Wound care : a collaborative practice handbook for health professionals / [edited by] Carrie Sussman, Barbara Bates-Jensen. The fourth edition of Wound Care: A Handbook of Collaborative Practice for Health Professionals is truly a new book with a new look.
Susie Seaman, CFNP, MSN, CWOCN
Geoffrey Sussman, OAM FPS, FAIPM, FACP, FAWA
Nancy Tomaselli, RN, MSN, CS, CRNP, CWOCN, LNC
Terry Treadwell, MD, FACS
Matthew J. Trovato, MD
Scott Ward, PT, PhD
Patricio Meneses, PhD
Liza Ovington, PhD, CWS
Craig Pastor, MD
Gregory K. Patterson, MD
Mary Ellen Posthauer, RD, CD, LD
Gregory Scott Schultz, PhD
Simone Bollaerts, BN, IWCC
Gail Bursch, MSEd—PT
Michael Chiacchiero, DPT
Mary Dockter, PhD, Med
Martha Henao Bloyer, MSPT
Susan Lowe, BSPT, MS Exercise Physiology, DPT, GCS
Rose Ortega, BSPT, MS in Health Science Education, Post-Professional DPT
Mary Walden, MSN, CWOCN
ASSESSMENT
The family history provides information about the general health of the patient's relatives. Aspects of the patient's environment can play an important role in the patient's health and illness.
DIAGNOSIS
In physical therapy, the patient would then be identified as a non-candidate for the referred service. In wound care, functional diagnosis is an assessment of related impairments and associated disabilities that affect the condition of the wound and its ability to heal.
PROGNOSIS AND GOALS
The functional outcome would be correctly written as: "The wound is free of infection and wound healing has progressed from the inflammatory phase to the proliferative phase." A functional outcome reports the result of the intervention, such as: “The patient performs daily activities wearing/using orthopedic equipment.
REEVALUATION
Description of the sustained outcome or change in impairment or disability as a result of the intervention (eg, pressure relief allows the patient to sit up in a wheelchair for 2 hours twice daily). A change in wound tissue characteristics and size can also be used as a functional outcome; for example "Free of necrosis, reduced risk of infection and size reduced 50%, wound clean and stable, reduced frequency of visits required" (Appendix 1.3).
CONCLUSION
An outcome expresses the result of an intervention—not the intervention or process—to achieve an outcome (eg, wound recurrence/closure). The functional outcome report: the next generation in physical therapy reporting in documenting physical therapy outcomes.
Scientific research into the physiology of wound healing has made great progress in recent decades. As a physician, you must understand basic skin and soft tissue anatomy and the science of wound healing and stay abreast of new research discoveries regarding both acute and chronic wounds.
ANATOMY AND PHYSIOLOGY OF THE SKIN AND SOFT TISSUES
Hydration and lubrication of the stratum corneum is important to keep the skin intact. During aging, several changes occur in the epidermis that alter the function and appearance of the skin structures.
WOUND HEALING PHYSIOLOGY: AN OVERVIEW
Granulation tissue stageClot and exudate
Causative factors that influence the orderly course of the healing process are presented in this chapter for each phase of wound healing. Timeliness refers to progressing the healing phases in a way that will heal the wound quickly.
INFLAMMATORY PHASE
The following is a description of the key processes of the acute inflammatory phase, including: For example, TGF-ß and PDGF are specific chemoattractants for macrophages during the inflammatory phase that continues into the proliferative phase (discussed on page 23)39 (see Figure 2.23).
HYPOTHERMIA, PLATELET ACTIVATION, AND THE COAGULATION CASCADE
Proinflammatory; Stimulates the synthesis of nitric oxide (NO) Amplifies inflammatory response through increased synthesis of IL-1 and IL-6. Activate cellular migration of ECM; controls epithelialization Proinflammatory; enhances inflammatory response through increased synthesis of IL-1 and IL-6.
