Instructor’s Manual for Wound Management: Principles and Practice 4 th Edition Betsy A. Myers, DHS, MPT, OCS, CLT, CWS Assistant Professor of Physical Therapy, University of Tennessee at Chattanooga Chattanooga, TN and Staff Physical Therapist, Saint Francis Health System Tulsa, OK LECTURE NOTES iii TABLE OF CONTENTS Introduction 1 Chapter 1 Integumentary Anatomy 2 Chapter 2 Wound Healing 6 Chapter 3 Factors Affecting Wound Healing 9 Chapter 4 Examination of Patients with Open Wounds 12 Chapter 5 Debridement 20 Chapter 6 Management of Infection 28 Chapter 7 Dressing Selection and Bandaging 36 Chapter 8 Biophysical Agents 43 Chapter 9 Nutrition and Interdisciplinary Care 51 Chapter 10 Arterial Insufficiency Ulcers 54 Chapter 11 Venous Insufficiency Ulcers 58 Chapter 12 Pressure Injuries 68 Chapter 13 Neuropathic Ulcers 74 Chapter 14 Burns 80 Chapter 15 Lymphedema 86 Chapter 16 Miscellaneous Wounds 92 Chapter 17 Basic Dermatology 96 1 INTRODUCTION This Instructor’s Resource Manual will save course instructors valuable time and allows for consistent and inclusive presentation of material from the 4 th edition of Wound Management: Principles and Practice . The manual includes a preview of chapter objectives, key terms, and a chapter outline to quickly focus instructors on the material to be covered. Next, the manual provides key discussion points for each chapter to spur student conversation and help students learn key points. Third, the manual provides teaching tips for instructors to help students master chapter objectives. The manual also contains comprehensive laboratory activities. Student laboratory handouts contain step-by-step procedures for wound management techniques, written activities to reinforce chapter material, as well as opportunities for guided practice of physical skills both individually and in small groups. The instructor laboratory handout contains supply lists and answers to student laboratory activities. A separate infection control lab is included to help students learn operational definitions of key terms such as contamination, disinfect, clean, and sterile. Laboratory activities are made even easier by taking advantage of the many videos provided in the accompanying website to watch complex skills such as pulsatile lavage with suction, multilayer compression bandaging, and sterile procedures. Instructors can access MyHealthProfessionsKit to access many resources in an electronic format. It includes the complete test bank that allows instructors to design customized quizzes and exams. The MyTest wizard guides you through the steps to create a simple test with drag and-drop or point-and-click transfer. Instructors can select test questions either manually or randomly and use online spell-checking and other tools to quickly polish their test content and presentation. The question formats include multiple choice, fill-in-the-blank, true/false, and essay. Instructors can save their tests in a variety of formats both locally and on a network, print up to 25 variations of a single test, and publish tests in an online course. The instructor manual also includes a PowerPoint Lecture package that contains key discussion points, along with figures and tables, full color images of patients with open wounds, and video links for each chapter. This feature provides dynamic, fully designed, integrated lectures that are ready to use and allows instructors to customize the materials to meet their specific course needs. An electronic version of this Instructor’s Resource Manual can be accessed. Of course, the manual also contains all of the updates of the 4 th edition of the textbook including the latest information from the National Pressure Ulcer Advisory Panel on pressure injures, current data on biofilms and wound infections, new standards regarding circulation required for tissue healing, and contemporary evidence on neuropathy and the treatment of patients with neuropathic ulcers. 2 Chapter 1 Integumentary Anatomy MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1. All of the following are functions of the dermis EXCEPT: A. Provides sensation. B. Houses epidermal appendages. C. Assists with thermoregulation. D. Assists with vitamin D production. 2. Cells that can be found in the dermis are: A. Merkel cells. B. fibroblasts. C. Langerhans' cells. D. melanocytes. 3. The stratum corneum can be found in the: A. dermis. B. fascia. C. epidermis. D. adipose tissue. 