final integ – Flashcards

use of fluid to remove loosely adherent cellular debris, surface bacteria, wound exudate, dressing residue, and residual topical agents. Facilitates debridement, assists with achieving and maintaining a moist wound environment, and enhances wound healing.

granular nondraining: Pulsed lavage with suction, Estim, US, Hyperbaric oxygen granular draining: Pulsed lavage with suction, whirlpool, Estim, US, low frequency US, Hyperbaric oxygen necrotic nondraining: whirlpool, Pulsed lavage with suction, Estim, low freq US, Hyperbaric oxygen necrotic draining: whirlpool, Pulsed lavage with suction, Estim, US to periwound, low freq US, Hyperbaric oxygen closed wound with red, raised scar limiting ROM: cont. US

nonselective mechanical debridement. debride loosely adherent devitalized tissues, foreign debris, and surface bacteria. softens necrotic tissue and eschar, facilitating their removal. hydrates the wound bed and promotes moist wound healing. promotes circulation, which can enhance wound healing. decreased patient pain complaint during wound care procedures. eases range of motion for patients with burn injuries. without agitation- used to help soak off adherent wound dressings while minimizing pain and trauma to the wound bed.

delivery of a wound irrigant under pressure by an electrically powered device. MC irrigant- saline, followed by tap water. Involves the regular, automatic interruption of fluid flow with a handheld device to regulate irrigation pressure. With concurrent suction, Applies a negative pressure to the wound bed, which removes the irrigant and facilitatse the removal of pathogens and enhance granulation tissue formation, epithelialization, and local tissue perfusion.

facilitates wound healing by: restoring the current of injury, causing galvanotaxis, stimulating cells, enhancing blood flow, combating infection, reducing edema, and enhancing autolysis. Restores the current of injury- Normally, the epidermis is (-) with respect to the dermis, = bioelectric field or "skin battery." A break in skin continuity ↓ skin's electrical resistance and disrupts the skin battery, making the wound (+) compared to the surrounding tissues. Local change in polarity, or endogenous current of injury, triggers the wound healing cascade. Causes Galvanotaxis- stimulation of cells to move along an electrical gradient. attract and enhance the migration of macrophages, neutrophils, fibroblasts, endothelial cells, and keratinocytes. Stimulates cells- general increase in cell proliferation. Increases blood flow- resulting in higher capillary oxygen tension and tissue partial pressure of oxygen. Greater oxygen availability ↑ ability to fight infection and body's ability to build new tissue in all 3 phases of wound healing. Increases bactericidal abilities- antibacterial effect on wound tissues. Reduces edema- by reducing microvascular permeability induced by injury and inflammation. Facilitates debridement- (negative or cathodal stim) facilitate autolytic debridement.

not a lot of research: support the use of low frequency (25-40 kHz) ultrasound in combination with saline mist to assist with debridement of adherent fibrin and to decrease bioburden within chronic wounds. Proliferative phase- stimulate fibroblast proliferation, resulting in greater collagen deposition, enhanced granulation tissue formation, facilitate/increased angiogenesis, and hastened wound contraction. later phases of wound healing: ↑ wound tensile strength. maturation and remodeling phase: stronger and more pliable scar

↑ local blood flow and capillary filling and lymphatic flow and ↑ enhancing tissue perfusion and oxygenation. approximate wound edges, facilitating wound contraction and closure. due to the warm, moist wound healing environment obtained through the use of foam and a semi-occlusive film dressing.

administration of 100% medical-grade oxygen at greater than 1.5 atmospheres absolute pressure. Oxygen reaches a wound bed by being attached to hemoglobin molecules. Under normal atmospheric pressure, hemoglobin is 97% saturated with oxygen. Under the high pressures of HBO, oxygen dissolved within the plasma is increased by about a factor of 14. Tissue partial pressures of oxygen must be greater than 40 mm Hg for normal healing. HBO therapy: ↑ concentration gradient for oxygen (improves oxygen's ability to diffuse into the affected area and hemoglobin's ability to carry oxygen, ultimately providing more oxygen for cell metabolism), ability of white blood cells to kill bacteria by providing an oxidative burst to help reduce bacterial growth, and stimulate angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, and wound contraction. Pressure of HBO and patient positioning: reduce edema.

