,2006).

Effective debridement (higher debridement index)will be more support the wound closure (Saap &Falanga, 2002).

Methods surgical debridement, autolytic,enzymatic, biologic, and mechanical debridement(Kirshen et al., 2006; Sibbald et al., 2000).


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...........Infection Control & Improve Healing

Antiseptics Effect

Sodium hypochloritesolution

High pH causes irritation to skin. Dakins Solution and Eusol(buffered preparation) can select out gram-negativemicroorganisms

Hydrogen peroxide Desloughing agent while effervescing. Can harm healthygranulation tissue and may form air emboli if packed in deepsinuses.

Mercuric chloride,crystal violet, Proflavine

Bacteriostatic agents active against gram-positive speciesonly. May be mutagens and can have systemic toxicity.

Cetrimide (quaternaryammonium)

Good detergent, active against gram-positive and negativeorganisms, but high toxicity to tissue.

Chlorhexidine Active against gram-positive and negative organisms, withsmall effect on tissue.

Chlorhexidine Active against gram-positive and negative organisms, withsmall effect on tissue.

Acetic acid (0.5% to 5%) Low pH, effective against Pseudomonas species, may selectout S aureus.

Povidone iodine Broad spectrum of activity, although decreased in thepresence of pus or exudate. Toxic with prolonged use or overlarge areas

1. Wound Hygiene

Wound cleansing (Sibbald et al., 2007)

...........Inflamation & Infection Control

Moist environment accelerate woundhealing approximately 50% (Geronemus &Robins, 1982)

No one dressing that complete all

recommended requirements includingkeep wound moist but maintain peri-wound dry, absorb exudate effectively,improve healing, simple applied, andinexpensive (Sibbald, 2000).

Topical Agent; Honey based dressing,silver containing dressing, Becaplermingel, dll

2.2.2.2. Maintaining Wound Moisture and Stimulate New Cells Growth


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........Dressing

Honey Based Dressing Antimicrobial, Anti-inflammatory, Promotes

debridement (slough and necrotic wounds),Provides a moist wound environment,Reduces wound mal odor (Acton &Dunwoody, 2008).

Effective improve healing rate in mild tomoderate superficial and partial thicknessburns compared with some conventionaldressings (Jull Andrew, Rodgers, andWalker, 2008)

Effective for Venous leg ulcers, Pressureulcers, Burns, Surgical wounds, Necrotizingfasciitis, Diabetic foot wounds (White, 2005).

Decreased in wound pH and a reduction inwound size (Gethin Cowman, & Conroy2008).

Silver containing dressing

Effective in reducing wound depth, and lessdeterioration than hydrofiber containing calciumalginate dressing (Jude, Apelqvist, Spraul, &Martini, 2007).

Beneficence including reducing wound size,

less adverse effects, exudates and periwoundmaceration control and improve granulation(quantities/qualities) (Coutts & Sibbald (2005)

No significant different in improving healingprocess therefore there was insufficientevidence to recommend the use of silver-containing dressings or topical agents fortreatment of infected or contaminated chronicwounds (Vermeulen, van-Hattem, Storm-Versloot, & Ubbink, 2007).

........Dressing

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