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Wound Healing/ Bandaging VTDRG pp. ____________ CTVT pp. 971-993 Wound Formation Wounds are created when an insult disrupts the ____________ of the tissue. • These wounds can either be created purposefully (______ incision) or incidental (___________injury). The process of wound healing begins ________________ after the insult Wounds are ______________ based on whether they are surgically created or are traumatic, and their level of contamination • Wound Classification __________________________ __________________________ __________________________ __________________________ Clean Wounds Are made under _____________ conditions Are non-traumatic Are _________________, operative wounds that do not enter a hollow ___________ like the GI or urinary tract. Clean-Contaminated Wounds… …are a ______wound into which a hollow viscus is entered without significant ____________________. ◦ GI, urogenital, or respiratory tract are examples of a hollow viscus. …are _____________ occurring wounds with ____________ contamination. …are a ______________ wound with a minor break in _____________technique. Contaminated Wounds… …are open, _________________ wounds …are surgical wounds with a __________ break in sterile technique Are a surgical wound into ____________________ areas such as the colon or inflamed/contaminated skin. Dirty and Infected Wounds… …are any old, traumatic wound …are an _____________ wound or perforated viscera …are a wound with a high ______________ count Phases of Wound Healing __________________________ __________________________ __________________________ __________________________ __________________________ Inflammatory Phase ◦ Phase begins ___________________ after injury. ◦ _________ will fill the wound and clean the wound surface. ◦ Blood vessels _______________ to slow down any hemorrhaging ◦ __________ form to help stabilize the wound edge Debridement Phase ◦ This phase begins approximately ___ hours after injury. ◦ The ________________ of white blood cells, dead tissue and fluid collect on the wound ◦ These exudates are commonly associated with wounds Lag Phase Lag Phase During the first 3-5 days, wound strength is minimal ________________________ phase + ____________________________phase = “Lag Phase” Repair/Proliferative Phase ◦ ____-____days after injury the repair phase usually begins ◦ This phase continues as ____________________ tissue is formed Maturation Phase ◦ ______-______days following injury and begins when ______________ is adequately deposited to help form a scar. ◦ This process may take __________ to ________ to complete Factors that affect wound healing Host factors Things that often can delay wound healing ◦ ______________ ◦ ______________ ◦ ______________ Factors that affect wound healing Foreign material in a wound: Not always a ___________________! These factors can interfere with normal wound healing ◦ Surgical implants ◦ Drains ◦ Suture Factors that affect wound healing Contamination: Tissue becomes infected if the bacteria multiply to a critical number of organisms. The presence of infection will ______________ stop the repair phase ◦ With proper wound care, many complications can be avoided. Medications: ◦ ______________ delay all phases of wound healing. Factors that affect wound healing Blood supply to wound Amount of movement allowed Both can be affected by a bandage Factors that affect wound healing Blood supply: Important for wound healing because it is responsible for supplying _________ and metabolic _______________ (a substance upon which a enzyme acts) to the cells Do not use overly-___________ bandages; they can compromise the wound’s blood supply Wound Management ***In order to protect the patient and yourself, _________ should be worn when managing wounds. It is a good idea to respect the wound from the start since we do not know if any multi drug resistant organisms are present*** Immediate Wound Care Cover wound with a clean dry bandage to prevent contamination. (If appropriate) Water-soluble ointment may be applied to keep the wound moist and reduce contamination when clipping hair around wound. Once the patient is stabilized and other life threatening injuries have been addressed the wound can be prepared for treatment Wound Treatment In order to obtain quality cleaning, __________ and pain relief is generally warranted Chlorhexidine scrub is used to complete a “dirty” prep of the area before a __________ prep is done. It is important to make sure that the chlorhexidine does not enter the wound as scrubs cause irritation, toxicity, and pain ____________ is not recommended in management of open wounds Sterile gloves and drape material can definitely reduce new contamination and create a cleaner work environment Wound Lavage Why is it done? ◦ Remove ____________ and loose particles ◦ Reduce ______________ How is it done? ◦ Flush with large volumes of _____________________ crystalloids ◦ No added antibiotics, soaps, detergents or antiseptics. ◦ Mechanical action of the lavage Lavaging the Wound Using a warm, sterile, isotonic solution is preferred for any wound. ◦ LRS or 0.9% Sodium Chloride are both commonly used and are easily available. Tap water should not be used unless the wound is excessively dirty. ◦ Tap water can be cytotoxic to fibroblasts due