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الموضوع: wound care presentation

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    افتراضي wound care presentation

    The outlines:


    1-the introduction.


    2-definition.


    3-classification of wounds.


    4-process of wound healing.


    5- Factors Affecting Wound Healing.



    6-complications of wound healing.



    7- Wound Assessment Chart Guidelines .



    8-diagnostic procedures.



    9-guidance for management of wound infection.



    10-special consideration related to flood conditions.



    11-physical therapy modalities in wound care

    12-types of wound debridement.



    13-dressing and rules of wound care.



    a-the five rules of wound care.



    b-dressing classification.



    14- Adverse effects of dressings.



    15-wound cleansers.



    16-suture removing guidelines.



    17-references.



    the introduction:



    the skin is the body largest organ. It composes one sixth of the total body weight. the integument is a protective barrier against disease causing organism .


    Injury to the integument poses risk to safety and triggers a complex healing response.





    Definition:



    [FONT='Times New Roman','serif']— [/font]A wound is a disruption of normal anatomical structure and function that results from pathological process beginning internally or externally to the involved organ.















    [FONT='Times New Roman','serif']: [/font]Wound classification



    Descriptive qualities


    cleanliness



    Severity of injury



    cause



    Status of skin integrity



    1-laceration.


    2-abrasion.


    3-contusion.



    1-clean.


    2-clean contaminated


    3-contaminated


    4-infected.


    5-colonized.



    1-super facial.


    2-penterating.


    3-perforating.



    1-intentional.


    2-uninentional.



    1-open.


    2- closed.


    3-acute.


    4-chronic.





    Examples:


    [FONT='Times New Roman','serif']— [/font]1-open wound like (surgical incision,


    gunshot).


    [FONT='Times New Roman','serif']— [/font]2-closed wound like(tear of visceral organ).


    [FONT='Times New Roman','serif']— [/font]3-acute wound (trauma by sharp object).


    4-chronic wound(pressure sores).


    [FONT='Times New Roman','serif']— [/font]5-intentional(surgical incision).


    [FONT='Times New Roman','serif']— [/font]6-unintentional(burn).


    [FONT='Times New Roman','serif']— [/font]7-superfacial(abrasion ,first degree burn).


    [FONT='Times New Roman','serif']— [/font] 8-pentrating(gunshot ,stab wound).


    [FONT='Times New Roman','serif']— [/font]9-perforating wound is penetrating wound in which foreign object enters and exist an internal organ.


    [FONT='Times New Roman','serif']— [/font]10-clean wound is wound containing no pathologic organism.(closed surgical wound not entering GIT , RT, genitalia , or uninfected UT , or o


    [FONT='Times New Roman','serif']— [/font]pharyngeal cavity)


    [FONT='Times New Roman','serif']— [/font]11-clean contaminated is wound made under aseptic technique but involving bodycavity that harbors microorganisms like surgical wound entering gastrointestinal under controlled conditions.


    12-contaminated(open traumatic accidental wound)


    13-laceration wound is tearing of tissues with irregular wound edges.


    14-abrasion wound like wound resulting from fall(skinned knee or elbow).


    15-contusion wound is wound caused by blow to body by blunt object.


    Process of wound healing:





    The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. This overview will help in identifying the various stages of wound healing.

    [FONT='Verdana','sans-serif']I. Inflammatory Phase [/font]
    A) Immediate to 2-5 days
    B) Hemostasis
    • [FONT='Verdana','sans-serif']Vasoconstriction [/font]
    • [FONT='Verdana','sans-serif']Platelet aggregation [/font]
    • [FONT='Verdana','sans-serif']Thromboplastin makes clot [/font]
    C) Inflammation
    • [FONT='Verdana','sans-serif']Vasodilation [/font]
    • [FONT='Verdana','sans-serif']Phagocytosis [/font]

    [FONT='Verdana','sans-serif']II. Proliferative Phase [/font]
    A) 2 days to 3 weeks
    B) Granulation
    • [FONT='Verdana','sans-serif']Fibroblasts lay bed of collagen [/font]
    • [FONT='Verdana','sans-serif']Fills defect and produces new capillaries [/font]
    C) Contraction
    • [FONT='Verdana','sans-serif']Wound edges pull together to reduce defect [/font]
    D) Epithelialization
    • [FONT='Verdana','sans-serif']Crosses moist surface [/font]
    • [FONT='Verdana','sans-serif']Cell travel about 3 cm from point of origin in all directions [/font]

    [FONT='Verdana','sans-serif']III. Remodeling Phase [/font]
    [FONT='Verdana','sans-serif']A) 3 weeks to 2 years [/font]
    [FONT='Verdana','sans-serif']B) New collagen forms which increases tensile strength to wounds [/font]
    [FONT='Verdana','sans-serif']C) Scar tissue is only 80 percent as strong as original tissue .[/font]

    Factors Affecting Wound Healing


    Age

    [FONT='Verdana','sans-serif']The physiological changes that occur with ageing place the older patient at higher risk of poor wound healing. Reduced skin elasticity and collagen replacement influence healing. The immune system also declines with age making older patients more susceptible to infection. Older people can also present with other chronic diseases, which affect their circulation and oxygenation to the wound bed.[/font]
    Dehydration

    [FONT='Verdana','sans-serif']This leads to an electrolyte imbalance and impaired cellular function. It is a particular problem in patients with burns and fistulae.[/font]
    Hand Washing

    [FONT='Verdana','sans-serif']Effective hand washing greatly reduces the risk of transferring pathogenic organisms from one patient to another by direct contact or by contamination of inanimate objects that are shared.[/font]
    Infection

