WOUNDS_AND_WOUND_HEALING (2) (1) (1).pptx

wound healing

1. WOUNDS AND WOUND HEALING Presented by – Mrs. Khushnasib Associate Professor Subject – Adult health nursing

2. INTRODUCTION A wound is a damage or disruption to the normal anatomical structure and function. Wounds range from simple break in the epithelial integrity of the skin and extending to damage of deeper structures – subcutaneous tissues, tendons, muscles, vessels, nerves, parenchymal organs and bone Wounds may be intentional, accidental or following a disease process A wound represents a violation of natural defence barriers and encourages invasion by micro-organisms. 21-02-2024 10:44 2 RHC, IBADAN D.A. OMONIYI

3. CLASSIFICATION OF WOUNDS Aim of classification: diagnosis and stratification, prognostic information, guide management, uniformity of documentation Wounds can be classified using the following criteria: Time - acute, subacute, chronic Aetiology – surgical, penetrating trauma, blunt trauma, burns, frost bite Morphology – abrasion, incision, laceration, degloving, ulceration Degree of contamination – aseptic, contaminated, septic Complexity – simple, complex, complicated For Surgical wounds: CDC, ASEPSIS, Southampton 21-02-2024 10:44 3 RHC, IBADAN D.A. OMONIYI

4. CLASSIFICATION OF WOUNDS 21-02-2024 10:44 4 RHC, IBADAN D.A. OMONIYI Avulsion/Degloving injury Contusion Abrasion Crush injury Laceration Burn injury

5. CLASSIFICATION OF WOUNDS CDC Classification of Surgical Wounds Clean: Elective, not emergency, non-traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered. Clean-contaminated: Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g. appendectomy) not encountering infected urine or bile; minor technique break. 21-02-2024 10:44 5 RHC, IBADAN D.A. OMONIYI

6. CLASSIFICATION OF WOUNDS CDC Classification of Surgical Wounds Contaminated: Non-purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma <4 hours old; chronic open wounds to be grafted or covered. Dirty: Purulent inflammation (e.g. abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma >4 hours old. 21-02-2024 10:44 6 RHC, IBADAN D.A. OMONIYI

7. CLASSIFICATION OF WOUNDS ASEPSIS Classification of Surgical Wounds 21-02-2024 10:44 7 RHC, IBADAN D.A. OMONIYI

8. CLASSIFICATION OF WOUNDS Southampton Classification of Surgical Wounds 21-02-2024 10:44 8 RHC, IBADAN D.A. OMONIYI

9. PHYSIOLOGY OF WOUND HEALING Wound healing is a complex process involving coordinated interactions between diverse immunological and biological systems Wound healing is a continuous process but can be differentiated into four time-dependent phases for understanding: Coagulation and haemostasis phase Inflammation phase Proliferation phase Remodelling phase 21-02-2024 10:44 9 RHC, IBADAN D.A. OMONIYI

10. PHYSIOLOGY OF WOUND HEALING Coagulation and Haemostasis Phase Primary aims: Prevent exsanguination Provide matrix for invading cells in the later phases of healing Rapid reflex vasoconstriction occurs following noxious insult Process effective only in transversally interrupted vessels Vasoconstriction effective for few minutes until hypoxia and acidosis set in Formation of clot via coagulation cascade further limits blood loss 21-02-2024 10:44 10 RHC, IBADAN D.A. OMONIYI

11. PHYSIOLOGY OF WOUND HEALING Inflammatory Phase Primary aim: establish an immune barrier against invading micro organisms Further divided into: Early inflammatory phase Late inflammatory phase Involves both the humoral and cellular immune response 21-02-2024 10:44 11 RHC, IBADAN D.A. OMONIYI

12. PHYSIOLOGY OF WOUND HEALING Early Inflammatory Phase Begins during the late phase of coagulation Serves the following functions: Activates complement cascade Initiates molecular events leading to the infiltration of wound site by neutrophils Neutrophils mobilized to wound site within 24-36 h of injury for phagocytosis Phagocytosis is by proteolytic enzymes and free radical species 21-02-2024 10:44 12 RHC, IBADAN D.A. OMONIYI

