9/06/2015 Today’s topics • Understanding the physiology of wound healing • Assessment of the wound and surrounding skin Ulcer & wound management in • Determining product choice General Practice • Discuss alternative management options on wound care • What information is important in Jan Rice documentation? Director • Benefits of holistic approach to wound Jan Rice WoundCareServices management woundconsultant8@gmail.com • Explore factors influencing healing Responses following injury: Why did this skin tear become a chronic non 1. Blood clotting and formation of fibrin healing ulcer?? network 4. Remodeling and scar formation: 2. Acute inflammation: • Care staff need to be able • Type III collagen replaced by type to review a wound and • activation of neutrophils I collagen: collagen bundles are determine if it is following larger and oriented with principal • phagocytosis of foreign bodies the anticipated healing lines of stress in tissue trajectory • release of hyaluronic acid and glycosaminoglycan • Increased amounts of chemicals (chemoattractants) into ECM. • When a wound fails to such as chrondroitin and dermatan follow the normal phases or sulfate 3. Inflammatory response: stages of healing then an • Scar tissue continues to form for detailed assessment is influx of fibroblasts into ECM several months required beginnings of granulation tissue formation • Blood vessels that are unattached • Assessment includes past are resorbed generation of new blood vessels medical and surgical and current pharmacological deposition of type III collagen fibers (thin and • Scar becomes pale and avascular review together with a randomly oriented) wound assessment fibrin clot is dissolved, enzymes released and phagocytosis continues 9/06/2015 WoundCareServices 0418367485 3 Cells required.......all in theory working Phases or stage of wound healing cohesively together.... • Haemostasis – bleeding ceases and a clot is formed • Inflammatory/destructive phase — debris and • Platelets unwanted dead cells are removed through the • Neutrophils bodies natural cleansing process-autolysis • When the area is clean the body begins to grow • Macrophages ne capillaries and tissue- proliferation • Fibroblasts • When the granulation tissue is level with the sides of the wound, skin begins to migrate across • Myofibroblasts the granulation tissue • Eventually – in time it all gains strength and matures-but only 80% strength never 100% 9/06/2015 WoundCareServices 0418367485 5 9/06/2015 WoundCareServices 0418367485 6 1
9/06/2015 Physiological processes predominating in the Not to forget also .... different types of wound healing • The role of Type of healing Primary Secondary Superficial wounds Healing growth mechanism factors and • Formulation of + ++ cytokines granulation tissue • Proteases • Formulation of +++ ++ and new connective inhibitors of tissue • • proteases Contraction +++ Epithelialisation + + +++ 9/06/2015 WoundCareServices 0418367485 7 9/06/2015 WoundCareServices 0418367485 8 Yes wound healing and the What changes for chronic wounds? understanding of this is complex • Not all wounds follow the • Wound fluid studies show: sequence we expect – Increased pro-inflammatory cytokines • It is up to the clinician – Imbalance between matrix metalloproteinases overseeing care to pick up that something is not (MMP9, MMP2)and the tissue inhibitors of right metalloproteinases • Close supervision of • Swab/biopsy studies show: wounds is essential – Presence of a biofilm • Staff should seek help if – Inflammation of vessel intima they feel out of their depth! http://topnews.co.uk/images/imagecache/main_image/pathology- services08.jpg 9/06/2015 WoundCareServices 0418367485 9 9/06/2015 WoundCareServices 0418367485 10 What may cause this increase in pro- inflammatory cytokines? Some suggestions may include: • Bacterial contamination ( discuss this later) So as a clinician what should you • Repeated trauma be asking? • Ischaemia Why is this wound ‘over -inflammed ’???? • Underlying diseases — including mal nutrition http://www.emc.maricopa.edu/faculty/farabee/bi obk/Bacteria.GIF 9/06/2015 WoundCareServices 0418367485 11 9/06/2015 WoundCareServices 0418367485 12 2
