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Wound Care 2

What is Vitamin A used for in wound healing and where is it stored? Potentiates epithelial repair and collagen synthesis, effects macrophage availability and inflammatory reactions; fat soluble and stored in liver
When can Vitamin A be deleted? Malnutrition, infection or severe injury
What vitamin produces and increases cell adhesion, membrane microviscosity, stimulates the deposition of matrix glycosaminoglycans, and is an essential cofactor for collagen synthesis and cross linkage? Vitamin A - works as an antagonist to glucocorticoids
Which Vitamin supports the inflammatory stages of healing, stimulates cellular differentiation in fibroblasts and collagen? Vitamin A - a deficiency will result in delayed wound healing and infection
What makes up the vitamin B complex Thiamine, riboflavin, pyridoxine (important cofactors in the cross linkage of collagen) pantothenic acid, and folate
What does the vitamin B complex do in wound healing? Act as cofactors in many enzyme systems involved in the release of energy esp of carbs; Central to cell metabolism; There can be disturbances in protein, fat, and carb metabolism with deficiency
Which part of the vitamin B complex is involved in the synthesis and oxidation of fatty acids, the deamination of amino acids, and the function of a number of enzymes? Riboflavin
What can a riboflavin deficiency lead to? delayed epithelization, decreased total collagen, and slowed wound contraction – maturation of collagen may be impaired due to cross-linking and decreased tensile strength
How does pantothenic acid work in wound healing? acts as a coenzyme in carbohydrate and fat metobolism; possibly important in incorporation of the amino acid proline into fibroblasts
Deficiency in which 3 vitamin B complex components results in WBC dysfunction? pyridoxine (B6), pantothenic acid (B5), and folate (B9)
Where are vitamin B deficiencies seen? developing countries, elderly, extreme poor intake, and alcoholics
Which vitamin is essential for collagen formation and is required for hydroxylation for collagen synthesis? Vitamin C (ascorbic acid) - Significant role within the proliferation and maturation phases; Reducing agent acting as an electron donor and cofactor for the hydroxylation of proline and lysine
Which vitamin protects iron and copper containing metalloenzymes that are essential for cross linking? Vitamin C - Acts as a carrier for sulfate groups required for the formation of glycosaminoglycans; Decreased tensile strength if Vitamin C is deficient during healing
Scurvy is caused by? Deficiency in Vitamin C for 60-90 days
Which 2 vitamins act as Antioxidants; working as free radical scavengers; attach to oxidizing radicals preventing oxidation of the cell membrane Vitamin C and E - vitamin E supplementation may increase tensile strength of irradiated wounds
The 3 trace elements Zinc, copper, iron
Which trace element is required for epiithelialization and cellular proliferation resulting in a weaker closed wound? Zinc - 2nd most widely occurring element in human body - functions: Collagen formation, immune function, and a constituent of enzyme systems (metalloenzymes)
How many biochemical reactions is zinc used for? 50 reactions, and more than 300 enzymes use zinc to modulate their activities - these enzymes metabolize carbohydrates and fats into nucleic acids and proteins
What is an important role of zinc? Scavenger of superoxide radicals - Vague connection between alteration in zinc status related to hypertrophy of wounds - Plasma carries the zinc to wounded tissue - Zinc deficiency leads to decreased collagen tensile strength
What does a surplus of zinc result in? toxicity, copper deficiency
Which trace element works like zinc and is responsible for catalyzing the oxidation of lysyl residues on collagen? Copper - aids the cross linkage and scar strength, involved in the superoxide dismutase enzyme system
The 2 pt populations that are prone to copper deficiency Total parenteral nutrition (TPN) patients after gastric resection; Malabsorption syndrome patients after prolonged antacid use and zinc supplementation
What are the roles of Iron in wound healing? Essential for the normal transport of oxygen and Hgb; Involved as a component of the enzyme systems necessary for the oxidation of glucose to energy; Essential cofactor for both lysyl and prolyl hydroxylase
What does iron deficiency affect? collagen synthesis via the procollagen peptide
What are some warnings about antibiotics use? Overuse of misuse of antibiotics can have severe effects that can cause death; Do not use antibiotics unless you know what you are treating; Cardinal signs of inflammation can be easily mistaken for infection
Antibiotics are associated with: resistant organisms, C Diff Colitis, Increased costs and toxicity (nephrotic)
When is a wound culture imperative? If there is any question of infection: > 10^5 is infection – Anything less is colonization - May treat colonization topically but never treat systemically - Always eval the wound and sxs of the wound if the labs do not agree w/ your clinical findings
When is fungus normal? Fungus is NEVER normal - fungal infection is ALWAYS infection
Why won't systemic antibiotics reach the intended site or have the required effective concentration? Infected wounds have decreased blood flow - need to remove dead or devitalized tissue surgically to help speed healing
How do steroids affect the inflammatory phase? Impairs it by delaying the cascade of healing - suppress mitotic activity of fibroblasts; systemic vitamin A can reduce effect
How do NSAIDS affect wound healing? Diminishes inflammatory response, unclear effects on chronic wound healing
What are immunosuppressive agents used for? autoimmune, cancer, transplantation and some hematologic disorders - alters wound healing by affecting cell duplication and may not be able to be stopped due to use
What is the problem with using topical agents for wounds? DO NO HARM: Most topical agents do not have an FDA approved indication for use on open wounds – Most wound cleansing agents have been found to be toxic to fibroblasts and neutrophils.
What are the 2 topical agents that can be used? Dakin’s solution - 1/4 strength (0.125% hypochlorite) most commonly used; Topical Lidocaine - Has been shown to decrease leukocyte migration into a wound bed.
How does Diabetes affect wound healing? Alters the micro/macrovascular system, decreased tissue perfusion and oxygenation, RBCs become sticky and block microcirculation, peripheral neuropathy causes altered sensation and pain
What are 2 side effects of diabetes? Excessive unrecognized pressure from amb w/ decreased sensation leads to plantar pressure ulcers; increased glucose levels lead to altered neutrophil cell function
What are the goals for diabetic wound healing and possible modalities? Goal: Max granulation tissue; Modalities: e-stim, VAC dressing, debridement, pulsed irrigation, and heat therapy - 50% of amputations in US are diabetic
What are the effects of HIV on wound healing? Suppresses collagen synthesis via fibroblast dysfunction; Suppresses collagen synthesis with altered phagocytic activity in the wound bed; Absence of T cells causes decreased wound tensile strength
How does HIV affect collagen deposition? Absence of T cells causes decreased collagen deposition; Wound sepsis increased due to overall decrease in immune function; Inability to mount inflammatory response making it difficult to determine infection
How does chemotherapy and radiation affect the skin in cancer pts? Makes skin fragile and prone to shear, friction and infection; radiation makes skin so rigid that weight changes cause skin separation will not heal
How does arterial insufficiency affect wound healing? Alters blood flow and oxygen delivery; Thrombolytic therapy; Alters the micro an macrovascular system; Subcutaneous scarring can lead to further microvascular alteration
How does venous insufficiency result in ulcers? Tissues become macerated from poor venous return; Increased pressure (without normal cycling) causes hemodynamic alterations; These alterations lead to decreased tissue oxygenation that ultimately leads to ulceration
What are measures to limit the spread of infection to pts, healthcare workers and the community? Infection Control
What is the study of disease determinants, occurrence and distribution? Epidemiology
What is the total destruction of all forms of microbial life, including highly resistant endospores? Sterilization
What is the reduction of the number of organisms present on inanimate objects? Disinfection
What is a method to reduce the amount of microorganisms on skin or living tissue? Antisepsis
What are the parts of a nutritional assessment? – Discuss diet intake and appropriateness of diet – Identify any malnutrition – Obtain true height and weight – Look for wasting during history taking
How do you measure a wound? Measure: at regular intervals, the widest portions and any tracts
How to measure lower limb girth? • Measure over malleoli then 5, 15, and 25 cm proximally bilaterally • Ensure to mark distances from malleoli with girth measurements
Which type of PVD is there limb wasting? Arterial insufficiency
Which type of PVD is there swelling or edema? venous insufficiency
How do you rate insufficiency? Class 0 - no signs of chronic venous insufficiency; Class 1 - mild edema in the limb or distended superficial veins; Class 2 - significant edema and/or hemosiderin (dark purple/rusting) staining; Class 3 - active or healed ulcers
How to rate pitting edema 1+ barely perceptive depression; 2+ easily identified depression and takes 15 sec to rebound; 3+ depression takes 15-30 sec rebound; 4+ depression lasts greater than 30 sec
What can cause increased girth? CHF, early venous insufficiency, lymphedema, or possible pregnancy
How do you rate pulse strength in the extremities? 0 is no pulse, 1+ is barely palpable, 2+ is diminished, 3+ is normal, 4+ is bounding/strong/possible aneurysm
Which PVD has diminished pulses? Arterial insufficiency
Which PVD has blunting or diffuseness of pulse Venous insufficiency
How do you check for venous insufficiency check for pitting edema and look for varicosities
How do you perform the Rubor of dependency? Evaluates LE for ischemia; pt supine and note color of plantar foot; passively elevate LE to 45 deg for 60 sec; Move limb to dependent position; <15 sec normal pink returns is normal, >30 sec and is dark red then test is positive
How do you perform the venous filling test? Tests venous insufficiency; supine with passive limb elevation by 45 deg for 60 sec; <15 sec refill is normal, >30 sec is positive
What is the avg capillary refill time? 2-3 sec
What are the grade of claudication? Grade I: Pain, discomfort, cramping or weakness w/ min exercise; Grade II: Moderate pain; Grade III: Severe/intense pain; Grade IV: Excruciating/unbearable pain 
How do you test Cutaneous sensibility? Monofilament test: 5.07 monofilament bends when 10 g of pressure causes bowing • Vibration • Light touch • Sharp and dull sensation • Proprioception
Created by: rjchokito