wound physiology cf

Clare Fenwick Griffith Univeristy Gold Coast 2010

Wound Physiology and AssessmentDr. Clare Fenwick

2010


Aspects of wound care?

What causes wounds (pathophysiology)?Can I eliminate the cause?

How do wounds heal (healing physiology)? What am I looking for (clinical assessment)? How will I treat the wound (product

knowledge)? What skills do I need (clinical knowledge)? Did it work (evaluation)? If not, why not


What causes/exacerbates wounds?

Wounds are generally classified as acute or chronic

Trauma/Surgery Underlying conditions Medications Lifestyle risks


How do wounds heal?

Haemostasis- vasoconstriction- platelet creation- biochemical response

Tissue Repair- inflammation (inflammatory phase)

- reconstruction (proliferative phase)

- maturation (remodeling phase)


Haemostasis

Vasoconstriction response: Arteries, arterioles and capillaries spasm to cease bleeding

Platelet response: Damaged endothelium exposes collagen fibres, platelets adhere resulting in a plug

Biochemical response: Clotting factors released causing clot formation, retraction and breakdown


Tissue Repair - inflammation

Inflammation stage (0-5 days)

Capillaries spasm, a clot forms and the wound becomes ischemicHistamine is released causing vasodilation in surrounding tissueOedema and pressure initiates the pain pathwayDefence cells migrate protecting from bacteria and clearing debris

HEAT

OEDEMA

ERYTHEMA

PAIN


Tissue Repair - reconstruction

Reconstruction stage (2-24 days): a time of cleaning and healing

Defence cells continue to clean up bacteria and clear debrisGranulation or angiogenesis appears (bumpy red new tissue) Contraction occursEpithelialisation commences


Tissue Repair - maturation

Maturation stage (24days – 1 year)

Remodelling of the wound occurs.

Previously laid collagen fibres are broken down and new stronger collagen fibres are laid down

Rosy pink scar is still remodelling; scar similar to the surrounding skin has finished this stage

A scar has only 80% of strength and elasticity

Contracture

Remodelling

(Myers, 2004)


Stage I – Nonblanchable erythema of intact skin

Stage II – Partial thickness, involving loss of the epidermis and/or dermis

Stage III – Full thickness, involving loss of the epidermis, dermis and subcutaneous

Stage IV – Full thickness, involving loss of the epidermis, dermis, subcutaneous and exposing muscle bone or supporting structures

Wound staging

STAGE ISTAGE IISTAGE IIISTAGE IV


Are you totally lost yet?


What am I looking for?

General client assessment

Assessment of the wound

Assessment of environmentaland local factors


General client assessment

Overall health Co-morbidities Mobility status Nutritional status Sensory functioning status Psychosocial status Pain Current medication


Assessment of the wound

Wound aetiology Wound location Wound dimensions Wound bed Wound drainage Wound temperature Wound infection Peri-wound


Wound aetiology


Wound location

PRESSURE ULCERS


Wound dimensions

4.2cm length3.6cm width

Wound bed

12 o’clock 3cm9 o’clock 4cm6 o’clock 4.5cm3 o’clock 3.2cm

16cm circumference

TUNNELLING WOUND


Wound Bed: Five tissue colours

Pearly pink colour – Epithelial tissue

Beefy red colour – Granulating tissue

Stringy yellow colour – Sloughy tissue

Hard black colour – Necrotic tissue

Pus green colour – Infected tissue

EPITHELIASING TISSUE

GRANULATING TISSUE

SLOUGHY TISSUENECROTIC TISSUE

INFECTED TISSUE


Wound drainage

Exudate is assessed by;

Type Amount Colour Consistency Odour


Wound Temperature

Wounds heal best at constant temperatures of 37 - 38 º C

Wounds left to cool down take about 3- 4 hours to restore to healing temperature (Shultz 2002)

Keep it warm, keep it moist


Peri-wound

Attached or unattached Indistinct or well defined Macerated or dry Thickened and calloused Irregular or round Red, white or blue


Nothing is how it seems


Assessment of environmentaland local factors

INTRINSIC (inherent to the person)

EXTRINSIC (control from outside person)

Age Pressure, friction, shearing

Underlying disease processes Temperature

Nutritional status Infection

Gender Hydration

Psychological state Foreign bodies


Modes of Healing

Primary Intention Secondary Intention Tertiary Intention Skin Graft Skin Flap

Primary Intention

Secondary Intention(Surgeries and procedures 2003)

Skin Flaps


QUESTIONS???


References

Carville, K. (2001). Wound Care Manual. Western Australia: Silver Chain Foundation.

Coleman, K. (2004). Wonderful World of Wounds. In C. Fenwick (Ed.). Gold Coast.

Hand-Surgical Approaches, Skin Flaps. (2003). Retrieved 17 February, 2004, from http://www.orthoteers.co.uk/Nrujp~ij33lm/Images9/flaps3.jpg

Edwards, S. L. (1998). High Temperature. Professional Nurse, 13(8), 521-526. Fierer, J., & Goldberg, C. (2002). Gangrene of the hand. Retrieved 2004, 2 February, from http://medicine.ucsd.edu/Clinicalimg/extremities-diabetic-foot-infection.html

Helmerd, D. (2003). Brown Recluse Spider Bite. In C. Fenwick (Ed.). Gold Coast.


References

Morgan, S. (1990). A comparison of three methods of managing fever in the neurologic patient. Journal of Neuroscience Nursing, 22(1), 19-24

Myers, B. A. (2004). Wound Management Principles and Practice. New Jersey: Prentice Hall.

Shultz, M. (2002). Wound Care. Retrieved 17 February, 2004, from http://www.medpharm.co.za/sapj/2002/july/wound.html

SpinalNet. (2004). Skin and Wound Healing. Retrieved February 4, 2004, from http://www.spinalnet.co.uk/EEndCom/GBCON/Homepage.nsf/0/98BEE04F593CFD2D00256C46004B1D74?OpenDocument

Surgeries & Procedures, Skin Grafts. (2003). Retrieved 17 February, 2004, from http://health.allrefer.com/health/skin-graft-skin-graft.html

Wound Assessment. (2000). Retrieved 13 February, 2004, from http://www.medpharm.co.za/nursing/2000/sec2000/wound.html

wound physiology cf

Education

subcutaneous stage

wound physiology

causesexacerbates wounds

wounds pathophysiology

laid collagen fibres

wound product knowledge

aspects of wound care

new stronger collagen