    [FONT='Verdana','sans-serif']Infection has been defined as the deposition and multiplication of organisms in tissue with an associated host reaction. If the host reaction is small or negligible then the organism is described as colonising the wound rather than infecting it. It is important to distinguish between colonisation and infection since colonised wounds will heal without the need for antibiotics (Cutting 1994).[/font]
    Contamination is the deposition and survival, but not the multiplication, of the organism Ayton 1985).
    [FONT='Verdana','sans-serif']Wound infection is a problem because, at the most fundamental level, infection stops a wound from healing by:[/font]
    • [FONT='Verdana','sans-serif']Prolonging the inflammatory phase[/font]
    • [FONT='Verdana','sans-serif']Disrupting the normal clotting mechanisms[/font]
    • [FONT='Verdana','sans-serif']Promoting disordered leukocyte function and ultimately preventing the development of new blood vessels and formation of granulation tissue.[/font]
    [FONT='Verdana','sans-serif']Assessment of a wound in order to identify wound infection should not be limited to swabbing the wound for bacteriological analysis.[/font]
    [FONT='Verdana','sans-serif']Infection occurs when virulence factors expressed by one or more micro-organisms in a wound out-compete the person's immune system. Subsequent invasions and spread of microorganisms in good tissue provokes a series of local and systemic responses such as:[/font]
    i) Surgical (acute wounds)
    • [FONT='Verdana','sans-serif']local pain / tenderness[/font]
    • [FONT='Verdana','sans-serif']local swelling / oedema[/font]
    • [FONT='Verdana','sans-serif']increased exudate either serous or purulent or haemoserous[/font]
    • [FONT='Verdana','sans-serif']separation of wound edges / wound breakdown[/font]
    • [FONT='Verdana','sans-serif']pyrexia[/font]
    • [FONT='Verdana','sans-serif']delayed healing[/font]
    ii) Chronic wounds
    • [FONT='Verdana','sans-serif']delayed healing[/font]
    • [FONT='Verdana','sans-serif']increased fragility or change in appearance of granulation tissue[/font]
    • [FONT='Verdana','sans-serif']unexpected pain / tenderness[/font]
    • [FONT='Verdana','sans-serif']pocketing or bridging of epithelial tissue[/font]
    • [FONT='Verdana','sans-serif']an abnormal smell[/font]
    • [FONT='Verdana','sans-serif']presence of exudate either serous or purulent haemoserous[/font]
    • [FONT='Verdana','sans-serif']local swelling / oedema[/font]
    • [FONT='Verdana','sans-serif']extending margin or erythema[/font]
    • [FONT='Verdana','sans-serif']pyrexia[/font]
    • [FONT='Verdana','sans-serif']wound breakdown[/font]
    Medication

    [FONT='Verdana','sans-serif']Anti-inflammatory, cytotoxic, immunosuppressive and anticoagulant drugs all reduce healing rates by interrupting cell division or the clotting process.[/font]
    Oxygenation and tissue perfusion
    • [FONT='Verdana','sans-serif']Good wound oxygenation is essential for wound healing. Oxygen influences angiogenesis, epithelialisation and resistance to infection[/font]
    • [FONT='Verdana','sans-serif']Discourage smoking[/font]
    Personal and oral hygiene
    • [FONT='Verdana','sans-serif']The need for good personal and oral hygiene should be discussed with the patient.[/font]
    Nutrition
    • [FONT='Verdana','sans-serif']Protein is required for all the phases of wound healing, particularly important for collagen synthesis.[/font]
    • [FONT='Verdana','sans-serif']Glucose balance is essential for wound healing.[/font]
    • [FONT='Verdana','sans-serif']Iron, required to transport oxygen.[/font]
    • [FONT='Verdana','sans-serif']Minerals, zinc, copper, are important for enzyme systems and immune systems. Zinc deficiency contributes to disruption in granulation tissue formation.[/font]
    • [FONT='Verdana','sans-serif']Vitamins A, B complex and C, are responsible for supporting epithelialisation and collagen formation. It is also important for the inflammatory phase of wound healing.[/font]
    • [FONT='Verdana','sans-serif']Carbohydrates and fats. These provide the energy required for cell function. When the patient does not have enough, the body breaks down protein to meet the energy needs. Fatty acids and essential for wound healing.[/font]
    • [FONT='Verdana','sans-serif']Refer to Dietician if patient is malnourished[/font]
    PATIENT EDUCATION - suggest to patient that:
    • [FONT='Verdana','sans-serif']Food is there to be enjoyed[/font]
    • [FONT='Verdana','sans-serif']Variety in what we eat is healthy[/font]
    • [FONT='Verdana','sans-serif']They should eat the right amount to be a healthy weight. This will vary for age, sex and level of activity.[/font]
    • [FONT='Verdana','sans-serif']They should try not to eat too much fat, sugar or salt.[/font]
    • [FONT='Verdana','sans-serif']The diet should provide plenty of vitamins and minerals[/font]
    • [FONT='Verdana','sans-serif']Keep levels of alcohol within recommended limits[/font]


    Complications of wound healing[FONT='Times New Roman','serif']:[/font]

    1-hemorrhage.

    [FONT='Times New Roman','serif']Hemorrhage occurring after homeostasis indicates a slipped suture, a dislodged clot, infection ,or erosion of blood vessel by foreign object (eg.drain) [/font]
    [FONT='Times New Roman','serif']Hemorrhage may occur externally or internally.[/font]
    [FONT='Times New Roman','serif']The nurse can detect internal bleeding by looking for distention or swelling of the affected body part.[/font]
    [FONT='Times New Roman','serif']A change in the type and amount of drainage from a surgical drain .[/font]

    2-infection.

    [FONT='Times New Roman','serif']Wound infection is the second most common nosocomial infection according to the CDC. [/font]

    [FONT='Times New Roman','serif']A wound is infected if purulent material drains from it. even if the culture is not taken or has a –ve result .why?[/font]
    [FONT='Times New Roman','serif']Because many wounds colonies of non infectious resident bacteria.[/font]
    [FONT='Times New Roman','serif']All chronic dermal wound are considered contaminated with bacteria.[/font]
    a.What is the difference between infection and contamination / colonization?
    [FONT='Times New Roman','serif']Wounds with more than 100,000 organism per milliliter .are infected the only exception is when the organism is beta –hemolytic streptococcus the presence of this organism of less than 100,000 organism per milliliter.[/font]
    [FONT='Times New Roman','serif']The chance of wound infection is greater when the wound contains dead or traumatic tissue.[/font]