to additives that make it safe for drinking. Lavaging the Wound Lavage pressure is the goal for successful removal of debris without destroying healthy tissue. Recommended lavage pressure is between 8-12 psi. 18g needle and a 35cc syringe are recommended to achieve ideal pressure. A 3 way stop-cock may also be used Copious lavage may also be achieved with a bulb syringe and bowl. “The solution to pollution is dilution.” This sums up the reason for copious lavage. Initial Evaluation of the Wound The wound should be _____________ to determine the extent of damage A sterile _______________ can be used to gently probe where visualization may be compromised. The results are then used to decide the best way to cover the wound and facilitate healing. Wound Debridement Removes ____________, devitalized, or _______________ tissue. Removes foreign material Methods: ◦ ◦ ◦ ◦ SX excision of affected tissue “en bloc” Means that you remove the entire wound via sx incision. Enzymatic debridement (trypsin products Hypertonic solutions like honey or sugar. (these are mentioned on pg. 980 in your book.) ◦ Medicinal ___________ ingest debris and liquefy necrotic tissue. En bloc Wound Debridement Types of Wound Healing Wound healing and wound ________ go hand in hand. _____________ (first) Intention healing = surgical apposition of edges with suture or staples _____________ Intention = healing via the formation of granulation tissue and epithelialization. ◦ Recommended for wounds older than 6-8 hrs. ◦ Takes a longer time to complete healing ◦ Extra cost to manage the fragile wound (epithelialization) _____________ Intention healing = __________ closure. ◦ Wounds older than 6-8 hrs., infected, or necrotic wounds ◦ Wound allowed to form healthy granulation tissue and THEN is closed by apposition or surgical excision. (Primary closure). Wound Closure The method of closure depends on the __________________ of the wound. Types of Wound Closure ___________________ Closure ___________________ Primary Closure ___________________ Closure Primary Wound Closure Healing by ____________ intention ◦ ◦ ◦ ◦ ◦ Suturing or grafting a wound Fresh, clean, sharply incised wounds Should have minimal contamination Plenty of surrounding tissue to close Should be done within ____ hours from incident. ◦ (____________ granulation tissue can form.) Primary Wound Closure Delayed Primary Wound Closure Allows any local contamination or infection to be controlled prior to closure Wound can be closed ___-___ days after injury, before ______________________ appears in the wound. _______________ contamination _______________ trauma May require some cleansing and debridement Secondary Wound Closure Healing by contraction and epithelialization ________________, contaminated, traumatized wound Cleansing and debridement are ___________. Closure may be difficult Not always a desirable method of closure. Also known as “_________ intention wound healing”. Factors Determining Method of Closure/Healing _______ since injury Degree of contamination Amount of _______________ damage Thoroughness of debrideent Blood supply to the wound Patient’s ________________ Closure without tension or dead space ________________ of the wound Wounds that Require Special Management Abrasions Lacerations Burns Punctures Degloving Injuries Decubitus Ulcers Abrasions _______________ wounds that heal well by reepithelialization. Maintaining a ____________ environment will speed this process. Not recommended to let this type of wound “________________”. ◦ Takes longer to heal than a moist environment. Lacerations Have sharply incised edges with ___________ tissue trauma. Can be superficial (_________) Can be deep (_______________, _____________.) <12 hours after injury ◦ Minimal debridement, lavage, primary closure >12 hours after injury ◦ ___________ debridement, primary closure Burns Classified by how _______ into the tissue, and how large the affected area is. ◦ First, second, third and fourth degrees Animals with extensive burns are critically ill and need intensive care to survive. Severe burns often require skin ______________. Puncture/Bite wounds Challenging to asess if injury goes __________ than visibility allows Management includes _______________, lavage, and debridement. ___________ may be placed if there is extensive dead space. ◦ Helps prevent formation of seroma/hematoma. Degloving Wounds Defined by a large section of skin torn off the underlying tissue in a “glove” like fashion. Abrasion of ____________ or exposure of ___________ are common Take _________ to __________ of wound care. Tend to be highly contaminated (dragging injuries or falling/jumping from moving vehicle. Require aggressive wound _____________ and debridement, as well as possible skin grafting. Decubitus Ulcers/Pressure Sores Develop over bony proiminences caused by compression during long periods of ___________________. Recumbent, ______________, obese, or _________ breed dogs are most prone. Soft bedding and/or frequent turning are the best prevention. If these wounds are advanced, reconstructive SX may be required. Now that we know how to care for the wound… Let’s talk about how to BANDAGE it!!! Bandaging Bandaging: Purpose _________________ ◦ To prevent simple fractures from becoming more complicated ◦ Protection from licking, scratching, biting, and other