About Arimedica:  This site has one purpose, to post and disseminate teaching
materials on certain subjects of medical and scientific interest.  It reflects
the interests and activities of its author, Marc E. Gottlieb, MD,  Phoenix,
Arizona, and colleagues.  It is focused on Wounds, Wound Practice, and related
issues of science and clinical arts.  It was started simply as a place to post
presentations in lieu of bringing printed materials to lectures and symposia.

Wound Topics include complex wound causing disorders and unique wound topics including:

Coagulopathies – Understanding wounds and pathologies due to coagulopathic and micro-occlusive disorders.

Auto-immunopathy – Understanding wounds and pathologies due to auto-immune and inflammatory disorders.

Integra – All about Integra artificial skin, it’s biology and clinical use, especially for chronic wounds.

VT & Angiogenesis – The VT model of angiogenesis and the physics of biological network formation.

Smith and Nephew Global Wound Academy

http://www.globalwoundacademy.com/

The company take on their website: The Academy offers the learner a series of modular courses at different levels through which you can extend your knowledge of wound care. To this effect, ‘The Learning Zone’ presents the theory of wound management moving from basic principles of physiology to advanced wound care and applications and current research in the management of patients with wounds. In addition to this the interactive patient studies enable you to assess, diagnose and treat patients based on their medical history and the results of the clinical tests.

Healthpoint

http://www.thewoundinstitute.com/

The company take on their website: The Wound Institute is dedicated to helping clinicians gain a deeper understanding of wound care and treatment. Here you will find practical, evidence-based resources on most major wound types—information that you can apply directly to your patient population. The Wound Institute contains fully accredited CE/CME programs in wound care education, along with relevant case studies and exercises. You will also find interactive animations and streaming videos, to make your experience engaging, useful and rewarding.

Convatec

http://academy.convatec.com/en/acd-home/acd-home/0/home/0/387/0/default.html?

The company take on their website: ConvaTec recognizes the many pressures faced by health care professionals today including the increasing focus on best practices and evidence-based decisions. With this in mind, we founded this site to provide you, the health care professional, with access to important learning opportunities. We trust that the educational modules you find here will help you in your mission of delivering better patient care outcomes.

KCI

http://www.kci1.com/992.asp

The company take on their website: Wound care is usually considered more an art than a science, with multiple layers of complexity. KCI’s wound care education programs are designed to support clinicians’ efforts to navigate through the labyrinth of information on wound types, assessment, care planning, interventions, products and outcomes management.

If its not a pressure ulcer, then what is it?

Intertrigo:

Inflammation of the skin folds caused by friction, perspiration and bioburden.

Assessment characteristics include: erythema, maceration, denuded skin, itching, odor, and satellite skin lesions

Denuded Skin:

Loss of the epidermis is caused by exposure to feces, urine, body fluids, wound drainage or friction

Assessment characteristics include: history of exposure to feces, urine, body fluids, wound drainage or friction and epidermal loss

Friction:

Mechanical force exerted on skin that is dragged across any surface. It is present with shear. (NPUAP, 2007)

Assessment characteristics include: skin is rough and red, the wound is superficial, and observation of how the skin moves across the bed surface

Shear:

Interaction of both gravity and friction against the surface of the skin; when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves, stretches, and angulates or tears the underlying capillaries and blood vessels causing tissue damage. (NPUAP, 2007)

Assessment characteristics include: Deep undermining wound and the observation of how tissue rubs against tissue

Irritant Contact Dermatitis:

Acute irritant dermatitis usually occurs after a short single exposure to a potent irritant. Wound exudate has a very irritant effect on skin surrounding a wound. Preparations such as antiseptics, adhesives, and bandages applied directly to the skin, may be contributing factors in the production of this type of skin reaction.

Assessment characteristics include: Erythematous (redness of the skin), Scaling, and Papulovesicular dermatitis

Asteatotic Dermatitis:

Inflammation of the skin related to skin dryness.

Assessment characteristics include: It is pruritic, dry skin of the lower legs with a network of erythematous superficial fissures.

The condition is common in elderly patients.

Fungal / Yeast (Candidiasis):

Skin Infection of the Skin Folds and Peri-anal area.

Assessment characteristics include: peeling, bright red rash, rash may also appear white, small pustules, intense itching and burning, skin breakdown or blistering.

The vascular assessment will answer the question “Does the wound have enough blood supply to heal?”
Healthy tissue is bright, beefy red, shiny, and granular with a velvety appearance. Tissue with poor
vascular supply is pale pink or blanched to dull, dusky red color.

Physical vascular assessment includes: peripheral pulses, temperature, presence or absence of hair,
mild to severe pain, rest pain, edema, and gangrene. The vascular assessment should also include:

Pallor: White, pale, blanched color of a limb when in the upright position.

Rubor: Dark purple to bright red color of a limb when in a dependent position.

Intermittent claudication: Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a  specific distance. This suggests intermittent claudication and is caused by muscle ischemia.

Mottling or mottled skin: Irregular patchy skin coloring. Refers specifically related to blood
vessel changes in the skin which cause the patchy appearance. This may indicate
vascular insufficiency.