    [FONT='Times New Roman','serif']A contaminated or traumatic wound may show sign of infection within 2-3 days.[/font]
    [FONT='Times New Roman','serif']A surgical wound infection does not develop until the 4th or 5th postoperative day.[/font]
    b. How do I know if the wound I'm treating is infected?
    [FONT='Verdana','sans-serif']There are many tools that you have at your disposal to determine if an infection is present. To begin with, you should assess the clinical picture of this patient and his / her wound. Is the patient febrile? Are the vital signs normal or abnormal ? Does the wound appear red and swollen ? Is there purulent drainage or a foul odor ? Is the area around the wound warm to the touch as compared to nearby skin or skin on the opposite extremity? Is bone exposed (this could indicate osteomyelitis)? [/font]
    [FONT='Verdana','sans-serif']In addition, there are many laboratory tests to determine whether an infectious process is occurring. These include: white blood cell count (WBC), erythrocyte sedimentation rate (ESR), c-reactive protein, x-ray examination, deep tissue culture (not swab), nuclear medicine testing (gallium, technetium and indium scans) and blood cultures. [/font]
    [FONT='Verdana','sans-serif']There entire picture must be evaluated carefully. An abnormally high WBC without the clinical appearance of infection could indicate a false test, an infection occurring someplace else (such as a urinary tract infection) or another disease process altogether.[/font]
    c. Are all wounds infected?
    [FONT='Verdana','sans-serif']No, but you should consider all wounds as being contaminated with microorganisms. A contaminated wound will heal, an infected wound will not. Wound exudate contains bacteria killing enzymes that will help prevent an infection. Proper cleansing, debridement and maintaining of a moist wound environment will all create an condition that lessens the chance of infection. [/font]
    d. Are swab cultures important?
    [FONT='Verdana','sans-serif']As stated in the AHCPR guidelines, swab cultures do not effectively reveal the infecting organism. Swab cultures only collect the surface contaminating organisms. Tissue biopsy and culture, fluid aspiration cultures and possible bone biopsy are better alternatives for culturing the infecting organism. Note: the AHCPR guidelines state that osteomyelitis is detected in 69 percent of the cases where the WBC, ESR and plain x-rays were all positive, therefore, the need for an invasive bone biopsy may be reduced. [/font]
    e. How are infections treated?
    [FONT='Verdana','sans-serif']The first item to be discussed is infection control. We must all strive to avoid any type of cross contamination between patients or multiple wounds on the same patient. Hand washing, clean dressing supplies, new gloves and sterile instruments are all required to perform basic wound care. Proper disposal of contaminated waste is governed by the Occupational Safety and Health Administration (OSHA). Also, protect the wound from urine or fecal contamination. [/font]
    [FONT='Verdana','sans-serif']If a wound infection is suspected, notify the proper health care provider on the case immediately. Once an infection is diagnosed, the practitioner may order topical antibiotic flushes, topical antibiotic applications, oral or systemic antibiotics. An incision and drainage (I and D) may be necessary to decompress an abscess or remove devitalized tissue. These protocols will be determined by the extent of infection, infecting organism, medical history of the patient and any medical allergies. According to the AHCPR, one should not use topical antibiotics such as povidone iodine, iodophor, sodium hypochlorite [Dakin's Solution], hydrogen peroxide or acetic acid to reduce bacteria in wound tissue. These products have been shown to be cytotoxic and inhibit granulation tissue.[/font]
    3-dehiscence.

    [FONT='Verdana','sans-serif']Is patial or total separation of the wound layers.[/font]
    [FONT='Verdana','sans-serif']Risk factors for dehiscence:[/font]
    [FONT='Verdana','sans-serif']a-poor nutritional status .[/font]
    [FONT='Verdana','sans-serif']b-infection.[/font]
    [FONT='Verdana','sans-serif']c-obesity.,[/font]

    dehiscence often involves abdominal surgical wounds and occur after a sudden strain such as coughing, vomiting or sitting up in bed.

    [FONT='Times New Roman','serif']Clients often reports feeling as though something has given away.[/font]
    4-evisceration.

    [FONT='Times New Roman','serif']Protrusion of visceral organ through a wound opening .[/font]
    [FONT='Times New Roman','serif']The condition is a medical emergency that require a surgical repair.[/font]
    [FONT='Times New Roman','serif']The nurse a sterile towels soaked in a sterile saline to reduce chance of bacterial invasion and drying.[/font]
    [FONT='Times New Roman','serif']If the organ protruded through the wound ,blood supply to the tissue is compromised.[/font]
    [FONT='Times New Roman','serif']The client should be kept NPO .[/font]
    [FONT='Times New Roman','serif']Observe signs and symptoms of shock and prepare for ER surgery.[/font]
    5-fistula.

    [FONT='Times New Roman','serif']Is an abnormal passage between two organs or between an organ and the outside of the body.[/font]
    [FONT='Times New Roman','serif']Most fistula ,however form as a result of poor wound healing or as a complication of a disease such as crhons disease.[/font]
    [FONT='Times New Roman','serif']Trauma, infection , radiation exposure and disease such as cancer prevent tissue layers from closing properly and allow the fistula tract to form.[/font]
    6- delayed wound healing.

    [FONT='Times New Roman','serif']Some times referred as 3rd –intention wound healing .[/font]
    [FONT='Times New Roman','serif']delayed wound healing is a deliberate by the surgeon to allow effective cleansing of the clean contaminated wound or contaminated wound.[/font]
    [FONT='Times New Roman','serif']The wound is not closed until all evidence of edema and wound debris has been removed.[/font]
    7- Wound Assessment Chart Guidelines Assessment

    Elicit a careful history of injury i.e.:
    • mechanism of injury; associated blood loss; risk of contamination; deeper structure damage;
    • tetanus status;
    • consider Non accidental Iinjury;
    • underlying chronic illness or disability.
    Fully examine the injured part in particular checking for
    • underlying nerve, vessel and tendon damage. This requires assessment of movement while exploring the wound (especially in palmar or hand wounds).
    • Assess tissue damage or loss