VASODILATION
Macrophages are key players in both the inflammatory and proliferative phases of wound healing and arrive in the wound space approximately 2 to 3 days after injury. It also accelerates the activity of the leukocytes (neutrophils and eosinophils) in the thrombolysis of the hematoma, clotted blood that occurs in the wound after damage to the blood vessels at the time of the wound.74 This is essential for the progress. of the inflammatory phase.
INFLAMMATORY PHASE IN CHRONIC WOUNDS
Oxygen free radicals participate in many metabolic processes and serve as part of the defense mechanism against infection. When blood flow is restored to the ischemic tissue, further damage to the tissues occurs due to the disruption of the normal mechanisms of defense against injury by oxygen free radicals.
EPITHELIALIZATION PHASE
Free radicals are chemically very reactive and, if they escape, can cause severe damage to many chemical compounds that are part of the cell, especially the lipids that make up the cell membrane. This chemical reaction releases large numbers of free radicals.72 This overwhelms normal free radical defense mechanisms and leads to extensive damage to the endothelium by lipid peroxidation, with ultimate destruction of the microcirculation.
EPITHELIALIZATION PHASE IN CHRONIC WOUNDS
PROLIFERATIVE PHASE
In Figure 2.25A,B, the granulation starts on one side of the wound and "marches" across the wound bed. The myofi-broblast attaches itself to the wound skin margins and pulls the epidermal layer inward.
PROLIFERATIVE PHASE IN CHRONIC WOUNDS
The desire to learn more about the wound microenvironment has led researchers to look at wound fluid as a reflection of the microenvironment from which it was collected. However, investigators have made considerable efforts to study fluid from both acute and chronic wounds.
REMODELING PHASE
REMODELING PHASE IN CHRONIC WOUNDS
When collagen synthesis and lysis are out of balance, they never seem to reach equilibrium; the result is proliferative scarring or excessive healing. Other terms used to describe hypergranulation include exuberant granulation, hyperplasia, or “proud flesh” and are synonymous.
SUMMARY
FACTORS AFFECTING WOUND HEALING
Autonomic nervous system (ANS) neuropathy impairs the function of the sweat and sebaceous glands located in the skin. The acidity of the skin also changes, resulting in a deterioration in the ability to control surface bacteria.
Iatrogenic Factors in Chronic Wound Healing
Evaluation skills are necessary to interpret the appropriateness, relevance, reliability, and validity of tests and measurements. Data evaluation is a skill that is within the purview of licensed PTs, registered nurses, nurse specialists, physician assistants, nurse practitioners, and podiatrists who have advanced wound management skills and knowledge.
THE WOUND ASSESSMENT PROCESS
After the initial or baseline examination, reassess wound characteristics at regular intervals to measure any changes in wound status or in risk factors.70 How frequent should these regular intervals be. The documentation must be accurate and clearly reflect the patient's condition, examinations carried out, findings, care provided and correct notification of significant findings to the doctor.
ASSESSMENT OF SKIN AND WOUND ATTRIBUTES
The palms are best used to detect changes in soft tissue contours (induration, edema). Hair distribution can be used as an indicator of the level of vascular impairment and the need for vascular testing.
1 & 2 3
Ask the patient to report the start of the vibration sensation and the cessation of vibration (on-off). During the first 3 postoperative days, the temperature of the wound and adjacent tissue is typically the same.
WOUND CLASSIFICATION SYSTEMS Differential Diagnosis of Wound Etiology
Avoid using any wound grading system "in reverse" as a method for measuring wound healing. The NPUAP pressure ulcer grading system is probably one of the best known wound classification systems.
WOUND SEVERITY DIAGNOSIS
Marion Laboratory Red, Yellow, and Black Wound Classification System. Therefore, this is a popular classification system for neuro-. The Marion Laboratories color grading system is popular for its simplicity and ease of use.
EVALUATION OF WOUND HEALING STATUS
The absence of the wound healing phase indicates that the wound did not initiate the phase, for whatever reason (e.g., lack of circulation). A wound phase diagnosis of the epithelialization phase is based on findings of wound re-emergence.