4. A full-thickness wound involves the following tissue layers: A. Epidermis. B. Dermis and subcutaneous tissue. C. Subcutaneous tissue. D. Epidermis, dermis, and subcutaneous tissue. 5. A stage 2 pressure injury can also be described as a ______ lesion. A. Wagner grade 4. B. partial-thickness. C. superficial thickness. D. full-thickness. 6. An abrasion most commonly involves ______ . A. the epidermis, dermis, and subcutaneous tissue. B. fascia but not adipose tissue. C. the epidermis. D. the epidermis and dermis. 3 7. A callus is caused by a build-up of cells within the stratum basale. A. True. B. False. 8. The number of melanocytes determines an individual's skin color. A. True. B. False. 9. Mast cells produce the following substances: A. collagen. B. keratin. C. histamine. D. sebum. 10. Sudoriferous glands are present everywhere EXCEPT: A. the lips. B. the hands and feet. C. the feet. D. the hands. 11. Which of the following is true regarding hair follicles? A. They assist with infection control. B. They are located in the subcutaneous tissue. C. They are present everywhere except the palms and soles. D. They are composed of hard collagen. 12. When examining a patient's wound, you notice regularly arranged white fibrous tissue. What do you suspect this structure is? A. Muscle. B. Bone. C. Joint capsule. D. Tendon. 13. When examining a patient's wound, you notice gray-black, dry, leathery appearing irregular fibrous tissue. What do you suspect this structure is? A. Healthy tendon. B. Healthy muscle. C. Nonviable joint capsule. D. Nonviable bone. 14. When examining a patient's pressure injury, you are able to identify the patient's greater trochanter within the wound bed. How would you classify the extent of wound involvement? A. Superficial. B. Partial-thickness. 4 C. Full-thickness. D. Unable to determine from the information provided. 15. When examining a patient's wound, you notice regularly arranged red tissue. What do you suspect this structure is? A. Joint capsule. B. Bone. C. Tendon. D. Muscle. 16. A blister occurs: A. between the papillary and reticular dermis. B. at the junction between the epidermis and dermis. C. at the junction between the dermis and subcutaneous tissue. D. between the stratum basale and the stratum corneum. 17. The subcutaneous tissue consists of: A. keratin and adipose tissue. B. sudoriferous and sebaceous glands. C. adipose tissue and fascia. D. the epidermis and dermis. ESSAY. Write your answer in the space provided or on a separate sheet of paper. 18. List five functions of the epidermis. 19. List three functions of the dermis. 20. What is the function of the basement membrane? 1) B 2) D 3) C 4) D 5) B 6) C 7) B 8) B 9) C 10) A 11) C 12) D 13) C 14) C 5 15) D 16) B 17) C 18) Correct answers should include five of the following possible choices: * Provides a physical and chemical barrier. * Regulates fluid. * Provides light touch sensation. * Assists with thermoregulation. * Assists with excretion. * Assists with endogenous vitamin D production. * Contributes to cosmesis. 19) Correct answers should include three of the following possible choices: * Supports and nourishes the epidermis. * Houses epidermal appendages. * Assists with thermoregulation. * Provides sensation. 20) Correct answers should include the following key points: * Serves as a scaffolding for the epidermis. * Selective filter for substances moving between the epidermis and dermis. 6 Chapter 2 Wound Healing C HAPTER O BJECTIVES 1. Describe the vascular response of inflammation. 2. State the cells involved in the inflammatory phase and describe their functions. 3. Describe the proliferative phase of wound healing. 4. State the cells involved in the proliferative phase and describe their functions. 5. Describe the maturation and remodeling phase of wound healing. 6. Differentiate between wound closure by primary, secondary, and delayed primary wound closure. 7. Compare and contrast absence of inflammation and chronic inflammation. 8. Explain why absence of inflammation and chronic inflammation occur and interventions that may improve wound healing. 9. Compare and contrast hypogranulation and hypergranulation. 10. Explain why hypogranulation and hypergranulation occur and interventions that may improve wound healing. 11. Compare and contrast hypertrophic scarring, keloids, contractures, and wound dehiscence. 