    [FONT='Verdana','sans-serif']After assessing a wound, proper documentation is necessary for medical, legal and reimbursement reasons. A photograph of the wound is the most reliable documentation. Your charting should include the following information on each wound care visit: [/font]
    • Patient's name and date of visit
    • Vital signs - temp., pulse, respiration, blood pressure
    • Are the dressings intact? - (wet, dry, loose, clean, dirty)
    • Strikethrough - Is there drainage on the outside of the dressing material?
    • Location of wound - foot, leg, thigh, sacrum, elbow, shoulder, right, left, dorsal, plantar, medial, lateral, anterior, posterior, etc.
    • Size - length, width and depth measured in centimeters. (use a sterile cotton tip applicator to measure depth). DO NOT CROSS CONTAMINATE WOUNDS by using the same gloves, instruments, measuring devices, etc. if the patient has multiple wounds. Based on previous measurements, is the wound improving, deteriorating or remaining stagnant.
    • Tracking - defined as skin overhanging a dead space
    • Undermining - look for skin that overhangs the wound's edges
    • Drainage - Is there drainage on the contact layers of the dressing? What does it look like (serous, purulent, bloody, green, yellow, clear, thick, etc.) Is the drainage a breakdown of the wound dressing (like a hydrocolloid) or actual drainage from the wound? Yellow purulent drainage could indicate staphylococcus involvement. Green drainage could indicate pseudomonas involvement. Estimate the amount of drainage present.
    • Odor - Is there any odor from the wound? This can offer a great deal of information on which organism may be contaminating or infecting a wound. Fruity smell points toward staphylococcus organisms. Foul odor (fecal like) points toward gram negative bacteria.
    • Necrotic tissue - What percentage of the wound appears to be necrotic tissue. Necrotic tissue should be considered as any tissue that is not beefy red and granular. Where is the necrotic tissue? Draw a small diagram.
    • Infection - Is the wound red (or streaking redness), hot and swollen? Is there soreness out of proportion to what should be present given the patient's medical history and the progression and etiology of the wound? Infection should be assessed both clinically and with the help of lab data such as vitals and WBC count.
    • Stage pressure ulcers - refer to the section on staging pressure ulcers for a complete review. In short, an ulcer with an intact eschar should be noted as unstageable due to eschar formation. I strongly recommend that you DO NOT reverse stage a healing ulcer. For example, an ulcer initially documented as a stage 4 should not be documented as a stage 2 or a stage 1 as it heals. The reason is simple. Skin over a healed ulcer is only 70 - 80 percent as strong as undamaged skin. A new health care professional on the case may look at the latest notes and only see a stage 2 in the assessment and not realize that this patient is at high risk. I like to document that the wound is a healing stage 4 ulcer.
    • Classify non pressure ulcers - use Wagner classification for foot ulcers. Use "full thickness" or "partial thickness" phrasing to document other types of ulcers. Wagner Classification is as follows:
      • [FONT='Verdana','sans-serif']Grade 0 - Pre-ulcerative lesion, healed ulcers, presence of bony deformity [/font]
      • [FONT='Verdana','sans-serif']Grade 1 - Superficial ulcer without subcutaneous tissue involvement [/font]
      • [FONT='Verdana','sans-serif']Grade 2 - Penetration through the subcutaneous tissue (may expose bone, tendon, ligament, or joint capsule) [/font]
      • [FONT='Verdana','sans-serif']Grade 3 - Osteitis, abscess, or osteomyelitis [/font]
      • [FONT='Verdana','sans-serif']Grade 4 - Gangrene of the forefoot [/font]
      • [FONT='Verdana','sans-serif']Grade 5 - Gangrene of the entire foot [/font]
    • Past treatment - Note the past treatments and any changes in products. This will help new health care professionals on the case. Products that may not have produced the desired results won't be accidentally duplicated.
    • Current treatment - Document the type of irrigation, products and secondary dressings used during the dressing change.
    • Signature - Sign the bottom of the note.
    • Follow up - Contact the appropriate doctor, nurse, therapist or other health care professional to discuss your findings, especially if there is deterioration.
    [FONT='Verdana','sans-serif']Laboratory Data and diagnostic procedures:[/font]

    • [FONT='Verdana','sans-serif']Baseline CBC [/font]
    • [FONT='Verdana','sans-serif']Urine analysis [/font]
    • [FONT='Verdana','sans-serif']Serum electrolytes [/font]
    • [FONT='Verdana','sans-serif']Arterial blood gas [/font]
    • [FONT='Verdana','sans-serif']Carboxyhemoglobin levels [/font]
    • [FONT='Verdana','sans-serif']Chest x-ray/ other x-ray[/font]
    • [FONT='Times New Roman','serif']xray for radiopaque foreign body or underlying fracture [/font]
    • [FONT='Times New Roman','serif']ultrasound is useful for puncture wounds with a radiolucent foreign body such as thorn or splinter.[/font]


    Guidance for Management of Wound Infections:

    Most wound infections are due to staphylococci and streptococci. This would likely hold true even in the post-hurricane setting.
    • For initial antimicrobial treatment of infected wounds, beta-lactam antibiotics with anti-staphylococcal activity (cephalexin, dicloxacillin, ampicillin/sulbactam etc.) and clindamycin are recommended options.
    • Of note, recently an increasing number of community associated skin and soft tissue infections appear to be caused by methicillin-resistant [FONT='Calibri','sans-serif']Staphylococcus aureus (MRSA). Infections caused by this organism will not respond to treatment with beta-lactam antibiotics and should be considered in patients who fail to respond to this therapy. Treatment options for these community MRSA infections include trimethoprim-sulfamethoxazole (oral) or vancomycin (intravenous). Clindamycin is also a potential option, but not all isolates are susceptible. [/font]
    • Incision and drainage of any subcutaneous collections of pus (abscesses) is also an important component of treating wound infections.
    Special Considerations Related to Flood Conditions:

    Contamination of wounds with water (fresh or sea water) can lead to infections caused by waterborne organisms. Though infections with these organisms are uncommon, even after floods, this possibility should be considered in patients who fail to respond to initial therapies described above. Water-borne organisms often implicated in these infections include: Aeromonas spp., non-cholera Vibrio spp. and sometimes Pseudomonas or other Gram-negative rods.
    Trimethoprim/sulfamethoxazole, amoxicillin/clavulanate and newer fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin) will treat Aeromonas and the fluoroquinolones will also treat Pseudomonas and many other Gram-negative pathogens.
    Clinicians should consider Vibrio as a possible causative organism of wound infections incurred in coastal waters or from contact with shellfish or marine wildlife. Vibrio vulnificus wound infections may require extensive debridement and mortality can be high. These infections often manifest with bullous lesions that may be hemorrhagic. Persons with underlying hepatic disease or other immunocompromising illness are at highest risk of Vibrio vulnificus infection. When this infection is suspected, the recommendation is that patients be treated with a combination of ceftazidime and doxycycline.
    Physical Therapy Modalities in Wound Care:


    [FONT='Verdana','sans-serif']Electrical Stimulation [/font]


    [FONT='Verdana','sans-serif']Ultrasound[/font]


    [FONT='Verdana','sans-serif']Whirlpool[/font]


    [FONT='Verdana','sans-serif']Hyperbaric Oxygen[/font]


    Electrical Stimulation:


    Electrical stimulation is defined as the use of an electrical current to transfer energy to a wound. The type of electricity that is transferred is controlled by the electrical source. ( AHCPR 94). Capacitatively coupled electrical stimulation involves the transfer of electric current through an applied surface electrode pad that is in wet (electrolytic) contact ( capacitatively coupled) with the external skin surface and /or wound bed. When capacitatively coupled electrical stimulation is used, two electrodes are required to complete the electric circuit. Electrodes are usually placed over wet conductive medium, in the wound bed and on the skin a distance away from the wound.


    [FONT='Verdana','sans-serif']Ultrasound[/font]


    Ultrasound is a mechanical vibration delivered at a frequency above the range of human hearing. Clinical ultrasound units currently being manufactured typically deliver ultrasound at frequencies of 1 and 3 MHz with duty cycles ranging from 20 to 100 percent. Duty cycles less than 100% are usually termed pulsed ultrasound while a 100% duty cycle is referred to as continuous ultrasound.