ASSESSING WOUNDS IN THE INFLAMMATORY PHASE
During the assessment, record the presence or absence, color, odor, quantity, and quality of wound drainage. In wounds in the chronic inflammatory phase, necrotic tissue usually covers all or part of the wound surface.
1 & 2
If the odor persists, or the exudate expressed from the wound or adjacent tissue is colored or odorous, consider infection. Absence of exudate or dryness of the wound bed may indicate dryness and the need to add moisture (Fig. 3.36D).
13 & 4
The absence of the inflammatory phase, or the body's inability to mount an immune response to injury, can be due to many causes, including a state of immunosuppression (e.g., HIV infection/AIDS, cancer, diabetes, medications, or radiation ). treatment, excessive use of antiseptics and severe ischemia). There is no inflammatory phase with a hard, dry, black crust covering.
ASSESSING WOUNDS IN THE PROLIFERATIVE PHASE
This is a benchmark for the chronic proliferative phase and the wound must be treated to recover. The wound in Figure 3.36D is in the chronic inflammatory phase and has an absence of a proliferative phase.
ASSESSING WOUNDS IN THE EPITHELIALIZATION PHASE
The wound shown in Figure 3.49 is in both the chronic epithelialization phase and the chronic inflammatory phase. Absence of epithelialization attributes include dry, scaly, and hyperkeratotic skin at the edges of the wound.
REFERRAL CRITERIA
Each phase includes characteristics and criteria for the acute, chronic, or absent state of the phase by signs found in the adjacent, peripheral, and wound tissue. Changes in the color of the skin over bony areas (learn to identify the color of the skin that is normal for you).
SELF-CARE TEACHING GUIDELINES
Wound healing in the surgical patient: Influence of the perioperative stress response on perfusion.
INITIAL CONSIDERATIONS IN WOUND MEASUREMENT
Documenting the anatomical location of the wound is the first step in being able to reproduce measurements at that location. Record the anatomical name that clearly describes the location of the wound at the time of wound measurement.
WOUND MEASUREMENT: LINEAR METHODS
Note the significant differences in wound size between May and July. These depth measurements may or may not take place in the deepest part of the wound.
WOUND MEASUREMENT: WOUND TRACINGS
By pouring the rapidly hardening plastic into the wound, a mold is made of the wound. Measure across the wound SA from the 12:00 to 6:00 position and to the outer margin of erythema around the wound.
WOUND MEASUREMENT: WOUND PHOTOGRAPHY
Draw lines from the tissue features to the side of the chart and label with letter of key. Choose a camera with a zoom and/or macro function, if possible, to take close-up views of the wound.
REFERRAL CRITERIA AND SOURCES
SELF-CARE GUIDELINES
After the paint has dried (about 10 seconds), lift off the top layer of plastic wrap or cut off the top layer of the plastic bag. What anatomical feature of the wound must be identified for reliable wound measurement.
RESOURCES
Planimetric healing rate in venous ulcers of the leg treated with pressure dressing and hydrocolloid dressing. Paper presented at 15th Annual Meeting and Exposition of the Wound Healing Society, Chicago, IL; 2005.
SUGGESTED READINGS
Measurement of healing rate can predict the rate of complete wound healing in chronic diabetic foot ulceration. Clearly, this shows an agreement on the importance of frequent assessment; however, the best method for assessing wound healing is not agreed upon.
CRITERIA FOR EVALUATING WOUND HEALING TOOLS
An example of concurrent validation for wound healing tools is the ability of a tool to separate partial and full thickness wounds based on their scores on the tool. In other words, responsiveness is the tool's ability to respond quickly to changes in wound status.
WOUND CHARACTERISTICS ASSESSED IN WOUND HEALING MEASUREMENT TOOLS
Edges not attached to the base of the wound indicate a wound with some depth of tissue involvement (see Figure 5.5). The edges of the wound reflect some of the key features of the wound.