9/06/2015 Consider trauma when removing this Let’s start with the basics that we all type of dressing need to heal a wound... • A healthy body • Good food and fluids, no illicit drugs, including nicotine! • Stay young! • Healthy body shape! • No infection • No trauma on the wound itself • No dangerous chemicals placed on the skin or wound • A wound free of debris and other unwanted substances 9/06/2015 WoundCareServices 0418367485 13 9/06/2015 WoundCareServices 0418367485 14 Yes nearly impossible to achieve in this Wounds in these vulnerable people group... But we must try require you to ....... • Provide good food and fluids regularly • Ensure the vulnerable skin is not roughly handled-take care to prevent skin tears, wipe creases dry without causing more damage • If you wear gloves to remove dirty dressings then remove those gloves – wash your hands and then begin the clean procedure • Learn about dressings and their function • Learn how to clean a wounds not just give it a ‘lick and a flick’ 9/06/2015 WoundCareServices 0418367485 15 9/06/2015 WoundCareServices 0418367485 16 For your free copy Normal recommended daily intake for a contact 1800 671 628 healthy person versus those with wounds and also ask for the recipes using Arginaid extra and ask for the new patient guide- Support wound healing from the inside out. 25- 100- 1.2- 30 200mg 2g/kg cal 10- /day 15- /kg 30mg 25mg 8- 12- 12- 40 mg 50g Mini-nutritional assessment scale- 10Cal/kg 15mg 16mg available from www.mna-elderly.com Energy Protein Vitamin C Zinc Iron 9/06/2015 WoundCareServices 0418367485 17 9/06/2015 WoundCareServices 0418367485 18 3
9/06/2015 Some supplements • TwoCal, Ensure Plus, by Abbott 1800 225 311 • Arginaid, Arginaid Extra by Nestlé1800 671 628 Ageing • Cubitan, Fortisip by Nutricia 1800 060 057 • Pro-Form by Meiji-MGC Diary Co 1300 362 774 • Enprocal Repair-Prime nutrition-1800631103 There are many body systems that begin to fail or function less efficiently as the ageing process takes over 9/06/2015 WoundCareServices 0418367485 19 9/06/2015 WoundCareServices 0418367485 20 Functions of the skin Skin Care 1 . Protection from – • Consider the skin as a brick wall – a wall of • The entry of foreign material • Mechanical or thermic impact – i.e. pressure, heat, cold defense-and this certainly changes as you • UV-radiation • Microorganisms – i.e. bacteria, viruses age!! • Water loss 2 . Sensation – Reacts to heat and cold, touch, pressure, vibration etc. 3. Temperature regulation – Controls the transfer of heat across the body’s surface, letting it in or out as necessary 4. Communication – Others see our skin and can assess our mood, physical state (i.e. paling or blushing) and attractiveness 5. Storage – Storage centre for lipids and water 6. Synthesis – Produces vitamin D through exposure to UV radiation in sunlight 7. Excretion – Releases wastes including water, salts and toxins 8 . Absorption – Oxygen, nitrogen and carbon dioxide diffuse into the epidermis in small amounts. Medicine can also be administered through the skin by ointments or by an adhesive patch 9. Water resistance – Prevents body fluid and essential nutrients from being washed out of the body. 9/06/2015 WoundCareServices 0418367485 21 9/06/2015 WoundCareServices 0418367485 22 Changes in the skin of the elderly Skin care • Dermis loses 80% of its original thickness • Cleanse, pat dry no rubbing • 40% less collagen • Apply moisturiser immediately cleansing and • Sebum and sweat production is reduced once or twice again in a 24hr period • Epidermal layer separates more easily from the • www.woundsinternational.com/pdf/content_ dermis 10608.pdf • Elastin fibres decrease in number but increase in • Best practice statement for Emollient therapy- size www.bdn.org.uk • Decrease in Langerhan cells • Small blood vessels diminish by 40% 9/06/2015 WoundCareServices 0418367485 23 9/06/2015 WoundCareServices 0418367485 24 4
9/06/2015 The difference between emollient and moisturisers • Emollients- lipids that occlude the skin surface thus preventing water loss from the stratum corneum • Moisturisers – are lipid emulsions that actively hydrate the skin by application of a humectant to the skin 9/06/2015 WoundCareServices 0418367485 25 9/06/2015 WoundCareServices 0418367485 26 Other systems influenced by the Common products ageing process • Neurological • Respiratory • Cardiac • Renal • Gastro • Skeletal 9/06/2015 WoundCareServices 0418367485 27 9/06/2015 WoundCareServices 0418367485 28 Body build Body build Obese patients are less mobile, have poor oxygen Emaciated and thin delivery due to the fact that adipose tissue is poorly people however have less vascularised. They also have increased risk of wound protection against dehiscence and hernia formation, together with pressure, less insulator increased moisture in skin folds and thus infections. properties and lack of • Always think fungal skin infection when dealing with energy stores to maintain obese patients and skin rashes metabolic processes which results in early breakdown of protein. 9/06/2015 WoundCareServices 0418367485 29 9/06/2015 WoundCareServices 0418367485 30 5
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