13. PHYSIOLOGY OF WOUND HEALING 21-02-2024 10:44 13 RHC, IBADAN D.A. OMONIYI

14. PHYSIOLOGY OF WOUND HEALING 21-02-2024 10:44 14 RHC, IBADAN D.A. OMONIYI

15. PHYSIOLOGY OF WOUND HEALING Late Inflammatory Phase Tissue macrophages mobilized within 48-72 h to continue phagocytosis Macrophages have longer lifespan than neutrophils and work better at a lower pH Macrophages facilitates wound debridement, fibroblast proliferation and maturation, and angiogenesis Lymphocytes are the last cells to enter a wound site at 72 h 21-02-2024 10:44 15 RHC, IBADAN D.A. OMONIYI

16. PHYSIOLOGY OF WOUND HEALING 21-02-2024 10:44 16 RHC, IBADAN D.A. OMONIYI

17. PHYSIOLOGY OF WOUND HEALING 21-02-2024 10:44 17 RHC, IBADAN D.A. OMONIYI

18. PHYSIOLOGY OF WOUND HEALING Proliferative Phase Commences on day 3 of injury and lasts for 3 weeks It involves the following processes: Fibroblast migration, Collagen synthesis, Angiogenesis and granulation tissue formation, Wound contraction, and Re-epithelialization of wound surface 21-02-2024 10:44 18 RHC, IBADAN D.A. OMONIYI

19. PHYSIOLOGY OF WOUND HEALING Remodelling Phase The phase responsible for the development of new epithelium and final scar tissue formation This phase lasts 1-2 years or more Maturation of collagen – type I replacing type III until 4:1 is achieved Realignment of collagen fibres along lines of tension Decreased vascularity Collagen fibres regain about 80% of original strength 21-02-2024 10:44 19 RHC, IBADAN D.A. OMONIYI

20. PHYSIOLOGY OF WOUND HEALING 21-02-2024 10:44 20 RHC, IBADAN D.A. OMONIYI

21. PHYSIOLOGY OF WOUND HEALING Factors affecting wound healing: Site of the wound Structures involved Mechanism of wound Contamination Loss of tissue Other local factors – pressure, vascular insufficiency, radiation Systemic factors – malnutrition, diseases, medications, immune deficiencies, smoking 21-02-2024 10:44 21 RHC, IBADAN D.A. OMONIYI

22. PHYSIOLOGY OF WOUND HEALING Factors affecting surgical wound healing: 21-02-2024 10:44 22 RHC, IBADAN D.A. OMONIYI Surgical considerations Anaesthetic considerations Patient-related factors Surgical classification Tissue perfusion Diabetes Skin preparation Perioperative temperature Smoking Presence of suture or foreign body Concentration of inspired oxygen Previous radiotherapy or chemotherapy Site, duration and complexity Pain Alcoholism Suturing quality Blood transfusion Chronic renal failure Haematoma Jaundice Mechanical stress on wound Advanced age Medication Poor nutrition

23. PHYSIOLOGY OF WOUND HEALING Classification of Wound Healing Primary intention Wound edges apposed Minimal scar Secondary intention Wound left open Heals by granulation, contraction and epithelialization Poor scar Tertiary intention Also called delayed primary intention Wound initially left open Edges apposed later when healing conditions are favourable 21-02-2024 10:44 23 RHC, IBADAN D.A. OMONIYI

24. PATHOLOGY OF WOUND HEALING Chronic wound Necrotizing soft tissue infections Compartment syndrome Scars Contractures Genetic syndromes: Ehlers-Danlos, cutis laxa , homocystinuria, osteogenesis imperfecta 21-02-2024 10:44 RHC, IBADAN D.A. OMONIYI 24

25. MANAGEMENT OF WOUNDS A correct approach of treating wounds aims to effectively assist the healing process A wound represents a violation of natural defense barriers and encourages invasion by micro-organisms. Chief factors in otherwise immunocompetent individuals are the size and virulence of the inoculum, the presence of foreign body, and tissue hypoxia. 21-02-2024 10:44 25 RHC, IBADAN D.A. OMONIYI