    How does ultrasound benefit wound healing?


    Inflammatory Phase - ultrasound causes a degranulation of mast cells resulting in the release of histamine. Histamine and other chemical mediators released from the mast cell are felt to play a role in attracting neutrophils and monocytes to the injured site. These and other events appear to accelerate the acute inflammatory phase and promote healing.


    Proliferative Phase - ultrasound has been noted to effect fibroblasts and stimulate them to secrete collagen 1. This can accelerate the process of wound contraction and increase tensile strength of the healing tissue 2. Connective tissue will elongate better if both heat and stretch are combined. Continuous ultrasound at higher therapeutic intensities provides and effective means of heating deeper tissue prior to stretch.


    Frequency


    As the frequency of ultrasound is increased, the penetration of the signal decreases. For most dermal wounds, it is preferable therefore, to utilize a frequency of 3 MHz. 1 MHz wound be more effective on deeper structures or periwound skin.


    Considerations in the use of ultrasound


    As with other medical devices, inappropriate use can result in serious complications. The basic precautions should be taken:


    Treat at the lowest intensity that will produce the desired result.


    Assure that the applicator is kept in constant motion throughout treatment and that the proper acoustic coupling medium is used.


    Reduce the intensity or terminate treatment if the patient complains of any increase in pain.


    Application of ultrasound to wounds


    Prior to ultrasound treatment, remove dressings and clean wound of foreign debris or dressing residue.


    A [FONT='Verdana','sans-serif']hydrogel sheet[/font] should be placed in direct contact with te wound bed and wound margins, paying special attention to removing any air bubbles that might be present beneath the dressing. Remove any protective plastic covering on the hydrogel sheet.


    In cases where a cavity type of wound exists that prevents complete contact between the hydrogel sheet and the wound base, as sterile aqueous hydrogel filler should be used. The cavity is filled with the aqueous gel and then covered wit the hydrogel sheet. Remove all underlying air bubbles between the aqueous hydrogel and hydrogel sheet.


    Once the hydrogel sheet is in place, apply an ultrasonic coupling gel on top of the sheet. Select the appropriate sized applicator. (the area treated should be no larger than 1.5 to 2 times the size of the applicator. If a relatively large wound is being treated, it would need to be divided into sections.


    Set the ultrasound machine to a 20 % duty cycle at a frequency of 3 MHz.


    Applying light pressure, the sound head is placed in contact with the coupling medium on top of the hydrogel sheet and moved in a slow and deliberate manner using either a linear or circular technique.


    Set the intensity to less than 0.5 watts per square centimeter (usually 0.3 watts/cm 2). Reduce the intensity if the patient experiences pain or heat.


    Treatment duration is suggested to be about 1 to 2 minutes per zone.


    Acute wounds are treated 1 to 2 times per day until acute symptoms (inflammation) subside. Treatments can then decrease to 2 to 3 times per week


    Application of ultrasound to periwound tissue


    When it is desired to provide mild heating to the periwound tissue in order to stimulate circulation, higher intensity ultrasound can be given. Extreme are should be used, however, to assure the tissue is capable of handling the thermal levels delivered.


    To treat periwound tissue, 1 MHz, continuous ultrasound is usually employed. Again, an ultrasound applicator 1.5 to 2 times the size of the treatment area should be used. With an aqueous coupling medium in place, the sound head is placed lightly against the skin surface and moved in a slow and deliberate manner. The intensity is typically set to between 1 and 1.5 watts per square centimeter. This parameter is extremely variable and depends on the patient's circulatory, sensory and mental status. Thermal ultrasound should never be used in situations where impaired perception prevents the patient from sensing heat or pain. If at anytime during the treatment the patient should experience an increase in pain, the intensity should be turned down or the treatment discontinued.


    Treatment duration is slightly longer than that of pulsed ultrasound since a mild thermal effect is desired. Initial treatment is about 2-3 minutes per zone and can be increased by 30 second increments to a maximum of 5 minutes per zone and delivered 3 times per week




    [FONT='Verdana','sans-serif']Whirlpool[/font]



    Whirlpool is the physical agent most closely identified with physical therapy wound care.


    1. Whirlpool may be used at different temperature settings to modify its effect on circulation. Although it is the most commonly used modality, it's effect on wound healing has not been researched.


    Whirlpool tanks may be either permanent or portable, full body or extremity. The agitation force and direction of the turbulence may be adjusted to protect granulation tissue from trauma.


    2. How does this modality benefit a wound patient:


    Objectives of whirlpool treatment include:


    vasodilitation


    increased blood flow


    softening and loosening of necrotic tissue


    mechanical debridement


    wound cleansing: debris and topical agents


    exudate removal --- > reduced infection


    pain management


    3. Theory behind modality's effectiveness:


    Whirlpool effects the Inflammation Phase of healing


    Warm water increases vasodilitation of the superficial vessels


    Increased blood flow brings oxygen and nutrients to the tissues and removes metabolites



    Increased blood flow brings antibodies, leukocytes and systemic antibiotics


    Fluid shifts into the interstitial spaces leading to edema


    Softening and loosening of necrotic tissue aides phagocytosis


    Cleansing and removal of wound exudate controls infection


    Mechanical effects of whirlpool stimulate granulation tissue formation


    Sedation and analgesia are induced by the warm water


    4. How should a physical therapist use this modality on a wound?


    This treatment modality is often administered twice daily for 20 minutes, however, once daily treatment should be considered as an appropriate option. Following whirlpool, the wound and surrounding tissues should be rinsed vigorously with clean water to remove residue from the wound and surrounding tissues. The best types of wounds for whirlpool are those that fall into the categories of:


    Necrotic


    Moderate to heavy exudative wounds


    Wounds with debris


    Tissue which can tolerate moderate to heavy increased circulatory perfusion


    Ischemic wounds where vigorous perfusion to wound and surrounding tissues is desired


    Protocol:


    Whirlpool temperature Guide


    Water temperature range from 33.5 °C to 35.5 0C = 92 °F to 96 °F


    Water temperature should not exceed 1 °C above skin temperature in presence of PVD.


    Water temperature should not exceed 38 °C in presence of cardiopulmonary disease


    Water temperature of 32 °C blood flow of 2.3cc/100 cc of limb volume. Higher temperature gives greater blood flow volume.


    When using lower temperatures, avoid chilling by maintaining warm room temperature and use only for single limb, not whole body.