Capillary refill: The measurement of the rate of blood refill in empty capillaries . Measured
by pressing a nail bed or area of tissue until it turns white and then timing until the
return of color once the pressure is released. Normal refill time is less than 2 seconds.

Diagnostic studies for vascular assessment:
Transcutaneous oxygen measurement (TCOM)
Ankle brachial index (ABI)
Arterial duplex scan
Arteriogram
Magnetic Resonance Arteriogram (MRA)

Document a full patient history including:

Initiating event and the duration of the wound

Previous treatments and their outcomes

Diabetes control and prior complications

Medical conditions that may interfere with wound healing

Medications that may interfere with wound healing

Underlying pathophysiology   

Psycho-social barriers to wound healing

Severity of pain

Other Important Wound Documentation

Routine skin assessment and care

Moisture management

Nutritional status

Change in clinical status or wound healing progress

Education and follow up with the patient, family, and caregivers

Discuss family adherence to plan of care

Repositioning and turning schedules

Pressure-reducing support surfaces (both bed and chair)

Document referral to specialist and/or programs including:

                Nutritional management

                Diabetes management

                Smoking cessation

                Vascular surgeon

                Interventional Radiologist

                Allergist

                Infectious Disease

A. What is the underlying etiology contributing to the wound site?

Neuropathic, diabetic, end-stage renal disease, spinal cord injury, paraplegic, ischemic/pressure injury, dyspnea.

B. Where is the wound located anatomically?

Pressure points include: occiput (back of head), scapula, spine, elbow, sacrococcygeal, trocanter, ischial tuberosities, malleolus (ankle), heel.

Friction sites may include gluteal folds, under the abdominal pannus, any skin fold, under breasts, axilla, groin, buttocks (espcially if using briefs), heels.

Document in relation to head, feet, front, or back. Commonly used terms include: proximal/distal; superior/inferior; medial/lateral; anterior/posterior; dorsal/plantar.

C. What do the wound bed and wound edges look like?

Clean, raised, rolled, curled, smooth flat, irregular, clearly defined, epibole.

D. What size and shape is the wound?

Round, oval, semi-circular, T-shaped, rectangular, punched-out. Depth may be full thickness, partial thickness, unable to be assessed.

E. What kind of drainage is present, amount, color, and odor?

Serous, sanguinous, serosanguinous, purulent, tan, opaque, clear, cloudy. Odor may be foul or sweet, “yeasty”

F. What is the condition of the surrounding skin?

Smooth, glossy, moist, blistery, weepy, “woody”, intact, healthy, erythermatous, ecchymotic, macerated, dry callus, hyperpigmentation.

Grade 0: No ulcer in a high risk foot.

Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues.

Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation.

Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis.

Grade 4: Localized gangrene.

Grade 5: Extensive gangrene involving the whole foot.

Wagner, F., Levin, M., & O’Neal, L., 1983. Supplement: algorithms of foot care. In The Diabetic Foot. 3 rd ed. St. Louis, MO, CV. Mosby, 1983, p. 291–

302

Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk) (FROM THE NPUAP – 2007)

Intervention for Stage 1 pressure ulcers

Position patient off affected reddened area

Initiate turning schedule

Consider turning every two hours (3o degree turns off bone)

If the head of the bed has to be greater than 30 degrees turn every one hour

Keep skin clean, dry and supple.

Place protective barrier cream or hydrocolloid over the ulcer

Suspend heels or place in boots that will suspend the heels

Initiate a Dietary Consult (Nutrition assessment)

Remove the cause or the source of the ulcer including:

Divert urine moisture with catheterization

Divert liquid stool with Flexi-Seal Fecal Management System (ConvaTec)

Perform risk assessment and then place the patient on the appropriate pressure distribution mattress

Teach and document patient and family how to and the importance of shifting weight

Inflammatory phase (Start of injury up to 4 days)

Hemostasis

Vasoconstriction occurs soon after the tissue is damaged as injured vessels release serotonin, histamine, prostaglandins, and blood. Platelet aggregation and thromboplastin form a clot as fibrin binds the edges of the wound together and provides temporary wound closure.

Inflammation (1 to 4 days)

Lymphocytes trigger the inflammatory response, which increases capillary permeability (this causes wound edges to swell). Bacteria and other cellular debris (dead cells) are consumed by white blood cells. This reduces the formed clot. Macrophages mediate by releasing growth factors which increase the level of fibroblasts.

Proliferative phase (2-3 days to 30 days)

Fibroblasts lay the building blocks of the new extracellular matrix for collagen fibers and granulation tissue. Granulation tissue forms and that tissue fills in the open space of the wound. Angiogenesis, with capillary formation, connects blood flow into the newly developing granulating tissue. The wound begins to contract and epithelialization moves across and covers the surface of the wound.

Remodeling phase ( 3 weeks to 2 years)

Completion of contraction occurs as collagen fibers shorten and crosslink reducing the size of the scar, but increasing . This increases the tensile strength of the scar which will return to be approximately 80% as strong as the original tissue.