wound healing and grafting

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WOUND HEALING AND WOUND GRAFTING SUBMITTED TO: SUBMITTED BY: Prof. Chandrakala, M. Sc (N) Vineeth. M Vice Principal I Year M. Sc (N) SHNC SHNC

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DEFINITION OF WOUND: A wound is a disruption of normal anatomical structure and function that results from pathological process beginning internally or externally, to the involved organs. CLASSIFICATION OF WOUND: STATUS OF SKIN INTEGRITY: Open A break in skin or mucous membrane Caused by trauma, gunshot, surgical incision Closed No break in skin Caused by part of body being struck by blunt object ,twisting staining Acute Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity Caused by trauma from a sharp object Chronic Wound that fails to proceed through an orderly and timely manner to produce anatomical and functional integrity Caused by ulcers exposed to friction, shear, moisture

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CAUSE: Intentional Wound result from a therapy Caused by surgical incision, introduction of needle etc Unintentional Wound that occurs unexpectedly Traumatic injury, burns etc SEVERITY OF INJURY: Superficial Wound involves epidermal layer of skin Abrasion, 1st degree burn etc Penetrating Wound involves epidermal, dermis and deeper tissue and organ Gunshot wound Perforating Wound in which foreign body enters and exists in an internal organ

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CLEANLINESS: Clean Wound containing no pathogenic organism Clean contaminated Wound made under aseptic conditions but involving body cavity normally harbors microorganism Contaminated Wound existing under condition in which presence of microorganism Infected Bacterial organism present in wound site Colonized Wound containing micro organisms multiple in number DESCRIPTIVE QUALITIES: Laceration Tearing of tissue from irregular wound edges Abrasion Superficial wound involving scraping or rubbing Contusion Closed wound caused by a blow to body by blunt object characterized by swelling discoloration and pain

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WOUND HEALING DEFINITION: A complex and dynamic process that result in the restoration of anatomic continuity and function. PHASES OF WOUND HEALING: 1. VASCULAR RESPONSE PHASE: - Platelets - Fibrin meshwork - Vasoconstriction and vasodilatation 2. INFLAMMATORY PHASE: - Neutrophils - Macrophages - Decline of inflammatory phase

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CONT… 3. PROLIFERATIVE PHASE: - Angiogenesis - Granulation tissue formation - Collagen deposition - Epethelialization - Contraction 4. MATURATION AND REMODELING PHASE: -Collagen remodeling -Scar maturation

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WOUND HEALING INTENTION: A) Primary intention When wound edges are directly next to one another Little tissue loss Minimal scaring occurs Most surgical wounds heal by primary intension Wound closure performed by sutures, stales, etc B) Secondary intention The wound is allowed to granulate Surgeon may pack the wound with gauze or use a drainage system Granulation results broader scar Healing process can be slow due to presence of drainage from infection Wound care must be performed daily C) Tertiary intention The wound is initially cleaned ,debrided and observed typically 4-5 days before closure The wound is purposely left open

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FACTORS INFLUENCING WOUND HEALING: 1. INRINSIC FACTORS: Infection Foreign bodies Inadequate blood supply Smoking Neuropathy 2. EXTRINSIC FACTORS Protein malnutrition Carbohydrate malnutrition Lack of vitamin c intake Diabetes Gluco corticoid steroids

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SIGNS AND SYMPTOMS OF WOUND INFECTION: Fever Increased pulse rate Wound swelling Tenderness or discharge Incisional pain Increase number of WBCs Increased plasma proteins Malaise In chronic wound the tissue often appears pale and odorous

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MANAGEMENT OF PATIENT WITH WOUNDS: 1. MEDICAL MANAGEMENT: - Therapeutic baths - Pharmacologic therapy Cortico steroids Topical antibiotics - Intralesional therapy - Antibiotics - Dressings - Nutritional support - Vacuum assisted wound therapy 2. SURGICAL MANAGEMENT: - Grafts - Debridement NURSING MANAGEMENT: NURSING DIAGNOSIS: Impaired skin integrity related to changes in the barrier function of skin Acute pain and itching related to skin lesions Ineffective peripheral tissue perfusion related to edema Deficient knowledge about skin care and method of treating skin

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WOUND GRAFTS GRAFTS MAINLY 3 TYPES: Auto graft It is the graft from one part of the body to another in the same individual Allograft Graft from one individual to another in the same species Xenograft Graft from one species from another species

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SKIN GRAFTING DEFINITION: Skin taken from another part of the body and applied to the site where skin is missing. TYPES: Split skin graft: Skin graft is taken by shaving the surface layers including epidermis and dermis of the skin with a knife It is mainly taken from the thigh, abdomen etc Full thickness skin graft: Graft is taken by removing all the layers of the skin with a scalpel It is mainly taken from the arm, neck or behind ear

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APPLICATION OF THE GRAFT: Most common method of fixing graft to the recipient site is with surgical staples particularly to large recipient area In children or sensitive area of adults sewing the graft into place by using absorbable sutures. The important conditions in the application of skin graft are, The recipient site must have an adequate blood supply The graft must be in loose contact with its bed to avoid accumulation of blood and fluids The graft must be fixed firmly The area must be free of infection

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NURSING CARE AFTER GRAFTING: Instruct the patient to keep the affected part immobilized as much as possible When a graft is placed on a lower extremity, the part must be kept elevated If any sign and symptom of infection present means immediately report to the physician RISKS OF SKIN GRAFTING: Bleeding Infection Loss of grafted skin Nerve damage

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GRAFT HANDLE

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SKIN GRAFT

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FLAP GRAFTING DEFINITION: It is segment of tissue that has been left attached at one end (pedicle) while the other end was been moved to a recipient area TYPES: Classified according to blood supply 1. RANDOM PATTERN GRAFTS It received blood supply from segmental anastamotic or axial artery Examples include advancement and rotation flap 2. AXIAL PATTERN GRAFTS It receives blood supply from direct cutaneous arteries Examples include lateral fore head flap

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CONT… 3. TUBE PEDICLE GRAFTS Frequently raised from abdomen or inner arm The skin defect is then closed Examples include rectus abdominus flap 4. MYOCUTANEOUS FLAP It includes muscle facia and overlying skin Examples include ALT flap 5. FREE MYOCUTENEOUS FLAP Micro vascular technique allow the anaestamosis of artery and vein It can be detached from blood supply Can be transformed to other parts of the body Examples include RFFF flap

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RADIAL FORE ARM FREE FLAP

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TISSUE EXPANSION GRAFTING: The tissue expander can be placed subcutaneously in collapsed state Over several weeks can be inflated with saline through a subcutaneous port Skin can be gradually stretched to accommodate a greater area

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TISSUE EXPANDER

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