    5. Are there any risks or complication with this modality?


    Whirlpool may be contraindicated for the following wound situations:


    clean granulating wounds - clean granulating wounds are easily traumatized by the force of even a mild agitation


    epithelializing wounds


    migrating epidermal cells may be damaged by even minimal force


    new skin grafts - skin grafts will not tolerate the high shearing forces and turbulence


    new tissue flaps - tissue flaps are very sensitive to shearing forces and vasoconstriction which may occur if the water or air temperature cause chilling


    venous ulcers - it is undesirable to increase blood volume to an area where blood volume is already a problem - will complicate the problem; in addition, a dependent position will produce more dependent edema and stasis; the hard necrotic fibrin found in a venous ulcer are not effectively debrided by hydrotherapy.


    non-necrotic diabetic ulcers - callus will be softened leading to maceration, macerated tissue will not tolerate pressure and wound will be enlarged


    6. Should antiseptics be used in the whirlpool?


    There remains controversy about the use of antiseptic agents in the whirlpool. Much research indicates that the most commonly used antiseptic agents are harmful to the cells of tissue repair. In addition, they may not be able to reduce the number of bacteria when the bacteria are very numerous. A study by Bohannan found that four times as many bacteria were removed from a venous ulcer when rinsed vigorously with clean tap water than when the wound was only treated in a povodine iodine whirlpool. Patients with chronic wounds may develop allergic responses to the chemical agents.


    If antiseptics are to be used, they should be used for necrotic, heavily exudating wounds. Then monitor carefully and continue only until wound is clean. DO NOT OVERUSE.


    Commonly used antiseptics in the whirlpool are:


    povidine iodine


    sodium hypochlorite


    HiBiclens ®


    Chlorazene ® (chloramine)


    7. Are any patients/pathologies prohibited from using this modality?


    edema of the extremity


    lethargy


    unresponsiveness


    maceration


    upper extremity infection


    febrile conditions


    compromised cardiovascular or pulmonary function


    acute phlebitis


    renal failure


    dry gangrene - evaluate for ischemia


    incontinence of urine or feces, if in full body whirlpool


    8. Infection control in hydrotherapy


    Proper cleaning of whirlpool equipment and the use of disinfecting solutions selected to kill infectious organisms should be a policy and procedure of all health care facilities.


    Proper use of Universal precautions is important in controlling infection. Culturing of whirlpool equipment is not recommended unless there is an episode of unexplained nosocomial infections that can be traced back to use of the whirlpool equipment. A policy to prevent inhalation or contact dermatitis by the hydrotherapy personnel should be developed for each health care facility when using antiseptics and disinfecting agents.


    [FONT='Verdana','sans-serif']Hyperbaric Oxygen[/font]





    Rationale:


    In an hypoxic environment, wound healing is halted by decreased fibroblast proliferation collagen production, and capillary angiogenesis (1). Hypoxia also allows growth of anaerobic organisms, further complicating wound healing. Hyperbaric oxygen therapy provides a significant increase in tissue oxygenation in the hypoperfused, infected wound. It influences the rate of collagen deposition, angiogenesis, and bacterial clearance in wounds. The greatest benefits are achieved in tissues with compromised blood flow and oxygen supply.


    Diabetic Wounds:


    The increased wound oxygen tension achieved with HBO promotes wound healing, increases the host antimicrobial defenses and has a direct bacteriostatic effect on anaerobic microorganisms.


    Venous Stasis Ulcers:


    HBO therapy has a very limited role. It is only indicated in highly selected patients in the preparation of a granulating bed over debrided venous ulcer for eventual skin grafting. (2)


    Pressure Ulcers:


    HBO therapy may be useful when underlying osteomyelitis is present or to improve the soft tissue envelope for reconstruction.


    Arterial Insufficiency Ulcers:


    HBO therapy may be of benefit in selected cases, especially when a wound fails to heal despite maximum revascularization.


    Treatments:


    HBO treatments are performed at 2.0 to 25 ATA for 90 to 120 minutes of oxygen breathing. The initial treatment schedule is dictated by the severity of the disease process. In the presence of limb-threatening infection after debridement or compromised surgical flaps following amputation the patient should be treated twice daily. When the infection is under control and the soft tissue envelope improves, once daily treatments are adequate.





    Types of Wound Debridement



    Autolytic Debridement:


    Description:


    Autolysis uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is liquefied. It is also virtually painless for the patient. Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue. Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films.


    Best Uses:


    In stage III or IV wounds with light to moderate exudate


    Advantages:


    Very selective, with no damage to surrounding skin.


    The process is safe, using the body's own defense mechanisms to clean the wound of necrotic debris.


    Effective, versatile and easy to perform


    Little to no pain for the patient


    Disadvantages:


    Not as rapid as surgical debridement


    Wound must be monitored closely for signs of infection


    May promote anaerobic growth if an occlusive hydrocolloid is used


    Enzymatic Debridement:


    Description:


    Chemical enzymes are fast acting products that produce slough of necrotic tissue. Some enzymatic debriders are selective, while some are not.


    Best Uses:


    On any wound with a large amount of necrotic debris.


    Eschar formation


    Advantages:


    Fast acting


    Minimal or no damage to healthy tissue with proper application.


    Disadvantages:


    Expensive


    Requires a prescription


    Application must be performed carefully only to the necrotic tissue.


    May require a specific secondary dressing


    Inflammation or discomfort may occur


    Mechanical Debridement:


    Description:


    This technique has been used for decades in wound care. Allowing a dressing to proceed from moist to wet, then manually removing the dressing causes a form of non-selective debridement.


    Hydrotherapy is also a type of mechanical debridement. It's benefits vs. risks are of issue.


    Best Uses:


    Wounds with moderate amounts of necrotic debris


    Advantages:


    Cost of the actual material (ie. gauze) is low


    Disadvantages:


    Non-selective and may traumatize healthy or healing tissue


    Time consuming


    Can be painful to patient


    Hydrotherapy can cause tissue maceration. Also, waterborne pathogens may cause contamination or infection. Disinfecting additives may be cytotoxic.


    Surgical Debridement:


    Description:


    Sharp surgical debridement and laser debridement under anesthesia are the fastest methods of debridement.


    They are very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind


    Surgical debridement can be performed in the operating room or at bedside, depending on the extent of the necrotic material.


    Best Uses:


    Wounds with a large amount of necrotic tissue.


    In conjunction with infected tissue.


    Advantages:


    Fast and Selective


    Can be extremely effective


    Disadvantages:


    Painful to patient


    Costly, especially if an operating room is required


    Requires transport of patient if operating room is required



    Dressing and the 5 rules of wound care:



    Even with the increased avilabilty of dressings.


    An appropriate selection can be made if certain principles are maintained referred to as the 5 rules of wound care:



    R1:CATEGORIZATION:


    Learn about dressing by generic category and compare new products with those that already make up the category.