26. MANAGEMENT OF WOUNDS General principles of acute wound management 21-02-2024 10:44 26 RHC, IBADAN D.A. OMONIYI Steps Activities Assessment Accurate history: magnitude of trauma, contamination Diagnosis and stratification Associated injuries: neurovascular, musculoskeletal, visceral Need for referral/multidisciplinary approach/triage Preparation Prophylaxis: antibiotic, tetanus Analgesia/anaesthesia Exploration, toilet and debridement Haemostasis Definitive treatment Closure: when, how, where, which first? Drainage Referral/multidisciplinary approach? After care Dressings Removal of sutures/splints Surveillance for complications Physiotherapy and rehabilitation

27. MANAGEMENT OF WOUNDS Preparation Antibiotics have a role in reducing wound infections, but they do not replace the need for aseptic technique, atraumatic handling of tissue and good perioperative wound care. The role of antibiotic prophylaxis in clean wounds is controversial. Factors to consider: clinical environment with rate of infection > 4%, patient-related risk factors, disastrous consequence of infection such as in implant surgeries, The choice of antibiotic varies depending on the site of trauma or surgery Adjuncts to antibiotic prophylaxis: perioperative normothermia and oxygen supplementation 21-02-2024 10:44 27 RHC, IBADAN D.A. OMONIYI

28. MANAGEMENT OF WOUNDS Preparation A decision regarding tetanus prophylaxis must be made in every patient with an injury; more likely in wounds: contaminated with soil or manure with extensive devitalized tissue (especially muscle) in the lower limbs, axilla caused by bites that are punctured deeply. 21-02-2024 10:44 28 RHC, IBADAN D.A. OMONIYI

29. MANAGEMENT OF WOUNDS Preparation Acute post-traumatic wound is often contaminated, hence the need for wound toileting and debridement before definitive treatment Wound cleaning should be done promptly with water, saline and or antiseptics (chlorhexidine, cetrimide, povidone iodine) 21-02-2024 10:44 29 RHC, IBADAN D.A. OMONIYI

30. MANAGEMENT OF WOUNDS Preparation Debridement is the removal of foreign matter, necrotic and devitalized tissue from the wound Debridement aims to achieve a clean, well perfused area with low bacterial count. Surgical and mechanical debridement are commonly used in acute wounds Autolytic, enzymatic and biological methods are more relevant in wounds presenting late or in chronic wounds The skin must not be undermined because of the blood supply may be compromised. 21-02-2024 10:44 30 RHC, IBADAN D.A. OMONIYI

31. MANAGEMENT OF WOUNDS Wound Closure Of two types: Direct and Transplanted closure Direct closure: For clean wounds with satisfactory vascularity, haemostasis and not under tension Sutures, staples, skin tapes and cyanoacrylate glue are commonly used in direct closure of wounds. When non-absorbable tools are used for closure, removal is often by: 48 hours in the eyelid, 4 days in the face, 7–10 days in the trunk, 10–12 days in the upper limb, 10–14 days in the lower limb 21-02-2024 10:44 31 RHC, IBADAN D.A. OMONIYI

32. MANAGEMENT OF WOUNDS Wound Closure Transplanted closure refers to when non-native tissue is used to achieve closure, such as skin grafts and flaps Local or distant flaps are preferred to skin grafting if: the wound bed is not very vascular bare tendons or nerves are exposed the wound is over a bony prominence radiotherapy or repeat surgery is contemplated better cosmetic effect is required. 21-02-2024 10:44 32 RHC, IBADAN D.A. OMONIYI

33. MANAGEMENT OF WOUNDS Wound Drainage Wound drainage is usually employed if the risk of a fluid collection is estimated to be high Blood and wound fluid collecting within or under a wound may give rise to: pressure effects (vascular compromise, airway compromise, pressure on nerves, compartment syndromes) infectious complications (infected seroma, infected haematoma , abscess) unsightly swellings A closed system of drainage is preferred because it is aseptic. 21-02-2024 10:44 33 RHC, IBADAN D.A. OMONIYI

34. MANAGEMENT OF WOUNDS Adjuncts to Wound Healing Bioengineered skin Electrostimulation Growth factors Hydrotherapy Hyperbaric oxygen Lasers Negative pressure therapy Ultrasound 21-02-2024 10:44 34 RHC, IBADAN D.A. OMONIYI

35. Thank you 21-02-2024 10:44 RHC, IBADAN D.A. OMONIYI 35