I: all wound types (primary for healing granular wounds) C: wounds with active, profuse bleeding A: simple, quick, inexpensive, effective, can be used for any wound location and in any setting D: messy and may not use adequate amount of irrigant

I: infected wounds to help reduce bacterial load, on nondraining wounds to rehydrate the wound bed, on wounds with thick eschar to soften necrotic tissue, and on wounds with loosely adherent necrotic tissue or thick exudate to facilitate debridement. C: overused interventions in wound management. ulcers due to venous insufficiency, edema, or lymphedema. The dependent positioning and warm water temperature cause an increase in peripheral edema that will exacerbate venous insufficiency, traumatic edema, and lymphedema while the additional hydration will only increase the already heavy amounts of wound drainage. incontinent of bowel and have wounds that would require submersion of the perineum. Patients who are incontinent of urine and require submersion of the perineum should have a catheter placed. However, because this increases the risk of urinary tract infection, alternative interventions may need to be considered. active, profuse bleeding. Patients who are confused and combative and patients with uncontrolled seizures should not receive whirlpool treatments because of the risk of injury and possible drowning and to protect the clinician from splash injuries. clean, granulating wounds, as the force of agitation may traumatize granulation tissue and slow epithelialization. If whirlpool treatments are to be performed on patients with arterial insufficiency ulcers, the water temperature should be decreased to between 92 and 98°F to allow an increase in circulation while avoiding placing excessive metabolic demands on the tissues. Obese patients or wounds with undermining or tunneling should not be placed in the whirlpool. Water temperature should be decreased if a patient who is pregnant or has multiple sclerosis is to be immersed within a Hubbard tank. Patients with cardiac instability should not be fully immersed in a whirlpool unless cleared by their physician. A: comfortable, promotes moist healing, available, simple, effective D: can't calibrate pressure, expensive, requires time (setup/cleanup), potential for maceration, edema, cross-contamination

I: cleansing or debriding wounds due to arterial insufficiency, venous insufficiency, diabetes, pressure, small burns, surgery, or trauma. tunneling or undermining wounds with the use of interchangeable tips to facilitate irrigating areas of various sizes. (does not increase edema) so... venous insufficiency ulcers. Pulsed lavage may be most effective during the inflammatory phase of wound healing to soften and remove necrotic tissue and exudate. C: (with concurrent suction) near exposed arteries, nerves, tendons, capsules, or bones. body cavities, for facial wounds, on recent grafts or surgical procedures, or on wounds that are actively bleeding. latex allergies/sensitivities (precaution): on anticoagulants and insensitivity or deep tunneling wounds A: encourages thorough irrigation, any setting or location, quick, less expensive than whirlpool, low cross-contamination risk, decrease pain, ergonomical D: messy, more expensive than irrigation, no large wounds

I: chronic or recalcitrant wounds that are clean or infected, granular or necrotic. In combination with standard wound care: increased healing for wounds of various etiologies, including pressure ulcers, neuropathic ulcers, venous ulcers, arterial ulcers, burns, traumatic wounds, and surgical wounds. reserved for chronic, nonhealing wounds or for patients at risk for delayed wound healing. C: simple, uncomplicated wounds. wounds with osteomyelitis (cannot resolve a bone infection, and facilitating wound closure for these wounds would only result in abscess formation, must first be surgically debrided). in combination with topical agents containing heavy metal ions, actively bleeding wounds (attainment of hemostasis). with caution on patients with sensory neuropathy to avoid excessive current intensities. A: research supports efficacy, any setting, no pain, less setup/cleanup time than whirlpool D: more time consuming, risk of contamination, not used on extensive wounds

I: chronic or recalcitrant wounds that are clean or infected. Noncontact low-frequency ultrasound combined with saline mist -assist with the debridement of fibrin within chronic wound beds. C: presence of osteomyelitis, active profuse bleeding, severe arterial insufficiency, and acute deep vein thrombosis. on untreated acute wound infections. A: any setting, quick, less setup/cleanup time and dependency than whirlpool, doesn't hyperhydrate D: less research support, no medium or large wounds, painful/difficult to apply, risk of contamination