    The nurse should become familiar with indications , contraindication ,and side effects.



    The best dressing may be by combining products from different categories .to achieve several goals at the same time.



    R2:SELECTION:



    Select safe and most effective, user friendly and cost effective dressing possible.



    R3:CHANGE:


    Change dressing based on patient ,wound, and dressing assessment, not on standardized routines.


    Natural wound healing should be disturbed as little as possible, unless the wound is infected or with heavy discharge.



    It is common to leave chronic wound covered for 48-72hr and acute wound for 24hr.



    R4:EVOLUTION:


    As the wound progresses through the phases of wound healing the dressing protocol is altered to optimize wound healing .it is rare in chronic wounds ,that some dressing material is appropriate throughout the wound healing process.



    R5:PRACTICE :


    Practice with dressing material is required for the nurse to learn the performance parameters of the particular dressings.


    Refining skills of applying appropriate dressing correctly and learning about new dressing products are essential responsibilities .

    Ideal wound dressing

    No single dressing is suitable for all types of wounds. Often a number of different types of dressings will be used during the healing process of a single wound. Dressings should perform one or more of the following functions:
    • Maintain a moist environment at the wound/dressing interface
    • Absorb excess exudate without leakage to the surface of the dressing
    • Provide thermal insulation and mechanical protection
    • Provide bacterial protection
    • Allow gaseous and fluid exchange
    • Absorb wound odour
    • Be non-adherent to the wound and easily removed without trauma
    • Provide some debridement action (remove dead tissue and/or foreign particles)
    • Be non-toxic, non-allergenic and non-sensitising (to both patient and medical staff)
    • Sterile .


    Classification of wound dressings

    Synthetic wound dressings can be broadly categorized into the following types.

    Type


    Properties

    Passive products
    Traditional dressings that provide cover over the wound, e.g. gauze and tulle dressings
    Interactive products
    Polymeric films and forms which are mostly transparent, permeable to water vapour and oxygen, non-permeable to bacteria, e.g. hyaluronic acid, hydrogels, foam dressings
    Bioactive products
    Dressings which deliver substances active in wound healing, e.g. hydrocolloids, alginates, collagens, chitosan

    dressings types and their properties:

    The following table describes some of the many different types of wound dressings and their main properties.

    Dressing type


    Properties


    Gauze
    • Dressings can stick to the wound surface and disrupt the wound bed when removed
    • Only use on minor wounds or as secondary dressings

    Tulle
    • Dressing does not stick to wound surface
    • Suitable for flat, shallow wound
    • Useful in patient with sensitive skin
    • E.g. Jelonet®, Paranet®

    Semipermeable film
    • Sterile sheet of polyurethane coated with acrylic adhesive
    • Transparent allowing wound checks
    • Suitable for shallow wound with low exudate
    • E.g. OpSite®, Tegaderm®

    Hydrocolloids
    • Composed of carboxymethylcellulose, gelatin, pectin, elastomers and adhesives that turn into a gel when exudate is absorbed. This creates a warm, moist environment that promotes debridement
    • and healing
    • Depending on the hydrocolloid dressing chosen can be used in wounds with light to heavy exudate, sloughing or granulating wounds
    • Available in many forms (adhesive or non-adhesive pad, paste, powder) but most commonly as self-adhesive pads
    • E.g. DuoDERM®, Tegasorb®

    Hydrogels
    • Composed mainly of water in a complex network or fibres that keep the polymer gel intact. Water is released to keep the wound moist
    • Used for necrotic or sloughy wound beds to rehydrate and remove dead tissue. Do not use for moderate to heavily exudating wounds
    • E.g. Tegagel®, Intrasite®

    Alginates
    • Composed of calcium alginate (a seaweed component). When in contact with wound, calcium in the dressing is exchanged with sodium from wound fluid and this turns dressing into a gel that maintains a moist wound environment
    • Good for exudating wounds and helps in debridement of sloughing wounds
    • Do not use on low exudating wounds as this will cause dryness and scabbing
    • Dressing should be changed daily
    • E.g. Kaltostat®, Sorbsan®

    Polyurethane or silicone foams
    • Designed to absorb large amounts of exudates
    • Maintain a moist wound environment but are not as useful as alginates or hydrocolloids for debridement
    • Do not use on low exudating wounds as this will cause dryness and scabbing
    • E.g. Allevyn®, Lyofoam®

    Hydrofibre
    • Soft non-woven pad or ribbon dressing made from sodium carboxymethylcellulose fibres
    • Interact with wound drainage to form a soft gel
    • Absorb exudate and provide a moist environment in a deep wound that needs packing

    Collagens
    • Dressings come in pads, gels or particles
    • Promote the deposit of newly formed collagen in the wound bed
    • Absorb exudate and provide a moist environment








    Different types of wounds and the different stages of a healing wound require different dressings or combinations of dressings. The following table shows suitable dressings for particular wound types.

    wound type



    Clean, medium-to-high exudate (epithelialising)
    • Paraffin gauze
    • Knitted viscose primary dressing

    Clean, dry, low exudate (epithelialising)
    • Absorbent perforated plastic film-faced dressing
    • Vapour-permeable adhesive film dressing

    Clean, exudating (granulating)
    • Hydrocolloids
    • Foams
    • Alginates

    Slough-covered
    • Hydrocolloids
    • Hydrogels

    Dry, necrotic
    • Hydrocolloids
    • Hydrogels


    The dressings may require secondary dressings such as absorbent pad and bandages.
    [FONT='Verdana','sans-serif']DMERC Utilization Guide[/font]

    The following is the official DMERC utilization guideline for 1995. I believe that they only serve as guidelines and that differing protocols are appropriate, but need to be substantiated with documentation or medical necessity.


    Alginate wound cover......................Dressing change once daily


    Alginate wound filler......................Dressing change once daily, up to 2 six inch strips allowed per dressing change


    Composite dressing ........................3 times per week, one dressing per dressing change


    Contact layer ...................................once per week


    Foam dressing..................................up to 3 times per week


    Foam wound filler...........................once daily


    Gauze................................................3 times per day, no more than 2 pads on a wound


    (non-impregnated)


    Gauze ...............................................once daily


    (impregnated - other than water or saline)


    Gauze................................................Non-covered, reduced to regular non-impregnated gauze level


    (impregnated with water or saline)


    Hydrocolloid cover and filler .........3 times per week


    Hydrogel wound cover.....................once daily (or 3 times per week if using adhesive border)


    Hydrogel wound filler.....................once daily, no more than 3 ounces per wound in a 30 day period


    Specialty absorptive dressing.........once per day (or every other day if using adhesive border)


    Transparent film..............................up to 3 times per week


    Wound filler not classified..............once per day


    Wound pouch....................................up to 3 times per week


    Tape...................................................determined by frequency of dressing change


    Elastic bandage.................................one per week


    Gauze, elastic...................................determined by the frequency of dressing change of the primary dressing


    Gauze, non-elastic............................determined by the frequency of dressing change of the primary dressing.