12. Explain why hypertrophic scarring, keloids, contractures, and wound dehiscence may occur and interventions that may improve wound healing. K EY T ERMS Abrasion Angioblasts Angiogenesis Chemotactic agents Chemotaxis Closed wound Collagenases Contracture Current of injury Cytokines Cytotoxic agents Dehiscence Delayed primary closure Diapedesis Epibole Epithelialization Exudate Fibroblast Granulation tissue Growth factors Healed wound Hypergranulation Hypertrophic scarring Hypogranular Inflammation Integrins Keloids Macrophages Margination Mast cells Matrix metalloproteases (MMPs) Maturation/remodeling Myofibroblasts Platelets 7 Polymorphonuclear neutrophils (PMNs) Primary closure Proliferation Prostaglandins Scab Secondary closure Tissue inhibitors of matrix metalloproteases (TIMPs)Transudate Wound contraction C HAPTER O UTLINE I. Introduction II. Phases of Wound Healing A. Inflammation 1. Vascular response 2. Cellular response B. Proliferation 1. Angiogenesis 2. Granulation tissue formation 3. Wound contraction 4. Epithelialization C. Maturation and remodeling III. Types of Wound Closure A. Primary closure B. Secondary closure C. Delayed primary closure IV. Abnormal Wound Healing A. Absence of inflammation B. Chronic inflammation C. Hypogranulation or nonadvancing wound edge D. Hypergranulation E. Hypertrophic scarring F. Keloids G. Contractures H. Dehiscence D ISCUSSION P OINTS 1. Why is a wound likely to recur in the same location as a previous ulcer? 2. How can inflammation be both beneficial and problematic? 3. Why are inflamed wounds characterized by local redness, heat, swelling, pain, and decreased function? 4. When looking at an open wound, how might you be able to tell that the wound is primarily in the proliferative phase of wound healing? 8 5. You have been working with a 6-year-old patient with deeply pigmented skin who sustained a full-thickness burn covering 75% of his upper extremity. The burn wound is now closed. What information would you provide to an insurer about the patient’s wound healing and impairments to justify the patient’s requirement for continued physical therapy? 6. How are chronic wounds different from acute wounds? T EACHING T IPS 1. Using some of the images of patients with open wounds, have the students determine the primary phase of wound healing for each wound. Ensure that the students describe particular characteristics, such as the presence of granular budding or epithelialization. 2. Make a list of all of the cells involved in wound healing. Ask the students to describe their key functions and what phase(s) these functions occur in. 3. Have students group the various types of abnormal wound healing listed within the chapter by the phase of inflammation. 4. Have students use the chapter objectives to assess their understanding of the information provided. 5. Have students define a sampling of the key terms provided. Students may check their answers either within the chapter or by using the Glossary in Appendix A. 9 Chapter 3 Factors Affecting Wound Healing C HAPTER O BJECTIVES 1. State the difference between an acute and a chronic wound. 2. Describe wound characteristics associated with delayed wound healing. 3. Compare and contrast colonization and infection. 4. Describe local factors associated with delayed wound healing. 5. Describe systemic factors associated with delayed wound healing. 6. Identify potential barriers and methods to facilitate patient adherence. 7. Identify and prevent common inappropriate wound management practices which can delay wound healing. K EY T ERMS Acute wound Adherence Chronic wound Colonization Infection Macerated Necrotic tissue C HAPTER O UTLINE I. Introduction II. Wound Characteristics A. Mechanism of onset B. Times since onset C. Wound location D. Wound dimensions E. Temperature F. Wound hydration G. Infection H. Necrotic tissue or foreign bodies I. Changes in chronic wounds III. Local Factors A. Circulation B. Sensation C. Mechanical stress 10 IV. Systemic Factors A. Age B. Inadequate nutrition C. Comorbidities D. Medication E. Lifestyle choices V. Patient Adherence A. Understanding and Enhancing Adherence 1. Patient characteristics 2. Task characteristics 3. Health care provider characteristics VI. Inappropriate Wound Management D ISCUSSION P OINTS 1. Certain wound characteristics are known to affect the rate of wound healing. List some of these characteristics and describe what interventions can be used to address these factors to facilitate wound healing. 2. Now that you know more about normal wound healing and factors that can affect wound healing, how are chronic wounds different from acute wounds? 