I: chronic, acute, and traumatic wounds; partial-thickness burns; dehisced wounds; pressure ulcers; neuropathic ulcers; and muscle flaps and skin grafts. exposed bone, tendon, orthopedic injuries such as degloving, and hardware. post-surgical wounds and grafts C: dry wounds, necrotic wounds, in body cavities, over malignancies, and in the presence of exposed blood vessels or untreated osteomyelitis. immediately after an incision and drainage procedure to allow for adequate wound visualization and monitoring for infection. associated with at least six deaths and 77 injuries from 2007 to 2009, most related to excessive bleeding. Extreme caution: patients on anticoagulants, near vascular grafts or vasculature, and to wounds with active bleeding as the negative pressure may cause increased bleeding. A: cost less over time, any setting, maintains warm, moist environment D: no standard for use, pain with treatment and dressing changes, noisy, hinder pt mobility, difficult to obtain air-tight seal with drape, skin damage, increase would care costs

I: gas gangrene, crush injury, acute peripheral arterial insufficiency, acute traumatic peripheral ischemia, grade 3 or worse LE diabetic wounds, progressive necrotizing infection, Chronic refractory osteomyelitis, osteoadionecrosis, soft tissue radionecrosis, preparation and preservation of compromised grafts and flaps C: DVT, CHF, Claustrophobia, COPD, Pregnancy, severe arterial insufficiency A: TCOM test - predict treatment efficacy, prevent loss of limb D: extremely high cost, require extensive tx time

o Wound irrigation: soaking the wound with saline-moistened, whirlpool, and pulsed lavage. o Whirlpool- wound irrigation, soaking the wound with saline-moistened gauze, and pulsed lavage. o Pulsed lavage- Alternative interventions to pulsed lavage may include wound irrigation, soaking the wound with saline-moistened gauze, and whirlpool treatments. o Electrical Stimulation: Although less supported by research, ultrasound and hyperbaric oxygen may be appropriate alternative adjunctive interventions to facilitate wound healing. o Ultrasound: Estim, negative pressure wound therapy or topical growth factors are alternative interventions that may be beneficial as adjuncts to wound healing. Paraffin, soft tissue mobilization, or silicone dressings may be appropriate alternative interventions for assisting with scar tissue modulation. o Negative pressure- Because there is more extensive research supporting the use of estim, unless contraindicated, clinicians would be wise to perform a trial of high-voltage pulsed current prior to initiating NPWT. o Hyperbaric Oxygen chamber: Prior, the potential for revascularization must first be considered. In addition, estim is a less expensive, better researched intervention that may be beneficial as an adjunct to wound healing

MC irritant solution is normal saline. However, regular tap water is an acceptable alternative, with no additional risk of wound contamination if a clean water source is available. In fact, irrigation with regular tap water may result in faster wound healing and lower treatment cost than irrigation with saline. Wounds should be irrigated with pressures between 4 and 15 psi. This is equivalent to using a 35-mL syringe with a 19-gauge angiocatheter or a Waterpik at the lowest setting (6.0 psi). Recent recommendations suggest that pressures between 10 and 15 psi are most effective for preventing infection. Irrigating a wound after whirlpool treatment has been shown to remove four times as much bacteria as whirlpool alone.

During treatment, patients should be encouraged to perform active range of motion exercises unless contraindicated. Active motion may decrease the potential for edema and may decrease joint stiffness or impaired range of motion. Because irrigating a wound after whirlpool treatment has been shown to remove four times as much bacteria as whirlpool alone, clinicians should consider irrigating the wound after removing the patient from the whirlpool. Patients with edema in whom the benefits of whirlpool outweigh the potential side effects of increased swelling should be positioned supine with the involved extremity elevated for 10 minutes after whirlpool treatments. Ankle pumps or active range of motion will further assist with, but not completely resolve, the increase in edema. Showering technique- The patient or affected area is positioned over the empty whirlpool and sprayed with water between 92 and 98°F. The use of chemical additives- Chemical additives are contraindicated for use on patients with chemical wounds to prevent a chemical reaction. They are also contraindicated for use with the very young, older adults, and those with sensitivities to these agents.