    Adverse effects of dressings


    Wound dressings can cause problems, including:


    [FONT='Times New Roman','serif'] Wound cleansers — Clean the surface of the wound by removing bacteria and drainage. Products used might contain a detergent. Normal saline also can be used to clean wounds without harming new tissue.[/font]

    [FONT='Times New Roman','serif']Some brand name wound cleansers include: Puri-Clens (from Coloplast), Shurclens (from ConvaTec), UltraKlenz (from Carrington), Biolex Wound Cleanser (from Bard)[/font]
    [FONT='Times New Roman','serif']Instructions for making saline solution:[/font]
    1. [FONT='Times New Roman','serif']Use 1 gallon of distilled water or boil 1 gallon of tap water for five minutes. Do not use well water or sea water. [/font]
    2. [FONT='Times New Roman','serif']Add 8 teaspoons of table salt to the distilled or boiled water. [/font]
    3. [FONT='Times New Roman','serif']Mix the solution well until the salt is completely dissolved. Be sure storage container and mixing utensil are clean (boiled). [/font]
    Note: Cool to room temperature before using. This solution can be stored at room temperature in a tightly covered glass or plastic bottle for up to one week
    What about using povidone iodine, hydrogen peroxide, Dakin's, acetic acid and other agents?


    Please refer to the [FONT='Verdana','sans-serif']AHCPR [/font]Clinical Practice Guideline for a detailed discussion of these and other cleansers.


    In short, it has been determined that these products may actually slow wound healing. Some of these products are cytotoxic to human fibroblasts, reduce white blood cell viability and decrease phagocytic efficiency. Studies show that most of these products must be diluted to avoid these toxic effects and a dilution guide is available through the AHCPR guideline.


    On a more practical level, many of these products are drying agents as well as antimicrobial. We have already identified that [FONT='Verdana','sans-serif']exudate[/font] is necessary to create an evironment which stimulates more rapid wound healing. By drying the wound bed, the exudate and all its beneficial cells are removed from the area. Dry tissue tends to necrose and serve as a bacterial medium.


    In addition, we know that most wounds should be considered as contaminated and contaminated wounds will heal. The constant application of an anti-microbial agent is not necessary to produce rapid wound healing or avoid infection. In fact, there are clinical studies which have shown that a wound maintained in a moist environment (with exudate) has a lower infection rate than a wound which is dry.


    Is there a role for povidone iodine, hydrogen peroxide, Dakin's, acetic acid and other agents?


    Certainly! When discussing wound care, remember that there are chronic wounds and acute wounds. An acute wound, like a laceration, will most likely heal in an individual who has no medical problem that would delay wound closure. Avoiding infection is important in these cases, and maybe the healthcare provider feels comfortable using some of these products. Also, in a chronic wound that has an infection, it may be appropriate to use these products until the infection has resolved.


    From personal experience, I now apply a transparent film to all my minor cuts and abrasions, as I have found that my acute wounds heal very quickly with this protocol. I may also cleans the wound with one of the above products prior to the film's application.

    [FONT='Arial','sans-serif']Suture Removal Guidelines[/font]


    [FONT='Arial','sans-serif']Remove sutures early enough to avoid suture marks but late enough to prevent the wound from reopening. [/font]


    [FONT='Arial','sans-serif']With early suture removal reinforce the wound edges with Steri-Strips. [/font]


    [FONT='Arial','sans-serif']Always check to be sure the wound is ready for suture removal. If not recheck in 2 days. Consider removing every other suture.[/font]











    Site


    Adult


    Children


    Face


    4-5 days


    3-4 days


    Scalp


    6-7 days


    5-6 days


    Trunk


    7-10 days


    6-8 days


    Arm (not joint)


    7-10 days


    5-9 days


    Leg (not joint)


    8-10 days


    6-8 days


    Joint extensor surface


    8-14 days


    7-12 days


    Joint flexor surface


    8-10 days


    6-8 days


    Dorsum of hand


    7-9 days


    5-7 days


    Palm


    7-12 days


    7-10 days


    Sole of foot


    7-12 days


    7-10 days








    References:



    1-Royal collegue of surgeons of Edinburgh.surgicalknowledge and skills website,wound management,www.edu.rsed.ac.uk/wound 20%managment/content.htm.25Oct,2007.


    2-Emergency wound management for health care professionals,CDC,page last reviewed June 9,2006 ,http://www.bt.cdc.gov/disasters/emer...sp.25,Oct,2007.


    3-wound care information network ,n.d, http://www.medicaledu.com/hbo2.htm.


    4-[FONT='Arial','sans-serif'] Wound Management Core Information: Suturing and Biopsies[/font][FONT='Verdana','sans-serif'] http://www.npcentral.net/talks/core.suturing.shtml, Last updated: [/font][FONT='Verdana','sans-serif']October 23, 2002,3rdNov,07.[/font]


    5-SuzannneC.Smeltzer.Brenda G.Bare .Text book of Medical surgical nursing,Brunner &Suddarths,Lippencott,9th ed,p1454-1455.


    6-Patricia A.Potter , Anne G Perry .Fundamentals of nursing ,Potter.Perry,5th ed,USA,P1551-1552-1553-1554-1556.

  2. #2

    افتراضي

    اسفه اخوتي لأن الموضوع غيرمرتب اتمنى من المشرفين الأعزاء مساعدتي حتى ارفق الموضوع في ملف وشكرا لأني اعددته بنفسي

  3. #3

    افتراضي

    مشكور علي الموضوع الروعة انا بحاجة الي الوضوع ضروري ياريت تكملي معروفك وتشوفي احد المشرفين حتي يتمكن من ترتيب الموضوع ضروري جدا جداااااااااااااااااااا ارجو الرد علي اميلي يمنع وضع الأيميل في المشاركات ضروري في 18 الشهر
    التعديل الأخير تم بواسطة نور الهدى ; 11-18-2007 الساعة 07:52 AM

  4. #4

    افتراضي

    اخي اشكرك جداااااااااااااااااا انا لا ادري يبدو انه لا يمكنني ارفاق ملف بمشاركة لان لدي عدة مواضيع تهم التمريض واكرر الشكر

  5. #5

    افتراضي

    شكرا لك مجهود تستحقي عليك كل خير
    قضى الله حواجك


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