SUSSMAN WOUND HEALING TOOL
Try to judge what percentage of the wound has been filled with granulation tissue. The contraction is considered to be present when the open surface area of the wound is reduced.
Tissue Attributes
All items on the SWHT are scored as present (1) or absent (0), except location and stage of wound healing. This means that the wound progresses through stages corresponding to the stages of an acute wound.
Size Location and Wound Healing Phase Measures Wound depth and undermining indicate extent of wound. If a
Note that the attributes not good for healing all relate to attributes typically observed when the wound is in a chronic inflammatory phase of healing as presented in Chapter 3. After the aggressive intervention undertaken at week 2, the improvement in Wound Tissue Status from not good to good is significant in week 4.
PRESSURE ULCER SCALE FOR HEALING
Pompeo23 revised the way PUSH tool data were collected to capture system-wide wound outcome information. The PUSH tool has also been validated for use in monitoring healing of diabetic foot ulcers and venous ulcers.16-18 PUSH scores were used as an outcome measure to evaluate a community-based "Leg Club" support group on venous leg ulcer healing and demonstrated response to change in wound status for wounds that healed with the intervention.18 The possibility of using the PUSH tool for venous ulcers has also been positively evaluated in a venous leg ulcer clinic.16 As with PUSH tool use with pressure ulcers, when the PUSH tool is used for to monitor healing of diabetic foot ulcers and venous leg ulcers, it shows responsiveness to change with significant differences in PUSH scores between healing diabetic foot ulcers and venous ulcers compared with non-healing diabetic foot ulcers and venous ulcers.17 Aspects of the PUSH tool have been incorporated into several standardized patient assessment documents for various health care organizations, including OASIS for home care, MDS 3.0 for long-term care, and the proposed CARE tool for transitions across health care settings.
THE BATES-JENSEN WOUND ASSESSMENT TOOL
The total score can then be plotted on the wound continuum at the bottom of the tool to “see at a glance”. Using the BWAT score to determine severity status and guide treatment offers one approach to wound management.
Medical Diagnosis: Acute or Chronic Wound
Pressure ulcers: Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to incontinence, sweat or other fluids, e.g. Venous ulcers: Edema with leg elevation, ambulation and compression. Pressure ulcers: Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to incontinence, sweat or other fluids, e.g. Venous ulcers: Edema with leg elevation, ambulation and compression.
WOUND HEALING ASSESSMENT TOOLS DEVELOPED FOR SPECIFIC NEEDS OR
Based on exploratory factor analysis and clinical assessment, seven items were identified and included in the final version of the SCI-PUMT. At baseline, BWAT accounted for 49% and PUSH accounted for 46% of the variance in surface area and volume variables compared with 65% for SCI-PUMT.
CONCLUSION: CLINICAL UTILITY OF WOUND HEALING ASSESSMENT TOOLS
A group of experts identified a group of items designed to measure pressure ulcer healing, and another group of experts determined the content validity of the items. Because the item pool included items from the PUSH and BWAT, comparisons were made regarding the predictive validity and sensitivity of these tools to changes over time with those from the SCI-PUMT.
S PINAL C ORD I MPAIRMENT P RESSURE U LCER M ONITORING T OOL (SCI-PUMT)
- Undermining * * 0 = Healed, resolved wound 1 = None present
- Necrotic Tissue Type
- Exudate Amount 1 = None, dry wound
- Peripheral Tissue Edema
Measure the distance from the skin surface (ie, horizontal applicator) to the deepest aspect of the ulcer base. Place a ruler to measure the distance from the ulcer bed to the most distal aspect of the tunnel.
PROCEDURE FOR VASCULAR EVALUATION
Shallow ulcers in the sleeve distribution of the foot and ankle, usually the medial surface. This is primarily due to the loss of elastic recoil caused by “hardening” of the arteries.
NONINVASIVE ARTERIAL STUDIES
The normal flow is three-phase: The first sound represents forward flow during systole. The phasic flow patterns are primarily a subjective test in which the data is interpreted in a subjective manner by the clinician.