The patient should wear a mask due to aerosolization during treatment. To protect from a splash injury and aerosolization of pathogens, the clinician (and any other personnel in the room) must use appropriate barrier devices, including gloves, shoe coverings, hair covering over the ears, protective eyewear or face shield, moisture-resistant gown, and mask. The irrigant reservoir, typically one or more bags of normal saline, should be warmed to between 102 and 106°F, if possible to maintain normotherrnia. Depending on wound size and severity, between 1,000 and 3,000 mL of irrigant is required for thorough wound irrigation. The pump should be turned on, and the pressure adjusted according to the wound's needs, between 4 and 15 psi. Typically, lower pressures are used initially or with tunneling and undermining wounds. Treatments generally require 15-30 minutes. To decrease the risk of cross-contamination, the patient should be treated in a room with four walls and a door, rather than a curtained area. For inpatients, a private room is preferred. Treatment frequency may be as often as twice daily for wounds that are severely infected, contain significant amounts of necrotic tissue, or have thick exudate, or as infrequently as three times per week for granular wounds. Pulsed lavage should be discontinued when treatment goals have been met.

Because physical therapy personnel generally do not perform systemic HBO therapy, only cursory procedures are provided. Treatment frequency varies from twice daily to three times per week. Patients typically require anywhere between 10 and 60 treatments, with an average of between 37 and 44 treatments. If a 50% reduction in wound surface area is not noted after 10 HBO treatment sessions, the wound is unlikely to respond to this modality and alternative interventions should be considered.

3 techniques: direct, immersion and periwound. Direct technique- Unfortunately, occlusive dressings have too great a resistance to electrical flow to be used as a conductive medium for electrical stimulation, therefore, applied directly to the wound bed. If there is a decline in wound or no improvement after 2 weeks, alternative interventions must be considered. Immersion technique- wound is placed in a nonmetal basin filled with water. treatment electrode is then placed contact side down within the basin, essentially making the entire water-filled area the treatment electrode. beneficial for patients with multiple foot or hand ulcers. Major disadvantages - lack of controlled studies using this protocol, potential maceration of the periwound and hyperhydration of the wound bed, and dependent positioning. Periwound technique- application of electrodes to the intact periwound rather than the wound bed. Treatment electrodes are placed so as to straddle the wound bed. The two advantages to this technique include the ability to keep wound dressings in place and the decreased potential for wound contamination. Parameters: 80-125 Hz. Adjustable interpulse interval, 50-100 microseconds. intensity: 75- 200 volts and produce a comfortable paresthesia. decreased sensation: intensity- submotor and not exceed 200 volts. • 45-60 minutes or as little as 30 minutes if performed 2 x day. Inpatient treatments: once or twice daily, outpatient treatments: 3 x per wk

three techniques to facilitate wound healing: direct, periwound, and immersion. Direct technique: most researched: applying ultrasound directly to the wound bed. The wound should be irrigated and the clinician should perform any debridement necessary prior • Deep wounds- filled with an amorphous hydrogel or normal saline to allow the transmission of energy into the wound bed and covered with a barrier to prevent contamination from the conductive gel. sheet hydrogels appear to transmit the greatest amount of ultrasound energy= best barrier • 100% granular and a sheet hydro gel is used for bandaging= leave the dressing in place for several days and perform ultrasound over the dressing without removal and irrigation. • After selecting a wound barrier, ultrasound gel is applied over the barrier as a coupling medium. Because scars have intact skin barrier function, a barrier is not used when applying ultrasound to assist with scar remodeling. • Advantages: ability to maintain a sterile wound environment if desired, minimal risk for wound contamination, and the assumption that treating the wound directly will enhance wound healing more than using an indirect technique. Disadvantage: increased cost for wound care supplies if the wound will not also be bandaged with the sheet hydrogel. Periwound technique: applied to the intact periwound tissues to facilitate wound healing. Research: chronic leg ulcers = applied to the periwound may be more effective than ultrasound delivered to the wound bed. Beneficial: wounds are painful, tunneling, or necrotic. Advantages: ability to leave the wound dressing in place and the lowered risk of wound contamination. Disadvantage: by treating the periwound only, the ultrasound treatment will be less effective than treatment directly over the ulcer. Immersion Technique: underwater ultrasound for nonwound injuries. The affected area is exposed (in this case by removing the dressing, irrigating the wound, and performing any necessary debridement) and then placed in a nonmetal, waterfilled basin. The moving sound head is kept 0.5- 1.0 cm away from the surface of the wound and periwound. Advantageous: wounds that are painful or sensitive to pressure, or wounds in bony areas such as the malleolus. Disadvantages: need for dependent positioning, potential for contamination from the basin or sound head, potential for maceration or hyperhydration of the wound bed, and greater setup time. Parameters: Superficial- 3.0 MHz . Deeper- 1.0 MHz. Nonthermal effects: pulsed at 20- 25% with a low intensity, around 0.5- 1.0W/cm. • The treatment area (either wound and periwound or periwound only if using the indirect technique) should be divided into zones equal to 1.5 times the area of the sound head. Each zone should be treated for 2 minutes initially, increasing in 30-second intervals until reaching 3 minutes of treatment per zone. • Acute wounds: once or twice daily. Chronic wounds: daily to three times per week.