forms of self ___________________. ◦ From _________________________ ◦ Holding wound dressings and cold compresses in place ◦ Immobilizes the wound and promotes ____________. Bandaging: Purpose ____________________ ◦ To improve mobility ◦ To reduce pain and swelling ◦ Extra support for internal fixation of fractures Bandaging: Purpose ____________________: ◦ Compression bandages are a useful first aid measure to help arrest ________________. ◦ Post-operatively, bandaging is useful to prevent excess ___________; therefore reducing or preventing _____________. Bandaging: Purpose _______________________... ◦ …of a fractured limb to prevent further trauma to damaged soft tissue ◦ …of limb to aid speedy recovery of open wounds if near a joint, or where excessive ______________ is undesirable. ◦ …of limb, if fracture repair is complicated or near a joint, requiring complete ____________. ◦ …if ____________ fracture repair is not sufficient and extra support in the form of a bandage is needed. ◦ …following _______________ procedures; after dislocated hips have been ______________. Bandaging: purpose _____________/_____________ ◦ To hold ____ _______________ in place ◦ To keep limb extended for fluid lines, and other such procedures ◦ When necessary, secure tail bandage to base of tail. ◦ To tape _________ together above dog’s head for ______ or ________bandage. Bandaging for Wound Healing Promotion of wound healing by: ◦ Protecting the wound from additional trauma and contamination. ◦ Preventing wound from _______________. ◦ Preventing ________________ and seroma formation. ◦ _________________ the wound to prevent cellular and capillary disruption. ◦ Minimize post-op ______________ around incision ◦ Absorbs wound ____________ and lifts away foreign material and loose tissue as bandage is removed. ◦ Keeping the wound warm. Leaving a wound open to “dry out” and form a scab is never indicated Important Points to Remember The bandage the purpose for which it was intended. The bandage must be applied ____________, but not so tightly that _____________ is impaired. It must be as comfortable as possible for the patient. It must look _______________ to the owner. (Take pride in its appearance.) Bandaging Layers _____________________ Layer _____________________ Layer _____________________ Layer Primary Layer of Bandaging Primary (_______________) layer Is the _________ layer. Is in direct contact with the _______ or wound. Even _________ wounds should have a sterile primary layer. Telfa Pads Gauze squares Functions of Primary Layer _____________________ Deliver _____________________ Transmit _____________________ to second layer __________ wound Types of Primary Layers ___________________ ◦ Dry to dry ◦ Wet to dry ◦ Wet to wet ___________________ ◦ Semiocclusive ◦ Occlusive Primary Layer - Adherent An _______________ primary layer promotes debridement in the inflammatory stage ◦ Uses a wide __________ material (sterile gauze), allowing tissue to become incorporated into the bandage. This tissue is then ____________ with bandage changes. ◦ Not highly recommended due to unselective ___________________ and damage during the proliferative (repair) phase of wound healing. ◦ ___________________ to remove ◦ Must be changed ______________. Types of ADHERENT Primary Layers Dry to dry ◦ Used when __________, necrotic tissue is evident ◦ Absorbs ___________, necrotic tissue and foreign material ◦ Debris adheres to dry, sterile gauze and is removed with bandage change. Wet to dry ◦ Used for wounds with dry or semi-dry exudates ◦ Gauze is soaked in _________ or chlorhexidine and applied wet. ◦ Loosens material from wound by ___________________ ◦ As it dries, exudate is pulled into material and away from the wound. ◦ Bacteria proliferation and strike-through = disadvantages with wet to dry primary layer. Adherent Primary Layers - Continued Wet to wet ◦ Used on wounds with large amounts of ____________ and _________________. ◦ Material covering the wound is kept moist, sometimes by ______________ of fluid into the bandage. ◦ Absorbs fluid easily ◦ Can be used to ________ wounds, increasing capillary action and _______________ of wound ◦ Removed ______(less painful) ◦ Disadvantage: Little wound debridement because of _______________ adhesion to necrotic tissue Non-adherent Primary Layers Moist wound care is the most important management principle. A non-adherent bandage is usually a fine, mesh, ____________ material. This layer promotes moisture regeneration and epithelialization with __________ disruption of granulation bed. ◦ Moist wound care enhances _____________ debridement within the wound by drawing the exudate from the wound and allowing wound to bathe in cytokine-rich material. ◦ Involves the use of non-adherent ____________ bandage layer to keep the wound surface moist. ◦ Moist wound care results in less _________________ and less disruption during healing. Either _________________ or _____________ Primary, Non-adherent SEMIOCCLUSIVE layers Allows ________ and _________ to move through the dressing. Keeps wound moist yet draws exudate and debris from the wound Indicated for moderate to copious ____________ Must be changed frequently (q __-__ d), depending on _______________ production. Non-adherent, semiocclusive Primary Layer Examples are found on pg: 980 in CTVT, and include: ◦ ◦ ◦ ◦ ◦ Hydrogel Hydrocolloid Hydrophilic Polyurethane films Hydrophilic colloids Occlusive - Primary, non-adherent layer Impermeable to ___________________ Allows some _____ transfer Indicated for ______________ exudate Promotes ___________________________ Changed infrequently (q __-__ d) Can be used as a protective layer for new epithelium, preventing _______________ and abrasion of fragile tissue Some products adhere to skin (hydrophilic or non-hydrophilic) Secondary Bandage Layers Covers the ____________ layer, and supports the wound Purpose is to be able to ___________ and _________ fluids from the wound. Materials used in this layer include: ◦ Cast padding or rolled cotton ◦ Should not be applied with excessive _______________, but should be snug enough to keep primary layer in. Secondary Layer Examples Roll Cotton Cast Padding Tertiary Bandage Layer This is the _______________ layer that holds the bandage in place. Usually consists of _______ layers made up of: ◦ Cling/Kling gauze ◦ Vet Wrap or Elastikon Cling/Kling gauze Vet Wrap Tertiary Layer Should be ______-____________ to allow air flow _________-____________= outer layer becomes wet, allowing moisture and bacteria to wick to the rest of the bandage. MUST BE CHANGED _________________________ _____________________= contraindicated as it traps excess moisture leading to tissue maceration. Technician Note The middle _____toes of any bandaged limb should always be exposed to allow assessment of _______, _________, and ____________. Bandage Types __________________________ __________________________ __________________________ __________________________ __________________________ Robert Jones Badage Used for _________________ immobilization of fractures __________ to the elbow or stifle before surgery Must extend one joint ________ and ____________ the structure you wish to ________________. ___________, bulky bandage that provides __________ stabilization Robert Jones Procedure A large amount of rolled cotton is applied to the forelimb reaching ____________ the elbow Rolled cotton is then compressed with _________________. ________________ tape may be used at the bottom of bandage to secure Vet Wrap to patient and prevent ____________. Robert Jones Bandage Notice that the toes are still visible at the bottom of the bandage. Robert Jones - Note If applied correctly, the bandage should have a nice “_______” or “______” when thumped with the index finger. Modified Robert Jones Very common bandage in small animal medicine May be applied to __________or __________ Numerous indications ◦ Protect _____________or wound ◦ Provide support (______________) ◦ Prevent / reduce ______________ Modified Robert Jones - Tips Always work ________to ____________ on limb Maintain constant _____________ Use _____% overlap technique Place limb in _______________ position when wrapping Avoid _________________ Make sure the _______ toes are visible at all times! Modified Robert Jones Procedure Tape __________are placed on the ___________ aspects of the limb. A tongue depressor is placed between them to prevent adherence of the stirrups to each another Roll cotton is placed around the limb, covering the tape. (Cast padding may also be used if a thicker bandage is needed.) Elastic gauze is then tightly wrapped over cotton to compress it. After this, the tape from the stirrups are ________________ up over the gauze Protective, non-occlusive tape, like Vet Wrap is then applied over the entire bandage and forms the outer layer. Modified Robert Jones Pt. 1 Modified Robert Jones Pt.1 Modified Robert Jones Pt. 2 Notice that the non-occusive tape may again be applied to the distal portion to prevent slipping. Abdominal or Chest Bandage Must be applied ___________ but not so much that it restricts or puts pressure on chest or abdomen. Applied in the _____ layers as previously described Specialized Bandages May be needed on extremities that are difficult to bandage. (_______, ______, etc…) Make sure that bandage is secure enough to prevent slipping, but not so tight as to cause swelling/lack of _____________ Splints Caudal or “__________” splints Are used to support __________ portion of front limbs Not appropriate for injuries above _________. Limb should be well-padded to avoid pressure sores Always place on ___________ aspect of limb Caudal “Spoon” Splints Lateral Hind-limb Splints Are applied to the ____________ aspect of the _______ limb. Are not appropriate for injuries above the _________. Should be well padded to avoid pressure sores. Lateral Splints Casts Used to stabilize fractures distal to __________ or ____________. Immobilization of limbs to prevent ____________ or ____________ rupture. Must extend one joint above and below structure being stabilized. Casts After-care for Bandages, Casts and Splints Monitor patient _________ if hospitalized Make sure patient is not chafing or rubbing at bandaged area. (____________may be necessary) Exercise should be restricted to short leash-walks Protect bandage when walking outside with plastic bag, or old fluid bag that has holes cut in top and a lace placed for tying. (_______ min. maximum) Monitor _____________ if out-patient ◦ Client education is critical if out-patient Checking toes for: ____________, _______________, ____________ or foul _______________ from area The End!!!