3. In what ways are matrix metalloproteases (MMPs) beneficial? In what ways are they detrimental? 4. Circulation, sensation, and mechanical stress are local factors that affect wound healing. This chapter provides some ways in which clinicians can assist with improving circulation. a. How might a physical therapist address loss of sensation as a risk factor for delayed wound healing? b. How might a physical therapist address adverse mechanical stresses in a patient who is nonambulatory? T EACHING T IPS 1. Many times, in physical therapy, the terms acute and chronic are incorrectly used to denote arbitrary time frames for a rehabilitation program, such as acute, subacute, and chronic phases. Help the students clarify the proper use of the terms of acute wounds and chronic wounds using the definitions provided in the chapter. 2. Provide a scrambled list of factors known to affect wound healing. Have the students group these factors into the following categories: a. Wound characteristics b. Local factors c. Systemic factors d. Factors that can be modified with physical therapy interventions 11 e. Factors that can be modified with medical interventions f. Factors that cannot be modified 3. If students are having difficulty understanding what macerated tissue looks like, try having them put an adhesive bandage (e.g., a Band-Aid) on a finger, then soak the finger in a cup of water during the lecture portion of the class. 4. Integrate information from students’ previous or current coursework regarding the psychosocial aspects of disability and impairments with methods to enhance patient adherence. 5. Have the students use the chapter objectives to assess their understanding of the information provided. 6. Have the students define a sampling of the key terms provided. Students may check their answers either within the chapter or by using the Glossary in Appendix A. 12 Chapter 4 Examination of Patients with Open Wounds C HAPTER O BJECTIVES 1. Describe the four aspects of obtaining the history of patients with open wounds. 2. State the key components of the systems review for patients with open wounds. 3. Identify and document wound characteristics. 4. Identify and document periwound and associated skin characteristics. 5. Assess and document circulation. 6. Assess and document sensory integrity. 7. Classify open wounds based on extent of tissue damage. 8. Document goals for patients with open wounds. K EY T ERMS Capillary refill Eschar Induration Pitting edema Semmes–Weinstein monofilaments Sinus tract Slough Tunneling Undermining C HAPTER O UTLINE I. Introduction II. Examination A. History 1. Review of systems 2. General demographics 3. Lifestyle and functional status 4. Past and current general medical history 5. Past and current wound history B. Systems review 1. Cardiovascular/pulmonary system 2. Musculoskeletal system 3. Neuromuscular system 4. Integumentary system C. Tests and measures 1. Integumentary integrity a. Wound characteristics 13 i. Wound location ii Wound size iii Tunneling/undermining iv Wound bed v Wound edges vi Wound drainage vii Wound odor b. Periwound and associated skin characteristics i. Structure and quality ii. Color iii Epithelial appendages iv. Edema v. Temperature 3. Circulation 4. Sensory integrity III. Clinical Decision Making A. Diagnosis B. Prognosis C. Interventions D. Goals and outcomes D ISCUSSION P OINTS 1. Obtaining a medical history and performing a systems review are vital parts of the physical therapy examination. List some medical conditions that can adversely affect wound healing and describe why healing may be compromised. 2. Why might it be important to assess motor function and range of motion in a patient with an open wound? 3. What are some of the benefits and limitations of using direct measurement to determine wound size? 4. When assessing a patient’s wound bed, it is important to estimate what percentage of the wound bed is granular and what percentage is necrotic. Describe ways you might improve the reliability of your estimation. 5. When assessing a patient’s open wound, you notice minimal wound drainage. Is this desirable or problematic? Why? T EACHING T IPS 1. Many times, students and clinicians are under the mistaken belief that the examination of patients with open wounds is vastly different from the examination of patients that are classified within other practice patterns. Have the students note the similarities across practice patterns in the following portions of a physical therapy examination: