Wound Care 2
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| 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
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| When can Vitamin A be deleted? | Malnutrition, infection or severe injury
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| 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
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| 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
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| What makes up the vitamin B complex | Thiamine, riboflavin, pyridoxine (important cofactors in the cross linkage of collagen) pantothenic acid, and folate
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| 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
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| 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
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| 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
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| 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
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| Deficiency in which 3 vitamin B complex components results in WBC dysfunction? | pyridoxine (B6), pantothenic acid (B5), and folate (B9)
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| Where are vitamin B deficiencies seen? | developing countries, elderly, extreme poor intake, and alcoholics
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| 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
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| 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
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| Scurvy is caused by? | Deficiency in Vitamin C for 60-90 days
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| 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
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| The 3 trace elements | Zinc, copper, iron
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| 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)
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| 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
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| 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
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| What does a surplus of zinc result in? | toxicity, copper deficiency
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| 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
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| 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
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| 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
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| What does iron deficiency affect? | collagen synthesis via the procollagen peptide
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| 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
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| Antibiotics are associated with: | resistant organisms, C Diff Colitis, Increased costs and toxicity (nephrotic)
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| 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
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| When is fungus normal? | Fungus is NEVER normal - fungal infection is ALWAYS infection
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| 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
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| 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
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| How do NSAIDS affect wound healing? | Diminishes inflammatory response, unclear effects on chronic wound healing
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| 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
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| 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.
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| 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.
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| What are measures to limit the spread of infection to pts, healthcare workers and the community? | Infection Control
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| What is the study of disease determinants, occurrence and distribution? | Epidemiology
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| What is the total destruction of all forms of microbial life, including highly resistant endospores? | Sterilization
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| What is the reduction of the number of organisms present on inanimate objects? | Disinfection
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| What is a method to reduce the amount of microorganisms on skin or living tissue? | Antisepsis
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| 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
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| How do you measure a wound? | Measure: at regular intervals, the widest portions and any tracts
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| 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
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| Which type of PVD is there limb wasting? | Arterial insufficiency
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| Which type of PVD is there swelling or edema? | venous insufficiency
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| 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
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| 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
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| What can cause increased girth? | CHF, early venous insufficiency, lymphedema, or possible pregnancy
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| 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
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| Which PVD has diminished pulses? | Arterial insufficiency
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| Which PVD has blunting or diffuseness of pulse | Venous insufficiency
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| How do you check for venous insufficiency | check for pitting edema and look for varicosities
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| 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
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| 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
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| What is the avg capillary refill time? | 2-3 sec
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| 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

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| 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
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