Prior, the wound debrided so the wound bed is free of eschar, slough, and nonviable tissue. Next, the sterile foam is cut to the wound size and placed in the wound bed. Any areas of undermining or tunneling should also be lightly filled with appropriately sized foam pieces. The dressing is left in place up to 48-72 hours. If used on an infected wound, the dressing should be changed eve1y 12- 24 hours. The estimated cost of the pump and supplies is $100 per dressing change. When the dressing is removed the foam pieces are soaked with normal saline to facilitate trauma-free removal Parameters: The negative pump pressure is adjustable between 50 and 175 mm Hg. However, because the maximal increase in blood flow appears to occur with 125 mm Hg, most studies have been performed at this pressure. Pressure may need to be increased gradually to this level for patient comfort. the pump may be run continuously or intermittently, with the continuous mode recommended for flaps, grafts, painful or highly exudating wounds, tunneling or undermining wounds, and wounds in which the dressing application was difficult.

bandwidth of 200-400 nm. UVA and UVB (280-400 nm) have been used to treat psoriasis and dermatitis for many years. The beneficial effects of UVC therapy on wound healing are believed to be due to its ability to increase epithelial cell turnover, enhance cell proliferation, promote growth factor release, stimulate granulation tissue formation, enhance capillary blood flow, and increase vascular permeability. facilitate wound healing : ulcers due to venous insufficiency, arterial insufficiency, pressure, and diabetes. The National Pressure Ulcer Advisory Panel suggests that the short-term use of UV-C may be considered to reduce wound bioburden in critically colonized category/stage III/IV pressure ulcers. However, because there are few controlled studies documenting the ability of ultraviolet light to facilitate wound healing, this modality is not currently a standard treatment modality and is not reimbursed by Medicare and Medicaid services.

using helium-neon (HeNe, 632.8 nm), gallium-aluminum- arsenide (GaAlAs 830 nm laser), or gallium-arsenide (GaAs, 904 nm) lasers has been used successfully to treat venous insufficiency, pressure, and neuropathic ulcers. Laser is not currently reimbursed by Medicare increase cell proliferation, simulate mitochondria, decreased inflammation, bacteriocidal, stimulated GF production and release, increased collagen synthesis, organization, and maturation, increased angiogenesis, granulation tissue formation, epithelialization, faster wound contraction, higher wound tensile strength

MIRE, involves the delivery of near-infrared energy at 890 nm wavelength to the skin by way of flexible diode pads. MIRE therapy is purported to improve blood flow to the treated area by up to 400%.The resulting increased tissue perfusion and oxygenation are believed to result in enhanced wound healing, increased nitric oxide formation, and improved cell proliferation. While MIRE therapy has been used in patients with pressure ulcers, arterial insufficiency ulcers, and venous insufficiency ulcers,wound healing seems to be facilitated most in patients with neuropathic ulcers. Patients with diabetic peripheral neuropathy who received MIRE therapy for 30 minutes 3 days per week were found to have improved light touch sensation compared to those receiving sham treatment and to have a lower incidence of subsequent diabetic foot ulcers. Infrared technology currently has FDA approval only to improve circulation and decrease pain despite the manufacturers' promotion of effectiveness in wound healing and resolution of peripheral neuropathy. As of June 2010, the Centers for Medicare and Medicaid Services have determined that the use of infrared and MIRE are not reasonable and necessary and, therefore, are not covered interventions.